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http://emedicine.medscape.com/article/291573-overview
Primary Insomnia
Author: Catherine McVearry Kelso, MD, MS; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK) more... Updated: Mar 29, 2011
Types of Insomnia
Psychophysiologic insomnia
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The essential features of psychophysiologic insomnia include learned or behavioral insomnia and heightened arousal. The primary components involved are intermittent periods of stress that result in poor sleep and maladaptive behaviors. These include (1) a vicious cycle of trying harder to sleep and becoming more tense (ie, patients trying too hard to sleep) and (2) bedroom habits and routines (eg, brushing teeth) that actually condition the patient to become frustrated and aroused. Patients often report "racing thoughts" and sensitivity to their environment. Bad sleep habits, such as those naturally acquired during periods of stress, are occasionally reinforced. These are therefore not resolved and become persistent. Insomnia continues for years after the stress has abated, and is labeled persistent psychophysiologic insomnia.
Idiopathic insomnia
The essential feature of idiopathic insomnia is lifelong sleeplessness, with onset in infancy or childhood. Idiopathic insomnia can be aggravated by stress or tension. Lifelong sleeplessness is attributed to an abnormality in the neurologic control of the sleep-wake cycle for many areas of the reticular activating system (which promotes wakefulness), as well as in areas such as supra nuclei, raphe nuclei, and medial forebrain areas (which promote sleep). Possibly, a so-called neuroanatomic, neurophysiologic, or neurochemical lesion exists in the sleep state, with patients tending to be on the extreme end of the spectrum toward arousal.
Paradoxical insomnia
Paradoxical insomnia is also called sleep state misperception.[8] The essential feature is reports of severe insomnia without supporting objective evidence, such as daytime sleepiness.
Patient History
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A thorough clinical interview with the patient and his or her sleep partner is critical in making the correct diagnosis of primary insomnia.
Psychophysiologic insomnia
Sleep disturbance in these patients ranges from mild to severe. Insomnia may manifest as difficulty falling asleep or as frequent nocturnal awakenings. Patients often find that they can sleep well anywhere else but in their own bedroom. Patients with this type of insomnia tend to be more tense and dissatisfied compared to people who sleep well. Emotionally, they typically are repressors, denying problems.
Idiopathic insomnia
In patients with this condition, the insomnia is long-standing, typically beginning in early childhood. Patients often present with other hard-to-localize neurologic signs and symptoms, such as difficulty with attention or concentration, hyperactivity, and mild, nonfocal electroencephalographic abnormalities. Emotionally, persons with childhood-onset insomnia are often repressors, denying and minimizing emotional problems. These individuals often show atypical reactions, such as hypersensitivity or insensitivity, to medications.
Paradoxical insomnia
Patients report insomnia subjectively, while sleep duration and quality are completely normal.
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Anxiety disorders (eg, generalized anxiety, panic attacks, obsessive-compulsive disorder) Substance abuse (eg, alcohol or sedative/hypnotic withdrawal) Major life stressors and/or events Mood disorders (eg, depression, mania) Environmental causes of insomnia include the following: Noise Jet lag or shift work Bedroom too hot or cold Symptoms of the following conditions can mimic those of primary insomnia: Adjustment Disorders Alcohol-Related Psychosis Amphetamine Abuse Anxiety Disorders Apnea, Sleep Bipolar Affective Disorder Caffeine-Related Psychiatric Disorders Circadian rhythm sleep disorder Cocaine-Related Psychiatric Disorders Depression Hyperthyroidism Obstructive Sleep Apnea-Hypopnea Syndrome Parasomnias Postpartum Depression Posttraumatic Stress Disorder Schizophrenia Substance abuse can cause insomnia during the intoxication phase, during the sustained use phase, and during withdrawal.
Sleep diary
This is a questionnaire (shown below) completed by the patient each morning to describe the previous night's sleep.
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Data from the sleep diary may help to minimize distortions in sleep information recalled in the physician's office.
