Insomnia

Question 1

Define insomnia.

Answer 1

A complaint of difficulty initiating or maintaining sleep/ early awakening / non-restorative sleep

• Daytime consequences
• Sleep difficulty occurs despite adequate opportunity and circumstances for sleep

Question 2

What are daytime consequences associated with insomnia?

Answer 2

• Fatigue or malaise
• Attention, concentration, or memory impairment
• Social or vocational dysfunction or poor school performance
• Mood disturbance of irritability
• Daytime sleepiness
• Motivation, energy, or initiative reduction
• Proneness for errors/actions while at work or driving
• Tension, headaches, or GI symptoms in response to sleep loss
• Concerns or worries about sleep

Question 3

Which populations have increased prevalence of insomnia?

Answer 3

• women
• older persons
• those with medical or psychiatric conditions

Question 4

What is insomnia a risk factor for?

Answer 4

Insomnia can increase the risk of other psychiatric conditions

• depression
• anxiety
• alcohol dependence
• drug dependence

Question 5

Insomnia is linked to which other medical condition?

Answer 5

Individuals with insomnia tend to have increased sympathetic tone
- Increased HTN and cardiovascular disease

Question 6

What are the criteria for chronic insomnia disorder?

Answer 6

• Symptoms occur > 3 times/week

- Symptoms occur for >3 months

Question 7

What is the criteria for short term insomnia disorder?

Answer 7

• Symptoms present for <3 months

Question 8

What are the characteristics of insomnia?

Answer 8

• Fatigue/sleepiness
• Overestimation of symptoms (psychophysiologic disturbance)
• Elevated anxiety, depression, anger, or psychological profile

Question 9

What cortisol abnormality do insomnia patients often have?

Answer 9

Lack of cortisol drop when sleeping => increased arousal

Question 10

What cardiac abnormalities do insomnia patients often have?

Answer 10

Elevated heat rate and blood pressure at sleep onset.

- Sympathetic activation

Question 11

What differences are seen in EEG with insomnia patients?

Answer 11

Increases EEG activity

Question 12

What are the symptoms of core dysregulation in insomnia?

Answer 12

• HPA axis activation
• Sympathetic activation
• Functional neuroanatomic changes
• EEG arousal
• Cognitive arousal
• Mood disturbances

Question 13

What psychiatric issues should be considered in patients who have difficulty falling asleep (DFA)?

Answer 13

• Anxiety/depression/Delayed Sleep Phase/conditioned arousal

Question 14

What should be considered when a patient complains of sustained mid cycle awakening (MCA)?

Answer 14

• Conditioned arousal/depression/ anxiety

Question 15

What should be considered when a patient complains of BRIEF/repetitive mid cycle awakening (MCA)?

Answer 15

• Not consistent with chronic insomnia
• Physiologic events/other
  
  • i.e. sleep apnea

Question 16

What should be considered when a patient complains of early morning awakening (EMA)?

Answer 16

• Depression / Advanced Sleep Phase / conditioned arousal

Question 17

What other nocturnal symptoms are associated with insomnia?

Answer 17

• Respiratory (snoring/apean)
• Motor
• Behavior disturbance
• Nocturnal panic
• Nightmare
• Headache
• Gastroesophageal reflux
• Pain
• Nocturia
• Night sweats
• Other parsommnia

Question 18

What is the clinical assessment for insomnia?

Answer 18

• Medical/neurologica; assessment
  
  • Pulmonary/endocrine/ neurologicalENT
• Psychiatric evaluation
  
  • Depression/anxiety disorder/substance
• Sleep study only when physiological sleep disorder is suspected

Question 19

What are the characteristics of short term insomnia?

Answer 19

• Related to actue stressor
• Usually self limited
• May become chronic if complicated by conditioned arousal
• Treatment focused on prevention of complications
  
  • sleep hygiene
• Hypnotics aare indicated
  0 follow up

Question 20

What psychiatric disorders are related to chronic insomnia?

