Insomnia

Insomnia is a sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, trouble going back to sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, early awakenings, and feeling tired upon waking. The disorder can be acute (< 3 months), which can progress to the chronic form (≥ 3 months). Multiple risk factors contribute to having insomnia, including medical illnesses, psychiatric disorders, medications, and the sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep environment. Diagnosis starts with a detailed history and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep diagnostic aids ( sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep diary, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep problems questionnaire). The 1st line of management is nonpharmacologic, i.e., identifying the stressor(s), implementing sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep hygiene, and utilizing cognitive behavioral therapy. Medications are used with nonpharmacologic intervention or after initial management has failed.

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Definition and Classifications

Definition

Insomnia is the subjective perception of difficulty with sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep initiation, duration, consolidation, or quality despite adequate opportunity for sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, resulting in daytime functional impairment.

Classifications

By duration: 

  • Acute insomnia (< 3 months):
    • Transient or short-term insomnia
    • Due to a certain trigger (i.e., sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep environment, illness) and usually associated with anxiety or life change
    • Can evolve to persistent or chronic form
  • Chronic insomnia (≥ 3 months)
    • Includes primary and comorbid insomnia
    • Muscular weakness, hallucinations, and double vision may be present.

By how sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep is impaired:

  • Sleep-onset insomnia: difficulty falling asleep at the beginning of the night
  • Sleep-maintenance insomnia: difficulty staying asleep
  • Early-morning awakening: waking too early and having difficulty getting back to sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
  • Paradoxical insomnia:
    • Sleep-state misperception
    • Dissociation between patient’s self-reported quality of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep and the findings from objective polysomnography (which are normal)

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Epidemiology and Etiology

Epidemiology

  • At least 30% of ambulatory patients report symptoms of insomnia.
  • More common in women and older adults
  • Increased prevalence in those who are unemployed, divorced, or widowed

Risk factors

  • Inadequate sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep hygiene: 
    • Irregular bedtime schedule
    • Using bed for work, eating, or watching television
    • Naps, especially after 3 pm
    • Stimulating activities (e.g., exercising) before bedtime
  • Environmental factors such as noise, light, and extreme temperatures
  • Underlying sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder such as restless leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg syndrome
  • Behavioral insomnia (alteration of the sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep cycle) such as from jet lag or shift work
  • Medical conditions or illnesses:
    • Diabetes 
    • GERD GERD Gastroesophageal reflux disease (GERD) occurs when the stomach acid frequently flows back into the esophagus. This backwash (acid reflux) can irritate the lining of the esophagus, causing symptoms such as retrosternal burning pain (heartburn). Gastroesophageal Reflux Disease
    • Hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism
    • Asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma 
    • Alzheimer disease Alzheimer disease As the most common cause of dementia, Alzheimer disease affects not only many individuals but also their families. Alzheimer disease is a progressive neurodegenerative disease that causes brain atrophy and presents with a decline in memory, cognition, and social skills. Alzheimer Disease 
    • Menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause (vasomotor symptoms)
    • Chronic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Mental health disorders: 
    • Depression
    • Anxiety disorders 
    • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)
  • Substance abuse/medication induced: 
    • Caffeine 
    • Nicotine 
    • Alcohol 
    • Amphetamines
    • Modafinil
    • Benzodiazepine or opioid withdrawal

Pathophysiology

  • In the brain, several structures are involved in controlling wakefulness and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep.
  • Sleep-promoting cells in the brainstem and hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus (containing the suprachiasmatic nucleus (SCN)) facilitate reduced activity of arousal centers.
  • Neurotransmitters that play major roles in insomnia:
    • Decreased inhibitory neurotransmitter (GABA) in the brainstem 
    • Activation of SCN and inhibition of melatonin produced by the pineal gland
    • Increased level of stress hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview such as cortisol 
  • Hyperarousal theory:
    • Increased brain arousal during non-rapid eye movement (NREM) sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
    • Activation of key brain areas, which, once activated, cause inhibition of brain pathways that induce sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
  • Cognitive-behavioral model:
    • Predisposing conditions (e.g., anxiety) interact with precipitating factors such as illness and bereavement, increasing the risk of insomnia.
    • Perpetuating factors (e.g., daytime behaviors, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake schedule) contribute to maintaining insomnia.
    • The “3P” model: predisposition, precipitation, and perpetuation of chronic insomnia 

