Chapter 10: Insomnia Flashcards
Prevalence of chronic insomnia in USA
20-30%
Increases with:
* age
* female gender
* comorbidities (40% have a psychiatric illness, most commonly depression)
* shift work
* primary sleep and circadian rhythm disorders (RLS, nocturia, narcolepsy, GERD)
Insomnia often precedes and is a risk factor for mood disorders.
Only 13% of insomnia patients ever consult a healthcare professional
One third of people with insomnia have OSA!
5 Key Steps of an integrative approach to insomnia
- acknowledges the critical role of consciousness or subjective experience (which is only partially addressed by CBT-I)
- emphasizes the promotion of sleep health, as opposed to symptom suppression
- recognizes the important social and relational context of sleep;
- underscores the central role of natural rhythms in life and health;
- strongly emphasizes the contribution of lifestyle
In insomnia there is a loss of REM sleep and there is dream loss. Part of the critical history is their dream story!
Insomnia definitions
- Insomnia disorder refers to difficulties with initiating or maintaining sleep, as well as nonrestorative sleep that is associated with excessive sleepiness or fatigue and with functional decrements for at least 4 weeks.
Primary = not attributable to a medical or pyschiatric cause
Secondary = viewed as a symptom of a primary disorder. Should be called COMORBID insomnia instead of secondary, to emphasize treating the insomnia directly still.
3 P Model of Insomnia
- Predisposing: substance use, illnesses, primary sleep disorders, long term use of circadian-disrupting meds, shift work.
- Precipitating: stressors (either negative or positive events like divorce or childbirth)
- Perpetuating: behaviors intended to manage or compensate for sleeplessness that inadvertently exacerbate the condition (daytime napping, caffeine, anxiety associated with attempts to control sleep)
Sleep Efficiency
The ratio of total time spent asleep to the amount of time spent in bed.
<85% is problematic
Conditioned Insomnia = a negative association of the bed with wakefulness that stems from a common practice of spending excessive time in bed to compensate for lost sleep.
Medications that suppress melatonin
- Analgesics
- Benzos
- antidepressants
- anticholinergics
- beta blockers
- calcium channel blockers
- diuretics
Meds that interfere with sleep
- *Alcohol
- *Antiarrhythmics
- *Anticonvulsants
- *Antihistamines
- *Appetite suppressants
- *Benzodiazepines
- *Bronchodilators
- *Caffeine
- *Carbidopa/levodopa
- *Corticosteroids
- *Decongestants
- *Diuretics
- *Estrogen
- *Lipophilic beta-blockers
- *Monoamine oxidase inhibitors
- *Nicotine
- *Pseudoephedrine
- *Sedatives
- *Selective serotonin reuptake inhibitors
- *Statins
- *Sympathomimetics
- *Tetrahydrozoline
- *Thyroid hormones
- *Tricyclic antidepressants
Pathophysiology of insomnia
Chronic cognitive-emotional hyperarousal associated with elevated metabolic rate, sympathetic overactivation, and chronic inflammation
* elevated body temp
* increased beta and gamma EEG
* elevated inghttime cortisol
* nocturnal SANS activation
* HPA overactivation
24-hr hyperarousal = less sleepy than normal counterparts, but more fatigued. The fatigue + hyperarousal = chronic tension –> depression.
bidirectional assocation with chronic inflammation (poor sleep can raise inflammation. Poor diet can lead to poor sleep)
Association with circadian core body temperature rhythm abnormalities.
“uspended in a limbic zone between fatigue and hyperarousal, neither a healthy descent into sleep nor a passionate ascension into waking are possible”
Dual process model of sleep regulation
- views sleep in terms of a dynamic interaction between homeostatic and circadian processes.
- As the homeostatic sleep drive gradually increases through the waking day, the circadian pacemaker exerts an equal but opposite force to maintain alertness.
- The potential for sleep normally occurs with the nightly, rhythmic release (shut off) of circadian alertness.
Hyperarousal may be understood as circadian alertness (wakefulness) that has gone awry
Polysomnogrophy
- multiple sleep parameters (respiration, EEG, movement, muscle tone)
- NOT routinely indicated for insomnia because it provides little useful diagnostic or therapeutic infromation
- Can be used to rule out periodic limb movement, OSA, or other conditions underlying persistent insomnia
- Home-based PSG is possibl
Consumer Sleep Technology
- Unclear validity and reliability
- May help improve patient-provider interaction and heighten patient’s interest
- May also negatively affect sleep self-efficacy by discouraging trust in one’s own sense of their sleep quality
Two basic approaches to insomnia
- Taking something to sleep
- Letting go of something to sleep
Chronic insomnia is not from insufficient sleepiness but rather is from excessive wakefulness. The latter approach focuses on reducing the noise of this excessive wakefulness / hyperarousal.
Taking something to sleep may help in short term but it can erode someone’s sleep self-efficacy.
Risks of sedative-hypnotics
- hypnotic agents may increase risk of cancer
- 10-15% increased mortality among occasional sleeping pill users
- 25% increased mortality among nightly sleeping pill users
- dependence
- tolerance
- damaged sleep architecture
- diminished deep sleep
- REM suppression
- Parasomnias
- anterograde amnesia
- morning angover
- undermined self-efficacy
- rebound insomnia with discontinuoation
- increased risk for falls
- cognitive impairment
- symptom suppression
Compare this to CAM sleep aids:
- provide less of a knockout and more of a gentle assist to sleep with significantly fewer adverse effects.
- think of these as “sleep appetizers” that remind them of the “taste” of sleep rather than provide a substitute
- the use of botanicals should always be complemented with lifestyle and body–mind recommendations and a specific plan for discontinuing use.
Melatonin
Insomnia Chptr
- Inhibited by blue light. Disinhibited by dim light and dark
- decreases nocturnal body temp, antiinflammatory, antioxidant, immune-mod, oncostatic
- suppressed by age, substances. May be factor in cancer and depression too
- high doses may disrupt sleep
- beneficial for sleep-onset latency, total sleep time, and sleep efficiency
- Sublingual bypasses first-pass liver metabolism resulting in more reliable serum levels.
- Sustained release given near bedtime helpful trhoughout sleep preiod.
- Immediate-release sublingual formulations at awakening better for sleep-maintenance insomnia and early morning awakenings (if you can sleep for at least 3 more hours)
- DOSE: 0.3 -0.5mg for adults.
- Contraindicated in pregnancy (?). Autoimmune illness exacerbation..
Valerian Root
- Does not impair psychomotor or cognitive performance
- Effective for mild-moderate insomnia
- Not addictive, no withdrawal
- Requires 2-4 WEEKS of nightly use before an effect
- High-quality products have unpleasant odor, which confirms potency
- Caution: pregnancy, liver disease
