Stop Insomnia Naturally

Natural Insomnia Program

The Insomnia Exercise Program is a simple audio program that works to Train Your Brain to switch from normal, fast-paced brain waves to slow, delta and theta waves and put you to sleep mind and body naturally. This is a 2-part program. Part 1 is a 25 minute audio where I lead you step by step to reach those slow theta and delta stages that knock you out in a deepest sleep of your life. This is done through a combination of mind, eye and relaxation exercises. Part 2 is a 50 minute audio of sound therapy where you hear the relaxing sound that draws you into the wonderful land of dreaming. After youve listened to the audio a few times, youll most likely be sound asleep long before it even comes to this part but it is important because it will draw you into deeper and deeper sleep so you dont wake up after a few minutes and not be able to doze off again. All you have to do is listen to the audio in your bed and get ready to fall asleep! Continue reading...

Natural Insomnia Program Summary


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The Pineal Gland and Melatonin

The pineal gland is a neuroendocrine gland that synthesizes and secretes melatonin ( M-acetyl-5-methoxytryptamine). y The afferent input to the pineal gland is transmitted from the retinal photoreceptors through the SCN and sympathetic nervous system. The circadian rhythm of melatonin is controlled by the SCN but is strongly entrained by light. The two effects of light are, first, to regulate melatonin secretion in accordance with diurnal light-dark cycles and, second, to suppress melatonin if given in brief intense pulses. Melatonin secretion increases during the night, reaching a peak level between 2 00 and 4 00 am, then gradually falls during the latter part of the night, and is present at very low levels during the day. Exogenous melatonin has been used with some success to avoid jet lag and may be useful for treatment of phase-shifted sleep and sleep disturbance due to shift work. Melatonin is available through health food stores and has received strong public attention. However,...

Sleep Problems and Remedies from Ambien to Zolpidem

The diagnosis of sleep problems is based on now standardized criteria summarized both in Diagnostic and statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the more detailed classification of the ICSD (International Classification of Sleep Disorders) (Pressman and Orr, 1997). Unlike psychiatric diagnoses, which are typically obtained from a conversation with a psychiatrist through structured interview, sleep disorders have more objective criteria, consisting of electroencephalogram (EEG) measures of (i) sleep latency, (ii) REM latency (including REM latency minus awake), (iii) amount of SWS, (iv) amount of REM sleep, (v) eye movement density in REM sleep, and (vi) sleep efficiency (i.e., total number of minutes of sleep divided by the total time in bed). There is abundant data using these measures not only in standard nonpsychiatric sleep disorders, such as apnea, but also in many psychiatric disorders (Douglass, 1996). Objectively measured sleep problems allow...

Sleep Hygiene Training

Given the frequency with which pain and headache patients suffer comorbid sleep disorders, and the impact of reduced sleep on these disorders, sleep hygiene Table 13.12 Patient guidelines for sleep hygiene With use of these methods, patients frequently experience a significant improvement in sleep over a 2-3-week period. Patients with more refractory sleep difficulties can be referred for polysomnography or additional sleep disorder evaluation.

Sleep Disorders of Parkinson s Disease

In the past few chapters, we have been looking at the earliest predictors of PD. We have seen that an anxious personality in young adulthood significantly predicts risk for developing PD decades later. In middle age, a certain personality profile of anxiousness, harm avoidance, ambitiousness, inflexibility, punctuality, and reduced novelty seeking is also a significant predictor for later development of parkinsonism. Data uncovered in the past couple of decades have now shown that specific types of sleep disorders often develop 10-20 years before onset of motor symptoms of PD. That is, certain types of sleep dysfunction predict PD onset in some individuals about two decades later (see table 9.1). From the point of view of the self, agentic and executive control systems come progressively under attack by the disease process that culminates in PD. There is an initial genetic, or epigenetic, vulnerability that weakens the agentic self system and manifests in generalized anxiety very...

REM Sleep Behavioral Disorder

Normal REM sleep is associated with skeletal muscle atonia interrupted by irregular muscle twitches. With the RBD, the muscle atonia that accompanies REM sleep is incomplete and patients have motor automatisms in which they appear to act out their dreams. y The disorder may begin fairly abruptly, or it may be preceded by months of progressively increasing nocturnal movements, vocalizations, and disturbing dreams. Presenting complaints include nocturnal shouting, violent behavior with acting out of dreams, and injuries during sleep to the patient or bed partner. y During the episodes, which usually last a few minutes, behavior may be limited to talking, laughing, and waving of the arms or it may include punching, kicking, or jumping out of bed. Some patients have a so-called Jekyll and Hyde syndrome with quiet peaceable behavior during the day that contrasts with the swearing and violence that accompanies REM sleep. The timing and duration of episodes parallel the distribution of REM...

Sleep Disorders Associated with Degenerative Disorders of the Central Nervous System

Degenerative disorders may also cause sleep disturbance due to the effects on sleep continuity of immobility, discomfort, and nocturnal disorientation. Depression and the effects of psychoactive medications also contribute to sleep problems in many patients, but sleep disturbance is also common in unmedicated nondepressed patients. For the patient with a degenerative neurological disorder and sleep complaints, the differential diagnosis may include direct and indirect effects of the disease, medication effects, poor sleep hygiene with excessive time in bed, circadian rhythm sleep disorders, RLS and PLM disorder, sleep- related breathing disorders, sundowning, and RBD. The history is the most important element for diagnosis. The relation of the onset of sleep disturbance to the onset of the degenerative disorder helps determine whether the two are related. For patients with insomnia or disruptive nocturnal behavior, the frequency and duration of awakenings should be noted, along with...

Clinical Presentation and Diagnosis of Sleep Disorders

Patients with sleep disorders may complain about daytime symptoms. A bed partner may witness hallmark characteristics of the sleep disorder. Patients with sleep complaints should have a careful sleep history performed to assess their possible sleep disorder in order to guide diagnostic and therapeutic decisions. Daytime Symptoms and Associated Characteristics EDS is the primary symptom described by patients with sleep disorders. It is usually described as not waking up refreshed in the morning, or falling asleep or fighting the urge to sleep during the day despite a night of sleep. Other daytime characteristics of sleep disorders include Nighttime Sleep Complaints Depending on the sleep disorder, patients may exhibit or experience various nocturnal complaints during sleep hours. Some of these complaints can be uncovered by clinical history alone (e.g., hallucinations, RLS, snoring), while others can be diagnosed during sleep studies (e.g., OSA, nighttime awakenings, somnambulism,...

Sleep Disordered Breathing and Neuromuscular Diseases

Weakness of the diaphragm is the most important cause of respiratory disturbance during sleep. Diaphragmatic workload increases in NREM sleep owing in part to airway narrowing caused by decreased tone in upper airway muscles, in part to sleep-related changes in lung mechanics and respiratory muscle activation, and in part to the increased load associated with the horizontal position. With neuromuscular disorders, weakness of upper airway muscles may further reduce airway diameter, leading to increased respiratory load. Diaphragm workload increases even further during REM sleep, because accessory muscles of respiration are inhibited and the diaphragm must perform almost all of the work of breathing. The increased workload during sleep may lead to diaphragm fatigue with hypoxia, hypercapnia, acidosis-induced muscle dysfunction, and progressively worsening hypoventilation during the latter portion of the night. Patients may complain of frequent awakenings, nocturnal dyspnea or...

Insomnia Difficulty Initiating or Maintaining Sleep

Insomnia is often characterized by difficulty falling asleep, frequent nocturnal awakenings, and early-morning awakenings, which may result in daytime impairments in concentration and school or work performance. In comorbid insomnia, social factors (e.g., family difficulties, bereavement), medications (e.g., antidepressants, ft-agonists, corticosteroids, decongestants), and coexisting medical or psychiatric conditions (e.g., depression, bipolar disorder) may help to explain difficulties in initiating and maintaining sleep. Insomnia may be described as transient (a few days), short term (less than 3 weeks), or chronic (greater than 1 month) in duration.

Sleep Problems

Sleep problems and fatigue are common in PD and may be due to medications, uncontrolled PD symptoms, or many other medical and psychological causes. The patient's bed partner can provide useful information on the patient's quality of sleep. Patients may benefit from instruction on good sleep hygiene, adjustment of therapy to control nighttime PD symptoms, or cognitive behavioral therapy. Referral to a sleep specialist may be necessary. Amantadine and selegiline may worsen insomnia selegiline and tricyclic antidepressants may worsen RBD and some antidepressants and antipsychotics may worsen RLS. Short-acting benzodiazepines (e.g., zaleplon, zolpidem), and sedating antidepressants (e.g., trazodone) are used for short periods to improve insomnia. However, benzodiazepines may increase the risk of falling. Antidepressants may worsen cognition and hypotension. Ramelteon may prove beneficial in patients with circadian sleep disorders (study in progress). Pramipexole, melatonin, and...


