Insomnia

Insomnia
The term insomnia is loosely used to refer to all complaints of inability to initiate or maintain sleep. Although this loose definition is close to true, there are several disorders that may be misdiagnosed as insomnia if a complete understanding of sleep medicine is not present but most importantly if a complete sleep history is not elicited.

INSOMNIA
» Adjustment insomnia
» Psychophysiologic insomnia
» Paradoxical insomnia
» Idiopathic insomnia
» Insomnia due to mental disorder
» Inadequate sleep hygiene
» Behavioral insomnia of childhood
» Insomnia due to drug or substance
» Insomnia due to medical condition
» Insomnia not due to substance or known physiologic condition, Unspecified (Nonorganic insomnia NOS)
» Physiological (Organic) Insomnia, Unspecified
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Adjustment insomnia (Adjustment sleep disorder):
This is typically seen in patients that develop insomnia following a significant event such as a death, divorce or major upheaval that disrupts their lives. There is usually a clear complaint of the symptom developing after the precipitating event.
Evaluation: Strong history taking is required. Identification of the precipitating event, and a review of sleep patterns required
Treatment: This involves a recognition of the precipitating event and making efforts to address it. That may include the use of psychotherapy or counseling in cases of grief or other major upheavals.
In cases of adjustment insomnia, it is considered more appropriate to use sedatives and hypnotics to help with sleep and to prevent long term or chronic insomnia.
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Psychophysiologic insomnia
This is a condition in which an individual is unable to initiate sleep easily. In this condition the patient dwells on things and issues that prevent the patient from being able to go to sleep. The patient develops bad routines and habits that are not supportive of sleep. Example is focusing on the next days work etc. it is also referred to as learned insomnia.
Not common between 6-12 years of age. Occurs in adolescence
The patient develops significant frustration around the sleep process and sleep may be perceived as an impossible task. In a situation in which the patient is very tired, the patient may go to bed and begin to perform sleep inappropriate functions as well as having an increased alertness. The sleep latency is prolonged, and the sleep may be fragmented with prolonged wake after sleep onset intervals.
Evaluation: History and physical examination, sleep logs, actigraphy

Treatment:
Education and reassurance. Improved sleep hygiene (Not sufficient as a standalone measure), cognitive-behavioral therapy, sedative/hypnotics in difficult cases.

Improved sleep hygiene: General guidelines about health and sleep practices including, diet, exercise, substance use and abuse, also environmental factors including, light, noise and temperature and any other factors that may disturb sleep.
Also general information about normal sleep

Cognitive –behavioral treatment:
Relaxation training (Validated): This involves the use of clinical procedures  aimed at reducing somatic tension

  • Progressive muscle relaxation
  • Biofeedback
  • Diaphragmatic breathing
  • Autogenic training. Also to reduce intrusive thoughts at bedtime
  • Imagery training, thought stopping
  • Meditation

Stimulus control (Validated)
This is considered the first line and most validated behavioral therapy for chronic insomnia. Designed to decondition presleep arousal and reassociate the bed/bedroom environment with rapid well consolidated sleep

Typical instructions include:
Maintain fixed wake time 7 days a week
Avoid any behavior in bed/bedroom outside of sleep and sexual activity
Sleep only in bedroom
Leave the bedroom when awake for approximately 15-20 minutes
Return only when sleepy.

Sleep restriction (Validated)
Limits patient time in bed to average total sleep time. Improves sleep quality by improving sleep
efficiency
Instructions:

  • Establish a fixed wake time
  • Limit subjects total time in bed to an amount that averages total sleep time
  • Increase sleep time by 15 minutes if sleep efficiency is greater than 90% and sleep latency is less than 15 minutes.

Cognitive therapy (Validated)
Psychologic methods aimed at challenging and changing misconceptions about sleep and faulty beliefs about insomnia and its perceived daytime consequences.

  • Cognitive therapy
  • Paradoxical intention

Paradoxical intention (Validated):
Medical management of insomnia
Non pharmacologic/natural/herbal aids

  • Valerian
  • Kava-kava
  • L-Tryptophan
  • Melatonin

Pharmacologic aids
OTC sleep aids

  • Antihistamines: Either alone or with analgesics. (Benadryl)
  • Melatonin

Pharmacologic aids
(FDA approved >16 yrs)

  • Benzodiazepine hypnotics
  • Non-benzodiazepine hypnotics
  • Selective melatonin receptor agonist

Pharmacologic aids
Off label sleep aids

  • Trazodone: Sedating antidepressant
  • Other antidepressants: Amitriptyline, doxepin and mirtazapine
  • Sedating antipsychotics: Quetiapine

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Paradoxical insomnia
This is a condition in which a patient relates a history of insufficient sleep that is incompatible with the patient. Also this is a condition where the perceived sleep time is less than the true sleep time in the patient.
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Idiopathic insomnia

This condition is also now as chronic insomnia of childhood and the symptoms typically start in childhood. The patient has a history of persistent difficulty with sleep initiation which has been present from childhood. is a condition in which a patient relates a history of insufficient sleep that is incompatible with the patient. Also this is a condition where the perceived sleep time is less than the true sleep time in the patient.
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Insomnia due to mental disorder

Inadequate sleep hygiene
This results from behaviors or practices that have a negative effect on sleep by reducing total sleep to a period less than that required by the patient for optimal sleep time.

