1. Diplomate: American Academy of Sleep Medicine
INSOMNIA
Liphard O. D’Souza, M.D.
Diplomate: American Academy of Sleep Medicine
6128 E. 38th St., Ste. 303
Tulsa, OK
(918)

2. Insomnia A broad term denoting unsatisfactory sleep
Perception that sleep is inadequate or abnormal
Common problem
A symptom, not a disease or sign, therefore difficult to measure

3. Diagnosis Complaint that the sleep is: Brief or inadequate
Light or easily disrupted
Non-refreshing or non-restorative

4. International Congress of Sleep Disorders Classification
Based on the duration of symptoms
Transient or acute
Few days to 2-4 weeks
Chronic
Persisting for more than 1-3 months

5. Definitions Mild Moderate Severe
Almost nightly complaint of non-restorative sleep
Associated with little or no impairment of social or occupational functioning
Moderate
Nightly complaints of disturbed sleep
Mild to moderate impairment of social or occupational function
Severe
Severe daytime dysfunction

6. Classification Sleep initiating insomnia Sleep maintaining insomnia
Early morning insomnia
Short period of sleep
Non-restorative sleep
Multiple awakenings
Combination of above patterns

7. Presentation Goals Review of normal sleep cycle Causes of insomnia
Diagnosis and assessment of insomnia
Treatment modalities

8. Stages of Sleep Non-Rapid Eye Movement (NREM) sleep
Stage I
Stage II
Stages I & II are light sleep
Stage III
Stage IV
Stages III & IV are deep sleep
Rapid Eye Movement (REM) sleep

9. Normal Sleep Pattern

10. Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.)
Why do we sleep?
Not clear, but has to do with regeneration (NREM) and brain development/memory (REM) – REM sleep is essential for the development of the mammalian brain
Stages III & IV are involved in synaptic “pruning and tuning”
Why do we get sleepy?
Circadian factors
Process S: linear increase in sleepiness
Process C: rhythmic fluctuations of the circadian alert system
Other factors: sleep duration, quality, time awake, etc.

11. Causes
Insomnia is a downstream symptom of an upstream problem, for example:
Medical
Psychological/ Psychiatric
Behavioral
Parasomnias
Drug-induced
Combination of factors in chronic insomnia

12. Normal Sleep Values
Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle
4-6 NREM/REM cycles per night
Sleep structure changes throughout life
Wakefulness after sleep
Less than 30 minutes
Sleep Onset Latency (SOL)
REM Sleep Latency
minutes

13. Epidemiology
Studies throughout the world show that it occurs everywhere
Depending on the area, study, etc., between 10-50% of the population are affected
Increases with age
Twice as common in females
Up to the age of 30, there is little difference between sexes
Beyond 30 years, it is more common in females
Beyond 70 years, females are affected twice as much as males

14. Etiology Symptom of numerous diverse etiologies
Usually due to more than one factor and each needs a separate evaluation
In all cases, one should strive to find the cause as it will dictate the proper treatment

15. 3 P’s of Acute Insomnia Predisposition Precipitation Perpetuation
Anxiety, depression, etc.
Precipitation
Sudden change in life
Perpetuation
Poor sleep hygiene
Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia
Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia

16. Acute Insomnia Resolves with the management of inciting factors
Adjustment sleep disorder
Acute stress such as momentous life events or unfamiliar sleep environments
PSG: increased SOL, increased awakenings and sleep fragmentation with poor sleep efficiency
More common in women and those with anxiety
Jet Lag
Symptoms last longer with eastbound travel
Remits spontaneously in 2-3 days
More common in the elderly

17. Chronic Insomnia Primary or Intrinsic Secondary or Extrinsic Causes
Changes in circadian rhythm, behavior, environment
Body movements in sleep
Medical, neurological, psychiatric disorders
Drugs

18. Primary/Intrinsic Insomnia
Idiopathic
Starts early in childhood, rare but relentless course
Rare disorders affect both genders
CNS abnormalities, unknown etiology, etc.
Sleep State Misinterpretation (5%)
Underestimate of the sleep obtained
Females affected more than males
Psychophysiological insomnia (30%)
Maladaptive sleep-preventing behaviors develop and progress to become dominant factors
Females more than males

19. Secondary/Extrinsic Insomnia
Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness
Advanced sleep phase syndrome
Delayed sleep phase syndrome
Irregular sleep/wake patterns
Non-24 hour sleep/wake syndrome
Shift work sleep disorder
Short sleeper

20. Environmental factors
Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep
Inadequate sleep
Limit setting sleep disorder
Nocturnal eating/drinking syndrome
Sleep onset association disorder
Environmental factors
Environmental sleep disorder
Food allergy insomnia
Toxin-induced sleep disorder

21. Medical Disorders: Respiratory
Movement disorders
PLMS disorder (5%)
RLS syndrome (12%)
REM behavior disorder
Medical Disorders: Respiratory
Altitude insomnia
Central alveolar hypoventilation syndrome
Central apnea syndrome
COPD
OSAS (4-6%)
Sleep-related asthma

22. Medical: Musculoskeletal
Medical: Cardiac
Nocturnal myocardial ischemia
Medical: GI
Peptic ulcer disease
GERD
Medical: Musculoskeletal
Fibromyalgia
Arthritis
Medical: Endocrine
Hyperthyroidism
Cushing’s disease
Menstrual cycle association
Pregnancy

23. Medical: Neurological
Cerebral degeneration disorder
Dementia
Fatal familial insomnia
Parkinson’s disease
Sleep related epilepsy
Sleep related headaches
Medical: Psychiatric
Alcoholism
Anxiety disorders
Mood disorders
Panic disorders
Psychosis
Drug dependency