The prevalence of insomnia increases with age and is nearly 1.5 times greater in females than in males. Approximately one-third of patients older than age 65 have persistent insomnia.45 In the adult population, about 10 will experience chronic insomnia and slightly more will experience short-term insomnia. Insomnia is most frequently a symptom or manifestation of an underlying disorder (comorbid insomnia) but may occur in the absence of contributing factors (primary insomnia). Early treatment of insomnia may prevent the development ofpersistent psychophysiologic insomnia. Forty percent of patients with psychiatric conditions will have accompanying insomnia. Comorbid insomnia may be triggered by acute stress and disappears when the stress resolves. Numerous coexisting medical conditions, such as pain, thyroid ab normalities, asthma, and reflux, and medications, including selective serotonin reup-take inhibitors (SSRIs), steroids, stimulants, and -agonists, can interfere with sleep and...

Sleep disorders

The second category is NREM sleep arousal disorders sleep drunkenness, sleep-walking and sleep terrors. In these conditions, there is a partial arousal from deep sleep the person may appear to be awake but fails to respond normally to commands. Often the person is distressed, but may be very resistant to consolation and may even become violent, with no recollection the next morning. Sleep-walking occurs in the first third of the night's sleep the person may be clumsy and injure themselves. Sleep terrors usually occur suddenly the person comes straight out of deep sleep, unlike a normal awakening, and is confused. These are associated with fear, a piercing scream, wide open eyes and a pounding heart. These attacks are frequently followed by uncontrolled running. Rapid eye movement sleep disorders form the third category of parasomnias. These include nightmares, sleep paralysis and REM sleep behaviour disorder. In a nightmare the person wakes fully oriented but aware of an experience in...

REM Sleep

The anatomical substrates for the different components of REM sleep are as follows 3. Muscle atonia, except for respiratory and ocular muscles, is a tonic event of REM sleep. Electrical stimulation studies have shown that muscle atonia occurs following activation of the medullary magnocellular reticular nucleus and the rostral nucleus pontis oralis. Muscle paralysis arises at the spinal cord level, from a centrally mediated hyperpolarization of the alpha motor neurons through the action of the inhibitory neurotransmitter glycine. 5. Rapid eye movements are another phasic event of REM sleep. Horizontal eye movements arise from burst neurons in the parabducens reticular formation in the pons, and vertical eye movements are associated with activation of the midbrain reticular formation. Positron emission tomography has shown that REM-related eye movements involve cortical areas similar to those used during wakefulness. 6. PGO activity is a phasic feature of REM sleep, generated in the...

Physiological Function of Sleep

Sleep evolves during life and changes with maturation and aging. During infancy, 16 to 18 hours a day are spent sleeping, with sleep-wake states initially occurring every 3 to 4 hours. By 6 months of age, a more prolonged sleep period occurs during the night. REM sleep time occupies as much as 80 percent of sleep time in the newborn, with a steady decrease until only approximately 20 percent of sleep is REM in the adult. Sleep spindles appear at approximately 2 years of age. During adolescence, sleep requirement increases, and the sleep pattern is one of phase delay. 8 Because school schedules do not allow for late awakening, the most common cause of daytime sleepiness in this age group is insufficient sleep. In adulthood, the need for sleep is relatively constant. With aging, sleep tends to become more fragmented, and night sleep may decrease with a corresponding increase of daytime napping. With aging, the amount of SWS decreases. Although REM sleep time remains stable with aging,...

Anxiety and Obsessive Compulsive Disorder Syndromes

Anxiety is an extremely common occurrence that affects everyone at some time and is characterized by an unpleasant and unjustified sense of fear that is usually associated with autonomic symptoms including hypervigilance, palpitations, sweating, lightheadedness, hyperventilation, diarrhea, and urinary frequency as well as fatigue and insomnia. Anxiety is thought to be mediated through the limbic system, particularly the cingulate gyrus and the septal-hippocampal pathway, as well as the frontal and temporal cortex. The term anxiety disorder is used to denote significant distress and dysfunction resulting from anxiety, including panic attacks and anxiety with specific phobias. Chronic, moderately severe anxiety tends to run in families and may be associated with other anxiety disorders or depression. The differential diagnosis of anxiety states includes other psychiatric conditions such as anxious depression as well as schizophrenia, which may present as a panic attack with disordered...

Reactions resulting from fi blockade

Central nervous system effects occur with some P-blockers, including nightmares, hallucinations, insomnia and depression. These effects are more common with the lipophilic drugs (e.g. propranolol, aceb-utolol, oxprenolol and metoprolol). Gastrointestinal reactions include nausea, vomiting and diarrhoea.

Anxiety and Depression

If anxiety is severe enough to require drug therapy, a ben-zodiazepine such as lorazepam (Ativan), 0.5 to 1 mg two or three times a day, may be effective. Antidepressants such as nortriptyline (Pamelor), desipramine (Norpramin), and doxepin in low doses (25-75 mg at bedtime) have analgesic properties and can help with insomnia and agitation. Selective serotonin reuptake inhibitors (SSRIs) and sero-tonin-norepinephrine reuptake inhibitors (SNRIs) may also be effective. Mirtazapine may provide the advantage of improved sleep and appetite. Psychostimulants such as methylphenidate (Ritalin), 2.5 to 10 mg orally at 9 am and 12 noon, take effect quickly and can relieve depression and pain in some terminally ill patients, especially when prognosis is limited (Block, 2000).

The Patient with Posttraumatic Stress Disorder

Hyperarousal symptoms include difficulty in falling or staying asleep, irritability, outbursts of anger, difficulty in concentration, overprotectiveness of oneself or others, and an exaggerated startle response. People who were abused in a bed commonly experience insomnia. People with an exaggerated startle response may jump at loud noises or if someone touches them on the back.

Keeping Track Of Your Side Effects

* Examples dry mouth, urinating frequently, rash, acne, stomachaches, insomnia, headaches, fatigue, hair loss, problems with concentration, hand tremor, If you're not sure which medication causes which side effect, simply list each side effect you experience and put a * next to each one.

Fibromyalgia Tired of Being Sick and Tired

Myalgia (muscle pain) characterizes this often-devastating chronic rheumatic pain disorder of unknown cause. The pain is usually described as achy but a few patients tell me they can also experience burning, throbbing, stabbing, or shooting pain. To make this dish sound even more appetizing, fibromyalgia is often accompanied by side orders of chronic headaches, strange skin sensations, temporomandibular joint pain (TMJ), insomnia, irritable bowel syndrome (IBS), anxiety, palpitations, fatigue, poor memory, painful menstruation, and depression. Fibromyalgia occurs mostly in women, many of whom have experienced insomnia, anxiety, stress, or depression along with the muscle aches. The symptoms are often severe enough to greatly interrupt their normal life and, in many cases, patients are unable to stay at work or continue normal household activities like cooking, childcare, or shopping.

Clinical Characteristics

Sleep disturbance is a common feature of delirium. The sleep-wake cycle may be reversed, or sleep may be fragmented and limited. Melatonin is related to the regulation of circadian rhythms, and changes in levels of melatonin may have a role in the sleep disturbance of delirium (Balan et al. 2003).

N H Uro Physio Logic Al Investigations

Deep sleep induces large, irregular 5 waves interspersed with alike activity. REM or paradoxical sleep occurs with rapid low-voltage irregular EEG activity, resembling arousal. Wakening during this period is associated with reports of dreaming. REM periods occur approximately every 50 min and occupy a total of 20 of the young adult's normal sleep time. They are associated with a marked reduction in skeletal muscle tone. Repeated awakening during REM sleep produces anxiety and irritability with an increased percentage of REM sleep in subsequent undisturbed nights.

