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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Insomnia Resident Survival Guide Microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Diagnosis|Diagnosis]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Treatment|Treatment]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Dos|Dos]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Insomnia resident survival guide#Don'ts|Don'ts]]
|}


{{WikiDoc CMG}}; {{AE}} {{RAB}}
{{WikiDoc CMG}}; {{AE}} {{RAB}}


{{SK}} Sleep difficulty, primary insomnia
==Overview==
==Overview==
[[Insomnia]] means inability to [[sleep]] or a total lack of [[sleep]]. It is a common problem that people present with in regular [[primary care]].The word '[[insomnia]]' originates from the Latin "in" (no) and "somnus" (sleep).It can be due to stress, [[anxiety]], [[depression]], [[Substance abuse|substance use]], [[sleep disorders]] or due to any chronic disorder. It is important to find out if the patient is really suffering from [[insomnia]] and is there a problem falling asleep or difficulty to remain asleep or difficulty in returning back to sleep after awakening from [[sleep]].It is important to find out the underlying cause of [[insomnia]].[[Insomnia]] can be mild, moderate and severe. Mild [[insomnia]] means complaint of an insufficient amount of [[sleep]] or not feeling rested after the habitual [[sleep]] episode almost every night and accompanied by little or no evidence of impairment of social or occupational functioning.Moderate [[insomnia]] means an insufficient amount of [[sleep]] or not feeling rested after the habitual [[sleep]] episode every night and accompanied by mild or moderate impairment of social or occupational functioning.Severe [[insomnia]] presents with severe impairment of social or occupational functioning. Severe [[insomnia]] is associated with feelings of [[restlessness]], [[Irritability|irritability,]] [[anxiety]], daytime [[fatigue]], and tiredness.[[Insomnia]] can be treated with non pharmacological therapy for example, [[sleep hygiene]] education, [[Cognitive-behavioral therapy|cognitive behavioral therapy,]][[Sleep|sleep restriction]]. Additionally, it can treeated with [[medication]]<nowiki/>s like [[Benzodiazepine|benzodiazepines]] and other second line therapy.
[[Insomnia]] means the inability to [[sleep]] or a total lack of [[sleep]]. The word '[[insomnia]]' comes from the Latin word "in" which means no and "somnus" which means [[sleep]]. It is critical to find out if the [[patient]] is really suffering from [[insomnia]] and if there is a problem in falling [[sleep|asleep]] or if it is difficult to remain [[sleep|asleep]] or return to [[sleep]] after awakening. Finding out the underlying cause of [[insomnia]] is also important. [[Insomnia]] can be [[idiopathic]] or could be due to [[circadian rhythm sleep disorder]], [[depression]], [[Stress (medicine)|stress]], [[anxiety]], [[Substance abuse|substance use]], [[sleep apnea|obstructive sleep apnea]], poor [[sleep]] hygiene, [[restless leg syndrome]] or due to [[medications]] or general health disorders. [[Insomnia]] can be divided into mild, moderate, and severe. In mild [[insomnia]] [[patients]] complain of an insufficient amount of [[sleep]] or not feeling rested after the habitual [[sleep]] episode almost every night which is accompanied by little or no evidence of impairment of social or occupational functioning. Moderate [[insomnia]] means an insufficient amount of [[sleep]] or not feeling rested after the habitual [[sleep]] episode every night which is accompanied by mild or moderate impairment of social or occupational functioning. Severe [[insomnia]] presents with severe impairment of social or occupational functioning and is associated with feelings of [[restlessness]], [[Irritability|irritability,]] [[anxiety]], daytime [[fatigue]], and [[Fatigue|tiredness]]. In the approach to treating [[insomnia]], a thorough history review is critical. [[Patients]] should be asked about their [[sleep]] routines, [[sleep]] quality and the duration of the complaint, daytime naps, [[medications]] they take and past medical and mental histories. If [[depression]] or [[alcoholism|alcohol abuse]] is suspected, further questions should be asked. Laboratory investigations to rule out [[anemia]] and [[thyroid disorders]] could be required for selected [[patients]]. Non-[[pharmacology|pharmacological]] and [[pharmacology|pharmacological]] [[treatments]] are two certain [[treatment]] approaches for [[insomnia]].


==Causes==
==Causes==
 
====Common Causes====
====Common Causes<ref name="pmid14661186">{{cite journal |vauthors=Drake CL, Roehrs T, Roth T |title=Insomnia causes, consequences, and therapeutics: an overview |journal=Depress Anxiety |volume=18 |issue=4 |pages=163–76 |date=2003 |pmid=14661186 |doi=10.1002/da.10151 |url= |issn=}}</ref>====
*[[Primary insomnia]]<ref name="pmid14661186">{{cite journal |vauthors=Drake CL, Roehrs T, Roth T |title=Insomnia causes, consequences, and therapeutics: an overview |journal=Depress Anxiety |volume=18 |issue=4 |pages=163–76 |date=2003 |pmid=14661186 |doi=10.1002/da.10151 |url= |issn=}}</ref>
 
