Insomnia

Question 1

most people how much sleep per night?

Answer 1

8 hours

Question 2

how much population does insomnia affect?

Answer 2

at least 30%

Question 3

insomnia is classified as a

Answer 3

dyssomnia

Question 4

what is dyssomnia?

Answer 4

sleep disorder characterized by problems in timing, quality, or amount of sleep

Question 5

what is parasomnia?

Answer 5

sleep disorder characterized by abnormalities in physiology or behavior associated with sleep

Question 6

based on DSM5, insomnia is associated with at least one of the following symptoms:

Answer 6

1. difficulty initiating sleep
2. difficulty maintaining sleep
3. early-morning awakening with inability to return to sleep

Question 7

sleep disturbance causes distress or impairment in

Answer 7

social, occupational, educational, academic, behavioral, or other important areas of functioning

Question 8

disturbance occurs at least

Answer 8

3 nights per week and is present for at least 3 months

Question 9

disturbance is NOT attributable to the

Answer 9

1. physiologic effects of a substance or

2. a coexisting medical or mental disorder

Question 10

women report insomnia

Answer 10

50% more often than men

Question 11

what are the 2 major endogenous etiology for insomnia?

Answer 11

1. excitatory neurotransmitters in excess at night

2. inhibitory neurotransmitter deficiency at night

Question 12

what are the 4 causes of excitatory neurotransmitters in excess at night?

Answer 12

1. norepinephrine from the locus ceruleus
2. serotonin from the raphe nucleus
3. dopamine from the ventral tegmental area
4. histamine from the tuberomammillary nucleus

Question 13

what are the 3 causes of inhibitory neurotransmitter deficiency at night

Answer 13

1. loss of GABA tone
2. loss of melatonergic tone
3. loss of adenosinergic tone

Question 14

what are the psychiatric causes for insomnia?

Answer 14

1. major depressive disorder
2. bipolar disorder
3. generalized anxiety disorder/PTSD

Question 15

Insomnia is classified as a

Answer 15

dyssomnia

Question 16

Dyssomnia =

Answer 16

sleep disorder characterized by problems in

1. timing,
2. quality, or
3. amount of sleep

Question 17

Parasomnia =

Answer 17

sleep disorder characterized by abnormalities in physiology or behavior associated with sleep

Question 18

what is insomnia?

Answer 18

Complaint of dissatisfaction with sleep quantity or quality, associated with at least one of the following symptoms:

1. Difficulty initiating sleep
2. Difficulty maintaining sleep
3. Early-morning awakening with inability to return to sleep

Question 19

to be considered as insomnia

Answer 19

1. Disturbance occurs at least 3 nights per week and is present for at least 3 months
2. Disturbance is not attributable to the physiologic effects of a substance or a coexisting medical or mental disorder

Question 20

summary of the insomnia?

Answer 20

1. Diagnosis of insomnia requires that sleep disturbance causes distress or impairment in functioning
2. Always address underlying medical, psychiatric or environmental causes of insomnia and treat those 1st
3. Always address substance use or withdrawal that may be causing insomnia –> avoid caffeine and alcohol
4. Begin with patient education, behavioral hygiene or counseling focusing or document why you skipped this step
5. Consider OTC and Rx agents when needed

Question 21

Antagonizing 5HT2a creates

Answer 21

deeper sleep patterns

Question 22

Antagonizing 5HT1d and 7 promotes a more accurate

Answer 22

circadian clock

Question 23

When patients are depressed or even anxious, one can often choose

Answer 23

an antidepressant or antipsychotic with these properties (instead of the more standard SSRI, SNRI, NDRI antidepressants that often have insomnia as a key side effect)

Question 24

A bonus would be if the antidepressant also antagonizes

Answer 24

the histamine-1 (H1) receptor which decreases arousal and produces sedation for sleep initiation…

Question 25

Anxiety symptoms that can lead to insomnia

Answer 25

1. Getting caught up in thoughts about past events 2. Excessive worrying about future events 3. Feeling overwhelmed by responsibilities

Question 26

After many nights of insomnia, some may experience anxiety about the possibility of not being able to sleep

Answer 26

1. Worrying about how many hours of sleep one can get 2. Concern about next day functioning if sleep is not attained 3. Anxiety about sleep may cause insomnia and insomnia may cause anxiety about sleep… 4. Essentially, at night patients get their brain into a more wakeful, vigilant state. This is conditioned that a stimulus and response relationship exists ie. I get in bed, therefore I am wide awake and worried about failing to sleep yet again

Question 27

what are the 3 psychiatric causes of insomnia?

Answer 27

Psychiatric causes are common: 1. Major depressive disorder - Short sleep latency, repeated nighttime awakenings, waking too early in the morning 2. Bipolar disorder - Manic and hypomanic patients have problems falling asleep and maintaining sleep 3. Generalized anxiety disorder/PTSD - Trouble falling asleep/nightmares

Question 28

hardcore of insomnia def

Answer 28

1. difficulty initiating sleep 2. difficulty maintaining sleep 3. early morning awakening with inability to return to sleep

Question 29

sleep disturbance causes

Answer 29

distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning

Question 30

to be qualiified as insomnia, it can't be

Answer 30

Disturbance is not attributable to the physiologic effects of a substance or a coexisting medical or mental disorder

Question 31

Excitatory neurotransmitters in excess at night

Answer 31

1. Norepinephrine from the locus ceruleus 2. Serotonin from the raphe nucleus 3. Dopamine from the ventral tegmental area 4. Histamine from the tuberomammillary nucleus (--> histamine wakes you up!)

Question 32

you can get insomnia if Inhibitory neurotransmitter deficiency at night

Answer 32

1. Loss GABA tone 2. Loss of melatonergic tone 3. Loss of adenosinergic tone

Question 33

3 exogenous causes for insomnia

Answer 33

1. use of CNS stimulants --> caffeine 2. withdrawal from sedative drugs 3. Medical conditions

Question 34

what is the 1st step for insomnia treatment?

Answer 34

1st Step and Initial management strategy is 1. diagnosis, 2. informed consent and 3. education

Question 35

what is the 2nd step for insomnia treatment?

Answer 35

1. Behavioral counseling | 2. Sleep hygiene/Stimulus control

Question 36

to manage the insomnia

Answer 36

1. Sleep restriction therapy 2. Cognitive therapy - Talking through - Imagery 3. Behavioral therapy - Diary/Log book (wake/bed time, #hrs asleep, abnormal events at night, next day consequences) - Progressive relaxation - Self hypnosis

Question 37

Behavioral therapy

Answer 37

- Diary/Log book (wake/bed time, #hrs asleep, abnormal events at night, next day consequences) - Progressive relaxation - Self hypnosis

Question 38

Rx agents/non-habit forming | Antihistamines

Answer 38

doxepin

Question 39

Melatonin1+2 agonists

Answer 39

ramelteon | tasimelteon

Question 40

Rx agents/mild-habit forming | Benzodiazepine Receptor Agonists (BZRA)

Answer 40

zolpidem zaleplon ezopiclone

Question 41

Orexin 1+2 antagonists

Answer 41

suvorexant

Question 42

2nd step of management in insomnia is

Answer 42

behavioral counseling that includes sleep hygiene/stimulus control

Question 43

what are cognitive therapy for insomnia?

Answer 43

1. talking through | 2. imagery

Question 44

what are the components for behavioral therapy?

Answer 44

1. diary/log book (wake/bed time, # hrs asleep) 2. progressive relaxation 3. self hypnosis

Question 45

You have to also decide if the are medically compromised

Answer 45

Apnea patients do not get sedatives | Patients with restless legs get D2 agonists