Answer 20

Mood disorder 
	Major depressive disorder 
Anxiety disorder 
	Generalized (versus psychophysiogic insomnia)
	Panic disorder (nocturnal)
	PTSD (nightmares)
Personality disorder
Psychosis

Question 21

What substances may affect sleep?

Answer 21

• Caffeine
• Steroids
• Other Methylxanthines (bronchodilators)
• Prescription meds (ie antidepressants)
• Alcohol (Short-half-life / MCA and 2d-half fragmentation)
• Nicotine
• Withdrawal from sleep meds (rebound insomnia)

Question 22

What factors can affect circadian rhythm?

Answer 22

• Jet lag (especially west-east difficulty falling asleep)
• Delayed sleep phase (difficulty initiating sleep and awakening at conventional times)
• Advanced sleep phase (evening sleepiness and early morning arousal)
• Shift work
• Irregular sleep wake rhythm (disabled/shut-ins)

Question 23

What neurological disorders affect sleep?

Answer 23

• Neuroanatomical/physiological insult (neurodegenerative/TBI)
• Pain
• Breathing disturbance (CPOD)
• GERD
• Parkinson’s
• Endocrine/metabolic disorder
• Anxiety/depression

Question 24

What criteria are necessary to consider sleep apnea?

Answer 24

Snoring AND
	Observed apnea OR
	Excessive sleepiness OR
	Cardio-vascular disease
* If two of these are present => do a  sleep study

Question 25

What are the symptoms of restless leg syndrome?

Answer 25

- Desire (compulsion) to move the limbs usually associated with paresthesias/dysesthesias => patients are aware - Motor restlessness - Symptoms are worse or exclusively present at rest (i.e. lying, sitting) with at least partial and temporary relief by activity - Symptoms are worse in evening/night * May often have periodic limb movement disorder

Question 26

What are the symptoms of periodic limb movement disorder?

Answer 26

- Clinical features of interrupted, light sleep and/or daytime sleepiness => Patients are unaware - Polysomnographic monitoring demonstrates: - Repetitive episodes of muscle contraction (0.5 to 5 seconds in duration) with typical periodicity of 20 to 40 seconds - Arousal or awakenings may be associated with the movements

Question 27

What are causes of restless leg syndrome?

Answer 27

``` Familial / sporadic Neuropathy/Radiculopathy/Myelopathy Fe deficiency End-stage renal disease Rheumatoid arthritis Substances ```

Question 28

What drugs are used to treat restless leg syndrome?

Answer 28

- Dopamimetic agents - Agonists – Ropinirole/Pramipexole - Carbidopa-Levodopa - Benzodiazepines - Clonazepam - Opioids - Anticonvulsants - Neurontin - Tegretol

Question 29

What are the challenges of drugs used for insomnia?

Answer 29

- Short term relief | - Effects may wane

Question 30

What is the best long term treatment for insomnia?

Answer 30

- CBT

Question 31

What drugs are used for insomnia?

Answer 31

- Benzodiazepines - Benzodiazepine receptor agonists - Imidazopyridines (Zolpidem/Ambien) - Cyclopyrrolones (Eszopiclone/Lunesta) - Pyrazolopyrimidines (Zaleplon/Sonata) - Melatonin agonists - Rameleteon/Rozerem - Histamine antagonist - Doxepin/Silenor - Sedating anti- depressants - TCAs - Trazodone - Mirtazapine

Question 32

What are the elements of CBT for insomnia?

Answer 32

- Cognitive distortions - Relaxation training - Biofeedback - Stimulus control - Sleep restriction

Question 33

What are the components of sleep restriction therapy?

Answer 33

- Restrict time in bed to actual sleep time - Increase time in by by 15 minutes for average sleep efficiency over one week - Decrease time in bed by 15 minutes for average sleep efficiency over one week - Continue weekly alteration as above - Maintain sleep hygiene

Question 34

How is CBT for insomnia delivered?

Answer 34

``` Individual therapy Group therapy Phone therapy Self-help bibliotherapy Internet-based ```