*[[Circadian rhythm disorder]], such as:<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
*[[Primary insomnia]]
**[[Delayed sleep phase disorder]]
*[[Delayed sleep phase disorder]]
**[[Advanced sleep phase syndrome]]
*[[Depression]]
**[[Jet lag]]
*[[Anxiety]]
**[[Shift work sleep disorder]]
*[[Obstructive sleep apnoea]]
**[[Non-24-hour sleep-wake syndrome]]
*[[Restless legs]]
*[[Depression]]<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
*[[Alcohol problem]]
*[[Anxiety]]<ref name="pmid14661186">{{cite journal |vauthors=Drake CL, Roehrs T, Roth T |title=Insomnia causes, consequences, and therapeutics: an overview |journal=Depress Anxiety |volume=18 |issue=4 |pages=163–76 |date=2003 |pmid=14661186 |doi=10.1002/da.10151 |url= |issn=}}</ref>
*[[Other substance problem]]
*[[Obstructive sleep apnea]]
*Poor [[sleep hygiene]]:
**[[alcoholism|Alcohol abuse]] or other [[substance abuse]]<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
**[[Caffeine]]
**Inappropriate [[sleep]] environment (light, noise, improper temperature and mattress)
*[[Restless leg syndrome]]
*[[Bruxism]]
*[[Bruxism]]
*[[Sleep walking]]
*General health problems:<ref name="pmid14661186">{{cite journal |vauthors=Drake CL, Roehrs T, Roth T |title=Insomnia causes, consequences, and therapeutics: an overview |journal=Depress Anxiety |volume=18 |issue=4 |pages=163–76 |date=2003 |pmid=14661186 |doi=10.1002/da.10151 |url= |issn=}}</ref><ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
*[[General health problems]] :  
**Chronic [[pain]]
**Chronic [[pain]]
**[[Cancer]]
**[[Cancer]]
**[[Heart failure]]
**[[Diabetes]]
**[[Diabetes]]
**[[Heart disease]]
**[[Asthma]]
**[[Asthma]]
**[[Gastroesophageal reflux disease|Gastroesophageal reflux disease (GERD)]]
**[[Arthritis]]
**[[Overactive thyroid gland|Overactive thyroid]]
**[[Rhinitis]]
**[[Nephrology|Renal disorders]]
**[[Gastroesophageal reflux disease|Gastroesophageal reflux disease]] ([[Gastroesophageal reflux disease|GERD]])
**[[Hyperthyroidism]] and other [[Endocrine disorders|endocrine problems]]
**[[Parkinson's disease]]
**[[Parkinson's disease]]
**[[Alzheimer's disease|Alzheimer's disease.]]
**[[Alzheimer's disease|Alzheimer's disease]]
*[[Sleep walking]]
**[[Benign prostatic hyperplasia|Prostate hypertrophy]]
*[[Stress]]
*[[Environmental factors]] like noise, light, or temperature
*[[Jet lag]]
*[[Work shift insomnia]]
*[[Medication]] induced [[insomnia]]:
*[[Medication]] induced [[insomnia]]:
**Medications for cold
**[[Corticosteroids]]<ref name="pmid24347992">{{cite journal| author=Ciriaco M, Ventrice P, Russo G, Scicchitano M, Mazzitello G, Scicchitano F | display-authors=etal| title=Corticosteroid-related central nervous system side effects. | journal=J Pharmacol Pharmacother | year= 2013 | volume= 4 | issue= Suppl 1 | pages= S94-8 | pmid=24347992 | doi=10.4103/0976-500X.120975 | pmc=3853679 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24347992  }} </ref>
**[[Allergies]]
**[[Stimulants]]
**[[Medications]] for[[depression]]
**[[Antidepressants]]
**[[Medication]]<nowiki/>s for high [[blood pressure]]
**[[Medication|Medications]] for [[asthma]] (such as [[Bronchodilator|long-acting β2-agonists]])
**[[Medication|Medications]] for [[asthma]]
*[[Caffeine]]
*[[Hyperthyroidism]] and other [[Endocrine disorders|endocrine problems]]
*Age related [[insomnia]]
*Age related [[insomnia]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[Insomnia]]<ref name="urlInsomnia - A Clinical Guide to Assessment and Treatment | Charles M. Morin | Springer">{{cite web |url=https://www.springer.com/us/book/9780306477508 |title=Insomnia - A Clinical Guide to Assessment and Treatment &#124; Charles M. Morin &#124; Springer |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlInsomnia | SpringerLink">{{cite web |url=https://link.springer.com/book/10.1007/978-94-010-9428-3 |title=Insomnia &#124; SpringerLink |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid28728626">{{cite journal |vauthors=Grandner MA, Chakravorty S |title=Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed |journal=J Clin Sleep Med |volume=13 |issue=8 |pages=937–939 |date=August 2017 |pmid=28728626 |pmc=5529129 |doi=10.5664/jcsm.6688 |url= |issn=}}</ref><ref name="pmid17824495">{{cite journal |vauthors=Roth T |title=Insomnia: definition, prevalence, etiology, and consequences |journal=J Clin Sleep Med |volume=3 |issue=5 Suppl |pages=S7–10 |date=August 2007 |pmid=17824495 |pmc=1978319 |doi= |url= |issn=}}</ref>
Shown below is an algorithm summarizing the diagnosis of [[Insomnia]]<ref name="urlInsomnia - A Clinical Guide to Assessment and Treatment | Charles M. Morin | Springer">{{cite web |url=https://www.springer.com/us/book/9780306477508 |title=Insomnia - A Clinical Guide to Assessment and Treatment &#124; Charles M. Morin &#124; Springer |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlInsomnia | SpringerLink">{{cite web |url=https://link.springer.com/book/10.1007/978-94-010-9428-3 |title=Insomnia &#124; SpringerLink |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="pmid28728626">{{cite journal |vauthors=Grandner MA, Chakravorty S |title=Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed |journal=J Clin Sleep Med |volume=13 |issue=8 |pages=937–939 |date=August 2017 |pmid=28728626 |pmc=5529129 |doi=10.5664/jcsm.6688 |url= |issn=}}</ref><ref name="pmid17824495">{{cite journal |vauthors=Roth T |title=Insomnia: definition, prevalence, etiology, and consequences |journal=J Clin Sleep Med |volume=3 |issue=5 Suppl |pages=S7–10 |date=August 2007 |pmid=17824495 |pmc=1978319 |doi= |url= |issn=}}</ref><ref name="pmid20814491">{{cite journal| author=Saddichha S| title=Diagnosis and treatment of chronic insomnia. | journal=Ann Indian Acad Neurol | year= 2010 | volume= 13 | issue= 2 | pages= 94-102 | pmid=20814491 | doi=10.4103/0972-2327.64628 | pmc=2924526 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20814491  }} </ref>
 
'''Abbreviations:''' EEG: Electroencephalogram; EOG: Electrooculography; ECG: Electrocardiograph; BMI: Body Mass Index: TSH: Thyroid Stimulating Hormone
<br />
 