Neurophysiological Bases Of Evoked Electrical Brain Activity

Evoked potentials are systematic changes of the EEG induced by incoming information to the brain. Every sensory stimulus elicits electrical activity that is projected by selective and specialized afferent fiber systems to the corresponding cortical sensory areas, where it induces changes of the ongoing electrical activity. These changes depend on (1) the function state of the brain (information processing is different during various sleep stages and in differ

Causal Inference Goes Beyond Covariation Tracking

Our consideration shows that, contrary to the causal mechanism view, prior knowledge of noncausality neither precludes nor refutes observation-based causal discovery. Thagard (2000) gave a striking historic illustration of this fact. Even though the stomach had been regarded as too acidic an environment for viruses to survive, a virus was inferred to be a cause of stomach ulcer. Prior causal knowledge may render a novel candidate causal relation more or less plausible but cannot rule it out definitively. Moreover, prior causal knowledge is often stochastic. Consider a situation in which one observes that insomia results whenever one drinks champagne. Now, there may be a straightforward physiological causal mechanism linking cause and effect, but it is also plausible that the relation is not causal it could easily be that drinking and insomnia are both caused by a third variable - for example, attending parties (cf. Gopnik et al., 2004).

Depression and Physical Symptom Perception

Pediatric patients with depression often have co-occurring physical symptoms, which include joint pain, limb pain, back pain, gastrointestinal problems, fatigue, weakness, and appetite changes. Chronic abdominal pain and headaches are particularly common manifestations of depression in children, although other physical symptoms may include diarrhea, insomnia, and nervousness (Croffie et al. 2000 Deda et al. 2000).

Primary Mood Disorders

Physically ill pediatric patients must meet the full DSM-IV-TR criteria for primary depressive episode for this diagnosis to be made however, no standardized approach currently exists for diagnosing depression among individuals who are physically ill. Clinicians are challenged to determine whether the classic signs and symptoms of clinical depression, such as dysphoria, anhedonia, fatigue, pain, psycho-motor retardation, anorexia, weight loss, cognitive impairment, and insomnia, represent demoralization, the physical illness itself, the effects of medical treatments, and or prolonged separations from family and friends. The presence of feelings of worth-lessness, inappropriate guilt, diminished ability to think, or suicidal thoughts is generally more consistent with the diagnosis of a primary depressive episode (Goldston et al. 1994). Youngsters at risk for a primary depression are those who have had a previous depressive episode, histories of parental depression, adverse family...

General Medical Therapy

Corticosteroids provide symptomatic improvement in most patients with increased intracranial pressure from edema. The effects of corticosteroids appear within 24 to 48 hours after the initial administration and usually peak at 1 week. Steroids produce a significant reduction in brain tumor volume and an even greater reduction in peritumoral edema, but they are not without pitfalls. The side effects of long-term glucocorticoids are well known and have the potential to cause disability greater than that produced by the tumor itself, particularly in the form of insomnia, steroid-induced (proximal) myopathy, facial adiposity, osteoporotic compression fractures, and non-dose-related risk of aseptic necrosis of the hip.25

Sleep Stress And The Restoration Of Brain And Mind Introductory Remarks

More research has been done on sleep mechanisms than any other state-control processes of the brain. We now know the locations of the major circuits that control slow-wave sleep (SWS) as well as those periodic arousals that are full of vivid emotional dreams and rapid eye movements (REM sleep). We know much about the neurophysiological changes that reflect these natural tides of the brain and the major neurochemistries that control these passages of consciousness, but rather little about the adaptive functions of sleep stages at a scientific level. as it often is to get to sleep, one usually wakes feeling emotionally less burdened. Was it simply due to the passage of time and ensuing forgetfulness, or was there an active emotional restoration process proceeding under the cover of our daily doses of unconsciousness during SWS and or altered consciousness during REM sleep No one knows for sure, but the number of intriguing, psychiatrically relevant findings that are emerging...

Restorative Effects of Sleep

As mentioned above, sleep problems are common in psychiatric disorders. Again, the most prominent example is the tendency of depressed individuals to sustain sleep poorly and to wake in the middle of the night, partly because their pituitary adrenal stress waking alarm system become active much earlier than normal (Kryger et al., 2000). Other features include an excessively rapid entry into the REM phase after sleep onset. Since sleep recruits endogenous antistress mechanisms and depression impairs quality sleep, the sleep problems of depression may tend to perpetuate ongoing problems. Although there is likely some truth to that hypothesis, such a problem would have to reside within the disruption of SWS rather than REM. A remarkable finding is that REM sleep deprivation is a fairly effective short-term antidepressant, and practically all of the pharmacological antidepressants are excellent REM sleep inhibitors (Kryger et al., 2000). One could construct a provisional explanation by...

Are sedativeshypnotics ever indicated in chronic low back pain

The role of sedative-hypnotics in chronic spine pain is controversial. Adequate restorative sleep is very important for patients with chronic spine pain. Many spine patients have sleep difficulties. The two hypnotics used most often are zolpidem (Ambien) and eszopicine (Lunesta). Limited data suggest zolpidem is somewhat more effective but also has more adverse effects, the most serious of which include sleep walking, talking, and eating, as well as some memory loss. The most serious adverse effects of eszopicine include a very bad taste in the mouth and feelings of anxiety. However, both drugs are generally preferred over the benzodiazepines, such as clonazepam or temazepam (Restoril). Long-acting drugs, such as diazepam or flurazepam (Dalmane), may accumulate with chronic use and produce cognitive impairment and depression, and there may be rebound insomnia when the drugs are discontinued.

Graduate Medical Training

1Bibliographic searches were conducted of the primary biomedical bibliographic databases, MEDLINE, EMBASE, CINHAL, and Psychlnfo. The searches included articles from January 1980 to January 2008. The terms used for these searches, many in combination with each other, included resident(s), residency, internship, fatigue, sleep, sleep disorders, burnout, mood, depression, work schedule(s), work hours, 80-hour workweek, adverse events, medical errors, job satisfaction, handoffs, handovers, transitions, mortality, patient outcomes, patient safety, quality of care, medical education, graduate medical education, workload, and performance. Publications dated after January 2008 were added to the evidence base of this report as they became available or were brought to the attention of IOM staff.

Impact on Younger Children

Children from 3 to 5 years of age who go through divorce tend to be fearful and resort to immature or aggressive behavior in the immediate aftermath. They often have difficulty falling asleep at bedtime or sleeping through the night. They might return to security blankets or old toys. Some may have lapses in toilet training. But these types of behavior rarely last for more than a few weeks or months. Most children are confused about what is happening or about why mom or dad has left. Children often try to deny that anything has changed.

The Dark Side Develops

Tim, an Iraq veteran who lost both legs in a roadside ambush where most of his buddies died, has been taking drugs for years. He's been diagnosed with Post-traumatic Stress Disorder (PTSD) and uses several drugs, including alcohol, to help him relax and sleep. He is distressed that he has gradually needed more and more drugs to get to sleep, even for a short time. This has added to his troubles because of the increasing cost, and searching for drugs seems to dominate his activities. He is beginning to worry that he is addicted.

Why Do Patients Sometimes Not Comply With Treatment

Epilepsy is a chronic disorder with intermittent symptoms, the treatment of which is often associated with adverse effects. Therefore, problems with compliance are expected and frequently occur. Many patients whose seizures are well controlled will experiment with reducing or discontinuing their medication. Most patients who are receiving long-term pharmacotherapy occasionally forget one or more doses. In some cases, they frequently forget certain doses, such as the midday dose (because they are at work or busy) or the bedtime dose (because they fall asleep first).

Clinical Features

The pineal gland is richly innervated with sympathetic noradrenergic input via a pathway originating in the retina and coursing through the suprachiasmatic nucleus of the hypothalamus and the superior cervical ganglion.31 Upon stimulation, the pineal gland converts sympathetic input into hormonal output by producing melatonin, which in turn has regulatory effects on hormones such as luteinizing hormone and follicle-stimulating hormone.16 The pineal gland can be considered a neuroendocrine transducer that synchronizes hormonal release with phases of the light-dark cycle by means of its sympathetic input. However, the exact relationship between the pineal gland and human circadian rhythm remains unclear and is an active area of investigation.

What Practitioners Say It Does

Biofeedback therapies were developed to treat a wide range of symptoms and problems, including stress, urinary incontinence, sleep disorders, Raynaud's disease, migraine headache, hypertension, addictions, vascular disorders, and many others. The procedure involves focusing the mind on a biological function and mentally visualizing or picturing the desired change. This might be warming the temperature of one's hands, tightening blood vessels to eliminate headaches, or inducing other physiological events to help relieve the particular disorder. According to practitioners, biofeedback creates a greater awareness of specific body parts and their functions. With training, increased awareness of physiologic functions enables the patient to regulate these functions.