Treatment:

Improved sleep hygiene: General guidelines about health and sleep practices including, diet, exercise, substance use and abuse, also environmental factors including, light, noise and temperature and any other factors that may disturb sleep.
Also general information about normal sleep
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Behavioral insomnia of childhood

Behavioral insomnia of childhood; Limit setting type:


ICSD CLASSIFICATION CRITERIA

  • The patient has difficulty in initiating sleep
  • The patient stalls or refuses to go to bed at an appropriate time
  • Once sleep period is initiated, sleep is of normal quality quantity and duration
  • Sleep study demonstrates normal timing, quality and duration of the sleep period
  • No significant underlyng mental or medical disorder to account for complaint
  • Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep

In this condition the patient typically a child resists going to bed. The child is typically put to bed and continuously finds reasons to leave the sleep environment in order to stay awake. There is also a strong component of lack of firm disciplinary controls on the part of the parents. Typically the parents do not enforce sleep time and when attempted the child will attempt to engage parents a variety of ways including making requests for things, tantrums, complaining of fears. Parents give in to child and habit becomes formed over time.

Evaluation: Strong history taking
Treatment: First educating the caregivers on the problem and their role in perpetuating it. Setting firm limits for activities that the child can engage in at or after bedtime. The use of bedtime pass cards. Reward and removal strategies for reinforcement of good sleep patterns.
Medication: Should not be considered in this condition
Behavioral insomnia of childhood; Sleep onset type:

ICSD CLASSIFICATION:

  • The patient has a complaint of insomnia
  • Complaint is temporally associated with the absence of certain conditions
  • The disorder is present for at least 3 weeks
  • With the particular association present, sleep is normal in onset, duration and quality
  • Sleep study demonstrates normal timing, duration and quality of sleep when association is present and prolonged sleep latency and frequency or duration of awakenings when association is absent
  • No significant underlyng mental or medical disorder to account for complaint
  • Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep

In this condition, the subject is unable to sleep or resists going to sleep unless a specific set of conditions are present at bed/sleep time. That condition may be a parent lying down beside the child till the child has fallen asleep. If the condition is not available at bedtime or when the patient wakes up, then the patient has extreme difficulty returning to sleep and typically stays awake. Behavior is usually set between 6 months and 3 years. Usually occurs at greater than 3 months as the patient enters a developmental stage characterized by greater attachment to parents, fear of strangers and realization of threatening circumstances.
Evaluation: Strong history taking
Treatment: Good sleep hygiene, breaking any bedtime patterns that you do not want to have to reenact after the patient has initiated sleep. Behavioral modification techniques including extinction (Graduated or total), scheduled awakenings, appropriate non pharmacologic sleep/relaxation aids
If these techniques are used, there is an expectation that crying spells may persist for 2-3 hours and place significant burden on parents resulting in shorter sleep duration and poor quality sleep in the child. With most patients the period of severe protestation is about a week with a significant decrease in protestation thereafter provided the routine has remained firm. Usually there may be a rebound in about 2 weeks. If parent stays firm this usually lasts 2-3 days.

Unmodified/total extinction: This involves parents putting the child to bed at a designated bedtime and then ignoring the child till morning. Parents may continue to monitor for issues related to safety and illness. Objective is to reduce undesired behaviors by eliminating parental attention as a reinforcer.

Graduated extinction: This involves parents ignoring bedtime crying and tantrums for pre-determined periods before briefly checking on the child. A progressive or fixed schedule is used to check on the child. Like unmodified extinction, the goal is for the child to develop self soothing techniques and be able to fall asleep independent of undesired sleep associations

Positive routines: With positive routines a set of enjoyable and quiet routines are established leading up to bedtime
Faded bedtime with response costs: With faded bedtime, the bedtime is temporarily delayed to more naturally coincide with the child’s natural sleep onset time and is then fading it earlier as the child begins to fall asleep rapidly. Response cost involves taking the child out of the bed for prescribed brief periods if sleep is not achieved

Scheduled awakenings: This involves parents preemptively awakening their child prior to typical spontaneous awakening, and then providing the usual response (feeding, rocking, soothing) as though the child had awakened spontaneously.

Parental education: Involves parent education to prevent the occurrence of the development of sleep problems. Behavioral interventions are incorporated into these parent education programs

Medication: Not typically required or recommended, though may be considered in cases when the parents/caregivers are going to use it as part of an active behavioral process.
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Insomnia due to drug or substance:
Several of the medications that are used today have the ability to cause insomnia because of their stimulant natures. In these cases, medication management in terms of timing of use of medication or altering the dose or type of medicine used may be necessary
Evaluation: History and physical examination. Review medication history
Treatment: Improve sleep hygiene, Adjust dose and timing of medication, Change medication. Start sedative hypnotics if necessary
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Insomnia due to medical condition

Insomnia not due to substance or known physiologic condition, Unspecified (Nonorganic insomnia NOS)


Physiological(Organic) Insomnia, Unspecified
· Other disorders that may mimic insomnia include circadian rhythm disorders such as delayed sleep phase syndrome, Non 24 hour sleep wake syndrome and irregular sleep-wake pattern.
· In general, a good history will help to differentiate the etiology of the complaint of insomnia and the correct definition of this diagnosis will allow for the implementation of an effective treatment plan.
· Every treatment plan should include
1. Reinforcement of sleep hygiene
2. Maintenance of sleep logs
3. Behavioral modification and the addition if necessary, of modalities such as stimulus control, sleep restriction, relaxation techniques, biofeedback
4. Close follow up
5. When necessary pharmacologic aids

If there is any question regarding the diagnosis and management of these conditions then refer the patient to a sleep disorders specialist for further evaluation and management.

** Pharmacologic management without emphasis on behavioral modification should be discouraged strongly**
Close follow up is important!!!