Insomnia

Definition

Must meet all these criteria:

1. A complaint of difficulty initiating sleep, difficulty maintaining sleep, (hence, waking up

too early). In children: resistance to going to bed at the appropriate time. In individuals
with dementia: difficulty in sleeping without caregiver assistance.
2. The above sleep difficulty occurs despite adequate opportunity and circumstances for
sleep.

3. The impaired sleep produces deficits in daytime function

Types of Insomnia

Short-term: that is, less than 3 months.

Chronic insomnia: Symptoms occur at least 3 nights/week, for 3 months. And do not related to
other sleep disorder.

Other insomnia: Difficulty initiating and maintaining sleep that does not meet criteria for short-
term or chronic insomnia

Clinical features:

Insomniac patients describe difficulty falling asleep, staying asleep, or waking up too early.
Patients may also describe variability in sleeping, such as one or several nights of poor sleeping
followed by a night of better sleep. Insomnia should also include either a sleep latency or period
of wake. Sleep latency for children and young adults is 20 minute, while in adults is 30 minute.
The same rule also applies to period of wake. Early morning awakening of minimum 30 minutes
before desired time is also a clinical feature of insomnia.

Comorbidities
Insomnia commonly coexists with psychiatric or medical disorders, other sleep disorders, or use
of certain medications or substances. At times there is a clear temporal relationship between the
insomnia and the condition that is known to disrupt sleep, and a separate diagnosis of insomnia is
not given unless the insomnia is notable by severity or focus.

Psychiatric disorders: Depression, Anxiety, Substance Abuse, PTSD

Medical conditions: Pulmonary disease, Pain (e.g Arthritis, Cancer) , Heart failure
Medications: CNS Stimulants, MAOI antidepressants, SSRIs, Norepinephrine and Dopamine
Reuptake Inhibitor, Selective serotonin and norepinephrine reuptake inhibitors (e.g. venlafaxine),
Beta antagonists , Glucocorticoids (eg prednisone, and cortisol). Withdrawal of sedatives,
hypnotics and glucocrticoids can also produce insomnia.

Diagnosis

Requires sleep history. Sleep history can be obtained from a sleep log/diary.
Differential diagnosis

Insomnia is often confused with short duration sleep, circadian rhythm disorders, chronic sleep
restriction (insufficient sleep syndrome), and sleep-disruptive environmental circumstances.

Short duration sleep – Sleep for a short duration can be normal, as some individuals simply
require less sleep and can sleep fewer hours without daytime complaints. Short duration sleep is
distinguished from insomnia by the absence of daytime impairment.

Circadian rhythm disorders:

 Delayed sleep-wake phase disorder – Difficulty initiating sleep needs to be differentiated

from delayed sleep-wake phase disorder. Patients with sleep onset insomnia may have
trouble whenever attempting to fall asleep, while individuals with delayed sleep-wake
phase disorder fall asleep and sleep normally if they go to bed at the correct point in their
circadian rhythm.

 Advanced sleep-wake phase disorder – Patients with sleep maintenance insomnia or early
morning awakening associated with insomnia need to be differentiated from patients with
advanced sleep-wake phase disorder. Patients with sleep maintenance insomnia will have
sleep difficulty whenever they attempt to sleep while patients with advanced sleep-wake
phase disorder will sleep normally if they go to bed, and get up at an earlier clock time.

Chronic sleep restriction – Chronic sleep restriction and insomnia are both characterized by a
short duration of sleep and impaired daytime function; however, chronic sleep restriction is due
to volitional partial sleep loss or insufficient opportunity to sleep. Sleep restricted individuals
will rapidly fall asleep if given the opportunity, and this distinguishes them from patients with
insomnia, who typically feel fatigued during the day, but are unable to fall asleep if given a
chance to take a nap.

Sleep-disruptive environmental circumstances – Environmental factors such as noise, light, or

temperature can disturb sleep. Insomnia is diagnosed only when there are sleep difficulties in a
sleep-conducive environment. Poor sleep in a disruptive environment could be classified as other
sleep disorder.

Treatment

All patients with insomnia should receive therapy for any medical condition, psychiatric illness,
substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia. They
should also receive basic behavioral counseling about sleep hygiene and stimulus control
For patients who continue to have insomnia that is sufficiently burdensome to warrant other
interventions, reasonable approaches include behavioral therapy, medication, or both:

1. Behavioral therapies beyond sleep hygiene and stimulus control include relaxation, sleep
restriction therapy, cognitive therapy, and cognitive behavioral therapy.
2. Approved medications used to treat insomnia include benzodiazepines,
nonbenzodiazepine sedatives, melatonin agonists, and antidepressants.