{{Family tree/start}}
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | |A01=Patient with [[insomnia]]}}
{{Family tree | | | | | | | A01 | | | |A01=[[Patient]] with [[insomnia]]}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Take complete history}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Do initial [[screening]]}}
{{Family tree | | | | | | | B01 | | | |B01=<div style="float: left; text-align: left;">Take a complete history<br>[[Physical examination]], especially [[Vital signs]], [[Body Mass Index]] }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Ask the following questions about the complaint :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: center;"> '''Ask the following questions:'''<br>
----
----
❑ Do you have diffi culty primarily in
<div style="float: left; text-align: left">❑ Do you have trouble in falling asleep? Or do you wake up too early?<br><br>❑ Do you struggle going back to [[sleep]] if you wake up during the night? <br><br>❑ Do you take any [[Sedative|sleeping-pills]] or any other [[medication|medications]] to help you [[sleep]]?<br><br>❑ How often does your [[insomnia]] occur? How many nights have you suffered from the same problem each week? Do you notice any association between your [[symptom]] and seasonal changes or [[menstrual cycle]] (if applicable)?<br><br>❑Tell me about any disturbances at home that may have affected your [[sleep]], such as lights, temperature, loud noise or any other environmental factors.<br></div>}}
 falling asleep
 staying asleep
 waking too early? <br><br>❑ Do you have trouble going back to [[sleep]] if you wake during the night? <br><br>❑ Do you take any medications to help you sleep?<br><br>
Is there anything in your home that disturbs your [[sleep]] such as loud TV, pets, infants, noise, lights, etc.? <br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 30em; padding:1em;"> '''Ask the following questions about [[sleep ]]pattern :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 27em; width: 60em; padding:1em;"> '''Ask the following questions about [[sleep]] routine:'''<br>
----
----
Can you describe to me the pattern of your [[sleep]]? <br><br>❑ What time do you go to bed? <br><br>❑ How much time do you take to fall asleep<br><br>
When do you go to bed usually?<br><br>❑ How much time is generally required to fall asleep?<br><br>❑ When do you wake up in the morning?<br><br>❑ Do you wake up throughout the night? If yes, please tell me the number and duration of your awakenings per night.<br><br>❑How many hours do you [[sleep]] regularly at night?<br><br>❑ Do you usually take a nap during the day?<br><br>❑ Do you have a specific work schedule that may affect your [[sleep]]?<br><br>❑ Do you have the same schedule on the weekends or during holidays?</div>}}
Can you tell me the number and duration of awakenings per night? <br><br>❑ How many hours do you [[sleep]]?<br><br>❑When do you wake up in the morning?<br><br>❑ How many nights per week have you suffered from the same problem?<br><br>❑How is your routine different at the weekends or during holidays? Do you have the same bedtime?<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask the following questions about [[sleep]] quality :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 8em; width: 60em; padding:1em;"> '''Ask the following questions about quality of [[sleep]] :'''<br>
----
----
How do you feel about the quality of your [[sleep]]? <br><br>❑ Do you feel refreshed in the morning or restless? <br><br></div>}}
Tell me about the quality of your [[sleep]]?<br><br>❑ Do you feel refreshed in the morning or tired?<br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 15em; width: 30em; padding:1em;"> '''Ask the following questions about effects on regular daily activity :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 14em; width: 60em; padding:1em;"> '''Ask the following questions about the impact of [[insomnia]] on daily activities :'''<br>
----
----
❑Does it interfere with your function the next day? <br><br>❑ Do you feel unrefreshed in the morning, fatigued, have poor concentration or irritability <br><br></div>}}
❑ Does it hamper your function the next day?<br><br>❑ Do you feel unrefreshed/tired in the morning?<br><br>❑ Have you noticed having difficulty to [[Concentration|concentrate]] recently?<br><br>❑ Have you felt any [[irritability]] recently?<br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Ask the following questions about onset of the complaint :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 60em; padding:1em;"> '''Ask the following questions about [[insomnia]] time span:'''<br>
----
----
Do you remember how did it start? <br><br>❑ For how long are you having this sleeping problem? <br><br>❑Was there any particular event going on that that time?<br><br>❑Has there been any variation in your sleep patterns since then?<br><br>❑Is there any exacerbating factors?<br><br>❑Is there any alleviating factors?<br><br>❑Tell me more about the impact or intrusiveness</div>}}
Tell me when and how did it start?<br><br>❑ How many days/months have you had [[sleep]] problems?<br><br>❑ Do you remember any particular event/[[Stress (medicine)|stress]] going on that time?<br><br>❑ Have there been any changes in your sleep patterns since then?<br><br>❑ Are there any factors that further augment the problem?<br><br>❑ Are there any factors that decrease the problem?<br>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Ask the following questions about past history :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 16em; width: 60em; padding:1em;"> '''Ask the following questions about past history :'''<br>
----
----
Were you a good sleeper previously? <br><br>❑ Tell me more about your [[sleep]] pattern in childhood? <br><br>❑Tell me more about your [[sleep]] pattern in adulthood?<br><br>❑Has there been any similar episode previously? If yes, how did you overcome it? Have you taken any medication or therapy for it in the past?<br><br></div>}}
Did you [[sleep]] well previously?<br><br>❑ Tell me more about your [[sleep]] pattern in your early life.<br><br>❑ Tell me more about your [[sleep]] pattern in your [[adult|adulthood]].<br><br>❑ Did you have similar episodes previously? If yes, how did they subside? Have you taken any [[medication]] or [[therapy]] for your problem in the past?<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Ask the following questions about General Health :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 4em; width: 60em; padding:1em;"> '''Ask the following questions about the general health :'''<br>
----
----
❑ Do you have any chronic illness? If yes, what medications do you take for it?<br><br></div>}}
❑ Do you have any chronic [[diseases]]? If yes, what [[medication|medications]] do you take for it?<br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 10em; width: 30em; padding:1em;"> '''Ask the following questions about Psychological functioning :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 4em; width: 60em; padding:1em;"> '''Ask the following questions about [[Mental health|mental and psychological health]]:'''<br>
----
----
❑Are you the kind of person who copes up well with stressfull situations? <br><br></div>}}
❑ Can you cope well with stressful/unexpected situations? <br><br></div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Do initial [[screening]] for [[depression]] with patient health questionnaire (PHQ)-9<ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref>}}
{{Family tree | | | | | | | B01 | | | |B01= Do initial [[screening]] for [[depression]] with the [[patient]] health questionnaire (PHQ)-9<ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;"> '''PHQ-9 questionnaire :Over the last 2 weeks, how often have you been bothered by any of the following problems?'''<ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref><br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 30em; width: 60em; padding:1em;"> '''PHQ-9 questionnaire: Over the last 2 weeks, how often have you been bothered by any of the following problems?'''<ref name="pmid11556941">{{cite journal |vauthors=Kroenke K, Spitzer RL, Williams JB |title=The PHQ-9: validity of a brief depression severity measure |journal=J Gen Intern Med |volume=16 |issue=9 |pages=606–13 |date=September 2001 |pmid=11556941 |pmc=1495268 |doi=10.1046/j.1525-1497.2001.016009606.x |url= |issn=}}</ref><br>
----
----
❑Have you felt little interest or pleasure in doing things? <br><br>❑Have you been feeling down, [[depressed]], or hopeless<br><br>❑ Did you have trouble falling or staying asleep, or sleeping too much<br><br>❑ Have you had a feeling of being tired or having little energy<br><br>❑Did you have a poor appetite or habit of overeating<br><br>❑Have you felt bad about yourself—or that you are a failure or have let yourself or your family down<br><br>❑Was there any trouble concentrating on things, such as reading the newspaper or watching television<br><br>❑Moving or speaking so slowly that other people could have noticed? Have you been fidgety or restless that you have been moving around a lot more than usual<br><br>❑Have you ever had thoughts that you would be better off dead or of hurting yourself in some way</div>}}
❑ Have you felt little interest or pleasure in doing things that you used to enjoy previously?<br><br>❑ Have you been feeling down, [[depressed]], or hopeless?<br><br>❑ Did you have trouble falling or staying asleep, or [[sleep|sleeping]] a lot?<br><br>❑ Have you had a feeling of being [[Fatigue|tired]] or having little energy?<br><br>❑ Did you have a poor [[appetite]] or habit of [[overeating]]?<br><br>❑ Have you felt bad about yourself or that you are a failure or have let yourself or your family down?<br><br>❑ Do you notice any trouble with [[concentration|concentrating]] on things, such as [[reading]] a newspaper or watching television?<br><br>❑ Did you ever move or speak so slowly that other people could have noticed? Have you been fidgety or restless/moving around much more than usual?<br><br>❑ Have you ever had thoughts of hurting yourself or committing suicide?</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Do initial [[screening]] for alcohol abuse with CAGE questionnaire<ref name="pmid25146056">{{cite journal |vauthors=Williams N |title=The CAGE questionnaire |journal=Occup Med (Lond) |volume=64 |issue=6 |pages=473–4 |date=September 2014 |pmid=25146056 |doi=10.1093/occmed/kqu058 |url= |issn=}}</ref>}}
{{Family tree | | | | | | | B01 | | | |B01= Do initial [[screening]] for [[Alcoholism|alcohol abuse]] with CAGE questionnaire<ref name="pmid25146056">{{cite journal |vauthors=Williams N |title=The CAGE questionnaire |journal=Occup Med (Lond) |volume=64 |issue=6 |pages=473–4 |date=September 2014 |pmid=25146056 |doi=10.1093/occmed/kqu058 |url= |issn=}}</ref>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 30em; padding:1em;"> '''Ask the following CAGE questionnaire :'''<ref name="pmid25146056">{{cite journal |vauthors=Williams N |title=The CAGE questionnaire |journal=Occup Med (Lond) |volume=64 |issue=6 |pages=473–4 |date=September 2014 |pmid=25146056 |doi=10.1093/occmed/kqu058 |url= |issn=}}</ref><br>
{{Family tree | | | | | | | B02 |-|B03| | | | |B02=<div style="float: left; text-align: left; height: 13em; width: 60em; padding:1em;"> '''Ask the following CAGE questionnaire :'''<ref name="pmid25146056">{{cite journal |vauthors=Williams N |title=The CAGE questionnaire |journal=Occup Med (Lond) |volume=64 |issue=6 |pages=473–4 |date=September 2014 |pmid=25146056 |doi=10.1093/occmed/kqu058 |url= |issn=}}</ref><br>
----
----
❑Have you ever felt you needed to cut down on your drinking? <br><br>❑Have people annoyed you by criticizing your drinking?<br><br>❑ Have you ever felt guilty about drinking?<br><br>❑Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
❑ Have you ever felt that you need to cut down on your drinking?<br><br>❑Have people annoyed you by telling you to stop drinking?<br><br>❑ Have you ever felt guilty about drinking?<br><br>❑ Have you ever felt you needed a drink first thing in the morning (Eye-opener)?</div>|B03=If two answers are yes, do further evaluation for [[alcoholism]].}}
</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01=2 yes answers indicate that there is a possibility of alcoholism, so should be investigated further }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 |-| H01 | | |H01=Longer naps may cause difficulty in falling asleep at night |B01= Do you take day time nap? If yes, tell me about frequency, timing, and duration}}
{{Family tree | | | | | | | B01 |-| H01 | | |H01=Longer naps may cause difficulty in falling asleep at night |B01= Do you take a daytime nap? If yes, tell me about frequency, timing, and duration}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 |-| H01 | | |H01=If the patient sleeps better when on holiday or at weekends, think of delayed [[sleep]] phase disorder |B01=Where are you sleeping when you have the problem? Does the problem persists throughout the weeks and months or when you sleep elsewhere }}
{{Family tree | | | | | | | B01 |-| H01 | | |H01=If the [[patient]] [[sleep|sleeps]] better when on holiday or on the weekend, think of delayed [[sleep]] phase disorder |B01=How often do you experience difficulty in falling asleep? Does it change on holidays or weekends? }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}


