Chapter 10: Insomnia Flashcards
(30 cards)
Prevalence of chronic insomnia in USA
20-30%
Increases with:
* age
* female gender
* comorbidities (40% have a psychiatric illness, most commonly depression)
* shift work
* primary sleep and circadian rhythm disorders (RLS, nocturia, narcolepsy, GERD)
Insomnia often precedes and is a risk factor for mood disorders.
Only 13% of insomnia patients ever consult a healthcare professional
One third of people with insomnia have OSA!
5 Key Steps of an integrative approach to insomnia
- acknowledges the critical role of consciousness or subjective experience (which is only partially addressed by CBT-I)
- emphasizes the promotion of sleep health, as opposed to symptom suppression
- recognizes the important social and relational context of sleep;
- underscores the central role of natural rhythms in life and health;
- strongly emphasizes the contribution of lifestyle
In insomnia there is a loss of REM sleep and there is dream loss. Part of the critical history is their dream story!
Insomnia definitions
- Insomnia disorder refers to difficulties with initiating or maintaining sleep, as well as nonrestorative sleep that is associated with excessive sleepiness or fatigue and with functional decrements for at least 4 weeks.
Primary = not attributable to a medical or pyschiatric cause
Secondary = viewed as a symptom of a primary disorder. Should be called COMORBID insomnia instead of secondary, to emphasize treating the insomnia directly still.
3 P Model of Insomnia
- Predisposing: substance use, illnesses, primary sleep disorders, long term use of circadian-disrupting meds, shift work.
- Precipitating: stressors (either negative or positive events like divorce or childbirth)
- Perpetuating: behaviors intended to manage or compensate for sleeplessness that inadvertently exacerbate the condition (daytime napping, caffeine, anxiety associated with attempts to control sleep)
Sleep Efficiency
The ratio of total time spent asleep to the amount of time spent in bed.
<85% is problematic
Conditioned Insomnia = a negative association of the bed with wakefulness that stems from a common practice of spending excessive time in bed to compensate for lost sleep.
Medications that suppress melatonin
- Analgesics
- Benzos
- antidepressants
- anticholinergics
- beta blockers
- calcium channel blockers
- diuretics
Meds that interfere with sleep
- *Alcohol
- *Antiarrhythmics
- *Anticonvulsants
- *Antihistamines
- *Appetite suppressants
- *Benzodiazepines
- *Bronchodilators
- *Caffeine
- *Carbidopa/levodopa
- *Corticosteroids
- *Decongestants
- *Diuretics
- *Estrogen
- *Lipophilic beta-blockers
- *Monoamine oxidase inhibitors
- *Nicotine
- *Pseudoephedrine
- *Sedatives
- *Selective serotonin reuptake inhibitors
- *Statins
- *Sympathomimetics
- *Tetrahydrozoline
- *Thyroid hormones
- *Tricyclic antidepressants
Pathophysiology of insomnia
Chronic cognitive-emotional hyperarousal associated with elevated metabolic rate, sympathetic overactivation, and chronic inflammation
* elevated body temp
* increased beta and gamma EEG
* elevated inghttime cortisol
* nocturnal SANS activation
* HPA overactivation
24-hr hyperarousal = less sleepy than normal counterparts, but more fatigued. The fatigue + hyperarousal = chronic tension –> depression.
bidirectional assocation with chronic inflammation (poor sleep can raise inflammation. Poor diet can lead to poor sleep)
Association with circadian core body temperature rhythm abnormalities.
“uspended in a limbic zone between fatigue and hyperarousal, neither a healthy descent into sleep nor a passionate ascension into waking are possible”
Dual process model of sleep regulation
- views sleep in terms of a dynamic interaction between homeostatic and circadian processes.
- As the homeostatic sleep drive gradually increases through the waking day, the circadian pacemaker exerts an equal but opposite force to maintain alertness.
- The potential for sleep normally occurs with the nightly, rhythmic release (shut off) of circadian alertness.
Hyperarousal may be understood as circadian alertness (wakefulness) that has gone awry
Polysomnogrophy
- multiple sleep parameters (respiration, EEG, movement, muscle tone)
- NOT routinely indicated for insomnia because it provides little useful diagnostic or therapeutic infromation
- Can be used to rule out periodic limb movement, OSA, or other conditions underlying persistent insomnia
- Home-based PSG is possibl
Consumer Sleep Technology
- Unclear validity and reliability
- May help improve patient-provider interaction and heighten patient’s interest
- May also negatively affect sleep self-efficacy by discouraging trust in one’s own sense of their sleep quality
Two basic approaches to insomnia
- Taking something to sleep
- Letting go of something to sleep
Chronic insomnia is not from insufficient sleepiness but rather is from excessive wakefulness. The latter approach focuses on reducing the noise of this excessive wakefulness / hyperarousal.