Clinical Presentation and Diagnosis

Symptoms

  • Difficulty falling asleep
  • Daytime sleepiness
  • General fatigue and tiredness
  • Problems with concentration or memory
  • Irritability
  • Increased errors or accidents

Diagnostic aids

  • History:
    • Medical and psychiatric history
    • Sleep history
    • Interview of the bed partner about the quantity and quality of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
  • Physical and neurologic exam (helps determine comorbid conditions)
  • Self-report screening tools (e.g., sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep problems questionnaire)
  • Sleep diary: kept over 2–4 weeks to assess patterns of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep  
  • Polysomnography:
    • Not required for diagnosis
    • Utilized to rule out other sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders

DSM-5 criteria for insomnia disorder

  • Difficulty initiating or maintaining sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, or early-morning awakening without being able to return to sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
  • Social, occupational, or behavioral impairment 
  • Symptoms for at least 3 nights per week
  • Symptoms noted for at least 3 months
  • Sleep difficulty present despite having ample opportunity for sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
  • Sleep disturbance cannot be explained by any other sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake disorder.
  • Sleep difficulty is not due to the physiological effect of a substance, mental disorder, or any medical condition.

Management

Nonpharmacologic treatment

  • Short-term or acute insomnia:
    • Identify the stressor(s) and address accordingly.
    • Use of medication(s):
      • If insomnia interferes with daytime function
      • Temporary
  • Chronic Insomnia:
    • Improve sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep hygiene:
      • Avoid alcohol, caffeinated drinks, and large meals at least 4 hours before bedtime.
      • Maintain regular exercise patterns but no exercising too close to bedtime (3 hours). 
      • Avoid napping or daytime sleeping. 
      • Use bed only for sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep/sex (no eating/television/cellphone in bed).
      • Reduce light exposure around bedtime.
    • Cognitive-behavioral therapy:
      • 1st line of treatment 
      • Goal is to increase sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep efficiency, address maladaptive thoughts, and promote a stable routine of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep/wake times. 
      • Set a time for sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep each day (follow a sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep schedule)
      • Sleep restriction: reduce time in bed to total hours of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
      • Stimulus control: if anxious when unable to sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, should get out of bed 
      • Sleep hygiene
  • Treat any underlying pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, depression, or other comorbidities before intensive sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep treatment.

Pharmacologic treatment

  • Hypnotic benzodiazepine receptor agonists (BZRAs):
    • Mechanism: acts on GABA receptor without specific affinity to different subtypes of GABA
    • High risk of tolerance, abuse, and dependence as well as cognitive impairments linked with long-term use 
    • Examples: temazepam, clonazepam, triazolam 
  • Nonbenzodiazepine BZRAs:
    • Mechanism: 
      • Benzodiazepine receptor agonists that act on GABA receptor (similar to benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines)
      • Selective affinity (GABA-A subunit subtypes), which reduces side effects
    • Fewer adverse effects and abuse potential than benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines
    • Examples: zolpidem, zaleplon, eszopiclone 
  • Dual orexin receptor antagonists 
    • Mechanism: 
      • Orexin or hypocretin system promotes arousal or wakefulness.
      • Orexin receptor antagonists counteract the orexin-mediated nighttime awakening. 
    • Examples: lemborexant, suvorexant 
  • Melatonin agonists:
    • Mechanism: Melatonin is a natural hormone associated with the establishment of the circadian rhythm and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake cycle. 
    • Examples: 
      • Melatonin: natural hormone (over the counter) 
      • Ramelteon: highly selective melatonin receptor agonist with higher affinity and selectivity than melatonin   
  • Histamine receptor antagonist:
    • Mechanism: H1 receptor antagonist producing sedation
    • Example: doxepin
  • Antidepressants with sedative properties: 
    • Exact mechanism unknown but thought to work through antihistamine and serotonin effects 
    • Off-label use  
    • Examples: trazodone, mirtazapine, amitriptyline, doxepin