{{Family tree | | | | | | | B01 |-| H01 | | |H01=Consider [[obstructive sleep apnea]]|B01=How do you feel on awakening?<br><br>❑Do you feel unrefreshed and still sleepy after waking up?<br><br>❑Any symptoms such as headaches or dry mouth?<br><br>❑Ask about daytime sleepiness—falling asleep in waiting rooms, as a passenger in a car, or during lectures<br><br>❑Do you snore, ask partners if possible about heavy snoring, pauses in breathing, and gasping}}
{{Family tree | | | | | | | B01 |-| H01 | | |H01=Run more evaluation for [[obstructive sleep apnea]] if the [[patient]] has high [[body mass index]] (≥30) or neck circumference of 40 cm or more, or if feels unrefreshed and sleepy through the day or snores at nights.  |B01=How do you feel on awakening?<br><br>❑ Do you feel unrefreshed and sleepy after getting up from bed?<br><br>❑Have you suffered from a [[headache]] or [[Xerostomia|dry mouth]]?<br><br>❑Ask about daytime [[sleep|sleepiness]].<br><br>❑ Do you [[snore]], ask partners if possible, about heavy [[snoring]], pauses in breathing, and gasping}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 30em; padding:1em;"> '''Have you experienced any of the following :'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 60em; padding:1em;"> '''Have you experienced any of the following :'''<br>
----
----
❑Restless sleep <br><br>❑Leg or body twitching<br><br>❑ Leg jerking <br><br>❑Sleep walking or talking<br><br>❑Waking up in terror<br><br>❑Unusual night time behaviours
❑ Restless [[sleep]] <br><br>❑ Leg or body [[twitching]]<br><br>❑ Leg jerking <br><br>❑ [[Sleepwalking]] or talking<br><br>❑ [[Night terror|Sleep terror]]
</div>}}
</div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Do physical examination}}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 20em; width: 60em; padding:1em;"> '''The following [[physical examination]] and laboratory investigations are needed to rule out other [[disease|diseases]] such as [[chronic obstructive pulmonary disease]] ([[COPD]]), [[thyroid disease]], [[Rapid eye movement sleep|REM sleep disorders]], [[asthma]], or [[restless leg syndrome]]:'''<br>
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01=Physical examination is needed to rule out other diseases such as [[chronic obstructive pulmonary diseases]] (COPD), [[asthma]], or [[restless leg syndrome]] }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 35em; width: 30em; padding:1em;"> '''Record the [[Vital signs|vitals]] and do following investigations:'''<br>
----
----
❑ [[Blood pressure]]<br><br>❑ [[Weight]] <br><br>
❑ [[TSH]], [[Triiodothyronine|serum T3]], [[Thyroxine|serum T4]]<br><br>❑ [[Respiratory examination]]<br><br>❑ [[Ferritin]] levels: Low level has been associated to [restless leg syndrome]]<br><br>❑ [[Complete blood count]] to rule out [[anemia]] </div>}}
[[Body Mass Index]]:High body mass index (≥30) and neck circumference of 40 cm or greater increase the risk of [[obstructive sleep apnoea]]<br><br>❑[[Temperature]]<br><br>❑[[Heart rate]]<br><br>❑[[Respiratory rate]]<br><br>❑[[TSH]], serum T3, serum T4<br><br>❑[[Ferritin]] levels:Low level is seen in [[restless leg syndrome]]<br><br>❑Complete blood count to rule out [[anemia]] </div>}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B01 | | | |B01= Perform [[Polysomnography]] :to confirm [[sleep apnoea]] and limb movement disorders or [[restless legs syndrome]].It measures brain and muscle activity and assesses [[oxygen saturation]] overnight}}
{{Family tree | | | | | | | B01 | | | |B01= Perform [[polysomnography]]: to confirm [[sleep apnea]] and [[Limb (anatomy)|limb]] movement disorders or [[restless legs syndrome]]. It measures [[brain]] and [[muscle]] activity and assesses [[oxygen saturation]] throughout the night when [[patient]] is [[sleep|asleep]].}}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | |!| | | | | }}
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 25em; width: 30em; padding:1em;"> '''Do the following investigations if needed:'''<br>
{{Family tree | | | | | | | B02 | | | |B02=<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;"> '''Do the following investigations if needed:'''<br>
----
----
❑ [[Electroencephalogram]](EEG)<ref name="pmid12224842">{{cite journal |vauthors=Krystal AD, Edinger JD, Wohlgemuth WK, Marsh GR |title=NREM sleep EEG frequency spectral correlates of sleep complaints in primary insomnia subtypes |journal=Sleep |volume=25 |issue=6 |pages=630–40 |date=September 2002 |pmid=12224842 |doi= |url= |issn=}}</ref><br><br>❑ [[Electrooculography]] (EOG) <br><br>
❑ [[Electroencephalogram]](EEG)<ref name="pmid12224842">{{cite journal |vauthors=Krystal AD, Edinger JD, Wohlgemuth WK, Marsh GR |title=NREM sleep EEG frequency spectral correlates of sleep complaints in primary insomnia subtypes |journal=Sleep |volume=25 |issue=6 |pages=630–40 |date=September 2002 |pmid=12224842 |doi= |url= |issn=}}</ref><br><br>❑ [[Electrooculography]] (EOG) <br><br>
Line 138: Line 144:
==Treatment==
==Treatment==


The [[treatment]] of [[insomnia]] is below:<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref><ref name="pmid18035235">{{cite journal |vauthors=Joshi S |title=Nonpharmacologic therapy for insomnia in the elderly |journal=Clin Geriatr Med |volume=24 |issue=1 |pages=107–19, viii |date=February 2008 |pmid=18035235 |doi=10.1016/j.cger.2007.08.005 |url= |issn=}}</ref><ref>{{cite journal|doi=10.1002/14651858.CD00316}}</ref>


{{familytree/start |summary=Sample 6}}
{{familytree/start |summary=Sample 6}}
{{familytree | | | | | | | | A01 |A01=Patient comes with [[insomnia]]}}  
{{familytree | | | | | | | | A01 |A01=[[Patient]] with [[insomnia]]}}  
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=Non-pharmacological treatment|B02=Pharmacological treatment}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=Non-[[Pharmacology|pharmacological]] [[treatment]]|B02=[[medication|Pharmacological treatment]]}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | | | }}
{{familytree | | | |!| | | | | | | | | |!| |C01=C01}}
{{familytree | | | |!| | | | | | | | | | | |C01=C01}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | | | }}
{{familytree | | | |boxstyle=text-align: left; |  D01 | | | | | | | D03 |D01=•[[Stimulus control therapy]]
{{familytree | | | |boxstyle=text-align: left; |  D01 | | | | | | | |D01=• Stimulus control [[therapy]]
<br>• [[Sleep]] restriction<br>• [[Relaxation therapies]]<br>• Cognitive therapy<br>• Paradoxical intention<br>• [[Sleep]] hygiene education<br>•Behavioral intervention
<br>• [[Sleep]] [[Sleep deprivation|restriction]]<br>• Relaxation [[therapy|therapies]]<br>• [[Cognitive therapy]]<br>• Paradoxical intention<br>• [[Sleep]] hygiene education<br>• Behavioral intervention}}
|D03=• First line medications<br>•Second line medications<br>• Alternative treatment<br>}}
{{familytree/end}}
{{familytree/end}}