Monoamine Reuptake Inhibitors

Is produced rapidly in humans, with peak plasma levels of up to 3 times those of bupropion and a half-life of 24 hr. Therefore, orally administered bupropion is likely to lead to significant NE reuptake inhibition and relatively less DA reuptake inhibition. Bupropion increases locomotor activity and causes stereotyped behaviors in laboratory animals. In humans, it can cause restlessness, insomnia, anorexia, and psychosis. Bupropion is structurally related to phenylethylamines and unrelated to the TCAs, SSRIs, or MAOIs. It has no significant potency at binding to any known neurotransmitter receptors. Clinical studies have demonstrated that bupropion is effective in the treatment of major depressive episodes (Depression Guideline Panel, 1993). While early studies suggested that bupropion might be less likely to cause hypomania or mania in bipolar patients, subsequent studies suggested that it can cause mania and psychosis in bipolar patients, especially those with high pretreatment...

Monoamine Releasing Agents

Monoamine releasing agents are rapidly metabolized into inactive compounds and generally have relatively short half lives (4 to 8 hr). The most common side effects are insomnia, drowsiness, restlessness, nausea, weight loss, weight gain, and hypertension. At high doses these agents can cause a characteristic paranoid psychosis. These drugs are generally well tolerated in the clinical dose range (5 to 30 mg d-amphetamine day), with most patients experiencing no side effects and insomnia being the most common side effect reported.

Upon completion of this chapter the reader will be able to

Articulate the incidence and prevalence of sleep disorders, list the sequelae of undiagnosed or untreated sleep disorders, and appreciate the importance of successful treatment of sleep disorders. 2. Describe the pathophysiology and characteristic features of the sleep disorders covered in this chapter including insomnia, narcolepsy, restless legs syndrome (RLS), obstructive sleep apnea (OSA), and parasomnias. 3. Assess patient sleep complaints, conduct sleep histories, and evaluate sleep studies to recognize daytime and nighttime symptoms and characteristics of common sleep disorders. 4. Recommend and optimize appropriate sleep hygiene and nonpharmacologic therapies for the management and prevention of sleep disorders. 5. Recommend and optimize appropriate pharmacotherapy for sleep disorders. 6. Describe the components of a monitoring plan to assess safety and efficacy of pharmacotherapy for common sleep disorders. 7. Educate patients about preventive behavior, appropriate lifestyle...

Epidemiology and etiology

Approximately 50 of adults will report a sleep complaint over the course of their lives. In general, sleep disturbances increase with age, and each disorder may have gender differences. The full extent and impact of disordered sleep on our society are not known because many patients' sleep disorders remain undiagnosed. Normal sleep, by definition, is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment. As a result, individuals with sleep disorders will exhibit or complain about consequent symptoms (e.g., daytime sleepiness), or a bed partner will observe hallmark characteristics of the sleep disorder. Insomnia, restless legs syndrome (RLS), and sleep-related breathing disorders are the most common sleep disorders.

Psychiatric Assessment

The psychiatric assessment must include particular attention to symptoms of restricting, purging, binge eating, and exercising, as well as feelings about shape and weight. Anxiety and compulsive behavior around food and weight require investigation. The presence of depressed mood, anhedonia, insomnia, decreased energy, and flattened affect must be explored given their associations with malnutrition (Franklin et al. 1948 Keys et al. 1950). Noting the time of onset of depression symptoms relative to disordered eating symptoms is important to help differentiate a primary depressive disorder from an eating disorder.

Neurophysiological and Neurochemical Mechanisms

Several studies with animals indicate that the frequency of time spent in REM sleep increases as a result of new learning, such as finding the way out of a maze. This relationship is evident in work conducted with cats, mice, rats, and newly hatched chicks. Therefore, rapid eye movement (REM) sleep may play an important role in the consolidation of such cognitive activities as learning, memory, and problem solving for both humans and other organisms that engage in REM sleep. The role of learning in REM sleep production may be connected to an underlying biological process. It has been suggested that new protein structures are being synthesized in the brain during REM sleep. Evidence indicates that the initiation of REM sleep does come from the brain stem, and then extends itself over the entire brain cortex. Because animal experiments indicate that protein synthesis is present in new learning, it has been hypothesized that it also takes place during REM sleep. Some theorists have used...

Understanding Tolerance Dependency Addiction and Withdrawal

Physical dependence and withdrawal occur with the chronic use of opioids, but they are not psychological phenomena and therefore are completely unrelated to addiction. Physical dependence means that withdrawal symptoms might occur if the drug is suddenly stopped. These symptoms include anxiety, irritability, alternating chills and hot flashes, excessive salivation, tearing eyes (lacrimation), runny nose, nausea, vomiting, abdominal cramps, insomnia, sweating (diaphoresis), and goose bumps (piloerection). Physical dependence is easily treated, thereby avoiding withdrawal, by gradually decreasing the daily doses of the opioid, for example, by 10 to 25 percent. Once a low daily dose of morphine (20 mg orally) is reached, the opioid can be discontinued without withdrawal symptoms occurring.

Acute stress disorder

To satisfy the criteria for the diagnosis of ASD, the individual must display acute dissociation (emotional numbing, derealization, depersonalization, reduced awareness of surroundings, dissociative amnesia), reexperiencing phenomena (intrusive memories, nightmares, flashbacks), avoidance (effortful avoidance of thoughts, conversations or places reminiscent of the trauma), and arousal symptoms (insomnia, heightened startle response, concentration deficits) (Bryant, 2001). Due to the difficulties associated with the issue of PTA and the reexperiencing of the event, some investigators (e.g., Warden et al., 1997) have proposed that the criteria for the diagnosis of PTSD be modified in the context of TBI to exclude the reexperiencing phenomena.

Nurses Responsibilities

Inpatient rehabilitation nurses monitor the vexing medical complications that accompany neurologic disease and immobility. Nurses initiate passive range of motion of paretic limbs, follow through on preventative measures for deep vein thrombosis, and turn an immobile patient every 2 hours, along with other measures to prevent pressure ulcers over bony prominences. They protect patients from being pulled across the bed, which can shear the skin, and work out ways to prevent incontinence so that moisture does not macerate the skin. Nurses also educate ancillary hospital personnel who might tug and sublux a paretic shoulder. Other responsibilities include assessments for sleep disorders such as apneic spells, respiratory function, swallowing, nutrition, and bowel and bladder function training in self-catheterization, care of skin and self-medication education about disease and personal matters such as sexuality and practice in self-care skills outside the formal therapy setting. Nurses...

Conscious processes are maintained by specific activating systems

The understanding of the brain mechanisms that sustain attention and consciousness was also greatly advanced by previous studies showing that electrical stimulation of the brain stem in lightly anesthetized cats produces the electroencephalographic pattern of arousal that is characteristic of attention and alertness 23 . Lesions of the same regions in monkeys also produce various coma-like states that resemble deep sleep. Some of the neural networks that control arousal and attention are embedded in what was initially known as the ascending reticular activating system, shown in Fig. 5.1 23 . In higher animals, including humans, this neuronal network reaches the intralaminar

Experiences require binding for integration into consciousness

As indicated previously, neurologists and neurosurgeons discovered that small tumors or cysts in the base of the brain or in the pituitary gland produced progressive loss of consciousness and coma, which in some cases were reversible after an operation. Additional studies made it clear that the mechanisms of wakefulness, sleep, and maintenance of consciousness take place through synchronization of an activating system that includes multiple brain regions.6 We now know that wakefulness is associated with a low-amplitude, high-frequency electroencephalogram, whereas deep sleep (physiological unconsciousness) is characterized by high-amplitude, low-frequency waves 43, 45, 49 . In addition, the level of consciousness during anesthesia can be accurately predicted by sophisticated analysis of the electroencephalogram 50 .

Epidural Steroid Injections

Complications of epidural injections include generic considerations for any invasive procedure (local tissue trauma, bruising, pain, infection) as well as those specific for trauma to the local spinal tissues, medication or steroid related side effects, and those associated with x-ray exposure during fluoroscopy. Minor complications including dural puncture with subsequent spinal headache, increased pain, elevated blood sugar level or blood pressure, sympathetic mediated symptoms such as flushing or vasovagal response and acute insomnia have been described and occur infrequently. Botwin et al reported an overall complication rate during fluoroscopically guided ESIs as occurring in less than 10 for lumbar injections13 and approaching 17 for cervical ESIs.14 Caudal injections had a rate of minor complications of 15.6 ,15 and for the thoracic spine, a 20.5 rate was reported.16 Intravascular needle placement has been noted in about 10 to 20 of lumbar injections.17 Subarachnoid needle...