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Differential Diagnosis

  • Narcolepsy Narcolepsy Narcolepsy is a neurological sleep disorder marked by daytime sleepiness and associated with cataplexy, hypnagogic hallucinations, and sleep paralysis. There are 2 types of narcolepsy: type 1 is associated with cataplexy and type 2 has no association with cataplexy. Narcolepsy: a sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder characterized by excessive daytime sleepiness and falling asleep at inappropriate times. Narcolepsy Narcolepsy Narcolepsy is a neurological sleep disorder marked by daytime sleepiness and associated with cataplexy, hypnagogic hallucinations, and sleep paralysis. There are 2 types of narcolepsy: type 1 is associated with cataplexy and type 2 has no association with cataplexy. Narcolepsy is associated with hallucinations (hypnagogic and hypnopompic, which occur upon falling and waking from sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, respectively) and cataplexy (emotionally triggered loss of muscle tone). Narcolepsy Narcolepsy Narcolepsy is a neurological sleep disorder marked by daytime sleepiness and associated with cataplexy, hypnagogic hallucinations, and sleep paralysis. There are 2 types of narcolepsy: type 1 is associated with cataplexy and type 2 has no association with cataplexy. Narcolepsy must be ruled out via history and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep study before diagnosis of primary insomnia.
  • Circadian rhythm sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake disorders: a group of conditions marked by recurrent patterns of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disruption. These conditions can be due to an alteration of the circadian system or a misalignment between the inner circadian rhythm and the sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep environment. Delayed sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake phase disorder manifests as delayed onset of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep and awakening. The sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep quality and duration are preserved. In advanced sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake phase disorder, there is early sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep onset and awakening. Diagnosis is generally clinical. Unlike in these disorders, in insomnia, the patient has difficulty falling asleep at any time. 
  • Hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism: caused by an excess of thyroid hormones Thyroid hormones The 2 primary thyroid hormones are triiodothyronine (T3) and thyroxine (T4). These hormones are synthesized and secreted by the thyroid, and they are responsible for stimulating metabolism in most cells of the body. Their secretion is regulated primarily by thyroid-stimulating hormone (TSH), which is produced by the pituitary gland. Thyroid Hormones T3 and T4. Clinical features of hyperthyroidism are mostly due to the body’s increased metabolic rate. Sleep disturbance is one of the important manifestations of this disease. Basic laboratory studies (thyroid-stimulating hormone) should rule out this disorder prior to making a diagnosis of primary insomnia
  • Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder: chronic multiple worries that are irrational and uncontrollable. The disorder is associated with fatigue, low concentration, restlessness, irritability, and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disturbance. Other anxiety disorders (e.g., phobias, social anxiety disorder Social anxiety disorder Social anxiety disorder, or social phobia, is a psychiatric illness marked by fear and avoidance of social interactions due to concerns about embarrassment. The disorder usually occurs in more than one social situation for more than 6 months and leads to a significant decline in function. Social Anxiety Disorder, PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)) can also cause sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disturbance. Full history should exclude anxiety disorders prior to making a diagnosis of primary insomnia.

References

  1. Bonnet M, Arand D. (2021). Risk factors, comorbidities and consequences of insomnia. UpToDate. Retrieved June 6, 2021, from https://www.uptodate.com/contents/risk-factors-comorbidities-and-consequences-of-insomnia-in-adults
  2. Claman D, Okeson K, Singer C. (2019). Sleep disorders. https://accessmedicine.mhmedical.com/content.aspx?bookid=2747&sectionid=230251345
  3. Conroy D. (2021). Paradoxical Insomnia. Medlink. Retrieved June 6, 2021, from https://www.medlink.com/articles/paradoxical-insomnia
  4. Kaur H, Spurling BC, Bollu PC. (2020). Chronic Insomnia. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK526136/
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