Insomnia Flashcards
perpetuating factors
mental arousal in bed (intrusive thoughts)
negative expectations
heightened somatic tension in bed
complaint more fixed over time
cognitions; cognitive distortions and catastrophization
insomnia is associated with
psychiatric disorders- major depressive disorder
certain substances
medical/neurological disorders
cognitive distortions
things you believe about your sleep
“chemical imbalance” “i should stay in bed even if i cant sleep”
catastrophization
worrying about what a poor night of sleep will mean for the rest of the day
daytime consequences
only one required to make diagnosis
4 nature of complaints
difficulty falling asleep
mid cycle awakening sustained
mid cycle awakening brief/repetitive
early morning awakening
difficulty falling asleep
anxiety, depression, delayed sleep phase, conditional arousal
mid cycle awakening
conditioned arousal, depression, anxiety
MCA (brief/repetitive)
phyisological event/other-Obstructive sleep apnea or other underlying medical sisue
early motnign awakening
depression
advanced sleep phase
cnditioned arousal
sleep logs
if person has ocd or anxiety- bad
epworth sleepiness scale
rate the likelihood of dosing off in following circumstances..
polysomnography
not indicated for routine evaluation of insomnia
Chronic Insomnia Disorder
> 3x/week, >3x/month
short-term insomnia disorder
symptoms present for <3 months
arousal and affective disturbance in insomnia
HPA axis: cortisol in insomnia patients higher during early sleep period- lacking cortisol drop
symp elevated HR and BP at sleep onset
medication beliefs
provide effect short-term relief for many with insomnia; improvements typically wane with discontinuation of medication
FDA approved hypnotics
benzos
BzRAs- benzo receptor agonists- Imidazopyridines, cycopyrrolones, pyrazolopyrmidines
melatonin agonists
histamine agonists
sedating anti-depressants
tricyclic antideprssants- amitriptyline
trazodone
mirtazpaine
most effective long term management
CBT
important in CBT
cogntiive distrotions, relaxation training, biofeedback, stimulus control, slepe rstriction (restrict time in bed to actual sleep time)
for average sleep efficiency greater than 85%
increase TIB by 15 minutes
for average sleep efficiency over one week less than 85%
decrease TIB by 15 mins
short term insomnia may be complicated by
conditioned arousal
treatment focused on short term insomnia
sleep hygiene! get out of bed
hypnotics as indicated
restless leg vs perioic limb mobement
bed partner telling story in periodic limb movement
clinical features of interrupted, light sleep and/or daytime sleepiness
etiology of periodic limb movement disorder
familial neuropathy/radiculopathy/myelopathy Fe deficiency end-stage renal RA substances (caffeine, alch)
PLMS polysomnograph
repeptive episodes of muscle contraction
treatment PLMS
dopamine agents - ropnirole, carbidopa
benzos
opioids
anticonvulsants
parasomnias tessted for by
multiple sleep latency test
4-5 nap opportunites at 2 hr intervals
narcolepsy
disorder of sleep-wake regulation involving inappropriate manigestations of REM sleep
etiology narcolepsy
destruction of orexin neurons in hypothalamus– maybe via HLA (inconclusive)
CSF-orexin
significantly reduced in patients with narcolepsy and cataplexy
cataplexy
inappropriate intrusion of REM atonia into waking
sleep-onset REM
sleep paralysis
in catalplexy, you typically maintain
consciousness
15% with full Nercoleptic tetrade
excessive sleepiness/sleep attacks cataplexy sleep paralysius hypnagogic/hypnapompic- really clear hallucinations with intruder disturbed nocturnal sleep
treatment narcolepsy
sleepiness- stimulations- amphetamine, metylphenidate, modonifil, gamahydroxybutryate, planned naps
cataplexy-rem suppressant (tricycle/ssri/snri), GHB
psychosocial support-education
idiopathic hypersomnia
excessive sleepiness daily for > 3 months (MSLT will show a mean latency <8 mins)
insufficient sleep ruled out
supportive features- long nocturnal sleep, sleep drunkeness, long unrefreshing naps, possible autnomic disturbance
parasomnias
abnormal events or behaviors whcih arise from sleep or sleep-wake transition
types of parasomnias
nREM
REM -rem behavior disorder, nightmares, sleep paralysis
nREM-disorder of arousal
sleep walking, night terrors, confusional arousals
patho of nREM
arise from stage 3/4 sleep
high amplitude delta waves
first third of the night (when we get most of our N3 sleep)
amnesia/partial recall
treatment nREM
gently guide back to bed remove dangerous items benzos psychogical treatment stop ambien if ambien started it!
REM behavior disorder
dream enactment associated with loss of muscle atonia in REM sleep
predom male
45-50% with neuropath but others are idiopathic
REM behavior associated neuropathy
synucleopathies
parkinsons
dementia with lewy bodies
multisystem atrophy
treatment of REM behavior disorder
neuro eval
pharm treatments-clonazepam
safety
