4/8/2023 0 Comments Chronic insomnia![]() Strategies and EvidenceĬognitive Behavioral Therapies Table 2. Circadian-rhythm disorders, such as shift-work sleep disorder and delayed-sleep-phase syndrome (a delay in the sleep period of more than two hours relative to conventional times), and voluntary insufficient sleep syndrome should be considered in the differential diagnosis, but these are not considered forms of insomnia. Several causes of the disorder may be present in a single patient. If insomnia persists despite treatment of secondary causes, then therapy for primary insomnia should be instituted. Insomnia secondary to other causes is more common than primary insomnia ( Table 1) and must be excluded or treated before making a diagnosis of primary insomnia. As compared with controls, patients with insomnia show increased global cerebral glucose metabolism on positron-emission tomography when awake and asleep, increased beta activity and decreased theta and delta activity on electroencephalography during sleep, an increased 24-hour metabolic rate, and higher levels of secretion of adrenocorticotropic hormone and cortisol. 3 The pathogenesis of primary insomnia is unknown, but available evidence suggests a state of hyperarousal. Insomnia can be classified as primary or secondary ( Table 1). Polysomnography is rarely needed unless there is a strong suspicion of sleep-disordered breathing or periodic limb movement disorder or unless insomnia fails to respond to treatment. Asking the patient to keep a diary documenting times of sleep for one to four weeks may be helpful. Taking a careful history from the patient and a bed partner, if present, usually allows accurate categorization of the causes of insomnia. 5 Consequences include fatigue, mood disturbances, problems with interpersonal relationships, occupational difficulties, and a reduced quality of life. ![]() 1 It may follow episodes of acute insomnia in patients who are predisposed to having the condition and may be perpetuated by behavioral and cognitive factors, such as worrying in bed and holding unreasonable expectations of sleep duration. Transient insomnia lasts less than one week, and short-term insomnia one to four weeks.Ĭhronic insomnia - insomnia lasting more than one month 3 - has a prevalence of 10 to 15 percent 2,4 and occurs more frequently in women, older adults, and patients with chronic medical and psychiatric disorders. 1 However, in clinical practice, a patient's subjective judgment of sleep quality and quantity is a more important factor. ![]() 1,2 (Difficulty with sleep maintenance implies waking after sleep has been initiated but before a desired wake time.) Most research studies adopt an arbitrary definition of a delay of more than 30 minutes in sleep onset or a sleep efficiency (the ratio of time asleep to time in bed) of less than 85 percent. Insomnia is defined as difficulty with the initiation, maintenance, duration, or quality of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep. How should her case be managed? The Clinical Problem She has no symptoms of sleep-disordered breathing or the restless legs syndrome and is otherwise well. Her bedtime is 11 p.m., and she has found that going to bed later does not allow her to fall asleep more easily. ![]() Despite having had no recurrence of depression and no major psychosocial stressors, the patient requires two hours to fall asleep most nights, and on the occasions that she falls asleep rapidly, she wakes at 2 a.m. The problem started after the birth of her second child 15 years earlier in association with mild postpartum depression. The article ends with the author's clinical recommendations.Ī 46-year-old woman has difficulty in falling asleep and staying asleep. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. This Journal feature begins with a case vignette highlighting a common clinical problem. 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