Actigraphy
This technique makes use of an activity monitor to record activities during sleep and waking. It is useful in the diagnosis of circadian rhythm sleep disorders, sleep state misperception, and other types of primary insomnia. In older adults treated for chronic primary insomnia, the clinical use of actigraphy is still suboptimal in detecting wakefulness.[15]
Full-night polysomnography
Full-night polysomnography (PSG) is indicated when suspicion of sleep apnea or movement disorders arises, when initial diagnosis is uncertain, when treatment fails, or when precipitous arousal occurs with violent or injurious behavior.[16, 17, 18, 15]
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mirtazapine,[21] especially in patients with depression or anxiety Combination BzRA or ramelteon and sedating antidepressant Amitriptyline should not be used in older patients because of a high anticholinergic side-effect profile. According to evidence-based recommendations on sleep disorders in older persons published in the Journal of American Geriatrics Society in 2009, clinically significant adverse effects can be associated with all FDA-approved medications for the treatment of insomnia (evidence level A), and the safest and most effective medications currently available are nonbenzodiazepines and melatonin receptor agonists (evidence level B or moderate).[22, 20] Prescriptions not recommended include the following:[16] Chloral hydrate, barbiturates, and nonbarbiturate nonbenzodiazepine drugs (ie, meprobamate), due to significant adverse effects and tolerance Off-label use of antiepileptic (gabapentin, tiagabine) and atypical antipsychotics (quetiapine, olanzapine) Regarding the above recommendation against the off-label use of antiepileptic and atypical antipsychotic drugs, there is Insufficient evidence of efficacy when these agents are used alone, and adverse effects can occur. They may be considered for patients with comorbid conditions and insomnia. Basic principles for the rational treatment of insomnia are to use the lowest effective dose, use intermittent dosing (2-3 nights/wk), use short term (2-3 wk at a time), discontinue after slow taper if the patient has been taking it regularly, and use agents with short and/or intermediate half-life to minimize daytime sedation. (See the table below.) Pharmacokinetic properties and risk-benefit ratio are the key factors in selecting the most appropriate medication.[23] Table 1. FDA-Approved Hypnotics for Insomnia (Open Table in a new window) Trade Name 15-30 mg 7.5-15 mg 1-2 mg 7.5-30 mg 0.5-4 mg; 1 mg in elderly 0.125-0.5 mg
Agent
Dose
Half-life
Comments
48-120 h 41 h
Do not use in older adults due to long half-life Do not use in older adults due to long half-life
Intermediate acting
Estazolam
10-24 h Sleep maintenance 3.5-18 h Sleep maintenance 12-20 h May be used if duration of action meets patients needs 1.5-5.5 h 6h 2.5 h 2.8 h Caution, rebound anxiety; not first-line agent Sleep onset and maintenance Primary use, sleep onset Primary use, sleep onset and maintenance Primary use, sleep onset; maintenance up to 4 h
Short acting
Triazolam
Halcion
Nonbenzodiazepine Intermediate acting Shortto-intermediate Eszopiclone Lunesta Zolpidem Zolpidem ER Short acting Zaleplon Ambien Ambien CR Sonata 2-3 mg; 1 mg in elderly and hepatic impairment 5-10 mg; 5 mg in elderly or hepatic impairment 12.5 mg; 6.25 mg in elderly or hepatic impairment
Melatonin Receptor Agonist Short acting Ramelteon Rozerem Primary use, sleep onset
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Nonpharmacologic Treatment
Psychological treatment for insomnia consists primarily of patient education and short-term cognitive-behavioral therapies. The focus is primarily on sleep hygiene or factors presumed to perpetuate insomnia. These therapies seek to modify maladaptive sleep habits and to educate patients about healthier sleep practices.[29]
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same time each morning regardless of how much the patient slept the previous night, and (5) to avoid daytime napping.
Relaxation therapies
Relaxation-based interventions are indicated based on the observation that patients with insomnia often display high levels of arousal (physiologic and cognitive) at night and during the daytime. The various techniques available to deactivate the arousal system are (1) progressive muscle relaxation, (2) biofeedback, and (3) imagery training and thought stopping.
Paradoxical intention
This method consists of persuading a patient to engage in his or her most feared behavior (ie, staying awake). This serves to eliminate performance anxiety so that sleep may come more easily.
