Insomnia Presentation
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About This Presentation
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Slide Content
SLEEPSLEEP
and and
INSOMNIAINSOMNIA
Lynn N. Stewart, M.D.Lynn N. Stewart, M.D.
Travis County Wellness and Health Travis County Wellness and Health
ClinicClinic
Austin, TXAustin, TX
and and
INSOMNIAINSOMNIA
Lynn N. Stewart, M.D.Lynn N. Stewart, M.D.
Travis County Wellness and Health Travis County Wellness and Health
ClinicClinic
Austin, TXAustin, TX
ObjectivesObjectives
By the conclusion of this lecture, you will be able to:By the conclusion of this lecture, you will be able to:
Learn about the process of sleepLearn about the process of sleep
Identify 4 main categories of insomniaIdentify 4 main categories of insomnia
Classify insomnia by stageClassify insomnia by stage
List at least 5 common etiologies of List at least 5 common etiologies of
insomniainsomnia
Discuss 5 or more principles of sleep Discuss 5 or more principles of sleep
hygienehygiene
Give 5 guidelines for drug therapyGive 5 guidelines for drug therapy
By the conclusion of this lecture, you will be able to:By the conclusion of this lecture, you will be able to:
Learn about the process of sleepLearn about the process of sleep
Identify 4 main categories of insomniaIdentify 4 main categories of insomnia
Classify insomnia by stageClassify insomnia by stage
List at least 5 common etiologies of List at least 5 common etiologies of
insomniainsomnia
Discuss 5 or more principles of sleep Discuss 5 or more principles of sleep
hygienehygiene
Give 5 guidelines for drug therapyGive 5 guidelines for drug therapy
Why do we care about sleep?Why do we care about sleep?
Sleep is a necessary restorative process Sleep is a necessary restorative process
that affects all aspects of functioning.that affects all aspects of functioning.
Sleep is an active process for the brain.Sleep is an active process for the brain.
Early in sleep slow-rolling eye movements Early in sleep slow-rolling eye movements
occur (non-rapid eye movement).occur (non-rapid eye movement).
Later—deeper in sleep–rapid eye Later—deeper in sleep–rapid eye
movements (REM) are associated with movements (REM) are associated with
irregular breathing and increased heart irregular breathing and increased heart
raterate
Sleep is a necessary restorative process Sleep is a necessary restorative process
that affects all aspects of functioning.that affects all aspects of functioning.
Sleep is an active process for the brain.Sleep is an active process for the brain.
Early in sleep slow-rolling eye movements Early in sleep slow-rolling eye movements
occur (non-rapid eye movement).occur (non-rapid eye movement).
Later—deeper in sleep–rapid eye Later—deeper in sleep–rapid eye
movements (REM) are associated with movements (REM) are associated with
irregular breathing and increased heart irregular breathing and increased heart
raterate
Sleep Stages and their functionSleep Stages and their function
Non-rapid Eye Movement (NREM)Non-rapid Eye Movement (NREM)
Stage 1: transition to sleepStage 1: transition to sleep
5% total time5% total time
Stage 2: 50% total timeStage 2: 50% total time
Stages 3 and 4: slow-wave sleepStages 3 and 4: slow-wave sleep
10-20% total sleep time10-20% total sleep time
Restful and restorative sleep Restful and restorative sleep
achieved hereachieved here
Rapid Eye Movement (REM)Rapid Eye Movement (REM)
20-25% total sleep time20-25% total sleep time
Non-rapid Eye Movement (NREM)Non-rapid Eye Movement (NREM)
Stage 1: transition to sleepStage 1: transition to sleep
5% total time5% total time
Stage 2: 50% total timeStage 2: 50% total time
Stages 3 and 4: slow-wave sleepStages 3 and 4: slow-wave sleep
10-20% total sleep time10-20% total sleep time
Restful and restorative sleep Restful and restorative sleep
achieved hereachieved here
Rapid Eye Movement (REM)Rapid Eye Movement (REM)
20-25% total sleep time20-25% total sleep time
Sleep Cycle and ArchitectureSleep Cycle and Architecture
Normal, healthy people start with NREM1 Normal, healthy people start with NREM1
then NREM 2, 3, 4, 3, 2, and then REM.then NREM 2, 3, 4, 3, 2, and then REM.
Cycle repeats at 90-120 minute intervalsCycle repeats at 90-120 minute intervals
Total cycle repeats 3-4 times a nightTotal cycle repeats 3-4 times a night
NREM 3 and 4: more prominent is first half NREM 3 and 4: more prominent is first half
of the night, and decrease later on.of the night, and decrease later on.
REM: less prominent in the early night, REM: less prominent in the early night,
and increases as the night progressesand increases as the night progresses
Normal, healthy people start with NREM1 Normal, healthy people start with NREM1
then NREM 2, 3, 4, 3, 2, and then REM.then NREM 2, 3, 4, 3, 2, and then REM.
