Insomnia Flashcards
Two types of sleep disorders?
Dyssomnias and Parasomnias
Dyssomnias: Definition?
Problems with timing, amount and quality of sleep
Examples of Dyssomnias?
insomnia, narcolepsy, sleep apnea
Parasomnias: Definition?
abnormal sleep physiology OR behavior
Examples of parasomnia
nightmare disorder, sleep terror disorder, sleepwalking disorder, bruxism
DSM5 insomnia definition
Not satisfied with sleep quality or quantity + 1 of the following:
- difficulty INITIATING sleep
- difficulty MAINTAINING sleep
- difficulty GOING back to sleep after early awakening
Other DSM5 criteria
MUST cause distress or impairment in life (social, occupational, educational, etc)
Other DSM5 criteria
MUST happen 3 times per week for at least 3 months
Other DSM5 criteria
Not due to substance or other disorder
Most common cause of insomnia?
caffeine
More insomnia with who?
elderly and women
What neurotransmitters are increased in insomnia?
NE, serotonin, dopamine, histamine
Formation locations of NE, Serotonin, dopamine and histamine
NE=locus ceruleus
Serotonin=raphe nucleus
Dopamine=Ventral tegmentum area
Histamine=tuberomamary nucleus
What neurotransmitters are decreased in insomnia?
GABA, melatonin, adenosine
Exogenous causes of insomnia?
- caffeine
- withdrawal from alcohol, benzos and barbs (sedating agents)
- Pain, endocrine disorders, pulm disorders (hyperthyroidism, COPD, obstructive sleep apnea, etc)
Mental Disorder causes of Insomnia?
- MDD
- Bipolar
- GAD, PTSD
Anxiety Causes of insomnia
- Thinking of past, future, etc
2. anxiety about falling asleep
Results/Effects of insomnia
- substance and alcohol abuse
- decreased quality of life
- increased absenteeism, impaired daytime performance,
- self medication
- mental disorders
First 2 steps in Management of insomnia
- Dx, informed consent, education (underlying medical issue that needs to be addressed?)
- BEHAVIORAL COUNSELING (sleep hygeine or stimulus control)
Next 3 steps in management of insomnia
- sleep restriction therapy (limit amt of time in bed to force sleep later)
- Cognitive therapy- talk it through
- behavioral therapy- diary, hypnosis, relaxation
LAST OPTION for insomnia management?
PHARMACOTHERAPY
first (out of 4) step in PHARM
- OTC
2 OTC examples for insomnia
- melatonin
2. antihistamines
second (out of 4) step in PHARM
- Nonhabit forming agents (1. antihistamines, 2. melatonin 1 &2 agonists)
non habit forming antihistamines? (1)
Doxepin
nonhabit forming melatonin 1&2 agonists? (2)
- Ramelteon
2. Tasimelteon
third (out of 4) step in PHARM
mild habit forming agents (1. Benzo agonists and 2. orexin antags)
Benzo agonists?
- zolpidem
- zaleplon
- ezoplicone
orexin antag?
suvorexant
fourth step in PHARM?
ADDICTING agents- benzos and off label
addicting benzos?
- triazolam
- temazepam
- flurazepam
off label?
trazodone, quetiapine
Trazodone
sedating antidepressant
Quetiapine
sedating antipsychotic
Who don’t get addictive rx?
addictive or riskier pts
Restless leg pts rx?
Get d2 agonists-treat underlying medical prob
What should be kept in mind for pts with sleep apnea?
No sedative rx!!!
Theoretical insomnia meds target where?
Serotonin receptors:
2a=deeper sleep patterns
1d and 7=more accurate circadian clock