Taking something to sleep may help in short term but it can erode someone’s sleep self-efficacy.
Risks of sedative-hypnotics
- hypnotic agents may increase risk of cancer
- 10-15% increased mortality among occasional sleeping pill users
- 25% increased mortality among nightly sleeping pill users
- dependence
- tolerance
- damaged sleep architecture
- diminished deep sleep
- REM suppression
- Parasomnias
- anterograde amnesia
- morning angover
- undermined self-efficacy
- rebound insomnia with discontinuoation
- increased risk for falls
- cognitive impairment
- symptom suppression
Compare this to CAM sleep aids:
- provide less of a knockout and more of a gentle assist to sleep with significantly fewer adverse effects.
- think of these as “sleep appetizers” that remind them of the “taste” of sleep rather than provide a substitute
- the use of botanicals should always be complemented with lifestyle and body–mind recommendations and a specific plan for discontinuing use.
Melatonin
Insomnia Chptr
- Inhibited by blue light. Disinhibited by dim light and dark
- decreases nocturnal body temp, antiinflammatory, antioxidant, immune-mod, oncostatic
- suppressed by age, substances. May be factor in cancer and depression too
- high doses may disrupt sleep
- beneficial for sleep-onset latency, total sleep time, and sleep efficiency
- Sublingual bypasses first-pass liver metabolism resulting in more reliable serum levels.
- Sustained release given near bedtime helpful trhoughout sleep preiod.
- Immediate-release sublingual formulations at awakening better for sleep-maintenance insomnia and early morning awakenings (if you can sleep for at least 3 more hours)
- DOSE: 0.3 -0.5mg for adults.
- Contraindicated in pregnancy (?). Autoimmune illness exacerbation..
Valerian Root
- Does not impair psychomotor or cognitive performance
- Effective for mild-moderate insomnia
- Not addictive, no withdrawal
- Requires 2-4 WEEKS of nightly use before an effect
- High-quality products have unpleasant odor, which confirms potency
- Caution: pregnancy, liver disease
Hops
- an approved rememdy in Germany
- Modest effect of valerian-hops combination
- Antispasmodic properrties - help with muscle tension
- May help with hot flashes and other menopausal sx
- CAUTIOn: avoid in pregnancy
L-theanine
- unique amino acid found in green and black tea
- helpful for anxiety, hypertension, and sleeplessness
- caution in pregnant or lactating. Can be antihypertensive. Avoid extracts of D-theanine
Lemon Balm
- frequently combined with other botanicals
- uplifting lemon-like fragrance
- avoid in pregnancy and lactation
Saffron
- research shows an effective sleep aid, especially within first week of treatment
- Appears safe
Jasmine
Effective when oil is diffused. As effective as benzos in one trial!
Cannabis and Insomnia
- short term management of sleep disturbances associated with OSA, fibromyalgia, chronic pain, and MS.
- inconclusive evidene for managing primary insomnia
- CBD can promote relaxation
- THC can reduce sleep onset latency
- But cannabis can also impair sleep quality
Vitamins and Sleep
Vitamin D and Magnesium are important!
Noise Reduction Approach to Insomnia
- Focuses on Body (biomedical factors), Mind (psychological factors) and Bed (environmental factosrs)
- Sleepiness-to-noise ratio in which sleepiness = propensity to sleep and noise = situations that interfere with sleep / experience of hyperarousal
- Noise is cumulative (coffee + stress + reflux together cross a threshold at which insomnia occurs)
Reducing Body Noise
insomnia
- manage comorbid conditions
- manage sleep side effects of meds
- manage alcohol and caffeine
- manage women’s health (PMDD, menopause). Melatonin can help with PMS and PMDD! Menopausal sx are commonly blamed for repeat waking, but for most women menopause doesnt cause sleep problems.
As one part of the Noise Reduction Approach to Insomnia.
Consuming two 8-oz cups of drip coffee within an hour of morning awakening will leave approximately 35mg of caffeine, the amount found in a cola drink, in one’s system near bedtime.