Cycle repeats at 90-120 minute intervalsCycle repeats at 90-120 minute intervals
Total cycle repeats 3-4 times a nightTotal cycle repeats 3-4 times a night
NREM 3 and 4: more prominent is first half NREM 3 and 4: more prominent is first half
of the night, and decrease later on.of the night, and decrease later on.
REM: less prominent in the early night, REM: less prominent in the early night,
and increases as the night progressesand increases as the night progresses
Sleep at different agesSleep at different ages
Sleep varies with ageSleep varies with age
Infants sleep 66% of the day; adults, 33%Infants sleep 66% of the day; adults, 33%
Elderly have a reduction in the depth, Elderly have a reduction in the depth,
intensity , and continuity of sleep:intensity , and continuity of sleep:
Increased sleep latencyIncreased sleep latency
Decreased REM latencyDecreased REM latency
Reduced NREM 3 and 4 Reduced NREM 3 and 4
Reduced total REM amountReduced total REM amount
Frequent awakeningsFrequent awakenings
Sleep varies with ageSleep varies with age
Infants sleep 66% of the day; adults, 33%Infants sleep 66% of the day; adults, 33%
Elderly have a reduction in the depth, Elderly have a reduction in the depth,
intensity , and continuity of sleep:intensity , and continuity of sleep:
Increased sleep latencyIncreased sleep latency
Decreased REM latencyDecreased REM latency
Reduced NREM 3 and 4 Reduced NREM 3 and 4
Reduced total REM amountReduced total REM amount
Frequent awakeningsFrequent awakenings
So what keeps us awake?So what keeps us awake?
The Reticular Activating System (RAS) of the The Reticular Activating System (RAS) of the
brain plays is mostly responsible for keeping us brain plays is mostly responsible for keeping us
awake and alert.awake and alert.
Narcolepsy is a clinical syndrome of daytime Narcolepsy is a clinical syndrome of daytime
sleepiness with cataplexy (bilateral muscle sleepiness with cataplexy (bilateral muscle
weakness leading to partial or complete weakness leading to partial or complete
collapse), hypnagogic hallucinations, and sleep collapse), hypnagogic hallucinations, and sleep
paralysis, and is associated with disordered paralysis, and is associated with disordered
REM sleep. Not all are required for the REM sleep. Not all are required for the
syndrome. A loss of orexin and hypocretin syndrome. A loss of orexin and hypocretin
neuropeptides is typically found.neuropeptides is typically found.
The Reticular Activating System (RAS) of the The Reticular Activating System (RAS) of the
brain plays is mostly responsible for keeping us brain plays is mostly responsible for keeping us
awake and alert.awake and alert.
Narcolepsy is a clinical syndrome of daytime Narcolepsy is a clinical syndrome of daytime
sleepiness with cataplexy (bilateral muscle sleepiness with cataplexy (bilateral muscle
weakness leading to partial or complete weakness leading to partial or complete
collapse), hypnagogic hallucinations, and sleep collapse), hypnagogic hallucinations, and sleep
paralysis, and is associated with disordered paralysis, and is associated with disordered
REM sleep. Not all are required for the REM sleep. Not all are required for the
syndrome. A loss of orexin and hypocretin syndrome. A loss of orexin and hypocretin
neuropeptides is typically found.neuropeptides is typically found.
Types of InsomniaTypes of Insomnia
Is the problem not being able to fall Is the problem not being able to fall
asleep?asleep?
→→Problems falling asleep are referred to as Problems falling asleep are referred to as
problems with “sleep latency.”problems with “sleep latency.”
Is the problem staying asleep?Is the problem staying asleep?
→→Problems staying asleep are referred to Problems staying asleep are referred to
as problems with “sleep maintenance.”as problems with “sleep maintenance.”
Is the problem not being able to fall Is the problem not being able to fall
asleep?asleep?
→→Problems falling asleep are referred to as Problems falling asleep are referred to as
problems with “sleep latency.”problems with “sleep latency.”
Is the problem staying asleep?Is the problem staying asleep?
→→Problems staying asleep are referred to Problems staying asleep are referred to
as problems with “sleep maintenance.”as problems with “sleep maintenance.”
Why Are We Talking About Why Are We Talking About
This?This?
Up to 40% of adults are affectedUp to 40% of adults are affected
1/3 adults are affected intermittently1/3 adults are affected intermittently
10% are chronic10% are chronic
Treatment alone costs $2-11 billionTreatment alone costs $2-11 billion
Total financial impact: $35 billionTotal financial impact: $35 billion
Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic
insomnia: an American Academy of Sleep Medicine Review. insomnia: an American Academy of Sleep Medicine Review. Sleep.Sleep.
