Insomnia

Question 1

Diagnoses that must be ruled out in order to diagnose insomnia

Answer 1

Narcolepsy

Breathing-related sleep disorder (OSA, OHS, etc)

Circadian rhythm sleep disorder

Parasomnia (sleepwalking, sleep terrors, etc)

Question 2

Insomnia disorder typcally onsets. . .

Answer 2

. . . in early adulthood

Question 3

Diagnostic criteria for insomnia disorder

Answer 3

• Predominant complaint of dissatisfaction with sleep quantity or quality associated with at least one of the following:
  
  • Difficulty initiating sleep
  • Difficulty maintaining sleep
  • Early morning awakening with inability to return to sleep
• Sleep disturbance occurs for at least 3 nights per week and for at least 3 months
• Sleep difficulty occurs despite adequate opportunity for sleep

Question 4

__ is often an element of insomnia

Answer 4

Nighttime preocupation with and anxiety regarding the inability to obtain adequate sleep is often an element of insomnia

Question 5

Treatment of insomnia

Answer 5

• Sleep hygiene education should ALWAYS be first-line
• CBT-I (CBT for insomnia) is useful to correct dysfunctional beliefs about sleep
• Pharmacotherapy
  
  • Melatonin receptor agonists (sleep promoting)
    
    • Ramelteon
    • Melatonin
  • GABA agonists (sleep promoting)
  • Central histamine antagonists (antagonize awake-promoting systems)
  • Selective hypocretin-orexin receptor antagonists (antagonize awake-promoting systems)
    
    • Suvorexant
  • Antidepressants (antagonize awake-promoting systems)
    
    • Trazadone
  • Antipsychotics (antagonize awake-promoting systems)
    
    • Olanzapine

Question 6

Stimulus control therapy with regards to insomnia

Answer 6

Patients are instructed to use their beds only for sleeping (and sex), and they should get in bed only if sleepy.

If they cannot fall asleep after 15 minutes, they should get up and go do something relaxing in another room, then return when they are sleepy.

Question 7

Using pharmacologic agents for sleep

Answer 7

These drugs can be helpful for people with difficult to treat insomnia

However, they should NOT be used consecutively for more than 2 weeks, as dependence will occur and worsen insomnia symptoms

Question 8

Typical course of insomnia disorder

Answer 8

It is often triggered by a stressful event, which the patient ruminates about overnight and interefers with sleep

However, even after the stressor is removed, the patient continues to struggle sleeping due to anxiety over their insomnia. This makes it a vicious cycle.

Question 9

Sleep problems due to a circadian rhythm sleep disorder

Answer 9

Characterized by a recurrent pattern of sleep disruption, which leads to excessive sleepiness and/or insomnia because of the mismatch between the sleep-wake cycle required in the person’s environment and the circadian sleep-wake pattern

A melatonin receptor agonist is particularly beneficial in these sleep disorders (melatonin or ramelteon).

Question 10

Common non-benzodiazepine hypnotics used for sleep aid in the elderly

Answer 10

Zolpidem and Zaleplon

They are similar, but zaleplon has a shorter half-life (1 hr) compared to zolpidem (4 hr)

Question 11

Suvorexant

Answer 11

Orexin antagonist sometimes used to treat insomnia in elderly patients (where anticholinergics need to be avoided)

Main side effects are daytime somnolence/sedation