24. Pharmacological causes
Alcohol dependent sleep disorder
Hypnotic dependent sleep disorder
Stimulus dependent sleep disorder
Medications
B-blockers
Theophylline
L-dopa

25. Parasomnia Events Physical phenomena occurring in sleep
Confusional arousals
Nightmares
Nocturnal leg cramps
Nocturnal paroxysmal dystonia
REM sleep behavior disorder
Rhythmic movement disorder
Painful erections
Sleep starts
Sleep terrors
Sleep walking
Abnormal swallowing
Hyperhidrosis
Laryngospasms

26. Physical, Emotional, and Cognitive Effects of Insomnia
Mood changes, irritability, poor concentration, memory defects, etc.
Impairs creative thinking, verbal processing, problem solving
Risk of errors, accidents due to excessive daytime sleepiness
Markedly increases if awake more than hours (micro-sleep attacks)
Increased appetite, decreased body temperature
Physiologic effects
Rats die after days of sleep deprivation
Hippocampal atrophy in chronic jet lag or shift work

27. Evaluation HISTORY! Sleep diary Precipitating factors
Psychiatric and medical disturbances
Medications
Sleep hygiene
Circadian tendencies
Cognitive distortions and conditional arousals
Sleep diary

28. Evaluation
PSG
if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM
Not routinely employed in the evaluation of transient or chronic insomnia
Should not be substituted for a careful clinical history

29. Epworth Sleepiness Scale
A good measure of excessive daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation:
0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance
Sitting and reading ____
Watching TV ____
Sitting inactive in a public place (ex. theater, meeting) ____
As a passenger in a car for an hour without a break ____
Lying down to rest in the afternoon ____
Sitting and talking to someone ____
In a car, while stopped for a few minutes in traffic ____
____ Total Score
Normal < Severe > 15

30. Insomnia questionnaire
I have real difficulty falling asleep.
Thoughts race through my mind and this prevents me from sleeping.
I wake during the night and can’t go back to sleep.
I wake up earlier in the morning than I would like to.
I’ll lie awake for half an hour or more before I fall asleep.
I anticipate a problem with sleep almost every night
If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.

31. Treatment Selection
Meet and educate about disease, goals, options, side effects, and document safety.
Identify the 3 P’s.
Intrinsic v. Extrinsic
Treat perpetuating causes
Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT

32. CBT
Longest lasting improvements, assuming the precipitating cause is dealt with
“counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances
Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones

33. CBT Examples “I need more hours of sleep or I will not function”
“I can never die”
Uses restructuring techniques
Short circuit cycle of insomnia, cognitive distortions, distress
Sleep hygiene, relaxation, stimulus control, sleep restrictions

34. Sleep Hygiene
Exercise earlier during the day, and no more than 4-6 hours before sleep
Keep bedroom dark and quiet, to be used only for sex or sleep
Curtail time in bed to only when sleepy
Fixed sleep/wake times for 365 days
Avoid naps
Avoid stimulus or stimulating activities before sleep or in bed
No alcohol at least 4 hours before sleep, no caffeine after noon, and quit smoking!!
Light snack before bedtime

35. Stimulus Control Use bedroom for sleep or sex only
Go to bed only when tired and sleepy
Remove clock from the bedroom to avoid constantly watching it
Regular sleep/wake times
Light therapy if required
No bright lights when you wake up at night

36. Sleep Restriction An effective form of treatment
Estimate the time actually asleep then limit bedtime to that amount, but no less than 5 hours
Add time in bed gradually once the patient sleeps more than 85% of that time

37. Pharmacotherapy
Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics
Trazadone
Seroquel
Self-medication with alcohol and over-the-counter medications
Benadryl
Nyquil

38. Hypnotics 5 questions to ask when choosing a hypnotic:
Are you looking for sleep initiation or maintenance?
What are the daytime residual effects of the drug?
Does tolerance develop to this drug?
Will rebound withdrawal insomnia occur when discontinued?
What is the half-life of the medication?

39. Benzodiazepines Dose Half-life Comments Flurazepam(Dalmane) 15,30 mg
Dose
Half-life
Comments
Flurazepam(Dalmane)
15,30 mg
Long
Daytime drowsiness common; rarely used
Clonazepam(Klonopin)
0.5-2 mg
Used for PLM, REM behavior disorder; can cause morning drowsiness
Temazepam (Restoril)
Intermediate
Estazolam (ProSom)
1-2 mg
Can cause agranulocytosis
Triazolam (Halcion)
0.125,0.25 mg
Short
Rebound insomnia may occur
Zolpidem (Ambien)
5,10 mg
A nonbenzodiazepam
Zopliclone (Sonata)
Short , hours
A nonbenzodiazepam

40. Recent Medication Additions
Eszopiclone 1,2,3 mg Intermediate
Approved for chronic insomnia
(Lunesta) Action 6-8 hrs.
Zolpidem 10 mg Action same as above
(Amvien CR)
Rozerem
(Ramelton)

41. Alternative Medications
Antidepressants
Not much research
Some, including SSRIs, can cause daytime drowsiness
Melatonin
Good for jet leg, especially in elderly, but not much information on long-term use
Reported to cause depression, vasoconstriction
Benadryl
Rarely indicated, can cause a hangover
Herbal supplements
Use in conjunction with a sleep log

42. Conclusion
Insomnia is a complex symptom with many causes and perpetuating influences
It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated
It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder
Depression in turn confers an increased risk of suicide, cardiovascular disease, death, etc.