Insomnia, which is characterized by difficulty sleeping, is a common health condition that causes dissatisfaction and dissatisfaction with the quality and quantity of sleep. Insomnia is different from purposeful sleep deprivation, because people with insomnia not only want to sleep but can also try to fall asleep.
Recent estimates indicate that between 10-20% of people with insomnia also experience psychosocial, medical, psychiatric, and underlying sleep disorders. Afternoon work is affected by both short and long term insomnia, while long term insomnia can lead to serious health and social effects.
Study: Insomnia. Image credit: Kleber Cordeiro / Shutterstock.com
A new article on Medical clinics in North America The Journal by Elijah L. Sutton MD of the Department of Medicine at the University of Washington evaluates the symptoms of insomnia and its treatment as reported by patients in primary care settings.
Insomnia at night is classified by its pattern and duration.
Caused by acute insomnia or by treating sedation-hypnosis to prevent the development of chronic insomnia. In comparison, chronic insomnia can lead to sleep-deprived beliefs, including helplessness, depression, and fear of the consequences of sleep deprivation.
Insomnia can be classified into three types based on its timing. These include sleep-induced insomnia, sleep-induced insomnia, and terminal insomnia.
Pathophysiology of insomnia and sleep
Sleep consists of two physical states, which include rapid eye movement (REM) and non-REM (NREM) sleep. During both REM and NREM sleep, the body and brain behave differently. For example, NREM consists of four stages, where stages 3 and 4 are deep and are known as “slow-wave” sleep.
Sleep disorders in which a person may present partially from deep sleep or REM sleep to the phase of light sleep, or short waking, disturbed sleep (insomnia) or disturbed sleep.
Both waking and sleeping conditions are under homeostatic and circadian control. The internal clock, which controls the circadian rhythm of the sleep and waking cycle, can be influenced by genetic and environmental factors. For example, the increase in time after the last sleep increases homeostatic drive, while the refreshing quality of sleep decreases it.
The daily pattern of fatigue and alertness, also called ‘chronotype’, is determined by many genes with polymorphism. A person’s chronotype fluctuates in childhood and adolescence until it finally stabilizes at age 25.
Insomnia can be caused by the effects of waking factors a few hours before going to bed. This may include exposure to bright light, upright body position, caffeine consumption, or mentally stimulating activities. In addition, insomnia can be caused by forced sleep, which can be reversed.
Sleep disorders that manifest as insomnia
There is limited information on why insomnia is a symptom of other health conditions. Some common sleep disorders that are often present as insomnia include Restless Leg Syndrome (RLS), Circadian Rhythm Disorder, and Sleep Apnea.
RLS is a common disorder with a prevalence of about 10%. This condition is more common in older people, women, during pregnancy, and those with chronic medical conditions.
RLS patients have reported two to three times higher rates of difficulty sitting and sleeping than the general population. Periodic limb movement (PLMS) is also found to be as prevalent as RLS and causes difficulty sleeping.
Circadian Rhythm Disorders 24-hour daytime sometimes feeling sleepy and being very awake at other times of the day that do not match social norms.
Delayed sleep phase syndrome (DSPS) is a type of circadian rhythm disorder in which people go to bed and wake up later than others. DSPS is associated with higher rates of smoking, caffeine use, alcohol use, depression, and attention-deficit / hyperactivity disorder (ADHD). Other common circadian rhythm disorders include non-24-hour circadian rhythm disorders and advanced phase sleep syndrome (ASPS).
Obstructive sleep apnea (OSA) can present as insomnia due to the short time between waking up. OSA can also coexist with certain types of insomnia, such as psychophysiological insomnia.
OSA is very common among the general population and is mostly associated with chronic conditions such as obesity and high blood pressure, the risk of this condition increases with age and body mass index (BMI). Central sleep apnea (CSA) can also present as insomnia; However, its prevalence in the general population is not fully described.
Both OSA and CSA may co-exist in the same patient. However, after continuous positive airway pressure (CPAP) therapy for OSA, CSA can be a problem if it occurs in the same patient.
Assessment of insomnia
Understanding the patient’s medical history is important for assessing insomnia. Questionnaires on insomnia severity, OSA risk, RLS, and chronotype are commonly used in sleep medicine research and practice. The hallmark features of RLS, circadian rhythm disorders, and sleep apnea should also be examined.
Laboratory work, a physical test, and sleep tests are not particularly useful in assessing insomnia. However, in some cases, polysomnography (PSG) may be useful in assessing insomnia, such as when PLMS or sleep apnea is suspected or patients have a history of circadian rhythm disorders.
Pharmacotherapy of insomnia depends on 2 general approaches: suppressing the sleep-promoting system (via GABAA or melatonin receptors) or suppressing one or more wake-promoting systems (specifically via histamine, acetylcholine, and / or serotonin receptors).
Ramelteon is a melatonin-receptor agonist that has been approved by the United States Food and Drug Administration (FDA) for the treatment of insomnia. Benzodiazepine (BDZ) receptor agonists, also called Z-drugs, are also helpful in the management of acute and chronic insomnia.
Sleep hygiene is an important non-drug intervention that can help people with insomnia. Cognitive behavioral therapy (CBT-I) for insomnia has also been reported to be effective in people with insomnia comorbidities, primary insomnia, and conditional insomnia. In fact, CBT-I is more effective than sleep meditation and relaxation therapy.
Dopa agonists or a (2) d ligands are also effective in treating RLS or PMLS. Sleep apnea can be treated by reducing airway obstruction, with standard treatment bilevel positive airway pressure or constant positive airway pressure (CPAP).
Avoiding supine sleep positions can also help reduce sleep apnea. Older cases of sleep apnea require surgery to remove obstructive tissue.
Circadian rhythm disorders can be treated using a four-pronged approach that includes expectant management, chronotherapy, phototherapy, and melatonin supplementation.
Insomnia is a widespread disorder that affects people worldwide. The severity of the condition varies from person to person and is more common in other medical conditions and in the elderly.
The patient’s medical history, along with the existence of any other sleep disorders, should be accurately evaluated to make a definitive diagnosis of a patient with insomnia. The two most common ways to treat insomnia are sleep hygiene and sedatives. Some lifestyle changes can also prevent chronic cases of insomnia.