Combined therapy
CBT and hypnotic medications are efficacious for short-term treatment of insomnia, but few patients achieve complete remission with any single treatment. Morin et al studied 160 adults with persistent insomnia and demonstrated that CBT used singly or in combination with zolpidem produced significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency during initial therapy. Combined therapy produced a higher remission rate compared with CBT alone during the 6-month extended therapy phase and the 6-month follow-up period (56% [43/74 and 32/59] vs 43% [34/75 and 28/68]). The long-term outcome was optimized when medication was discontinued during maintenance CBT.[31]
Patient Information
The following sleep hygiene recommendations, which include environmental and lifestyle modifications, should be used as an adjunct to other forms of therapy: Elimination of the use of caffeine, especially after noon No tobacco or alcohol use near bedtime Avoidance of heavy meals close to bedtime (may eat a light snack at bedtime) Engagement in exercise early in the day before dinner to alleviate stress, but not before bedtime Avoidance of daytime naps and establishment of a regular schedule for going to bed and getting up Maintenance of the bedroom at a comfortable temperature, and minimization of light and noise Family education and patient self-help information are also important. Resources on sleep disorders can be found at
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the National Sleep Foundation Web site. For patient education information, see eMedicine's Mental Health and Behavior Center and Sleep Disorders Center. As well as Primary Insomnia, Insomnia, Disorders That Disrupt Sleep (Parasomnias), Understanding Insomnia Medications, Sleep Disorders in Women, Sleep Disorders and Aging, and Sleeplessness and Circadian Rhythm Disorder.
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Ranjan, MD, and Kirk L Nelson, MD, to the development and writing of the source article.
References
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with melatonin: a double-blind, placebo-controlled, crossover study. J Psychiatry Neurosci. May 2003;28(3):191-6. [Medline]. [Full Text]. 21. Croom KF, Perry CM, Plosker GL. Mirtazapine: a review of its use in major depression and other psychiatric disorders. CNS Drugs. 2009;23(5):427-52. [Medline]. 22. Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. May 2009;57(5):761-89. [Medline]. [Full Text]. 23. Cotroneo A, Gareri P, Nicoletti N, Lacava R, Grassone D, Maina E, et al. Effectiveness and safety of hypnotic drugs in the treatment of insomnia in over 70-year old people. Arch Gerontol Geriatr. 2007;44 Suppl 1:121-4. [Medline]. 24. Rosenberg R, Seiden DJ, Hull SG, Erman M, Schwartz H, Anderson C, et al. APD125, a selective serotonin 5-HT(2A) receptor inverse agonist, significantly improves sleep maintenance in primary insomnia. Sleep. Dec 1 2008;31(12):1663-71. [Medline]. [Full Text]. 25. Teegarden BR, Al Shamma H, Xiong Y. 5-HT(2A) inverse-agonists for the treatment of insomnia. Curr Top Med Chem. 2008;8(11):969-76. [Medline]. 26. Farber R, Burke J, Ross D. Indiplon in the Treatment of Chronic Insomnia in Elderly Women. Obstet Gynecol. May 2006;107(4)(suppl). 27. Marrs JC. Indiplon: a nonbenzodiazepine sedative-hypnotic for the treatment of insomnia. Ann Pharmacother. Jul 2008;42(7):1070-9. [Medline]. 28. Scharf M, Rogowski R, Hull S, Cohn M, Mayleben D, Feldman N, et al. Efficacy and safety of doxepin 1 mg, 3 mg, and 6 mg in elderly patients with primary insomnia: A randomized, double-blind, placebo-controlled crossover study. J Clin Psychiatry. Oct 7 2008;[Medline]. 29. Blanger L, Morin CM, Langlois F, Ladouceur R. Insomnia and generalized anxiety disorder: effects of cognitive behavior therapy for gad on insomnia symptoms. J Anxiety Disord. 2004;18(4):561-71. [Medline]. 30. Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitivebehavioral insomnia therapy: a randomized clinical trial. Sleep. Feb 1 2007;30(2):203-12. [Medline]. 31. Morin CM, Vallires A, Guay B, Ivers H, Savard J, Mrette C, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. May 20 2009;301(19):2005-15. [Medline].
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