INSOMNIA

Liphard O. DSouza, M.D.

Diplomate: American Academy of Sleep
Medicine
6128 E. 38th St., Ste. 303
Tulsa, OK 74135
(918) 523-8572

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

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

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

Definitions
Mild
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
Nightly complaints of disturbed sleep
Severe daytime dysfunction

Classification
Sleep initiating insomnia
Sleep maintaining insomnia
Early morning insomnia
Short period of sleep

Non-restorative sleep
Multiple awakenings
Combination of above patterns

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

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

Normal Sleep Pattern

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.

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

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)

Less than 30 minutes

REM Sleep Latency

70-120 minutes

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

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

3 Ps of Acute Insomnia
Predisposition
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

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

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

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

Secondary/Extrinsic
Insomnia
1. 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

2. 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

3. Environmental factors
Environmental sleep disorder
Food allergy insomnia
Toxin-induced sleep disorder

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

6. Medical: Cardiac
Nocturnal myocardial ischemia
7. Medical: GI
Peptic ulcer disease
GERD
8. Medical: Musculoskeletal
Fibromyalgia
Arthritis
9. Medical: Endocrine
Hyperthyroidism
Cushings disease
Menstrual cycle association
Pregnancy

10. Medical: Neurological

Cerebral degeneration disorder
Dementia
Fatal familial insomnia
Parkinsons disease
Sleep related epilepsy
Sleep related headaches
11. Medical: Psychiatric
Alcoholism
Anxiety disorders
Mood disorders
Panic disorders
Psychosis
Drug dependency

12. Pharmacological causes

Alcohol dependent sleep disorder
Hypnotic dependent sleep disorder
Stimulus dependent sleep disorder
Medications
B-blockers
Theophylline
L-dopa

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

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 16-18 hours
(micro-sleep attacks)

Increased appetite, decreased body temperature

Physiologic effects
Rats die after 11-12 days of sleep deprivation
Hippocampal atrophy in chronic jet lag or shift work

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

Sleep diary

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

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 < 10
Severe > 15

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 cant go back to sleep.
I wake up earlier in the morning than I would like to.
Ill 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.

Treatment Selection
1. Meet and educate about disease, goals,

options, side effects, and document safety.

2. Identify the 3 Ps.
3. Intrinsic v. Extrinsic
4. Treat perpetuating causes
Sleep hygiene, progressive muscle relaxation,
biofeedback, stimulus control, sleep restriction,
cognitive behavior therapy (CBT), combination
of medications and CBT

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

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

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

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

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

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 overthe-counter medications

Benadryl
Nyquil

Hypnotics
5 questions to ask when choosing a
hypnotic:
1.
2.
3.
4.
5.

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?

Benzodiazepines

Dose

Half-life

Comments

Flurazepam(Dalmane)

15,30mg

Long

Daytimedrowsiness
common;rarelyused

Clonazepam(Klonopin)

0.5-2mg

Long

Temazepam(Restoril)

15,30mg

Intermediate

UsedforPLM,REM
behaviordisorder;can
causemorning
drowsiness

Estazolam(ProSom)

1-2mg

Intermediate

Cancause
agranulocytosis

Triazolam(Halcion)

0.125,0.25mg

Short

Reboundinsomniamay
occur

Zolpidem(Ambien)

5,10mg

Short

Anonbenzodiazepam

Zopliclone(Sonata)

5,10mg

Short,1-1.5hours

Anonbenzodiazepam

Recent Medication
Additions
Eszopiclone
Intermediate

1,2,3 mg

Approved for chronic insomnia

(Lunesta) Action 6-8 hrs.

Zolpidem 10 mg Action same as above
(Amvien CR)
Rozerem
(Ramelton)

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

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.