From the ancient Greeks to recent times

About 900 bce, Homer described a chieftain, Asclepius, who came to be seen as a god of healing. People were brought to his temples in the hope that he might visit them in their sleep and cure them. It took about another five hundred years for a rational school of philosophy to develop and for people to start to think more logically about sleep. Alcm on, a Greek medical writer and philosopher-scientist, living around 450 bce, was one of the first. He proposed that sleep was caused by blood flowing away from the surface of the body into large vessels and that we awake when it flows back into the body again. His ideas seem to have been taken up and modified by Hippocrates and Aristotle. Hippocrates developed a theory of the benefit or harm of sleep by observing its medical effects. He noticed that both excessive sleepiness and insomnia were undesirable and that people who were ill either slept a lot or were tired. On the other hand, sleep could restore the ill to health. Aristotle...

Diagnosis and Disability

For example, although depression is widely acknowledged to be a major source of disability (Jans et al. 2004 Murray and Lopez 1996), not all individuals with depression experience symptoms that cause functional impairment. Symptoms associated with depression, such as psychomotor retardation, insomnia, and impaired memory and concentration, can be disabling. However, depression can be experienced as an uncomfortable or distressing mood state whose symptoms do not create impairment that significantly interferes with work function (Gold and Shuman 2009).

The neuronal origin of sleep the sleep circuit

Current thinking is that we have specific neural circuits that keep us awake and if these are switched off we fall asleep. These neurons are in the reticular activating system in the brainstem. Signals from this system feed into the thalamus, which combines them with the sensory information it is receiving and relays it all to the cortex. The system uses a neurotransmitter, glutamate, which tends to activate nerves and therefore acts like a gate, allowing the passage of sensations to the thalamus and thence to the cortex. If this gate closes, we become insensible to the outside world, which is why we can sleep through noise or movement. There is a second wakefulness system in the hypothalamus, which is part of the autonomic nervous system and therefore responsible for regulating heart rate, breathing, sweating and other automatic processes. Signals spread from here When we are awake, our neurons fire in an organized, yet unpredictable, way. An EEG reflects this, showing apparently...

Assessment of Disability

Nevertheless, not every psychiatric symptom will cause work-related impairment in every individual, and not every individual who has a psychiatric symptom, or even a psychiatric disorder, will necessarily experience work impairment or disability. Someone suffering insomnia may have impaired judgment if his or her job involves flying planes or carrying a weapon, he or she may be functionally disabled, even if other prominent symptoms of depression are not present. Conversely, a sales representative or administrative assistant experiencing insomnia may be able to function adequately, even if not at the highest level of productivity, without creating undue risk to himself or herself or the public.

Prevalence and incidence of secondary affective disorders including demographic and psychiatric correlates

Varney, Martzke, and Roberts (1987) used a sample of 120 individuals diagnosed using the DSM-III, ranging in duration of coma from a few minutes to 8 days, who were interviewed at least two years (mean 3.4 years, range 2 to 8 years) following the injury. Ninety-two of the 120 (77 ) reported at least 6 of a list of depressive symptoms (i.e., poor memory or concentration 96 anergia 96 low libido 91 indifference 90 irritability 87 insomnia 87 dysphoria 85 anorexia 77 crying spells 67 suicidal ideation 51 social withdrawal 37 ) in contrast to a control group of back-injured subjects only 38 (23 60) of whom reported 6 symptoms. Of the subjects with depression, 46 (42 92) reported that their depressive symptoms did not commence until at least six months after the injury (an observation reported by the investigators and verified by the families of origin). Shukla, Cook, Mukherjee, Godwin, and Miller (1987) used the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L)...

Loss of Arousal Regulation

Elementary self-regulation involves an interconnected collection of neural patterns that maintain bodily processes and that represent, moment by moment, the state of the organism (Damasio, 1999). The immediate response to a traumatic experience involves dysregulation of arousal, with (a) exaggerated startle response, (b) over- or under-aroused physiological and emotional responses, (c) difficulty falling or staying asleep, and (d) dysregulation of eating, with lack of attention to needs for food and liquid. In people who develop PTSD, this pattern of disordered arousal persists.

Clinical Manifestations and Pathology

Convulsive or spasmodic ergotism affects the central nervous system, causing areas of degeneration in the spinal cord. Early German accounts mentioned tingling and mortification in the fingers and toes, with occasional extension to the rest of the body, and vomiting, diarrhea, intense hunger, anxiety, unrest, headache, vertigo, noises in the ear, stupor, and insomnia as symptoms. Often the limbs became stiff, accompanied by convulsive contractions of the muscles which led to staggering and awkward movements, often aggravated by being touched. Although many victims recovered, symptoms sometimes remained for long periods, resulting in permanent stiffness of the joints, muscular weakness, optic disorders, and occasional imbecility. In the 1930s, Ralph Stockman demonstrated that convulsive ergotism was caused by poisons (phytates) normally present in rye and other grains which, unless broken down in the bowel, were absorbed, creating lesions in the nervous system.

Individual Psychotherapy

Psychotherapy is the treatment modality unique to mental health clinicians. Within its framework, the child seeks to integrate the facets of his or her life. Through words, art, and play, the child conveys the experience of living with the threat of loss and transforms the essence of his or her reality into expression. Self-help techniques, such as relaxation, guided imagery, and hypnosis, may be integrated into the psychotherapy to reduce symptoms of nausea, fatigue, insomnia, and pain (Kazak 2005 Kazak et al. 1996 Kersun and Shemesh 2007 Steif and Heiligenstein 1989). These techniques are not restricted to psychotherapeutic intervention and may be employed by other disciplines trained in their methodology.

Impact of Duty Hours on Resident Well Being

More recently, a national sample of 682 interns who completed 12 monthly surveys reported being involved in 133 crashes during the year, 131 of which occurred upon leaving work (Barger et al., 2005). Interns were 2.3 times more likely to be involved in a crash after working extended shifts (their duty periods averaged 32 hours, during which they averaged less than 3 hours sleep) than those not working extended duty periods. These first-year residents were 5.9 times more likely to experience near-miss crashes after extended duty periods than after non-extended shifts. After five extended duty periods in a month, the risk of falling asleep while driving or stopped in traffic significantly increased (while driving OR 2.39, CI 2.31-2.46 stopped OR 3.69, CI 3.60-3.77) (Barger et al., 2005). Similarly, an earlier survey conducted by Steele and colleagues showed that emergency medical residents were at greater risk of being involved in near-miss or collision incidents after working a night...

Hemicrania Continua HC Treatment of Hemicrania Continua

Clearly, some patients cannot tolerate the central nervous, gastric, or renal side effects of this harsh drug additionally there are patients, such as those with diabetes, renal and or hepatic dysfunction, those on anticoagulation, or those with bleeding issues, who will never be able to take the medication. For these patients there are rays of hope in case reports showing benefit from high-dose melatonin, gabapentin, topiramate, and celecoxib. Ipsilateral occipital nerve stimulation and greater occipital nerve blocks are other approaches described as sometimes helpful. Greater occipital nerve block is easily performed and should always be considered early, in the hope it will induce long lasting relief.

Naps are essential for every twoyearold How can I accommodate this basic need in a treatment program that is

In most of the cases I work with, parents decide that therapy is a priority over naptime. In the beginning, it can be difficult because your child may get irritable and may even fall asleep during a treatment session (this happened to Jake initially). But parents often find that by changing their children's schedules so that bedtime is earlier and the morning routine more disciplined, their children are able to adjust to new, more demanding schedules with few problems.

Major Depression Definition

The DSM-III diagnosis of major depression requires a persistent period of dyspho-ric mood or loss of interest or pleasure and at least two weeks of four other symptoms, which may include significant weight loss or gain, appetite disturbance, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, inappropriate guilt, impaired concentration, recurrent suicidal ideas or a suicide attempt (APA, 1980). The DSM-III-R criteria are similar, but specify a two-week period of at least five symptoms, one of which must be depressed mood or loss of interest or pleasure (APA, 1987).

Different types of memory and learning are processed and stored in functionally distinct brain regions

Patients with bilateral removal of the hippocampus, such as Penfield's patient H.M., have intact long-term memory for events that occurred before the operation, but they lose the capacity to transfer their short-term (declarative) memory into long-term storage. These patients can remember names or events for seconds to a few minutes, but once they are distracted, they can never recollect what they apparently knew a few minutes earlier. They present the symptoms of a severe Alzheimer's disease. The hippocampal formation is now well established as being essential for consolidating declarative short-term into long-term memory, even though the precise mechanisms are not fully known. Interestingly, the same hippocampal cells active during the memory-learning period are also active during sleep. This re-playing of neuronal activity in hippocampal circuits during sleep is thought to be involved in memory consolidation in rats 14 . The deprivation of REM sleep in humans also has a negative...

