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Sarah Wills

on 31 October 2013

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Transcript of insomnia

...my mind is racing
...can't fall asleep
...i wake up in the middle of the night
... can't stay asleep
...i just want something to turn my mind off
...feels like I never went to bed
International Classification of Sleep Disorders (ICSD-2), American Academy of Sleep Medicine, 2005
"the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and results in some form of daytime impairment"
3. At least one of the following forms of daytime impairment related to the nighttime sleep difficulty reported by the patient:
fatigue or malaise;
attention, concentration or memory impairment;
social /vocational dysfunction or poor school performance;
mood disturbance or irritability;
daytime sleepiness;
motivation, energy or initiative reduction;
proneness for errors or accidents at work or while driving;
tension, headaches, or GI symptoms in response to sleep loss;
concerns or worries about sleep
the patients say:
the technical way:
diagnostic criteria
International Classification of Sleep Disorders (ICSD-2), American Academy of Sleep Medicine, 2005
1. A complaint of difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or sleep that is nonrestorative or poor in quality
2. The above sleep difficulty occurs despite adequate opportunity and circumstances for sleep
depression + insomnia
sleep hygiene
lasts less than one week
lasts one to four weeks
lasts more than a month
thank you!
8. circadian rhythm disorders:
5. restless leg syndrome
2. sleep-disordered breathing/obstructive sleep apnea
6. periodic limb movement disorder
= DSM 5 "insomnia disorder"
is insomnia as a diagnosis in and of itself. Has uncertain pathophysiology, but generally thought to result from a state of hyperarousal.
includes: idiopathic insomnia, psychophysiological insomnia, behavioral insomnia, paradoxical insomnia
is not in the DSM 5
is insomnia relating to another condition; it is much more common than primary insomnia.
-medical: restless leg syndrome,
chronic pain
, nocturnal cough syndrome, dyspnea, hot flashes, heart failure
-psychiatric: esp. anxiety and depression
-psychosocial: any adjustments/changes
-substance abuse
-inadequate sleep hygiene
-jet lag
-changed sleep schedule due to work, social responsibilities or an illness.
-delayed and advanced sleep-phase syndrome
-irregular sleep/wake cycle
3. heart failure (cheyne-stokes)
7. high altitude periodic breathing
4. medication- related
Central nervous system stimulants (dextroamphetamine, methylphenidate)
Antihypertensives (alpha blockers, beta blockers)
Respiratory medications (albuterol, theophylline)
Decongestants (phenylephrine, pseudoephedrine)
Hormones (corticosteroids, thyroid medications)
Antiepileptic drugs (lamotrigine)
Other noncontrolled substances (caffeine, alcohol, nicotine)
1. now anything that was in the "secondary" insomnia category
- One study found that

of adults develop symptoms of insomnia, while

develop chronic insomnia;
of patients discussed their difficulty sleeping with thier PCP during visit made more another complaint.
made insomnia their primary complaint.
-in the elderly,
had complaint of insomnia (only
reported "normal" sleep)
-higher prevalence of insomnia in women, elderly, people with a medical or psychiatric disorder, among those who are unemployed, widowed, separated or divorced, lower SES/educational status
1. Maintain a regular sleep and wake pattern; avoid napping.
2. Establish a relaxing routine to help you wind down before bed (read, warm bath, light snack, relaxation techniques, NO TV)
3. Use the bed only for sleep and sex.
4. The sleep environment is comfortable and nondistracting (bedding, noise, lighting)
5. Avoid caffeine, nicotine, alcohol, large amounts of food or outlandish food 4-6 hours before going to bed.
6. Regular exercise can help promote good sleep
7. If you do wake up in the middle of the night, and it takes longer than 15-30 minutes to fall asleep, leave bed and do a quiet activity until sleepy again.
1. start with keeping a sleep diary and education about sleep hygiene.
2. Comorbid medical and psychiatric conditions should be appropriately treated. Especially pain!
3. Nonpharmacologic interventions are superior to medications.
Sleep hygiene first! Try relaxation therapies.