3. Combination therapy involves initially prescribing both cognitive behavioral therapy and
a medication (usually for six to eight weeks), then tapering the medication off or to an as-
needed schedule while continuing cognitive behavioral therapy. The use of medication
prior to the initiation of behavioral therapy appears to be less effective

Behavioral Therapies

Stimulus control therapy: Patients with insomnia may associate their bed and bedroom with the
fear of not sleeping or other arousing events, rather than the more pleasurable anticipation of
sleep. Stimulus control therapy is a strategy whose purpose is to disrupt this association by
enhancing the likelihood of sleep.

Relaxation: Relaxation therapy may be implemented before each sleep period. There are two
common techniques for relaxation therapy: progressive muscle relaxation and the relaxation
response.

1. Progressive relaxation is based upon the theory that an individual can learn to relax one
muscle at a time until the entire body is relaxed. Beginning with the muscles in the face,
the muscles are contracted gently for one to two seconds and then relaxed. This is
 repeated several times. The same technique is used for other muscle groups, usually in
the following sequence: jaw and neck, upper arms, lower arms, fingers, chest, abdomen,
buttocks, thighs, calves, and feet. This cycle is repeated for approximately 45 minutes, if
necessary.
2. The relaxation response begins by lying or sitting comfortably. The eyes are closed and
relaxation is allowed to spread throughout the body. A relaxed, abdominal breathing
pattern is established. Thoughts are redirected away from everyday thoughts and toward a
neutral mental focusing device, such as a peaceful word or image

Sleep Restriction therapy: Some patients with insomnia stay in bed longer to try to make up for
lost sleep. This causes a circadian shift and a reduction in the homeostatic drive that makes sleep
onset the following night more difficult and results in the need to stay in bed even longer. Sleep
restriction therapy counteracts this tendency by limiting the total time allowed in bed, including
naps and other sleep periods outside of bed, in order to increase the drive to sleep.

Cognitive therapy: Patients who are awake at night commonly become concerned that they will
perform poorly the next day if they do not obtain adequate sleep. This worry can exacerbate their
difficulty falling asleep, creating a vicious cycle of wakefulness and concern. A person may
begin to blame all negative events in their life on poor sleep. During cognitive therapy, a person
works with a therapist to deal with anxiety and catastrophic thinking, while establishing realistic
expectations related to insomnia and the need for sleep

Cognitive behavioral therapy: CBT is a strategy that combines several of the previously
described approaches over several weeks. A sample 8-session CBT program may include an
introductory sleep education session, followed by two sessions that focus on stimulus control and
sleep restriction. These may be followed by two sessions that focus on cognitive therapy and
then a session on sleep hygiene. Finally, there may be a session that reviews and integrates the
previous session and a session that addresses future problems, such as stress and relapse. Patients
are encouraged to complete sleep logs as they learn and apply the various strategies. This allows
improvement to be measured.

The advantage of the educational nature of CBT is that it provides patients with tools to apply in
the future. Disadvantages of CBT include the duration of therapy and the relatively few
clinicians who are skilled at all of its components. The benefit of CBT may be reduced when it is
administered by less experienced clinicians.

CBT is particularly recommended for use in situations where medications are contraindicated or
may be more likely to produce side effects, such as older adults, pregnant women, and patients
with renal, hepatic, or pulmonary disease

Medications for insomnia:

Most clinicians select a sedative-hypnotic on the basis of the type of insomnia (ie, sleep onset or
sleep maintenance) and the duration of effect:
For patients with sleep onset insomnia, a short-acting medication is a reasonable choice for an
initial trial of pharmacologic therapy. This may improve the insomnia with less residual
somnolence the following morning. Examples of short-acting medications (duration of effect ≤8
hours) include zaleplon, zolpidem (Stilnox), triazolam, lorazepam, and ramelteon (Rozerem).

For patients with sleep maintenance insomnia, a longer-acting medication is preferable for an
initial trial of pharmacologic therapy. Examples of longer-acting medications include zolpidem
extended release, eszopiclone, temazepam, estazolam, and low dose doxepin. However, these
medications may increase the risk for hangover sedation and patients must be warned about this
possibility.