Part with Postpartum Depression

Postpartum depression affects approximately 10-20 percent of new mothers, and usually appears between two to eight weeks after delivery. This is different from postpartum blues (sadness, anxiety, insomnia, and weepiness) that appear within several days of delivery and go away in 10-12 days. The blues are common, affecting between 50 and 80 percent of all new mothers.

Oxycontin and Other Opiates

Because of the medical importance of this group of compounds, there are many different opiates produced and made available for treating humans. Heroin is one of the most dangerous opiates. It is quickly converted to its active metabolite and gets into the brain rapidly. There is a period of intense euphoria followed by feelings of tranquility. Withdrawal produces a craving for the drug, anxiety, insomnia, irritability, cramps and muscle aches. Withdrawal can last five to ten days and is unpleasant, although it is usually not life threatening. Overdose is a danger and if death occurs, it is often due to

Malingered Conditions

Mental health clinicians should bear in mind the malingered conditions that they may encounter in forensic and nonforensic settings. Literature reviews demonstrate that malingered conditions include dissociative identity disorder (McConville and LeBourgeois 2008), psychosis (Greenfield 1987), suicidally (Rissmiller et al. 1999), and PTSD (Frueh et al. 1997). Malingered conditions that cross the spectrum of psychiatry and neurology that have been reported include acute dystonia (Rubinstein 1978), amnesia (Bolan et al. 2002), chronic pain (Greve et al. 2009), cognitive deficits (Iverson and Binder 2000 Sweet 1999), dementia (Gittelman 1998), seizure (DeToledo 2001), and sleep disorder (Mahowald et al. 1992). Additionally, there are now several case reports documenting malingering by proxy behaviors, in which caretakers induce or report illness in a dependent in order to reap some external incentive for example, disability payments or controlled substances for the presumed benefit of the...

Paying Attention to the Audience

Although you should be sensitive to the mood of the entire audience, you should not overreact to the reaction of any one individual. For instance, you might encounter an audience member whose countenance is so angry that it frightens you to the point of distraction. In such cases, it is best not to look directly at that person. Perhaps that person has had an awful day and the expression of anger is not for you, but for someone else. Other times, you might have an audience member who is going to fall asleep on you no matter how well you present. In such cases, let the person sleep and focus on the rest of the audience. Perhaps that person has a new baby, and for that person your presentation is going to be the only quiet hour of the day.

Immediate postoperative care

Optimal immediate postoperative management involves appropriate analgesia and nursing. Sound nursing measures also have a profound impact on reducing the level of postoperative discomfort and pain. Giving the animal attention at regular intervals helps reduce the distress associated with pain and the unfamiliar environment, otherwise a cycle of pain distress sleeplessness can develop.

Treatment Interventions

More data have been reported on psychothera-peutic interventions in adults with CKD. Sleep disturbance, for example, is a commonly reported complaint of adults receiving dialysis (Iliescu et al. 2004 Novak et al. 2006). In a randomized, controlled prospective study, 24 adults who were undergoing peritoneal dialysis and who had insomnia were given a 4-week trial intervention with cognitive-behavioral therapy (CBT) (Chen et al. 2008). Results from the study included improvements in sleep quality and decreased daytime fatigue. In another investigation, a group CBT intervention was used to enhance adherence to fluid restriction in a group of adults receiving hemodialysis (Sharp et al. 2005). During the 4-week treatment, no significant improvement was seen in the immediate-treatment group when compared to a delayed-treatment group. However, the group receiving immediate treatment did demonstrate significant improvements at a 10-week follow-up assessment.

Had Enough Let Go of Stress

Oriental nutritional recommendations borrow much from the herbal culture. Both, to be the most effective, are individually prescribed by a qualified practitioner that examines and balances your whole system. If you had been experiencing chronic stress that resulted in erratic moods, insomnia that began after early waking, a red- to scarlet-tipped tongue, and increased thirst, an Oriental Medical diagnosis of deficient

Who should be considered for treatment

As to the objective signs of relative androgen deficiency, although a decrease of muscle mass and strength and a concomitant increase in central body fat and osteoporosis can most easily be objectified, they are not specific signs. Decreased libido and sexual desire, loss of memory, difficulty in concentration, forgetfulness, insomnia, irritability, depressed mood as well as decreased sense of well-being, are rather subjective feelings or impressions, less easily objectified and certainly difficult to differentiate from hormone-independent aging. Complaints of excessive sweating are not uncommon, whereas true hot flushes do occur in elderly men, although they are mainly prevalent in severe acquired hypogonadism such as under hormonal treatment for prostate cancer.

Depression Checklist Are You at Risk

> Insomnia, oversleeping, or early morning waking > Insomnia, fatigue, headache, stomachache, and dizziness One of the most common diagnoses in traditional Oriental Medicine is heart-blood deficiency As you can tell by the name, this condition deals with issues concerning the heart organ or channel. These issues are usually emotional. Blood deficiency implies an energetic weakness. This usually presents itself as palpitations, insomnia, poor memory, dizziness, jumpiness, dull complexion, confusion, and lack of concentration.

Evidence Based Treatment

Psychostimulants are often used to treat ADHD in children with HIV, although dosing is not well established and efficacy is variable. Often, higher dosages of stimulants are required to achieve scholastic benefit but need to be balanced against appetite loss, growth retardation, and insomnia, which are often significant issues for children with HIV. Clonidine, bupropion, and atomoxetine use in HIVpositive youth has also been described (Cesena et al. 1995 Pao and Wiener 2008). Treatment for behavioral disorders such as repetitive and persistent patterns of aggressive behaviors, serious violations of rules, and destruction of property (American Psy For treatment of depression in HIV-positive youth, current treatment guidelines for the management of depression in children can be followed. Antidepressants, including tricyclic antidepressants as well as SSRIs and bupropion, have been used empirically, and off label in many cases, in youth with HIV (Pao and Wiener 2008). There is no...

Oriental Medicine Manages the Immune System

Many of the secondary infections and symptoms of HIV AIDS can be treated with acupuncture and herbs. About 75 percent of gastrointestinal conditions such as appetite, digestion, bowel problems, and weight stabilizations, show improvement patients also report reductions in pain, fevers, night sweats, sore throats, and sleep disorders.

Specific Psychopharmacologic Considerations

The mood stabilizers and atypical antipsychotics are extremely useful as augmenting medications added to an adequate antidepressant dose that is not fully effective. Patients need not be psychotic or manic to benefit from the addition of these agents. The atypical antipsychotics are quite useful for nonpsychotic patients in severe depressive and anxiety states, with insomnia and agitation that do not immediately respond to antidepressants (Kaplan, 2000). These medications carry a much smaller risk of extrapyramidal motor system side effects or tardive dyskinesia than do the conventional antipsychotics since they occupy the dopamine receptors only transiently. The risk of tardive dyskinesia is estimated to be approximately 0.3 percent for these atypical agents. Sedation can be a significant initial side effect of quetiapine or olanzapine, though patients frequently develop tolerance to this effect. Weight gain occurs in most patients given olanzapine or mirtazapine, which can...

These letters appear before rmab which stands for monoclonal antibody

Ment model, with a terminal half-life of 19 to 28 days. Severe congestive heart failure may occur with concurrent anthracycline administration. Cardiac toxicity may be seen when the drug is administered months after anthracycline administration, so patients must be counseled on the signs and symptoms of heart failure. Other side effects include hypersensitivity reactions, fever, diarrhea, infections, chills, cough, headache, rash, and insomnia.

Patientreported outcomes and Cochrane reviews

Systematic review authors will select PROs for inclusion depending on the scope and aims of their review. PROs are most important when externally observable patient-important outcomes are unavailable, or rare. For many conditions, including pain, functional disorders, sexual dysfunction and insomnia, no satisfactory biological measures are available. Conditions in which outcomes are known only to the patients themselves, such as pain intensity and emotions, demand PROs as primary outcomes. PROs are also important when observable outcomes are available, because they reflect directly what is important to patients.

Acu Points to Relieve the Fatigue

Tiredness that is worse at midday, palpitation, poor memory, insomnia, dizziness, and dream-disturbed sleep. The conditions we've just discussed take consistent effort and follow-through to achieve desirable results. I believe that Oriental Medicine can make a significant contribution to your health, and would also urge you to incorporate an entire health team to bring the best possible care during the course of your treatments. But don't fall asleep on me now because we talk about insomnia, weight loss, and other tricky conditions in the next chapter Insomnia Cruisin' for a Snoozin' There's nothing more refreshing than to greet the day after a good night's sleep. It's equally frustrating to be part of the estimated one-third of Americans (twice as many women than men) that suffer from some form of insomnia. Seniors make up about 50 percent of all those who suffer from sleep disorders, but I'm seeing a growing number of adolescents and adults who complain...

