Insomnia

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The insomnias encompass a number of different disorders in which there is difficulty falling asleep or maintaining consolidated sleep, or the problem of awakening early in the morning before adequate sleep is obtained. The definition of adequate sleep varies between individuals, with some perceiving 5 hours as sufficient and others feeling that 8 or 9 hours of undisturbed sleep is necessary to be rested and alert the following day. The history is crucial to determining the possible etiologies of insomnia.y y y y

Sleep-onset insomnia refers to a prolonged latency from the time of going to bed until falling asleep. In psychophysiological insomnia, the patient may complain of feelings of anxiety, tension, worry, or persistent reflections over the problems of the past or future because they lay in bed to sleep. In acute insomnia, there may be an inciting event, such as the death or illness of a loved one, that is associated with the onset of insomnia. The pattern may become established over time, and the patient is left with a recurrent, persistent insomnia. In time, they may become apprehensive as they lie down to sleep, fearing that the struggle to obtain sleep will commence again. The greater the effort

TABLE 2-3 -- SELECTED ETIOLOGIES OF DISORDERS AFFECTING THE SLEEP-WAKE CYCLE

Etiological Category

Specific Etiologies

Chapter

Developmental structural disorders

Enuresis from structural anomalies

28

Degenerative and compressive structural disorders

Obstructive sleep apnea; upper airway resistance syndrome

29

The degenerative dementias

Alzheimers disease

33

Movement disorders

Parkinsons disease, multiple systems atrophy; dopa-responsive dystonia; hyperkinetic movements: tics, chorea, dystonia, tremor, hemiballism, hemifacial spasm, myoclonus of cortical origin

34

Degenerative motor, sensory, and autonomic disorders

Duchenne muscular dystrophy; myotonie dystrophy, limbgirdle dystrophy; amyotrophic lateral selerosis

36

Inherited muscle, neuromuscular, and neuronal disorders

Congential myopathies

37

Kleine-Levin sxndrome

38

Endogenous metabolic disorders

Thyroid diseas

Nutritional deficiencies and syndromes associated with alcoholism

Alcoholism

40

Transmissible spongiform encephalopathy

Fatal familial insomnia

43

Demyelinating disorders of the peripheral nervous system

Guillain-Barr syndrome

49

Autoimmune and inflammatory disorders

Rheumatoid arthritis; polymyositis, myasthenia gravis

50

Traumatic disorders

Post-traumatic hvpersomnia

51

Epilepsy

Sleep epilepsy; noctrunal paroxysmal dystonia

52

Headache and facial pain

Sleep-related headaehes

53

Sleep disorders

Narcolepsy; REM s]eep behavior disorder; restless legs syndrome; penodic limb movement disorder; primary insomnia; sleep walking, sleep talking; bruxism

54

Drug-induced and iatrogenic neurological disorders

Antidepressants; hypnotic-dependent sleep dOEsorder;stimulant-dependent sleep disorder

55

expended in trying to sleep, the more elusive sleep becomes. Watching the clock as each minute and hour passes only increases the sense of urgency, further confounding efforts to sleep. The bed may eventually be viewed as a battleground, and sleep is achieved more easily in a foreign environment.

Some patients report an inability to fall asleep quickly that arises from physical discomfort as they lie down. Patients with Parkinson's disease may observe stiffness and an inability to roll over in bed; patients with RLS may report unusual sensations of tightness, tension, creeping, or tingling in their calf muscles that is relieved only by movement; pain from arthritis, neuropathy, or muscle injury may be enhanced at night.

Patients with poor sleep hygiene may complain of sleep-onset insomnia. Late-day napping, caffeine and nicotine intake, exercising in the hours immediately before bed, or late night meals may all be factors contributing to insomnia. Using the bedroom and bed to work, read, eat, or watch television may also interfere with the ability to fall asleep.

Circadian rhythm disorders may also present as sleep-onset insomnia. y Patients with irregular sleep hours, such as shift workers or international travelers, are continuously fighting their inherent circadian rhythms. In particular, travel in an eastward direction may provoke an inability to sleep at the desired times in the new time zone. Adolescents are often phase delayed or so-called night owls, preferring a later bedtime and awakening time. In some individuals, this pattern may carry over into adulthood, causing significant problems with maintaining an acceptable job schedule and may be perceived as sleep-onset insomnia rather than phase-delayed sleep.

Insomnia may arise secondary to neurological or psychological disorders. y y [d Patients with dementia may have difficulty falling asleep at night. In some, there may even be a reversal of the normal day-night sleep cycle in which the patient is awake and wandering about throughout the night hours and napping intermittently throughout the day. Certain psychiatric disorders, such as major depression or bipolar disorder may be the cause of insomnia. Particularly in the acute manic or hypomanic phase, there may be significant problems with sleep onset. Schizophrenic patients may also report sleep onset insomnia.

Drugs may interfere with ability to sleep.y Some agents, such as stimulants and antiparkinson drugs, may be directly associated with insomnia. Other drugs may cause insomnia when they are discontinued. In particular, the discontinuation of chronic hypnosedative treatment may cause severe rebound insomnia. Establishing the pattern of medication intake and the association of medications with the onset of insomnia is vital to establishing this factor as the cause of insomnia.

Sleep fragmentation refers to an inability to maintain sleep over the night with frequent nocturnal awakenings and variable ability to fall back to sleep. Sleep may be disturbed by a variety of causes. Alcohol intake before bed, while promoting sleep onset, often causes disruption of sleep toward the end of the night. Primary sleep disorders may disrupt nocturnal sleep. PLMD may cause a patient to awaken without being aware of the cause. Sleep apnea, likewise, may cause sleep fragmentation in a patient who reports that initial sleep latency is short. A patient with sleep apnea may awaken with choking, or a sense of being unable to breathe. PSG is usually necessary to diagnose these causes of insomnia.

Medical and neurological conditions, including nocturia, cardiac disease, rheumatoid arthritis, fibromyalgia, and neuromuscular diseases may also cause sleep fragmentation.

Insomnia may also present as early-morning awakening.

Patients with this type of insomnia complain that they wake up for no reason at an early hour in the morning and are not able to reinitiate sleep. This type of insomnia is often seen in patients with major depression and is a frequent complaint of the elderly. In phase-advanced sleep, the major sleep period occurs early with bedtime and final awakening hours before desired.

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