Non-pharmacological treatment of [[insomnia]]:
===Non-pharmacological treatment of insomnia===


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=Stimulus control therapy <ref>{{cite journal|doi=10.1002/14651858.CD00316}}</ref>
{{familytree | | | | | | | | | |,|-| A01 |-| A02 | | | |A01=Stimulus control [[therapy]] <ref>{{cite journal|doi=10.1002/14651858.CD00316}}</ref>
|A02=<div style="float: left; text-align: left; height: 30em; width: 17em; padding:1em;"> '''The items:'''<br>
|A02=<div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
Going to bed only when feeling sleepy <br> ❑ Using bed only for sleep and sex <br> <br> ❑ Getting out of bed and going into another room if unable to fall asleep or returning to sleep within 15–20 minutes and returning to bed only when sleepy again <br> <br> ❑ Maintaining a regular time to wake up in the morning regardless of sleep duration the previous night  <br> <br> ❑ Avoid day time napping </div>}}
Go to bed only when you feel [[sleep|sleepy]] <br><br> ❑ Use bed only for [[sleep]] and sex <br> <br> ❑ If unable to fall [[sleep|asleep]], get out of the bed and return after 15–20 mins when [[sleep|sleepy]] again <br> <br> ❑ Maintaining a regular time to wake up in the morning regardless of sleep duration the previous night  <br> <br> ❑ Avoid daytime naps </div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= Sleep restriction<ref name="pmid18035235">{{cite journal |vauthors=Joshi S |title=Nonpharmacologic therapy for insomnia in the elderly |journal=Clin Geriatr Med |volume=24 |issue=1 |pages=107–19, viii |date=February 2008 |pmid=18035235 |doi=10.1016/j.cger.2007.08.005 |url= |issn=}}</ref> |B02=<div style="float: left; text-align: left; height: 25em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= [[Sleep]] [[Sleep deprivation|restriction]]<ref name="pmid18035235">{{cite journal |vauthors=Joshi S |title=Nonpharmacologic therapy for insomnia in the elderly |journal=Clin Geriatr Med |volume=24 |issue=1 |pages=107–19, viii |date=February 2008 |pmid=18035235 |doi=10.1016/j.cger.2007.08.005 |url= |issn=}}</ref> |B02=<div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
❑ Restricting the time spent in bed to nearly match the amount of time spent sleeping <ref name="pmid18035235">{{cite journal |vauthors=Joshi S |title=Nonpharmacologic therapy for insomnia in the elderly |journal=Clin Geriatr Med |volume=24 |issue=1 |pages=107–19, viii |date=February 2008 |pmid=18035235 |doi=10.1016/j.cger.2007.08.005 |url= |issn=}}</ref><br><br>❑To prevent excessive daytime sleepiness, time spent in bed should not be less than 5 hours per night <br> </div>}}
❑ Restricting the time spent in bed in order to nearly match the amount of time spent sleeping<ref name="pmid18035235">{{cite journal |vauthors=Joshi S |title=Nonpharmacologic therapy for insomnia in the elderly |journal=Clin Geriatr Med |volume=24 |issue=1 |pages=107–19, viii |date=February 2008 |pmid=18035235 |doi=10.1016/j.cger.2007.08.005 |url= |issn=}}</ref><br><br>❑ To prevent excessive daytime [[sleep|sleepiness]], time spent in bed should not be less than 5 hours per night <br> </div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= Behavioral intervention |B02= <div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | | | | |)|-| B01 |-| B02 | | | |B01= Behavioral intervention |B02= <div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
❑ Tell the patient keep a sleep diary for 2 weeks<br><br>❑ Discuss sleep hygiene <br> <br> ❑Encourage the patient to eliminate behavior incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bedroom at these time  <br> </div>}}
❑ Tell the [[patient]] to keep a [[sleep]] diary for 2 weeks.<br><br>❑ Discuss [[sleep]] hygiene <br> <br> ❑ Encourage the [[patient]] to give up behaviors incompatible with [[sleep]], such as lying in bed and worrying, by instructing the [[patient]] to leave the bed on these occasions. <br> </div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | C01 |-|+|-| C02 |-| C03 | | | |C01=Non-pharmacological treatment |C02=Relaxation therapies |C03= <div style="float: left; text-align: left; height: 20em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | C01 |-|+|-| C02 |-| C03 | | | |C01=Non-[[pharmacology|pharmacological]] [[treatment]] |C02=Relaxation [[therapy|therapies]] |C03= <div style="float: left; text-align:left;">'''Includes:'''<br>
----
----
❑ Progressive muscle relaxation <br><br>❑ [[Biofeedback techniques]]<br><br> ❑ Imagery training and thought stopping  <br> <br> ❑ Abdominal breathing<br><br> ❑ [[Meditation]], [[hypnosis]] </div>}}
❑ Progressive [[muscle]] relaxation <br><br>❑ [[Biofeedback techniques]]<br><br> ❑ Imagery training and thought stopping  <br> <br> ❑ [[abdomen|Abdominal]] [[breathing]]<br><br> ❑ [[Meditation]] and [[hypnosis]] </div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Cognitive therapy]] |D02= <div style="float: left; text-align: left; height: 15em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01=[[Cognitive therapy]] |D02= <div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
❑ Alter faulty beliefs and attitudes about sleep.  <br><br> ❑ Reduce the vicious cycle of insomnia, emotional distress, dysfunctional thoughts and further sleep disturbances <br></div>}}
❑ Alter inappropriate beliefs and attitudes about [[sleep]].  <br><br> ❑ Reduce [[anxiety]], emotional distress, dysfunctional thoughts and further [[sleep]] disturbances <br></div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01= [[Sleep]] hygiene education|D02= <div style="float: left; text-align: left; height: 15em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | | | | |)|-| D01 |-| D02 | | | |D01= [[Sleep]] hygiene education|D02= <div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
❑ Good health practices for example healthy diet, moderate exercise, and reduce substance use <br><br>❑ Check environmental factors for example light, noise, temperature, and mattress <br>  </div>}}
❑ Good healthy lifestyle practices such as a healthy [[Diet (nutrition)|diet]], moderate [[Physical exercise|exercise]], and reduce [[substance abuse|substance use]] <br><br>❑ Check environmental factors, for example, light, noise, temperature, and mattress <br>  </div>}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=Paradoxical intention|E02= <div style="float: left; text-align: left; height: 15em; width: 17em; padding:1em;"> '''The items:'''<br>
{{familytree | | | | | | | | | |`|-| E01 |-| E02 | | | |E01=Paradoxical intention|E02= <div style="float: left; text-align: left;"> '''Includes:'''<br>
----
----
❑ Convince the patient to engage in his or her most feared behavior, for example staying awake. If a patient stops trying to [[sleep]] and instead attempts to stay awake, performance anxiety will be reduced and sleep may come more easily<br> </div>}}
❑ Convince the [[patient]] to engage in his or her most feared behavior, for example staying awake. If [[patient]] stops trying to [[sleep]] and instead tries to stay awake, performance [[anxiety]] will be reduced and [[sleep]] may come more easily.<br> </div>}}


