How to manage a 30-year-old patient with a history of Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) on olanzapine (olanzapine) 5mg, presenting with insomnia and paranoia, feeling someone wants to kill her, with no suicidal ideation (SI) or homicidal ideation (HI)?

Management of Insomnia and Paranoia in a Patient with GAD and PTSD

For a 30-year-old patient with GAD and PTSD on olanzapine 5mg presenting with insomnia and paranoia without SI/HI, increase olanzapine to 5mg in the morning and 5-10mg at bedtime while initiating cognitive behavioral therapy for insomnia (CBT-I).

Assessment and Initial Management

• Evaluate the severity of paranoia and insomnia, as these symptoms may be interrelated - insomnia can worsen paranoid thoughts and psychotic experiences, while paranoia can contribute to sleep difficulties 1
• Assess for potential causes of symptom exacerbation, including medication side effects, substance use, or recent psychosocial stressors 2
• Rule out medical causes that could contribute to insomnia or paranoid thinking 3

Pharmacologic Management

Antipsychotic Adjustment

• Increase olanzapine dosage to address both paranoia and insomnia:
  • Consider split dosing with 5mg in the morning and 5-10mg at bedtime 4
  • Olanzapine has demonstrated efficacy for sleep disturbances in psychiatric patients 4
  • Monitor for metabolic side effects including weight gain, hyperglycemia, and dyslipidemia 5

Considerations for Medication Management

• Avoid adding benzodiazepines as first-line therapy due to:
  • Risk of dependence and abuse potential 5
  • Potential for cognitive impairment, especially with continued use 6
  • Possible paradoxical agitation in some patients 4
• If olanzapine adjustment is insufficient after 2-4 weeks, consider adding low-dose doxepin (3-6mg) for insomnia 4

Non-Pharmacologic Interventions

First-Line Treatment for Insomnia

• Initiate CBT-I as the primary treatment for insomnia, which includes: 4
  • Cognitive therapy addressing dysfunctional beliefs about sleep
  • Stimulus control (using bed only for sleep and sex)
  • Sleep restriction therapy
  • Sleep hygiene education
  • Relaxation techniques

Trauma-Focused Interventions

• For PTSD-related paranoia and nightmares, consider adding: 4
  • Exposure, Relaxation, and Rescripting Therapy (ERRT) for trauma-related nightmares
  • Progressive Deep Muscle Relaxation training
  • Systematic desensitization techniques

Monitoring and Follow-up

• Schedule follow-up within 1-2 weeks to assess response to treatment 2
• Monitor for:
  • Improvement in sleep quality and paranoid thoughts
  • Potential side effects of increased olanzapine dose 5
  • Adherence to CBT-I techniques and challenges with implementation 4

Safety Considerations

• Assess for worsening of paranoia that might indicate development of a more severe psychotic disorder 1
• Evaluate for emergence of suicidal ideation, as insomnia is a risk factor for suicidal thoughts 5
• Consider hospitalization if paranoia significantly worsens or if patient develops beliefs that could lead to harmful behavior 4

Treatment Algorithm

1. Increase olanzapine to split dosing (5mg morning, 5-10mg bedtime)
2. Initiate CBT-I with weekly sessions
3. Reassess in 1-2 weeks
4. If insufficient improvement:
   • Consider adding low-dose doxepin for insomnia
   • Intensify CBT-I and add ERRT for trauma-related nightmares
   • Consider referral to sleep specialist if insomnia persists despite interventions 4