Insomnia Flashcards
Define insomnia.
A complaint of difficulty initiating or maintaining sleep/ early awakening / non-restorative sleep
- Daytime consequences
- Sleep difficulty occurs despite adequate opportunity and circumstances for sleep
What are daytime consequences associated with insomnia?
- Fatigue or malaise
- Attention, concentration, or memory impairment
- Social or vocational dysfunction or poor school performance
- Mood disturbance of irritability
- Daytime sleepiness
- Motivation, energy, or initiative reduction
- Proneness for errors/actions while at work or driving
- Tension, headaches, or GI symptoms in response to sleep loss
- Concerns or worries about sleep
Which populations have increased prevalence of insomnia?
- women
- older persons
- those with medical or psychiatric conditions
What is insomnia a risk factor for?
Insomnia can increase the risk of other psychiatric conditions
- depression
- anxiety
- alcohol dependence
- drug dependence
Insomnia is linked to which other medical condition?
Individuals with insomnia tend to have increased sympathetic tone
- Increased HTN and cardiovascular disease
What are the criteria for chronic insomnia disorder?
- Symptoms occur > 3 times/week
- Symptoms occur for >3 months
What is the criteria for short term insomnia disorder?
- Symptoms present for <3 months
What are the characteristics of insomnia?
- Fatigue/sleepiness
- Overestimation of symptoms (psychophysiologic disturbance)
- Elevated anxiety, depression, anger, or psychological profile
What cortisol abnormality do insomnia patients often have?
Lack of cortisol drop when sleeping => increased arousal
What cardiac abnormalities do insomnia patients often have?
Elevated heat rate and blood pressure at sleep onset.
- Sympathetic activation
What differences are seen in EEG with insomnia patients?
Increases EEG activity
What are the symptoms of core dysregulation in insomnia?
- HPA axis activation
- Sympathetic activation
- Functional neuroanatomic changes
- EEG arousal
- Cognitive arousal
- Mood disturbances
What psychiatric issues should be considered in patients who have difficulty falling asleep (DFA)?
- Anxiety/depression/Delayed Sleep Phase/conditioned arousal
What should be considered when a patient complains of sustained mid cycle awakening (MCA)?
- Conditioned arousal/depression/ anxiety
What should be considered when a patient complains of BRIEF/repetitive mid cycle awakening (MCA)?
- Not consistent with chronic insomnia
- Physiologic events/other
- i.e. sleep apnea
What should be considered when a patient complains of early morning awakening (EMA)?
- Depression / Advanced Sleep Phase / conditioned arousal
What other nocturnal symptoms are associated with insomnia?
- Respiratory (snoring/apean)
- Motor
- Behavior disturbance
- Nocturnal panic
- Nightmare
- Headache
- Gastroesophageal reflux
- Pain
- Nocturia
- Night sweats
- Other parsommnia
What is the clinical assessment for insomnia?
- Medical/neurologica; assessment
- Pulmonary/endocrine/ neurologicalENT
- Psychiatric evaluation
- Depression/anxiety disorder/substance
- Sleep study only when physiological sleep disorder is suspected
What are the characteristics of short term insomnia?
- Related to actue stressor
- Usually self limited
- May become chronic if complicated by conditioned arousal
- Treatment focused on prevention of complications
- sleep hygiene
- Hypnotics aare indicated
0 follow up
What psychiatric disorders are related to chronic insomnia?
Mood disorder Major depressive disorder Anxiety disorder Generalized (versus psychophysiogic insomnia) Panic disorder (nocturnal) PTSD (nightmares) Personality disorder Psychosis
What substances may affect sleep?
- Caffeine
- Steroids
- Other Methylxanthines (bronchodilators)
- Prescription meds (ie antidepressants)
- Alcohol (Short-half-life / MCA and 2d-half fragmentation)
- Nicotine
- Withdrawal from sleep meds (rebound insomnia)
What factors can affect circadian rhythm?
- Jet lag (especially west-east difficulty falling asleep)
- Delayed sleep phase (difficulty initiating sleep and awakening at conventional times)
- Advanced sleep phase (evening sleepiness and early morning arousal)
- Shift work
- Irregular sleep wake rhythm (disabled/shut-ins)
What neurological disorders affect sleep?
- Neuroanatomical/physiological insult (neurodegenerative/TBI)
- Pain
- Breathing disturbance (CPOD)
- GERD
- Parkinson’s
- Endocrine/metabolic disorder
- Anxiety/depression
What criteria are necessary to consider sleep apnea?
Snoring AND Observed apnea OR Excessive sleepiness OR Cardio-vascular disease * If two of these are present => do a sleep study