{{familytree/end}}
{{familytree/end}}


 
===Pharmacological treatment of insomnia===
 
The following table is a summary of first and second line [[treatments]] of [[insomnia]]:<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>:
 
 
 
 
 
Pharmacological treatment of insomnia<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>:
{| class="wikitable"
{| class="wikitable"
! colspan="3" rowspan="1" |First line pharmacotherapy<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
! colspan="3" rowspan="1" |First line pharmacotherapy<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
|-
|-
! colspan="1" rowspan="1" |Medication
! colspan="1" rowspan="1" |[[Medication]]
! colspan="1" rowspan="1" |Recommended dosage
! colspan="1" rowspan="1" |Recommended [[dose|dosage]]
! colspan="1" rowspan="1" |Side effects
! colspan="1" rowspan="1" |[[Adverse effect (medicine)|Side effects]]
|-
|-
| colspan="1" rowspan="1" |[[Zopiclone]]
| colspan="1" rowspan="1" |[[Zopiclone]]
Line 214: Line 214:
[[Blurred vision]]
[[Blurred vision]]


[[Palpitation|Palpitations]]
[[Palpitation]]
|-
|-
| colspan="1" rowspan="1" |[[Zaleplon]]
| colspan="1" rowspan="1" |[[Zaleplon]]
Line 227: Line 227:
| colspan="1" rowspan="1" |[[Temazepam|Temazepam/]][[quazepam]]
| colspan="1" rowspan="1" |[[Temazepam|Temazepam/]][[quazepam]]
| colspan="1" rowspan="1" |10–30 mg
| colspan="1" rowspan="1" |10–30 mg
| colspan="1" rowspan="1" |Dependence and hang over
| colspan="1" rowspan="1" |[[addiction|Dependence]] and [[hangover|hangover]]
|-
|-
| colspan="3" rowspan="1" |'''Second line pharmacotherapy'''<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
! colspan="3" rowspan="1" |'''Second line [[pharmacology|pharmacotherapy]]'''<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
|-
|-
| colspan="1" rowspan="1" |[[Anti depressant]]:<br> • [[Amitriptyline]]<br>•[[Trazodone]]
| colspan="1" rowspan="1" |[[Antidepressants]]:<br> • [[Amitriptyline]]<br>• [[Trazodone]]
| colspan="1" rowspan="1" |• 10–50 mg
| colspan="1" rowspan="1" |• 10–50 mg
| colspan="1" rowspan="1" |• At low doses, [[anticholinergic]] effects rare<br><br>•Trazodone has risk of priapism
| colspan="1" rowspan="1" |• At low doses, [[anticholinergic]] effects are rare<br><br>• [[Trazodone]] has risk of [[priapism]]
|-
|-
| colspan="1" rowspan="1" |[[Antihistamines]]
| colspan="1" rowspan="1" |[[Antihistamines]]
| colspan="1" rowspan="1" |OTC drugs
| colspan="1" rowspan="1" |[[Over-the-counter drug|OTC drugs]]
| colspan="1" rowspan="1" |[[Sedation]] and [[tolerance]]
| colspan="1" rowspan="1" |[[Sedation]] and [[tolerance]]
|-
|-
| colspan="3" rowspan="1" |'''Medications with variable and insufficient effects'''<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
! colspan="3" rowspan="1" |'''Medications with variable and insufficient effects'''<ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref>
|-
|-
|'''Medications'''
|'''[[Medications]]'''
|'''Dose'''
|'''[[Dose]]'''
|'''Uses and Side effects'''
|'''Uses and [[Adverse effect (medicine)|side effects]]'''
|-
|-
| colspan="1" rowspan="1" |[[Valerian]]
| colspan="1" rowspan="1" |[[Valerian]]
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |
| colspan="1" rowspan="1" |May cause headache and daytime [[sedation]]
| colspan="1" rowspan="1" |May cause [[headache]] and daytime [[sedation]]
|-
|-
| colspan="1" rowspan="1" |[[Ramelteon]]
| colspan="1" rowspan="1" |[[Ramelteon]]
| colspan="1" rowspan="1" |8 mg
| colspan="1" rowspan="1" |8 mg
| colspan="1" rowspan="1" |Approved for [[Insomnia|chronic insomnia]] in elderly
| colspan="1" rowspan="1" |Approved for [[Insomnia|chronic insomnia]] in the [[Old age|elderly]]
|-
|-
| colspan="1" rowspan="1" |[[Melatonin]]
| colspan="1" rowspan="1" |[[Melatonin]]
| colspan="1" rowspan="1" |1–5 mg
| colspan="1" rowspan="1" |1–5 mg
| colspan="1" rowspan="1" |Experimental drugs still being evaluated
| colspan="1" rowspan="1" |Experimental [[medication|drugs]] still under evaluation
|-
|-
| colspan="1" rowspan="1" |[[Tryptophan|l-Tryptophan]]
| colspan="1" rowspan="1" |[[Tryptophan|l-Tryptophan]]
| colspan="1" rowspan="1" |0.5–2 g
| colspan="1" rowspan="1" |0.5–2 g
| colspan="1" rowspan="1" |Experimental drugs still being evaluated
| colspan="1" rowspan="1" |Experimental [[medications|drugs]] still under evaluation
|-
|-
| colspan="1" rowspan="1" |[[Indiplon]]
| colspan="1" rowspan="1" |[[Indiplon]]
| colspan="1" rowspan="1" |10–20 mg
| colspan="1" rowspan="1" |10–20 mg
| colspan="1" rowspan="1" |Experimental drugs still being evaluated
| colspan="1" rowspan="1" |Experimental [[medications|drugs]] still under evaluation
|}
|}
To read more about the treatment of insomina [[Insomnia|Click Here]].
To read more about the [[treatment]] of [[insomnia]], [[Insomnia|Click Here]].
<br />
<br />


==Do's==
==Dos<small><ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref></small>==


*Patient should keep your bedtime and wake time consistent from day to day, including weekends.
*[[Patient]] should keep consistent [[sleep]] and wake time everyday, including weekends.
*Patient should stay active and do regular [[exercise]]. Regular activity helps promote good [[sleep]].
*[[Patient]] should stay active and do regular [[physical exercise|exercise]]. Regular [[physical exercise|activity]] promotes good [[sleep]].
*Patient should check your [[Medication|medications]] to see if they may contribute to [[insomnia]].
*Check all of the [[patient]]'s [[Medication|medications]] to see if they may contribute to [[insomnia]].
*Make the bedroom comfortable for [[sleep]]. The room should be dark, quiet, and the temperature should be comfortable, not too warm or too cold.
*Make the bedroom comfortable for [[sleep]]. The room should be dark, quiet, and the temperature should be comfortable, not too warm or too cold.
*If light causes problems during [[sleep]], the patient should use a sleeping mask.
*If light cannot be modified during [[sleep]], the [[patient]] should use a sleeping mask.
*If sound causes the problem, the patient should cover up sounds by trying earplugs, a fan, white noise machine.
*If sound cannot be eliminated, the [[patient]] should cover up sounds by trying earplugs, a fan or a white noise machine.
*Always create a relaxing bedtime ritual, such as taking a warm bath, reading, or listening to soft music.
*Create a relaxing bedtime ritual and do it every night, such as taking a warm bath, reading, or listening to light music.
*If the patient can't fall asleep and is not sleepy, he/she should get up and do something calming, like reading until you feel sleepy
*If the [[patient]] can't fall [[sleep|asleep]] and is not [[sleep|sleepy]], he/she should get up and do something calming, like reading until feel sleepy.
*Patient should follow a routine to relax before bed. Read a book, listen to music, or take a bath.
 
