Sleep problems

Question 1

In a sleep history, what do you need to know about:

1) The presenting complaint? (12)
2) The usual daily routine? (3)
3) Family history?
4) daytime somnolence? (5)
5) the description of sleep? (4)

Answer 1

1) onset, duration, course, frequency, severity, effects on everyday life, pattern of symptoms, timing, fluctuations, exacerbating/ relieving factors, environmental factors, relevant current stressors.
2) waking (time, method), daily naps (when and duration), bedtime (preparations, time of going to bed/ falling asleep, activities in bed).
3) past and current Hx of medical and psychiatric problems.
4) General level of alertness during the day, when/ if sleep occurs during the day, effects on work/ social activities, periods of confusion, any episodes of collapse.
5) behaviour whilst asleep, dreams/ nightmares, episodes of wakening (and how they are dealt with), quality and satisfaction of sleep.

Question 2

1) Define insomnia.
2) What are individuals with insomnia preoccupied with?
3) What are the two types of insomnia?

Answer 2

1) Persistent problems (at least 3 days for a month) with falling asleep, maintaining sleep or poor quality sleep.
2) Individuals are preoccupied with their sleep problems, distressed by them and social or occupational functioning is affected.
3) Primary (caused by intrinsic and extrinsic factors) and secondary (due to medical or psychiatric illness, other sleep disorders or substance misuse).

Question 3

1) Describe the prevalence of insomnia.
2) Who is insomnia more common in?
3) What is clinically significant insomnia?
4) What is the prevalence of clinically significant insomnia?

Answer 3

1) Insomnia is a common complaint for about 30% of the general population.
2) More common in females than males and has a higher prevalence in the elderly.
3) Insomnia causing marked personal distress or interference with social and occupational functioning.
4) Present in about 9-12%.

Question 4

Name 9 causes of primary insomnia.

Answer 4

1) Psychophysiological insomnia.
2) Paradoxical insomnia.
3) Adjustment sleep disorder.
4) Inadequate sleep hygiene.
5) Idiopathic insomnia.
6) Behavioural insomnia of childhood.
7) Environmental sleep disorders.
8) Altitude insomnia.
9) Food allergy insomnia.

Question 5

Name 4 secondary or co-morbid causes of insomnia.

Answer 5

1) Sleep disorders classified elsewhere (sleep related breathing disorders, circadian rhythm disorders, sleep related movement disorders).
2) Insomnia due to a medical condition (pain, respiratory disorders, diabetes, Parkinson’s disease, endocrine disorders.
3) Insomnia due to a mental disorder.
4) Drugs and alcohol (antidepressants, anti-parkinsonian medication, bronchodilators, cardiovascular medication, chemotherapy agents, corticosteroids/ anabolic steroids, NSAIDs, stimulants).

Question 6

Name the 6 steps in the general management of insomnia.

Answer 6

1) Education about sleep.
2) Sleep hygiene (establishing good sleep habits)
3) Sleep hygiene (stimulus control)
4) Relaxation training
5) Sleep restriction
6) Medication

Question 7

Name 6 different classes of drugs that can be used for sleep.

Answer 7

1) BDZs
2) Z-drugs (usually first line)
3) Chloral hydrate
4) Sedating antidepressants
5) Sedating antipsychotics
6) Melatonin agonists

Question 8

What sleep abnormalities are usually seen in major affective disorders?

Answer 8

1) Initial insomnia
2) Frequent waking (often for prolonged periods)
3) Early morning waking
4) Vivid and disturbing dreams
5) Daytime fatigue

Question 9

Which 7 psychiatric disorders are commonly associated with abnormal sleep?

Answer 9

1) Major affective disorders
2) Anxiety disorders
3) Schizophrenia
4) Borderline PD
5) Eating disorders
6) Dementia
7) Alcohol use

Question 10

What symptoms of abnormal sleep are often associated with anxiety disorders?

Answer 10

Frequent waking, initial insomnia, reduced total sleep time and early morning waking.

Question 11

What sleep abnormalities do people with schizophrenia experience?

Answer 11

Increased nocturnal wakefulness and daytime somnolence.

Question 12

What might sleep problems in anorexia be due to?

Answer 12

Co-morbid depression.

Question 13

What disturbances to sleep does dementia cause?

Answer 13

reduction in sleep time, increases in sleep latency, increased fragmentation of normal sleep beyond that of the normal ageing process.

Question 14

How does alcohol exert its sedative effects?

Answer 14

Probably through a combination of GABA facilitation and glutamate inhibition.