INSOMNIAS INSOMNIAS General criteria for insomnia - PowerPoint Presentation

1. INSOMNIAS

2. INSOMNIAS General criteria for insomniaRepeated difficulty with sleep initiation, duration, consolidation or quality.Adequate sleep opportunity, persistent sleep difficulty and associated daytime dysfunctionAt least one of the forms of daytime impairment is reportedFatigue or malaiseAttention, concentration, or memory impairmentSocial vocational dysfunction or poor school performanceMood disturbance or irritabilityDaytime sleepinessMotivation, energy, or initiative reductionProne for errors or accidentsTension, headaches, or gastrointestinal symptomsConcerns or worries about sleep

3. 11 categories of INSOMNIA Adjustment InsomniaPsychophysiological InsomniaParadoxical InsomniaIdiopathic InsomniaInadequate Sleep HygieneBehavioral Insomnia of ChildhoodInsomnia due to Drug or Substance abuseInsomnia Due to Medical ConditionInsomnia Due to SubstanceKnown physiological condition or Unspecified (Non-organic Insomnia)Physiological (Organic) Insomnia, Unspecified

4. Adjustment Insomnia (Acute Insomnia) Symptoms meet the criteria for insomnia Sleep disturbance is temporally associated with identifiable stressorSleep disturbance is expected to resolve when acute stressor resolvesSleep disturbance last for less than 3 months

5. Adjustment Insomnia (Acute Insomnia) Key points: Associated with identifiable stressorShort duration (days to weeks) and resolves when stressors resolveMay present with complaints of daytime sleepiness or fatigue, difficulty staying awake, or repeated episodes of sleep during the dayOccurs at any ageMore often in woman than menPSG Findings: prolonged sleep latency, increased arousals and awakenings decreased sleep efficiency Reduced REM and SWS increased stage 1 and 2 sleep Treatment (recommended): Sedative hypnotics and behavioral psychotherapy

6. Psychophysiologic Insomnia(Learned or Conditioned Insomnia)Symptoms meet criteria for insomniaSymptoms present for > 1 monthPatient has evidence of conditioned sleep dysfunction and/or heightened arousal and bed secondary to one or more of the following:Excessive focus on an anxiety about sleepDifficulty falling asleep in bed and desired bedtimeAbility sleep better way from homeMental arousal in bed characterized by interest of thoughts or perceived inability to cease sleep preventing mental activityHeightened somatic tension with perceived inability to relax the body

7. Psychophysiologic Insomnia(Learned or Conditioned Insomnia)Key PointsAka chronic insomnia“racing mind” commonConditioned sleep dysfunction, heightened arousalPSG FindingsIncreased sleep latency and increased WASOMay show reverse first-night effect (better sleep away from home)Treatment (recommended): Cognitive behavioral psychotherapy

8. Paradoxical Insomnia (aka Sleep State Misperception)Symptoms meet criteria for insomniaInsomnia present > 1 monthOne or more the following criteria apply;Patient reports chronic pattern of little or no sleep on most nightsSleep log data during one or more weeks show an average sleep time below normal values often with no sleep recorded for several nightsPatient shows consistent mismatch between objective findings from polysomnography or actigraphy and subjective sleep estimates derived from self reportAt least one of the following is observed:Patient reports constant awareness of environmental stimuli during most nightsPatient reports pattern of conscious thoughts during the nightDaytime impairment reported is consistent with that reported by other insomnia subtypes but is less severe than expected given the extreme level of sleep deprivation reported

9. Paradoxical Insomnia (aka Sleep State Misperception)Key PointsDespite complaints of severe sleep deprivation, minimal daytime sleepiness is notedPSG Findings: Normal latencies and sleep times. Estimated sleep times are at least 50% less than actual Estimated onset latencies and wake after onset at least 1.5 times actual amount Severity of nocturnal complaints not matched with evidence for pathologic sleepinessMSLT latencies of <5 minutes are not evidentTreatment: Cognitive Behavioral Psychotherapy

10. Idiopathic Insomnia(Childhood-Onset Insomnia)Symptoms meet the criteria for insomniaCourse of the disorder is chronic as indicated by:Onset During infancy or in early childhoodNo identifiable precipitant or causePersistent coarse with no periods of sustained remission