==Don'ts==


*Advise patient to not take naps during the day, because naps make people less sleepy at night.
==Don'ts<small><ref name="pmid20814491">{{cite journal |vauthors=Saddichha S |title=Diagnosis and treatment of chronic insomnia |journal=Ann Indian Acad Neurol |volume=13 |issue=2 |pages=94–102 |date=April 2010 |pmid=20814491 |pmc=2924526 |doi=10.4103/0972-2327.64628 |url= |issn=}}</ref></small>==
*Patient should not use phones before bed,the light can make it harder to fall asleep.
*Advise the [[patient]] to avoid daytime naps, because naps make them less [[sleep|sleepy]] at night.
*Avoid [[caffeine]], [[nicotine]], and [[alcohol]] before going to bed. [[Caffeine]] and [[nicotine]] are [[Stimulant|stimulants]] and prevent from falling asleep
*[[Patient]] should not use phones or other screens before bed, the light can make it harder to fall asleep.
*Avoid eating a heavy meal late in the day.
*Advise the [[patient]] to avoid [[caffeine]], [[nicotine]], and [[alcohol]] before bed. [[Caffeine]] and [[nicotine]] are [[Stimulant|stimulants]] and prevent them from falling asleep.
*Avoid using the bed for anything other than [[sleep]] and [[Sex (activity)|sex]]
*Encourage the [[patient]] to avoid eating a heavy meal before bed.
*[[patient|Patients]] should avoid using the bed for anything other than [[sleep]] and [[Sex (activity)|sex]]


==References==
==References==
Line 298: Line 296:
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Psychiatry]]
[[Category:Psychiatry]]
[[Category:Up-To-Date]]

Latest revision as of 17:00, 14 January 2021

Insomnia Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Sleep difficulty, primary insomnia

Overview

Insomnia means the inability to sleep or a total lack of sleep. The word 'insomnia' comes from the Latin word "in" which means no and "somnus" which means sleep. It is critical to find out if the patient is really suffering from insomnia and if there is a problem in falling asleep or if it is difficult to remain asleep or return to sleep after awakening. Finding out the underlying cause of insomnia is also important. Insomnia can be idiopathic or could be due to circadian rhythm sleep disorder, depression, stress, anxiety, substance use, obstructive sleep apnea, poor sleep hygiene, restless leg syndrome or due to medications or general health disorders. Insomnia can be divided into mild, moderate, and severe. In mild insomnia patients complain of an insufficient amount of sleep or not feeling rested after the habitual sleep episode almost every night which is accompanied by little or no evidence of impairment of social or occupational functioning. Moderate insomnia means an insufficient amount of sleep or not feeling rested after the habitual sleep episode every night which is accompanied by mild or moderate impairment of social or occupational functioning. Severe insomnia presents with severe impairment of social or occupational functioning and is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness. In the approach to treating insomnia, a thorough history review is critical. Patients should be asked about their sleep routines, sleep quality and the duration of the complaint, daytime naps, medications they take and past medical and mental histories. If depression or alcohol abuse is suspected, further questions should be asked. Laboratory investigations to rule out anemia and thyroid disorders could be required for selected patients. Non-pharmacological and pharmacological treatments are two certain treatment approaches for insomnia.

Causes

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Insomnia[4][5][6][7][2]

Abbreviations: EEG: Electroencephalogram; EOG: Electrooculography; ECG: Electrocardiograph; BMI: Body Mass Index: TSH: Thyroid Stimulating Hormone

 
 
 
 
 
 
Patient with insomnia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take a complete history
Physical examination, especially Vital signs, Body Mass Index
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions:

❑ Do you have trouble in falling asleep? Or do you wake up too early?

❑ Do you struggle going back to sleep if you wake up during the night?

❑ Do you take any sleeping-pills or any other medications to help you sleep?

❑ How often does your insomnia occur? How many nights have you suffered from the same problem each week? Do you notice any association between your symptom and seasonal changes or menstrual cycle (if applicable)?

❑Tell me about any disturbances at home that may have affected your sleep, such as lights, temperature, loud noise or any other environmental factors.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about sleep routine:

❑ When do you go to bed usually?

❑ How much time is generally required to fall asleep?

❑ When do you wake up in the morning?

❑ Do you wake up throughout the night? If yes, please tell me the number and duration of your awakenings per night.

❑How many hours do you sleep regularly at night?

❑ Do you usually take a nap during the day?

❑ Do you have a specific work schedule that may affect your sleep?

❑ Do you have the same schedule on the weekends or during holidays?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about quality of sleep :

❑ Tell me about the quality of your sleep?

❑ Do you feel refreshed in the morning or tired?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about the impact of insomnia on daily activities :

❑ Does it hamper your function the next day?

❑ Do you feel unrefreshed/tired in the morning?

❑ Have you noticed having difficulty to concentrate recently?

❑ Have you felt any irritability recently?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about insomnia time span:

❑ Tell me when and how did it start?

❑ How many days/months have you had sleep problems?

❑ Do you remember any particular event/stress going on that time?

❑ Have there been any changes in your sleep patterns since then?

❑ Are there any factors that further augment the problem?

❑ Are there any factors that decrease the problem?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about past history :

❑ Did you sleep well previously?

❑ Tell me more about your sleep pattern in your early life.

❑ Tell me more about your sleep pattern in your adulthood.

❑ Did you have similar episodes previously? If yes, how did they subside? Have you taken any medication or therapy for your problem in the past?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about the general health :

❑ Do you have any chronic diseases? If yes, what medications do you take for it?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about mental and psychological health:

❑ Can you cope well with stressful/unexpected situations?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do initial screening for depression with the patient health questionnaire (PHQ)-9[8]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PHQ-9 questionnaire: Over the last 2 weeks, how often have you been bothered by any of the following problems?[8]

❑ Have you felt little interest or pleasure in doing things that you used to enjoy previously?

❑ Have you been feeling down, depressed, or hopeless?

❑ Did you have trouble falling or staying asleep, or sleeping a lot?

❑ Have you had a feeling of being tired or having little energy?

❑ Did you have a poor appetite or habit of overeating?

❑ Have you felt bad about yourself or that you are a failure or have let yourself or your family down?

❑ Do you notice any trouble with concentrating on things, such as reading a newspaper or watching television?

❑ Did you ever move or speak so slowly that other people could have noticed? Have you been fidgety or restless/moving around much more than usual?

❑ Have you ever had thoughts of hurting yourself or committing suicide?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do initial screening for alcohol abuse with CAGE questionnaire[9]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following CAGE questionnaire :[9]

❑ Have you ever felt that you need to cut down on your drinking?

❑Have people annoyed you by telling you to stop drinking?

❑ Have you ever felt guilty about drinking?

❑ Have you ever felt you needed a drink first thing in the morning (Eye-opener)?
 
If two answers are yes, do further evaluation for alcoholism.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you take a daytime nap? If yes, tell me about frequency, timing, and duration
 
Longer naps may cause difficulty in falling asleep at night
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How often do you experience difficulty in falling asleep? Does it change on holidays or weekends?
 
If the patient sleeps better when on holiday or on the weekend, think of delayed sleep phase disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How do you feel on awakening?

❑ Do you feel unrefreshed and sleepy after getting up from bed?

❑Have you suffered from a headache or dry mouth?

❑Ask about daytime sleepiness.