Acu Points to Soothe You to Sleep

Oriental Medicine takes a look at your overall health patterns and factors them into your sleep disorder. We first separate the sleep problems difficulty falling asleep (deficient blood condition), staying asleep (deficient yin condition), or both (deficient blood and yin). Sleep position is examined as well. Watch your intake of alcohol and narcotics. Alcohol can help you relax and fall asleep, but it often causes you to wake up in the middle of the night Fifty percent of people who regularly take sleeping pills worsen their insomnia. Chronic sleeping pill users are 50 percent more likely to die in automobile accidents than nonusers. Locate Yintang (Seal Hall) in between your eyebrows. Use your index fingers to gently press the point for 30 seconds while closing your eyes and breathing deeply. Repeat three to five times. Your free hand can cradle your elbow to keep your pressing arm relaxed if you choose to press with only one finger. This acu-point releases heat and wind and is used...

Complications of Surgery

Hypothalamic injury leads to debilitating consequences such as obesity, disorders of temperature regulation, somnolence, cardiorespiratory instability, and diabetes insipidus. Following surgery, up to 40 of patients experience debilitating weight gain of 12 to 20 kg year, which persist without plateau. Suppression of insulin secretion has been shown to be effective in preventing or reversing this complication.42 Minor surgical trauma to the hypothalamus can also cause sleep disorders, memory problems, apathy, and appetite changes.7,61

Roadblock 1 No Goals or Steps Identified Due to Lack of Experience in Thinking in Terms of Goals and Behaviors

To allow each of the members to speak about his or her own experience in setting goals. In Stage I, the therapist simply asks the group to talk about an area in their lives they would like to change. This strategy often will lead to group member statements, such as they would like to have improved symp-, resolve sleep problems, or increase their effectiveness cop-

Pathophysiology Of Mitral Stenosis

The elevated left atrial pressure transmitted to the pulmonary capillary bed will cause symptoms of dyspnea, paroxysmal nocturnal dyspnea, and even orthopnea (Table 3). The latter may be atypical, for these patients will have a raised left atrial pressure most of the time when the mitral obstruction is significant. Therefore, they may never feel comfortable enough to go to sleep once they are woken up from sleep because of dyspnea, and furthermore they may wake up with dyspneic sensation more than once in a night. These features are not seen in classical paroxysmal nocturnal dyspnea because of left ventricular failure where patients usually are able to fall asleep again after they have been up on their feet or up for a while in a recumbent position with their feet dangling. Furthermore, the classical paroxysmal nocturnal dyspnea does not occur more than once in a night.

Interpretation or Meaning of the Stressor

When listening for the precipitant of a crisis, it is important to understand the meaning of even minor stressors in the context of a patient's life. The robbery in Melinda's community had a personalized meaning to her that reawakened old wounds and PTSD symptoms, fueling a major emotional crisis. The following sequence of events, filtered through the lens of Melinda's select past personal experiences, created this current crisis. On learning of a local robbery, Melinda perceived a threat to her home and safety. This precipitant inundated her with traumatic memories of the hurricane and its aftereffects, which destroyed her home and her relationship. She felt anxious, insecure, and emotionally numb, and she was newly avoiding crowded places. The turmoil of her earlier relationship was being reenacted in her current marriage. Her nightmares interrupted her sleep, and she began using alcohol to fall asleep and quell her anxiety. Her alcohol abuse contributed to insomnia and feelings of...

Medications for Symptoms of Psychiatric Disorders

During the acute crisis or immediate posttraumatic state, insomnia or other sleep disturbances may greatly affect coping. Use of a nonbenzodiazepine such as Zolpidem, zaleplon, or eszopiclone can be considered as first-line pharmacologic treatment for acute sleep disturbances. The use of benzodiazepines for sleep or anxiety in the acute postcrisis state is questionable, with little support for efficacy and

Partial Focal Seizures

Complex partial seizures must be differentiated from typical and atypical absences. Psychogenic seizures, fugue states, panic attacks, inattention, sleep disorders, syncope, transient global amnesia, metabolic derangements, drug and alcohol ingestion, migraine, transient ischemic attacks, and fluctuations in mental status in patients with dementia should also be considered in the evaluation of patients with transient alterations in consciousness.

The Divorce and Final Years

Sara had experienced depressions throughout her life. In later years she lost weight. She suffered from insomnia, although during her creative periods she would work on her poems during the night, and she also had trouble getting up in the mornings, typical symptoms of depression. She took Veronal as a sleeping tablet. Her moods varied with the seasons. Her depressions were worse in winter, and she hated the cold weather since it brought on her respiratory illnesses. As she grew older, external events led to an intensification of her depression (such as the marital problems of her friends, the Untermeyers, and the suicide of their son).

Micro and Nanotechnology and the Aging Spine

In the United States by the year 2000, approximately 20 of all Americans were older than 65. Twelve percent were older than 85. With an aging population, a higher proportion of the elderly seek orthopedic treatment, due to the prevalence of musculoskeletal complaints. Currently, 25 of orthopedic patients are 65 and older. The Census Bureau projects that the 65 and older population will double from 33 million to 65 million by 2030, while the younger age groups will remain the same. Physicians will be faced with a greater number of individuals who are experiencing intellectual failure, immobility, instability, incontinence, insomnia, degenerative musculo-skeletal disorders, and iatrogenic problems.

Clinical Use and Adverse Effects of Specific Antiepileptic Drugs

Felbamate was approved in the United States in 1993 for the treatment of partial seizures in adults and as adjunctive therapy in children with the Lennox-Gastaut's syndrome. Just over 1 year later, the FDA recommended limiting its use due to its association with aplastic anemia. Currently, the FDA recommends that felbamate be used only in situations in which the risk of seizures exceeds the risks of the drug. As of December, 1995, there have been 31 cases of aplastic anemia reported, including 10 fatalities, and numerous cases of hepatitis. The mechanism of action of felbamate is unknown, although it likely has multiple actions including blockade of voltage-gated Na+ channels, potentiation of GABA transmission, and inhibition of excitatory neurotransmission through interaction with the NMDA receptor. Felbamate is effective against partial and generalized seizures, including absences. Common adverse effects include insomnia, weight loss, nausea, anorexia, dizziness, and lethargy....

Diagnosis of Mood Disorders

Insomnia or hypersomnia nearly every day. withdrawal, feelings of guilt or brooding about the past, and decreased activity, productivity, or effectiveness (Box 47-2). Neurovegetative symptoms such as insomnia or hyper-somnia, poor appetite or overeating, low energy, and poor concentration may be present but are less common than in major depressive episodes. These patients may state that they have been depressed for as long as they can remember and cannot recall episodes of recovery or remission of symptoms. In addition, dysthymic patients may periodically have superimposed major depressive episodes, often called double depression (APA, 2000). 2. Insomnia or hypersomnia

Initiation of Treatment

Once a patient has been initiated on an antidepressant, dosing should be optimized to treat depressive symptoms to remission while minimizing side effects (Box 47-8). Patients should be monitored for improvement in their mood and their specific array of depressive symptoms. Continued use of measurement-based care tools, such as the PHQ-9 or QIDS, can aid in the objective assessment of improvement. Patients should be followed more frequently on initiation of treatment, increasing time between appointments as the patient improves. Monitoring for side effects, particularly those that patients may be reluctant to bring up spontaneously, such as sexual side effects, can improve adherence and the therapeutic alliance. Patients should also be monitored for any worsening of mood, increased irritability, impulsiv-ity, insomnia, sudden switches into euphoria, or suicidal ideation. Such symptoms may suggest bipolar diathesis, in which case discontinuing the antidepressant and changing to mood...