11. Idiopathic Insomnia(Childhood-Onset Insomnia)Key PointsTypically complained of lifelong sleep difficulty beginning in infancy or childhoodFew periods of extended remissionSleep disturbance is the primary featureIn attempting to cope with insomnia, the individual has developed fevers and actually worsened the conditionMay have a familial tendencyPSG FindingsProlonged sleep latency and increased WASOReduced total sleep time and sleep efficiencyIncreased stages 1 and 2, decrease in 3Treatment (recommended): Cognitive Behavioral Psychotherapy

12. Inadequate Sleep Hygiene (aka sleep incompatible behaviors)Symptoms meet criteria for insomniaInsomnia present > 1 monthInadequate sleep hygiene practices are evident based on presence of at least one on the following:Improper sleep scheduling consisting of frequent naps and varying wake/sleep timesRoutine use of alcohol, nicotine, or caffeineEngaging and mentally stimulating, physically activating, or mostly upsetting activities close to bedtimeFrequent use of bed for activities other than sleep (eg. TV)Failure to maintain comfortable sleep environment

13. Inadequate Sleep Hygiene (aka sleep incompatible behaviors)Key PointsSpecific Behaviors make up this condition in 2 general categories: 1) practices that produce increased arousal 2) practices that are inconsistent with principles of sleep organizationCommonly used substances such as caffeine and nicotine may produce arousalAlcohol may also interfere by producing awakenings during sleepTend to spend more time in bed awake May contribute to mood and motor visual disturbances, reduced attention, reduced vigilance, or reduced concentrationPreoccupied with sleep difficulty is commonLittle insight into Practices of their sleepTreatment (recommended): Cognitive behavioral psychotherapy

14. Behavioral Insomnia of Childhood (sleep-onset type)Child symptoms meet criteria for insomnia based on parent reportsChild shows a pattern consistent with sleep onset association with the following symptoms:Falling asleep at an extended process requiring special conditionsSleep onset associations are highly problematic or demandingIn the absence of associated conditions, sleep onset is significantly delayed or disruptedAwakenings require caregiver intervention for child returned sleep

15. Behavioral Insomnia of Childhood (limit-setting sleep disorder)Child symptoms meet criteria for insomnia based on parent reportsChild shows a pattern consistent with limit-setting type with the following symptoms:Individual has difficulty initiating and maintaining sleepIndividual stalls or refuses getting into bed at appropriate time or refuses to return to bedCaregiver demonstrates insufficient or inappropriate limit setting

16. Behavioral Insomnia of Childhood (sleep-onset type)Key PointsSeen in 10-30% of childrenSleep onset association type:characterized by reliance on an appropriate sleep Associations and usually presents as frequent nighttime awakeningsProcess of falling asleep is associated with specific form of stimulation (rocking or watching television), object (bottle, toy), or setting (parents’ bed)Child unable to fall asleep within a reasonable time without these conditionsLimit setting typeStalling or refusing to go to sleepIf care ever enforces limits, sleep comes quickly; otherwise, sleep onset is delayedOften arises from parental difficulties in setting limits and managing behaviorTreatment (recommended): counseling

17. Insomnia due to drug or substancePatients symptoms meet the criteria for insomniaInsomnia is present for at least one monthOne of the following applies:Current ongoing dependence on or abuse of the drug or substance known to have sleep disrupted properties either during periods of abuse or intoxication or during periods of withdrawalPatient has current ongoing use of or exposure to a medication, food, or toxin known to have sleep disruptive properties in susceptible individualsInsomnia is temporally associated with substance exposure, use or abuse, or acute withdrawal17

18. Insomnia due to drug or substanceKey PointsMost common stimulants include caffeine, amphetamines, and cocaineMay also involve certain antidepressants, antihypertensive agents, hyperlipidemic medications, steroids, parkinsonian drugs, theophylline, anorectic agents, and antiepileptic medicationsPseudoephedrine and other nasal decongestion medsAlcohol may reduce sleep onset latency, but are more prone to fragmented and restless sleep; tolerance also develops18