Insomnia Flashcards
most people how much sleep per night?
8 hours
how much population does insomnia affect?
at least 30%
insomnia is classified as a
dyssomnia
what is dyssomnia?
sleep disorder characterized by problems in timing, quality, or amount of sleep
what is parasomnia?
sleep disorder characterized by abnormalities in physiology or behavior associated with sleep
based on DSM5, insomnia is associated with at least one of the following symptoms:
- difficulty initiating sleep
- difficulty maintaining sleep
- early-morning awakening with inability to return to sleep
sleep disturbance causes distress or impairment in
social, occupational, educational, academic, behavioral, or other important areas of functioning
disturbance occurs at least
3 nights per week and is present for at least 3 months
disturbance is NOT attributable to the
- physiologic effects of a substance or
2. a coexisting medical or mental disorder
women report insomnia
50% more often than men
what are the 2 major endogenous etiology for insomnia?
- excitatory neurotransmitters in excess at night
2. inhibitory neurotransmitter deficiency at night
what are the 4 causes of excitatory neurotransmitters in excess at night?
- norepinephrine from the locus ceruleus
- serotonin from the raphe nucleus
- dopamine from the ventral tegmental area
- histamine from the tuberomammillary nucleus
what are the 3 causes of inhibitory neurotransmitter deficiency at night
- loss of GABA tone
- loss of melatonergic tone
- loss of adenosinergic tone
what are the psychiatric causes for insomnia?
- major depressive disorder
- bipolar disorder
- generalized anxiety disorder/PTSD
Insomnia is classified as a
dyssomnia
Dyssomnia =
sleep disorder characterized by problems in
- timing,
- quality, or
- amount of sleep
Parasomnia =
sleep disorder characterized by abnormalities in physiology or behavior associated with sleep
what is insomnia?
Complaint of dissatisfaction with sleep quantity or quality, associated with at least one of the following symptoms:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early-morning awakening with inability to return to sleep
to be considered as insomnia
- Disturbance occurs at least 3 nights per week and is present for at least 3 months
- Disturbance is not attributable to the physiologic effects of a substance or a coexisting medical or mental disorder
summary of the insomnia?
- Diagnosis of insomnia requires that sleep disturbance causes distress or impairment in functioning
- Always address underlying medical, psychiatric or environmental causes of insomnia and treat those 1st
- Always address substance use or withdrawal that may be causing insomnia –> avoid caffeine and alcohol
- Begin with patient education, behavioral hygiene or counseling focusing or document why you skipped this step
- Consider OTC and Rx agents when needed
Antagonizing 5HT2a creates
deeper sleep patterns
Antagonizing 5HT1d and 7 promotes a more accurate
circadian clock
When patients are depressed or even anxious, one can often choose
an antidepressant or antipsychotic with these properties (instead of the more standard SSRI, SNRI, NDRI antidepressants that often have insomnia as a key side effect)
A bonus would be if the antidepressant also antagonizes
the histamine-1 (H1) receptor which decreases arousal and produces sedation for sleep initiation…
Anxiety symptoms that can lead to insomnia
- Getting caught up in thoughts about past events
- Excessive worrying about future events
- Feeling overwhelmed by responsibilities
After many nights of insomnia, some may experience anxiety about the possibility of not being able to sleep
- Worrying about how many hours of sleep one can get
- Concern about next day functioning if sleep is not attained
- Anxiety about sleep may cause insomnia and insomnia may cause anxiety about sleep…
- Essentially, at night patients get their brain into a more wakeful, vigilant state. This is conditioned that a stimulus and response relationship exists ie. I get in bed, therefore I am wide awake and worried about failing to sleep yet again
what are the 3 psychiatric causes of insomnia?
Psychiatric causes are common:
- Major depressive disorder
- Short sleep latency, repeated nighttime awakenings, waking too early in the morning - Bipolar disorder
- Manic and hypomanic patients have problems falling asleep and maintaining sleep - Generalized anxiety disorder/PTSD
- Trouble falling asleep/nightmares
hardcore of insomnia def
- difficulty initiating sleep
- difficulty maintaining sleep
- early morning awakening with inability to return to sleep
sleep disturbance causes
distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
to be qualiified as insomnia, it can’t be
Disturbance is not attributable to the physiologic effects of a substance or a coexisting medical or mental disorder
Excitatory neurotransmitters in excess at night
- Norepinephrine from the locus ceruleus
- Serotonin from the raphe nucleus
- Dopamine from the ventral tegmental area
- Histamine from the tuberomammillary nucleus (–> histamine wakes you up!)
you can get insomnia if Inhibitory neurotransmitter deficiency at night
- Loss GABA tone
- Loss of melatonergic tone
- Loss of adenosinergic tone
3 exogenous causes for insomnia
- use of CNS stimulants –> caffeine
- withdrawal from sedative drugs
- Medical conditions
what is the 1st step for insomnia treatment?
1st Step and Initial management strategy is
- diagnosis,
- informed consent and
- education
what is the 2nd step for insomnia treatment?
- Behavioral counseling
2. Sleep hygiene/Stimulus control
to manage the insomnia
- Sleep restriction therapy
- Cognitive therapy
- Talking through
- Imagery - Behavioral therapy
- Diary/Log book (wake/bed time, #hrs asleep, abnormal events at night, next day consequences)
- Progressive relaxation
- Self hypnosis
Behavioral therapy
- Diary/Log book (wake/bed time, #hrs asleep, abnormal events at night, next day consequences)
- Progressive relaxation
- Self hypnosis
Rx agents/non-habit forming
Antihistamines
doxepin
Melatonin1+2 agonists
ramelteon
tasimelteon
Rx agents/mild-habit forming
Benzodiazepine Receptor Agonists (BZRA)
zolpidem
zaleplon
ezopiclone
Orexin 1+2 antagonists
suvorexant
2nd step of management in insomnia is
behavioral counseling that includes sleep hygiene/stimulus control
what are cognitive therapy for insomnia?
- talking through
2. imagery
what are the components for behavioral therapy?
- diary/log book (wake/bed time, # hrs asleep)
- progressive relaxation
- self hypnosis
You have to also decide if the are medically compromised
Apnea patients do not get sedatives
Patients with restless legs get D2 agonists