❑ Do you snore, ask partners if possible, about heavy snoring, pauses in breathing, and gasping
 
Run more evaluation for obstructive sleep apnea if the patient has high body mass index (≥30) or neck circumference of 40 cm or more, or if feels unrefreshed and sleepy through the day or snores at nights.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you experienced any of the following :

❑ Restless sleep

❑ Leg or body twitching

❑ Leg jerking

Sleepwalking or talking

Sleep terror

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The following physical examination and laboratory investigations are needed to rule out other diseases such as chronic obstructive pulmonary disease (COPD), thyroid disease, REM sleep disorders, asthma, or restless leg syndrome:

TSH, serum T3, serum T4

Respiratory examination

Ferritin levels: Low level has been associated to [restless leg syndrome]]

Complete blood count to rule out anemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform polysomnography: to confirm sleep apnea and limb movement disorders or restless legs syndrome. It measures brain and muscle activity and assesses oxygen saturation throughout the night when patient is asleep.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following investigations if needed:

Electroencephalogram(EEG)[10]

Electrooculography (EOG)

Electrocardiograph(ECG)

❑Pulse oximetry

Actigraphy[2]

 
 
 

Treatment

The treatment of insomnia is below:[2][11][12]

 
 
 
 
 
 
 
Patient with insomnia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-pharmacological treatment
 
 
 
 
 
 
 
Pharmacological treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Stimulus control therapy
Sleep restriction
• Relaxation therapies
Cognitive therapy
• Paradoxical intention
Sleep hygiene education
• Behavioral intervention
 
 
 
 
 
 
 


Non-pharmacological treatment of insomnia

 
 
 
 
 
 
 
 
 
 
 
 
Stimulus control therapy [13]
 
Includes:

❑ Go to bed only when you feel sleepy

❑ Use bed only for sleep and sex

❑ If unable to fall asleep, get out of the bed and return after 15–20 mins when sleepy again

❑ Maintaining a regular time to wake up in the morning regardless of sleep duration the previous night

❑ Avoid daytime naps
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sleep restriction[11]
 
Includes:

❑ Restricting the time spent in bed in order to nearly match the amount of time spent sleeping[11]

❑ To prevent excessive daytime sleepiness, time spent in bed should not be less than 5 hours per night
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Behavioral intervention
 
Includes:

❑ Tell the patient to keep a sleep diary for 2 weeks.

❑ Discuss sleep hygiene

❑ Encourage the patient to give up behaviors incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bed on these occasions.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-pharmacological treatment
 
 
 
 
Relaxation therapies
 
Includes:

❑ Progressive muscle relaxation

Biofeedback techniques

❑ Imagery training and thought stopping

Abdominal breathing

Meditation and hypnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cognitive therapy
 
Includes:

❑ Alter inappropriate beliefs and attitudes about sleep.

❑ Reduce anxiety, emotional distress, dysfunctional thoughts and further sleep disturbances
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sleep hygiene education
 
Includes:

❑ Good healthy lifestyle practices such as a healthy diet, moderate exercise, and reduce substance use

❑ Check environmental factors, for example, light, noise, temperature, and mattress
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Paradoxical intention
 
Includes:

❑ Convince the patient to engage in his or her most feared behavior, for example staying awake. If patient stops trying to sleep and instead tries to stay awake, performance anxiety will be reduced and sleep may come more easily.
 
 
 
 
 
 

Pharmacological treatment of insomnia

The following table is a summary of first and second line treatments of insomnia:[2]:

First line pharmacotherapy[2]
Medication Recommended dosage Side effects
Zopiclone 3.75–7.5 mg Drowsiness

Dizziness

Anterograde amnesia

Nightmares

Blurred vision

Palpitation

Zaleplon 5–10 mg Headache

Dizziness

Somnolence

Nausea

Temazepam/quazepam 10–30 mg Dependence and hangover
Second line pharmacotherapy[2]
Antidepressants:
Amitriptyline
Trazodone
• 10–50 mg • At low doses, anticholinergic effects are rare

Trazodone has risk of priapism
Antihistamines OTC drugs Sedation and tolerance
Medications with variable and insufficient effects[2]
Medications Dose Uses and side effects
Valerian May cause headache and daytime sedation
Ramelteon 8 mg Approved for chronic insomnia in the elderly
Melatonin 1–5 mg Experimental drugs still under evaluation
l-Tryptophan 0.5–2 g Experimental drugs still under evaluation
Indiplon 10–20 mg Experimental drugs still under evaluation

To read more about the treatment of insomnia, Click Here.

Dos[2]

  • Patient should keep consistent sleep and wake time everyday, including weekends.
  • Patient should stay active and do regular exercise. Regular activity promotes good sleep.
  • Check all of the patient's medications to see if they may contribute to insomnia.
  • Make the bedroom comfortable for sleep. The room should be dark, quiet, and the temperature should be comfortable, not too warm or too cold.
  • If light cannot be modified during sleep, the patient should use a sleeping mask.
  • If sound cannot be eliminated, the patient should cover up sounds by trying earplugs, a fan or a white noise machine.
  • Create a relaxing bedtime ritual and do it every night, such as taking a warm bath, reading, or listening to light music.
  • If the patient can't fall asleep and is not sleepy, he/she should get up and do something calming, like reading until feel sleepy.

Don'ts[2]

References

  1. 1.0 1.1 1.2 Drake CL, Roehrs T, Roth T (2003). "Insomnia causes, consequences, and therapeutics: an overview". Depress Anxiety. 18 (4): 163–76. doi:10.1002/da.10151. PMID 14661186.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Saddichha S (April 2010). "Diagnosis and treatment of chronic insomnia". Ann Indian Acad Neurol. 13 (2): 94–102. doi:10.4103/0972-2327.64628. PMC 2924526. PMID 20814491.
  3. Ciriaco M, Ventrice P, Russo G, Scicchitano M, Mazzitello G, Scicchitano F; et al. (2013). "Corticosteroid-related central nervous system side effects". J Pharmacol Pharmacother. 4 (Suppl 1): S94–8. doi:10.4103/0976-500X.120975. PMC 3853679. PMID 24347992.
  4. "Insomnia - A Clinical Guide to Assessment and Treatment | Charles M. Morin | Springer".
  5. Grandner MA, Chakravorty S (August 2017). "Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed". J Clin Sleep Med. 13 (8): 937–939. doi:10.5664/jcsm.6688. PMC 5529129. PMID 28728626.
  6. Roth T (August 2007). "Insomnia: definition, prevalence, etiology, and consequences". J Clin Sleep Med. 3 (5 Suppl): S7–10. PMC 1978319. PMID 17824495.
  7. 8.0 8.1 Kroenke K, Spitzer RL, Williams JB (September 2001). "The PHQ-9: validity of a brief depression severity measure". J Gen Intern Med. 16 (9): 606–13. doi:10.1046/j.1525-1497.2001.016009606.x. PMC 1495268. PMID 11556941.
  8. 9.0 9.1 Williams N (September 2014). "The CAGE questionnaire". Occup Med (Lond). 64 (6): 473–4. doi:10.1093/occmed/kqu058. PMID 25146056.
  9. Krystal AD, Edinger JD, Wohlgemuth WK, Marsh GR (September 2002). "NREM sleep EEG frequency spectral correlates of sleep complaints in primary insomnia subtypes". Sleep. 25 (6): 630–40. PMID 12224842.
  10. 11.0 11.1 11.2 Joshi S (February 2008). "Nonpharmacologic therapy for insomnia in the elderly". Clin Geriatr Med. 24 (1): 107–19, viii. doi:10.1016/j.cger.2007.08.005. PMID 18035235.
  11. . doi:10.1002/14651858.CD00316. Missing or empty |title= (help)
  12. . doi:10.1002/14651858.CD00316. Missing or empty |title= (help)

CME Category:Psychiatry