Discontinuation of Treatment

For patients who have achieved ongoing remission and want to discontinue their medications, withdrawal of treatment should be gradual and carefully monitored (Box 47-9). Timing of discontinuation often depends on a patient's current life stressors and the potential consequences of depressive relapse (e.g., loss of new job, stress on recently repaired relationship). Antidepressants should be gradually withdrawn to minimize potential withdrawal syndromes and allow for rapid upward titration should depressive symptoms recur. Physicians should discuss early warning signs of relapse (insomnia, early-morning awakening, loss of interest in activities) and instruct patients to contact the physician should such symptoms recur. Risk of relapse is greatest in the first few months of discontinuing antidepressants, and thus a scheduled appointment in this period is often needed to

Medication Selection and Target Symptoms

Psychotropic medications are selected to address target symptoms that cause significant subjective distress or functional impairment (Green 2007). Target symptoms are often specific dimensions of a psychiatric diagnosis (e.g., sad mood as a symptom of depression). Target symptoms may also be a common shared dimension of multiple psychiatric disorders. For example, sleep disturbance can be a symptom common to depressive disorders, bipolar disorder, delirium, substance abuse, adjustment disorders, or sleep disorders. Target symptoms may also be present when full categorical criteria for a

Restless Legs Syndrome and Periodic Limb Movement Disorder

Restless legs syndrome (RLS) is characterized by unpleasant sensations of the legs that are worse in the evening and at night, and that are relieved by movement. '1 Most patients with RLS also have movements of the legs that occur periodically at 20- to 30-second intervals for minutes to hours during sleep. Although the term nocturnal myoclonus sometimes is used to describe these movements, they usually are not sudden lightning-like movements. Rather, they typically last for about 1 second and consist of extension of the great toe with variable degrees of ankle extension, knee extension, and hip extension or flexion. With PLM disorder, periodic movements occur during sleep but the unpleasant evening and nighttime sensations are absent. Arousals associated with the PLMs may lead to complaints of insomnia or daytime sleepiness, or the disorder may be asymptomatic. Clinical Features and Associated Disorders. Patients with RLS complain of a gradual buildup of a subcutaneous crawling,...

Chronobiological Disorders

People who sleep at the wrong time of day or who cannot sleep at the right time of night often have one of the six major chronobiological disorders jet lag syndrome, shift work sleep disorder, DSPS, advanced sleep phase syndrome, non-24-hour sleep-wake disorder, and irregular sleep-wake pattern disorder. '1' the suprachiasmatic nucleus, mediates the effects of light on circadian rhythms. Intensity, duration, and timing of light exposure determine its effect on the phase of the circadian system. Light pulses just before or during the first half of the dark phase produce phase delays, whereas light pulses during the second half of the dark phase or just after the end of the dark phase produce phase advances. Melatonin, a pineal hormone that is secreted mainly at night in humans, appears to have phase-shifting properties that are opposite to the effects of bright light Melatonin administered in the afternoon produces phase advances, whereas melatonin given in the morning produces phase...

Importance of Preparation

The management of pain and anxiety is important for several reasons. Poor management of pain in early childhood may alter neuronal circuits that process pain and result in heightened behavioral response to pain in later childhood (Ruda et al. 2000). Moreover, emotional factors such as increased anxiety, distress, anger, and depressed mood can increase pain perception and make future medical procedures and pain management more challenging (Frank et al. 1995 Kain et al. 2006). In a study aimed at exploring how preoperative anxiety in children affects postoperative variables (e.g., pain, behavioral recovery), Kain et al. (2006) found that increased anxiety before surgery is associated with increased postoperative pain, analgesic consumption, emergence of delirium, and sleep problems. Furthermore, youngsters exhibiting distress behaviors during procedures are likely to interfere with and delay the procedures. These findings suggest that effective preparation for medical procedures,...

Balance Disorders Frailty and Falls in the Elderly

Years half of these elderly persons fall repeatedly.157 Approximately 5 of falls cause a fracture and another 10 result in serious injury. Falls are a strong risk factor for placement in nursing homes.158 For many geriatric patients, the intrinsic and external causes of falls interact (Table 12-3) a drug causes mild delirium, arthritis makes weight bearing on the knees painful, and residual impairments from an old mild hemiparesis combine to make the person stumble over a raised crack on a sidewalk. Risks for a serious injury from falls in disabled elderly persons differ from independent persons. A Finnish study associated single status, low body mass index, impaired visual acuity, use of long-acting benzodiazepines, and impaired gait with injuries in the disabled group compared to insomnia and diminished sensation in the feet from a peripheral neuropathy in the able group.159 Weakness of the iliopsoas was another common finding in disabled subjects.

Sedative Hypnotics including Benzodiazepines

Withdrawal signs and symptoms from sedative-hypnotics include tachycardia, hypertension, fever, agitation, anxiety, hallucinations, insomnia, irritability, nightmares, sensory disturbances, tremor, tinnitus, anorexia, diarrhea, nausea, seizures, delirium, and death. Most sedative-hypnotic withdrawal is managed by either simple, slow, fixed-dose taper or substitution and taper. A simple taper involves decreasing the dose by no more than 10 every 1 to 2 weeks until the starting dose has been 75 decreased, then by 5 every 2 to 4 weeks for the last 25 until the taper is completed. Substitution and taper involves substituting a long-acting benzodiazepine (e.g., clonazepam) or phenobarbital for a shorter-acting drug and tapering as above. Conversion tables are available to calculate an approximate equivalent dose, and the dose is titrated over several days to a week, to achieve good relief of withdrawal symptoms before tapering is begun of the substitute, as with the simple taper method....

Obstructive Sleep Apnea

Arterial oxyhemoglobin saturation (SaO2 ) falls during apneas and hypopneas at a rate of 0.1 to 1.6 percent per second. The severity of hypoxemia is a function of baseline oxygenation, lung oxygen stores, the degree of airway narrowing, and apnea duration. Drops in SaO 2 to below 70 percent are common in severe obstructive sleep apnea. Apneas during REM sleep tend to produce greater decreases in SaO 2 owing to decreased lung oxygen reserves and increased duration of apneas. The repeated arousals to resume breathing, along with reduced amounts of REM sleep and slow-wave sleep, appear to be the major causes of daytime sleepiness in patients with OSA. Restless sleep is caused by the arousals at the end of apneas, which may be accompanied by jerks, twitches, and gross body movements. Changes in body position may occur several times per hour as patients attempt to find a sleeping position compatible with airway patency. With severe apnea, patients may sleep in a chair, on the couch,...

Benign Neonatal Familial and Nonfamilial Convulsions Benign idiopathic neonatal convulsions BINNC

The typical EEG reveals hypsarrhythmia, a chaotic pattern of high-amplitude slow waves with multifocal epileptiform discharges and poor interhemispheric synchrony ( Fig ). Sleep is markedly disrupted and REM sleep is reduced. An electrodecremental response consisting of generalized low-voltage fast activity accompanies spasms. By 3 years of age, hypsarrhythmia typically evolves to slow spike-wave complexes or multifocal spikes and sharp waves. Abnormalities on neuroimaging studies are found in over 60 percent of infants. These abnormalities include generalized

Evaluation Guidelines

There are a variety of laboratory tests that directly or indirectly may apply to the evaluation of sleep and sleep disorders ( Table 2 2 ). Neuroimaging. Neuroimaging is not usually necessary during the evaluation of a primary sleep disorder. If patients present with additional neurological symptoms and signs, or the clinical history is atypical, magnetic resonance imaging may be helpful. Insomnia PSG to indicate whether secondary to other sleep disorder EMG evidence of peripheral neuropathy in somepatients with RLS PSG assessing for nocturnal sleep disorder (sleep, apnea, PLMD) Multiple sleep latency test with shortened latency with or without REM onset naps who is present throughout the night. Videotaping abnormal sleep behaviors is possible. PSG testing provides objective data concerning sleep latency, sleep efficiency, sleep staging, severity and type of sleep apnea, periodic limb movements, and parasomnias. PSG is of more limited usefulness in the evaluation of insomnia, unless...

Alzheimers Disease and Alzheimers Dementia

Associated symptoms depression insomnia incontinence illusions hallucinations, catastrophic verbal, emotional, or physical outbursts sexual disorders weight loss during more advanced stages increased muscle tone, myoclonus, and abnormal gait Sedative hypnotic agents can be used in patients in whom sleep-wake disturbances are disrupting their home care. Agents that have few side effects or risks of exacerbating confusion and agitation include diphenhydramine, chloral hydrate, and zolpidem. Many patients fall asleep without difficulty but awaken at an early hour. In such instances, it is important that the sleeping aid be given when they waken. These medications help patients fall asleep, but they will not reliably keep them asleep for prolonged periods, which is in part why they are more advisable than longer acting agents.

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Fatal familial insomnia Sympathetic hyperactivity also occurs in a transmissible spongiform encephalopathy characterized by severe atrophy of the anteroventral and dorsomedial nuclei of the thalamus. This autosomal dominant disorder presents with disruption of endocrine circadian rhythms, motor dysfunction, and progressive intractable insomnia--thus its name, familial fatal insomnia (see Chapter.43 ) i6'

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