Insomnia

Question 1

what is the difference between dyssomnia and parasomnia? which one is insomnia classified as?

Answer 1

dyssomnia - sleep disorder characterized by problems in timing, quality, or amount of sleep
parasomnia - sleep disorder characterized by abnormalities in physiology or behavior associated with sleep
insomnia is classified as dyssomnia

Question 2

what is the DSM5 definition of insomnia? what is the time course?

Answer 2

complaint of dissatisfaction with sleep quantity or quality associated with at least one of the following symptoms

• difficulty initiating sleep
• difficulty maintaining sleep
• early morning awakening with inability to return to sleep

sleep disturbance causes distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
-disturbance occurs at least 3 nights per week and is present for at least 3 months

Question 3

what is insomnia NOT?

Answer 3

disturbance is not attributable to physiologic effects of a substance, or coexisting medical or mental disorder

Question 4

epidemiology of insomnia?

Answer 4

1/3 of adults report insomnia symptoms

• prevalence increases with age (esp. >60 yo)
• women report 50% more than men

Question 5

what are endogenous reasons for insomnia

Answer 5

1. excitatory neurotransmitters in excess at night
   - NE from locus ceruleus
   - serotonin from raphe nucleus
   - dopamine from ventral tegmental area
   - histamine from tuberomammillary nucleus
2. inhibitory neurotransmitter deficiency at night
   - loss of GABA tone
   - loss of melatonergic tone
   - loss of adenosinergic tone

Question 6

what are exogenous causes of insomnia?

Answer 6

physical causes

1. use of CNS stimulants (caffeine)
2. withdrawal of sedating agents (alcohol, barbiturates, benzodiazepines)
3. medical conditions (chronic pain, pulmonary disease, endocrine disorders)

Question 7

what are causes for insomnia secondary to mental disorders?

Answer 7

psychiatric causes are common

1. major depressive disorder (short sleep latency, repeated nighttime awakenings, waking up 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 8

what are effects of insomnia?

Answer 8

1. decreased quality of life
2. complaints of impaired daytime performance and more accidents, absenteeism, presenteeism
3. self-medication and risk of substance abuse occurs
4. association between insomnia and psychiatric disorders (major depression, alcoholism)

Question 9

what are the first through fourth steps in management of insomnia?

Answer 9

1. diagnosis, informed consent, and education
2. behavioral counseling (sleep hygiene, stimulus control)
3. sleep restriction, cognitive, or behavioral therapy
4. pharmacotherapy

Question 10

what step is psychotherapy in insomnia treatment?

Answer 10

third (after diagnosis/education and behavioral counseling)

-includes diary/log book, progressive relaxation, self-hypnosis

Question 11

what is the step-wise approach for pharmacotherapy? what are the treatments within each level?

Answer 11

1. OTC agents (melatonin, antihistamines)
2. Rx agents that are non-habit forming
   - antihistamines (doxepin)
   - melatonin 1/2 agonists (ramelteon, tasimelteon)
3. Rx agents that are mildly habit-forming
   - Benzodiazepines
   - Receptor Agonists (zolpidem, zaleplon, ezopiclone)
   - Orexin 1/2 antagonists (suvorexant)
4. Rx agents that are habit forming
   - Benzodiazepines (triazolam, temazepam, flurazepam)
5. Off label options
   - Trazodone is sedating antidepressant
   - Quetiapine is sedating antipsychotic