Insomnia

Insomnia: Intro & Types - Defining Dream Deficits

• Insomnia: Persistent difficulty with sleep initiation, duration, consolidation, or quality, despite adequate opportunity. Leads to daytime impairment.
• Types based on duration:
  • Short-term (Acute) Insomnia: Symptoms < 3 months. Often stress-related.
  • Chronic Insomnia:

    ⭐ Chronic insomnia is defined as symptoms (difficulty initiating/maintaining sleep, or early awakening) lasting ≥ 3 months occurring ≥ 3 times/week, causing significant distress or impairment.

  • Other Insomnia: Specific type, not meeting criteria for short-term or chronic.

Insomnia: Causes & Culprits - The Sleep Stealers

• Medical Conditions: Chronic pain, asthma/COPD, GERD, hyperthyroidism, RLS, heart failure.
• Psychiatric Disorders: Depression, anxiety disorders, PTSD, bipolar disorder.
• Medications/Substances: Stimulants (caffeine, nicotine), alcohol (disrupts sleep), decongestants, corticosteroids, some antidepressants.
• Situational/Environmental: Poor sleep hygiene, shift work, jet lag, stress, noise, light.

⭐ The '3P Model' (Predisposing, Precipitating, Perpetuating factors) is a key framework for understanding the development and persistence of chronic insomnia.

Insomnia: Diagnosis & Detective Work - Night's Unraveling

• Core Tools:
  • Detailed Sleep History: Pattern, duration, daytime impact; medical/psychiatric/substance Hx.
  • Sleep Diary: 1-2 weeks; records bedtime, sleep latency, awakenings, TST.
  • Actigraphy: Objective sleep-wake pattern.
• Questionnaires:
  • Insomnia Severity Index (ISI): Score ≥15 = clinical insomnia.
  • Epworth Sleepiness Scale (ESS): Assesses daytime sleepiness.
• Polysomnography (PSG):
  • Not routine. Indicated if OSA, PLMD, narcolepsy, or refractory insomnia suspected.

⭐ A thorough sleep history and a 1-2 week sleep diary are cornerstone diagnostic tools for insomnia; Polysomnography (PSG) is NOT routinely indicated unless other sleep disorders like OSA or PLMD are suspected.

Insomnia: Treatment Tango - Restoration Roadmap

⭐ Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line recommended treatment for chronic insomnia and has demonstrated superior long-term efficacy compared to pharmacotherapy.

• Non-Pharmacological (First-Line)

  • CBT-I: Multi-component therapy.
    • 📌 CBT-I Components (SLeep REST):
      • Stimulus control
      • Leep restriction (focus on sleep efficiency)
      • Relaxation techniques
      • Education (about sleep & healthy practices)
      • Sleep hygiene (reinforcement)
      • Thought restructuring (cognitive therapy)
  • Sleep Hygiene:
    • Consistent sleep-wake schedule.
    • Avoid stimulants (caffeine, nicotine) & alcohol near bedtime.
    • Optimize sleep environment: dark, quiet, cool.
    • Limit daytime naps to <30 mins.
    • Avoid heavy meals/excess fluids before bed.

• Pharmacological (Second-Line / Adjunctive)

  • Consider if CBT-I fails, is unavailable, or for short-term relief.
  • Principles: Lowest effective dose, shortest duration possible, monitor side effects (e.g., dependence, rebound insomnia), taper on discontinuation.
  • 
  • Common Classes:
    • Benzodiazepine Receptor Agonists (BzRAs):
      • Benzodiazepines (e.g., Lorazepam, Temazepam)
      • Non-Benzodiazepines / Z-drugs (e.g., Zolpidem, Eszopiclone) - generally preferred over BZDs for insomnia.
    • Melatonin Receptor Agonists (e.g., Ramelteon) - good for sleep-onset insomnia, no abuse potential.
    • Orexin Receptor Antagonists (e.g., Suvorexant, Lemborexant).
    • Sedating Antidepressants (low-dose, off-label): Trazodone, Doxepin.
  • ⚠️ Caution: Elderly, history of substance abuse, comorbid respiratory conditions, pregnancy.

High‑Yield Points - ⚡ Biggest Takeaways

• Insomnia: Difficulty initiating/maintaining sleep or non-restorative sleep, causing daytime impairment.
• Chronic insomnia: Symptoms last ≥3 months, occurring ≥3 times/week.
• CBT-I (Cognitive Behavioral Therapy for Insomnia) is first-line treatment, superior to drugs long-term.
• Pharmacotherapy (e.g., Z-drugs, short-acting Benzodiazepines) is for short-term use; be wary of dependence.
• Sleep hygiene is important but often insufficient alone for chronic cases.
• Always rule out secondary causes: depression, anxiety, pain, or substance use.
• Polysomnography (PSG) is generally not indicated for primary insomnia diagnosis unless other disorders are suspected_