Stimulus-control: disrupt the association between bed and anything other than sleep by increasing the likelihood of sleep.
Sleep-restriction therapy: restricts the amount of time in bed to consolidate sleep and improve sleep efficiency
Cognitive therapy: deal with worries and catastrophic thinking.

Cognitive behavioral therapy: a combination approach with lasting effects! There are cognitive behavioral therapies specifically for people with insomnia. (CBTI)
UpToDate: Treatment of Insomnia
-increase sleep time and improve sleep quality (reduce sleep-onset latency, awakenings, increased sleep efficiency)
-estazolam, triazolam, temazepam are preferred. They are rapid acting and have shorter half lives.
- quazepam, flurazepam have half lives longer than 24 hours
-SE: dependance/withdrawal, respiratory depression, daytime sleepiness, rebound insomnia, antegrade memory impairment
ZOLPIDEM (ambien)
-decreases sleep-onset latency and improves sleep quality
-no tolerance or rebound; abdominal pain

ZALEPLON (sonata)
-decreases sleep onset latency
-short half life (use again with nighttime awakenings up to four hours before determined wake time = better for sleep maintenance)
-change in color perception, less memory loss and psychomotor impairment

-Only hypnotic with FDA approval for more than 35 days
-decreases sleep-onset latency, awake time, number or awakenings per night and number of nights awakened per week. Improves total sleep time and quality of sleep.
-rare fatal overdoses when used with other CNS depressants
-unpleasant taste, amnesia, hallucinations, worsening depression

-reduces sleep onset latency and increases sleep periods.
-inconsistent improvement
-low likelihood of abuse and dependance
-suicidal ideation, somnolence, headache, fatigue, nausea, dizziness, increased prolactin levels.

sleep onset: try a short-acting (<8) to improve insomnia without residual morning effects. ZALEPLON, ZOLPIDEM, TRIAZOLAM, LORAZEPAM, RAMELTEON
sleep maintenance: try a longer acting, which may have hangover sedation. ZOLPIDEM ER, ESZOPICLONE, TEMAZEPAM,
Insomnia and depression run together - rx the insomnia too!!
Morawetz (2003)
Insomnia and Depression: Which Comes First?

70% of insomnia suffers who also had depression before treatment were no longer depressed/had a significant reduction in depression once their sleep had improved. People who did not learn to sleep better did not experience reduction in depression.

Taylor et al. (2007)
A Pilot Study of Cognitive-Behavioral Therapy of Insomnia in People with Mild Depression

With a 6 session CBTI intervention, 100% of participants had normalized sleep patterns, 87.5% had normalized depression scores. There were significant differences in pre and three-month post depression scores. CBTI ALONE EFFECTIVE IN AMELIORATING INSOMNIA AND DEPRESSION.
Maber et al. (2008)
Cognitive Behavioral Therapy for Insomnia Enhances Depression Outcomes in Patients with Comorbid Major Depressive Disorder and Insomnia

Treatment with escitalopram and CBTI vs. control had higher rates of MDD remission (61.5% vs 33.3%) and insomnia remission (50% vs. 7.7%).
can't remember
keep yawning
poor concentration
lack of energy
accident prone
Sleep complaints among elderly persons: an epidemiologic study of three communities.
AUFoley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG Sleep. 1995;18(6):425.

Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. Apr 2002;6(2):97-111.
UpToDate, Medscape
UpToDate, Medscape
1. Treat any medical/psychiatric illnesses or substance abuse that may be exacerbating the insomnia. Counsel about sleep hygiene and stimulus-control therapy.
3. Medication + CBTI for 6-8 weeks, than taper.
a. short-acting for sleep-onset
b. long-acting for sleep maintenance
4. Evaluation in a sleep study center before beginning a long-term medication
"But [Pooh] couldn't sleep. The more he tried to sleep the more he couldn't. He tried counting Sheep, which is sometimes a good way of getting to sleep, and, as that was no good, he tried counting Heffalumps. And that was worse. Because every Heffalump that he counted was making straight for a pot of Pooh's honey, and eating it all. For some minutes he lay there miserably, but when the five hundred and eighty-seventh Heffalump was licking its jaws, and saying to itself, 'Very good honey this, I don't know when I've tasted better,' Pooh could bear it no longer." (A.A. Milne)
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