-IBIS-1.5.0-
tx
mental/emotional
insomnia
diagnoses
definition and etiology
definition:
Difficulty falling asleep (initial insomnia) and/or frequent awakenings with difficulty falling back asleep or subsequent sleep that is restless and unsatisfying (early morning awakening insomnia or maintenance insomnia).
etiology:
In any year 30% of the population will experience insomnia with 4-6 million people a year receiving prescriptions for sedative hypnotics. Aging itself tends to decrease the total amount of sleep needed and the sleep garnered is more restless.
Causes of initial insomnia include: anxiety or tension; environmental change; emotional arousal; fear of insomnia; sleep phobia; disruptive environment; pain or discomfort; caffeine or alcohol ingestion.
Causes of maintenance insomnia include: depression; environmental change; sleep apnea; nocturnal myoclonus; hypoglycemia; parasomnias; pain or discomfort; drugs; alcohol.
However, the boundary between the causes of the two types of insomnia is not clearly established. Another cause for insomnia may be an inverted sleep rhythm, seen especially in the elderly and secondary to the inappropriate use of sedative hypnotics that are often prescribed to combat insomnia. Patients become sleepy in the morning, and sleep or catnap most of the day. This sets them up for interrupted and fitful sleep at night. The problem is made manifest when the medication is increased, and the patient wanders around in confusion or a stupor at night. If the medication is withdrawn, the patient experiences the rebound effect of wakefulness, which the patient interprets as a return of insomnia thus provoking a return to the sedatives.
Other factors can be involved in insomnia, so the conscientious physician will perform a detailed history and physical exam. The history should include a thorough checking for prescription, non-prescription and recreational drugs, to determine if the patient is taking a stimulant or any other substance known to interfere or interrupt sleep (such as diet pills; oral contraceptives; thyroid medicine; marijuana; beta-blockers; alcohol; chocolate; coffee, soda pop or tea). Eating or exercising late at night are also known to cause insomnia.
signs and symptoms
Primary and Secondary Insomnia:
primary insomnia: may be long-standing and hard to attribute to any immediate psychological or somatic events
secondary insomnia: from some acquired pain, anxiety, depression or other emotional upset or somatic event
lab findings:
Sleep lab testing can sometimes uncover problems achieving deep REM sleep or sleep apnea.
A sleep log is suggested to help diagnose as well as a polysomnograph in a sleep lab. The pattern of unipolar depression, for example, is characterized by frequent awakenings with a decreased REM latency (period of time from first fall asleep to first REM sleep), and shortened stages III and IV NREM sleep. Patients with a bipolar disorder show these same polysomnograph traits but also experience daytime drowsiness necessitating naps, while increasing their night-time rest period. In patients who are long-term users of sedative hypnotics, stages III, IV and REM sleep are shortened, there are frequent awakenings, and the stages of sleep are not clearly outlined.
course and prognosis
A recent onset insomnia is usually related to a current problem: e.g. health concerns, marital troubles, dilemmas at work, etc., and as such usually last less than three weeks. If no such mental/emotional reason can be uncovered then physical causes should be investigated. Insomnia that does not respond to simple measures is often due to an emotional upset, especially depression.
Morbidity can be very discomforting: chronic fatigue; anxiety about sleeping; lack of concentration, etc. Conventional treatment is sedative hypnotics if OTC drugs fail to help.
differential diagnosis
Narcolepsy, sleep apnea.
Affective disorders.
Restless leg syndrome or myoclonus.
Drug or stimulant use or withdrawal.
Mental problems such as depression.
footnotes