Behavioral Science - Insomnia - Thomas L. Schwartz Flashcards Preview

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What is dyssomnia? What conditions are classified as dyssomnias?

sleep disorder characterized by problems in timing, quality, or amount of sleep

insomnia, sleep apnea, narcolepsy


What is parasomnia? What conditions are classified as parasomnias?

sleep disorder characterized by abnormalities in physiology or behavior associated with sleep

Bruxism (involuntary or habitual grinding of the teeth during sleep), nightmare disorder, sleep terror disorder, sleepwalking disorder


DSM-V criteria for insomnia

Complaint of dissatisfaction with sleep quantity or quality, associated with at least one of these symptoms:

Difficulty initiating sleep
Difficulty maintaining sleep
Early-morning awakening with inability to return to sleep

Sleep disturbance causes distress or impairment

Disturbance occurs at least 3 nights per week and is present for at least 3 months

Disturbance is not attributable to the physiologic effects of a substance or a coexisting medical or mental disorder


What is the most common cause of insomnia?



Who gets more insomnia men or women?

Women - 50% more than men


What are possible endogenous causes of DSM-V criteria met insomnia disorder?

excess excitatory neurotransmitters at night time,
decificency of inhibitory neurotransmitters at night time


What inhibitory neurotransmitters may become dysregulated in insomnia? Excitatory?


SE - Raphe
Histamine - Tubulomammilary body


What medical conditions can cause insomnia?

Chronic pain

Pulmonary disease (chronic bronchitis, obstructive sleep apnea)

Endocrine disorders - hyperthyroidism, diabetes mellitus

Others: restless leg syndrome, CHF, nocturia secondary to diuresis


What psychiatric conditions can cause insomnia?

Major depressive disorder

Bipolar disorder

Generalized anxiety disorder/PTSD


What are the sleep symptoms associated with depression?

Short REM sleep latency, repeated nighttime awakenings, waking too early in the morning


What are the sleep symptoms associated with bipolar disorder?

Manic and hypomanic patients have problems falling asleep and maintaining sleep


What are the sleep symptoms associated with anxiety diorder/PTSD?

Trouble falling asleep/nightmare


What is the conditioned stimulus-response relationship between insomnia and anxiety?

General anxiety can lead to insomnia, which can progress in to anxiety about the insomnia itself - e.g. whether you will be able to fall asleep

Getting into bed (stimulus) leads to anxiety (state of increased wakefullness/vigilance) about falling asleep and inability to sleep (response)


What are some effects associations of insomnia?

Decreased quality of life

Complaints of impaired daytime performance and more accidents, absenteeism and presenteeism

Self-medication and risk of substance abuse occurs

Association between insomnia and psychiatric disorders
- predictor for development of major depression or alcohol dependence


1st step to management of insomnia

diagnosis, informed consent and education about causes of disorder and therapy

important to rule out other medical conditions that might be causing the insomnia. E.g. obstructive sleep apnea, chronic pain, diuretic use causing nocturia, hyperthyroidism, depression, anxiety


2nd step to management of insomnia

Behavioral counseling
Sleep hygiene/Stimulus control


3rd step in management of insomnia

Sleep restriction therapy

cognitive therapy ( e.g. work with therapist about sleep anxiety and sleep expectations)

behavioral therapy ( e.g. sleep logs, relaxation,self hypnosis)


What is sleep restriction therapy?

limit total time in bed to increase the drive to sleep (delayed sleep schedule can shift circadian clock resulting in sleeping in longer in morning)


4th step in management of insomnia

pharmacotherapy - stepwise approach

OTC>non-habit forming Rx>mild habit forming Rx>habit forming Rx

Melatonin/antihistamines>Rx antihistamines (doxepin)/Rx melatonin receptor agonists (ramelteon/tasimelteon)>BZRAs(zolpidem, zaleplon, ezopiclone)/Orexin recptor antagonists (suvorexant)>Benzos (temazepam, triazelam, flurazepam)/off label drugs (trazadone, quietidone)


Which serotonin receptors could be used as drug targets for insomnia?

antagonist for 5HT2a - causes deeper sleep
antagonists for 5HT1d and 5HT7 could promote a more accurate circadian rhythm

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