Benzodiazepines — Benzodiazepines are a class of sleep promoting medications that bind to

several gamma-aminobutyric acid (GABA) type A receptor subtypes. They reduce the time to the
onset of sleep, prolong stage 2 sleep, prolong total sleep time, and may slightly reduce the
relative amount of rapid eye movement (REM) sleep. In addition, they decrease anxiety, impair
memory, and have anticonvulsive properties.

Benzodiazepines commonly used for the treatment of insomnia include triazolam, estazolam,
lorazepam, temazepam, flurazepam, and quazepam. A primary difference among these
medications is their duration of action. Triazolam is short-acting; estazolam, lorazepam, and
temazepam are intermediate-acting; flurazepam and quazepam are long-acting (table 4) [41].
Diazepam is also long-acting, but is generally not used to treat insomnia because it has a long
duration of effect and can lead to the accumulation of active metabolites. The long-acting
benzodiazepines should be avoided in older adults because there is increased risk for adverse
effects in this patient population

Nonbenzodiazepines — A newer class of sleep promoting medications has also been approved
for the treatment of insomnia. These medications have a structure that is different from the
benzodiazepines and includes more targeted action at one GABA type A receptor. A consequence
of their greater specificity is less anxiolytic and anticonvulsant activity.

Nonbenzodiazepines commonly used to treat insomnia include zaleplon, zolpidem, eszopiclone,

and zolpidem extended release

Zaleplon has a very short half-life of about one hour. As a result, it is effective for patients who
have difficulty falling asleep (ie, sleep onset insomnia), but may not be effective for patients who
have difficulty maintaining sleep (ie, sleep maintenance insomnia). Neither persistent sleepiness
(ie, hangover effects) nor rebound insomnia is associated with zaleplon. Occasional side effects
include headache, dizziness, nausea, abdominal pain, and somnolence. Zaleplon is not indicated
for long-term use.

Zolpidem has a half-life of approximately 1.5 to 2.4 hours. It is indicated for the short-term
treatment of insomnia characterized by difficulty with sleep initiation. Neither hangover effects
nor rebound insomnia are associated with zolpidem. The most common side effects are
headache, dizziness, and somnolence. Zolpidem is not approved for long-term use. Zolpidem is
also available in a dissolvable tablet and as an oral spray for patients who have difficulty
swallowing a pill. A dissolvable tablet (1.75 to 3.5 mg) can be taken in the middle of the night for
sleep maintenance insomnia, with the requirement that at least four hours be available to sleep
after administration and at least five hours be available prior to driving. In January of 2013, the
US Food and Drug Administration (FDA) issued a safety announcement recommending use of a
lower dose in women than had been previously recommended. This should also be considered in
men.

Zolpidem extended release also has a half-life of about 1.5 to 2.4 hours, but is released over a
longer duration. It was developed to improve both sleep onset insomnia and sleep maintenance
insomnia while avoiding hangover effects, although it has never been directly compared to
regular zolpidem. Side effects of zolpidem extended release are relatively few, with the most
common being headache, somnolence, and dizziness. In January of 2013, the FDA recommended
use of a lower dose in women than had been previously recommended. This lower dose should
also be considered for men. In a follow up safety announcement, the FDA added a warning that
patients should not drive or engage in other activities that require complete mental alertness the
day after taking zolpidem extended release because zolpidem levels can remain high enough the
next day to impair these activities.

Sleep may be worse during the first night following discontinuation of this medicine. Zolpidem
extended release is not limited to short-term use and there is little evidence for abuse or
dependence in most patients. In theory, however, such medications could be habit forming with
long-term use

Eszopiclone has the longest half-life of the approved nonbenzodiazepines, approximately five to
seven hours. This may extend to nine hours in elderly patients. Eszopiclone is effective for both
sleep onset insomnia and sleep maintenance insomnia. It has not been associated with hangover
effects, but may have an unpleasant metallic taste. Other reported side effects are shared with
nonbenzodiazepines as a class (headache, dizziness, parasomnias)

Sleep may be worse on the first night after discontinuation of this medication. Eszopiclone is not
limited to short-term use and there is little evidence for abuse or dependence in most patients. In
theory, however, such medications could be habit forming with long-term use.

COMBINATION THERAPY — Combination therapy involves prescribing both cognitive

behavioral therapy (CBT) and a medication, usually for six to eight weeks. The medication is
then tapered off or to an as-needed schedule, while continuing the CBT.