1999;22:1134-11561999;22:1134-1156
Silber MH. Chronic insomnia. Silber MH. Chronic insomnia. N Engl J Med.N Engl J Med.2005;353:803-8102005;353:803-810
Saul S. Record sales of sleeping pills are causing worries. Saul S. Record sales of sleeping pills are causing worries. New York Times.New York Times. Feb 7, Feb 7,
2006.2006.
This?This?
Up to 40% of adults are affectedUp to 40% of adults are affected
1/3 adults are affected intermittently1/3 adults are affected intermittently
10% are chronic10% are chronic
Treatment alone costs $2-11 billionTreatment alone costs $2-11 billion
Total financial impact: $35 billionTotal financial impact: $35 billion
Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic
insomnia: an American Academy of Sleep Medicine Review. insomnia: an American Academy of Sleep Medicine Review. Sleep.Sleep.
1999;22:1134-11561999;22:1134-1156
Silber MH. Chronic insomnia. Silber MH. Chronic insomnia. N Engl J Med.N Engl J Med.2005;353:803-8102005;353:803-810
Saul S. Record sales of sleeping pills are causing worries. Saul S. Record sales of sleeping pills are causing worries. New York Times.New York Times. Feb 7, Feb 7,
2006.2006.
DefinitionDefinition
The The subjectivesubjective experience of inadequate experience of inadequate
or poor quality sleepor poor quality sleep
““I’M UP”I’M UP”
II - - difficultydifficulty IInitiating sleepnitiating sleep
MM - - difficulty difficulty MMaintaining sleepaintaining sleep
UU - - UUnrefreshing sleepnrefreshing sleep
PP - - PPremature awakeningremature awakening
The The subjectivesubjective experience of inadequate experience of inadequate
or poor quality sleepor poor quality sleep
““I’M UP”I’M UP”
II - - difficultydifficulty IInitiating sleepnitiating sleep
MM - - difficulty difficulty MMaintaining sleepaintaining sleep
UU - - UUnrefreshing sleepnrefreshing sleep
PP - - PPremature awakeningremature awakening
Daytime ConsequencesDaytime Consequences
Tiredness and lack of energyTiredness and lack of energy
Poor concentration and performancePoor concentration and performance
Irritability and/or depressionIrritability and/or depression
Feeling unwellFeeling unwell
Less able to enjoy lifeLess able to enjoy life
Increased illnessIncreased illness
Tiredness and lack of energyTiredness and lack of energy
Poor concentration and performancePoor concentration and performance
Irritability and/or depressionIrritability and/or depression
Feeling unwellFeeling unwell
Less able to enjoy lifeLess able to enjoy life
Increased illnessIncreased illness
Real ConsequencesReal Consequences
AbsenteeismAbsenteeism
PresenteeismPresenteeism
Social disabilitySocial disability
Increased Increased
healthcare healthcare
utilizationutilization
Fewer promotionsFewer promotions
Auto accidentsAuto accidents
Insomniacs have Insomniacs have
2.5x more 2.5x more
accidents due to accidents due to
fatiguefatigue
DepressionDepression
AbsenteeismAbsenteeism
PresenteeismPresenteeism
Social disabilitySocial disability
Increased Increased
healthcare healthcare
utilizationutilization
Fewer promotionsFewer promotions
Auto accidentsAuto accidents
Insomniacs have Insomniacs have
2.5x more 2.5x more
accidents due to accidents due to
fatiguefatigue
DepressionDepression
Real ConsequencesReal Consequences
Sleep deprivation (less than 6 hours of Sleep deprivation (less than 6 hours of
sleep a night) is an independent predictor sleep a night) is an independent predictor
of future weight gain AND obesity in of future weight gain AND obesity in
women.women.
RR=1.32 for gaining >15kg (>33#) over 16 RR=1.32 for gaining >15kg (>33#) over 16
years for those who sleep 5 hours/night; years for those who sleep 5 hours/night;
RR=1.12 for 6 hours/night when compared RR=1.12 for 6 hours/night when compared
against those who slept 7 hours/night against those who slept 7 hours/night
(after adjusting for exercise and caloric (after adjusting for exercise and caloric
intake).intake).
Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Family Family
Practice News Practice News 36 (15 Oct 2006):44.36 (15 Oct 2006):44.
Sleep deprivation (less than 6 hours of Sleep deprivation (less than 6 hours of
sleep a night) is an independent predictor sleep a night) is an independent predictor
of future weight gain AND obesity in of future weight gain AND obesity in
women.women.
RR=1.32 for gaining >15kg (>33#) over 16 RR=1.32 for gaining >15kg (>33#) over 16
years for those who sleep 5 hours/night; years for those who sleep 5 hours/night;
RR=1.12 for 6 hours/night when compared RR=1.12 for 6 hours/night when compared
against those who slept 7 hours/night against those who slept 7 hours/night
(after adjusting for exercise and caloric (after adjusting for exercise and caloric
intake).intake).
Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Family Family
Practice News Practice News 36 (15 Oct 2006):44.36 (15 Oct 2006):44.
Sleep DeprivationSleep Deprivation
Inadequate opportunity for sleepInadequate opportunity for sleep
Feel sleepy during the dayFeel sleepy during the day
insomniacs typically feel tired, not insomniacs typically feel tired, not
sleepysleepy
Fall asleep at inappropriate timesFall asleep at inappropriate times
Such as while driving, at work Such as while driving, at work
during an interview, while at family during an interview, while at family
events.events.
Inadequate opportunity for sleepInadequate opportunity for sleep
Feel sleepy during the dayFeel sleepy during the day
insomniacs typically feel tired, not insomniacs typically feel tired, not
sleepysleepy
Fall asleep at inappropriate timesFall asleep at inappropriate times
Such as while driving, at work Such as while driving, at work
during an interview, while at family during an interview, while at family
events.events.
Hyper Arousal State from InsomniaHyper Arousal State from Insomnia
Increased (short-term only)Increased (short-term only)::
Metabolic rateMetabolic rate
Heart rateHeart rate
TemperatureTemperature
Catecholamine metabolitesCatecholamine metabolites
Stress hormone levelsStress hormone levels
Fast EEG activity (electrical recording of brain Fast EEG activity (electrical recording of brain
activity=Electro Encephalo Gram)activity=Electro Encephalo Gram)
Increased (short-term only)Increased (short-term only)::
Metabolic rateMetabolic rate
Heart rateHeart rate
TemperatureTemperature
Catecholamine metabolitesCatecholamine metabolites
Stress hormone levelsStress hormone levels
Fast EEG activity (electrical recording of brain Fast EEG activity (electrical recording of brain
activity=Electro Encephalo Gram)activity=Electro Encephalo Gram)
Risk Factors for InsomniaRisk Factors for Insomnia
Prior episodePrior episode
Female gender Female gender
(1.3x)(1.3x)
Age > 65 (1.5x)Age > 65 (1.5x)
half the half the
population over population over
age 65age 65
40% of all 40% of all
hypnotic scriptshypnotic scripts
SnoringSnoring
Depression (which Depression (which
comes first?)comes first?)
Lower Lower
socioeconomic socioeconomic
statusstatus
Divorce / SeparationDivorce / Separation
WidowhoodWidowhood
Concurrent medical Concurrent medical
problemsproblems
Prior episodePrior episode
Female gender Female gender
(1.3x)(1.3x)
Age > 65 (1.5x)Age > 65 (1.5x)
half the half the
population over population over
age 65age 65
40% of all 40% of all
hypnotic scriptshypnotic scripts
SnoringSnoring
Depression (which Depression (which
comes first?)comes first?)
Lower Lower
socioeconomic socioeconomic
statusstatus
Divorce / SeparationDivorce / Separation
WidowhoodWidowhood
Concurrent medical Concurrent medical
problemsproblems
Stages of InsomniaStages of Insomnia
Transient: < 4 nights (days to weeks)Transient: < 4 nights (days to weeks)
Acute: > 2 nights a week for 2 weeksAcute: > 2 nights a week for 2 weeks
Chronic: 3 or more nights a week, for Chronic: 3 or more nights a week, for
4 or more weeks (months to years)4 or more weeks (months to years)
Critical: The inability to sleep during Critical: The inability to sleep during
lectureslectures
Transient: < 4 nights (days to weeks)Transient: < 4 nights (days to weeks)
Acute: > 2 nights a week for 2 weeksAcute: > 2 nights a week for 2 weeks
Chronic: 3 or more nights a week, for Chronic: 3 or more nights a week, for
4 or more weeks (months to years)4 or more weeks (months to years)
Critical: The inability to sleep during Critical: The inability to sleep during
lectureslectures
Psychiatric Causes of InsomniaPsychiatric Causes of Insomnia
DepressionDepression
Generalized Anxiety Generalized Anxiety
DisorderDisorder
StressStress
Post Traumatic Post Traumatic
Stress DisorderStress Disorder
Obsessive Obsessive
Compulsive Compulsive
DisorderDisorder
Adjustment Adjustment
disordersdisorders
Personality Personality
disordersdisorders
Bipolar disorderBipolar disorder
DysthymiaDysthymia
AnxietyAnxiety
Psychosis including Psychosis including
schizophreniaschizophrenia
DepressionDepression
Generalized Anxiety Generalized Anxiety
DisorderDisorder
StressStress
Post Traumatic Post Traumatic
Stress DisorderStress Disorder
Obsessive Obsessive
Compulsive Compulsive
DisorderDisorder
Adjustment Adjustment
disordersdisorders
Personality Personality
disordersdisorders
Bipolar disorderBipolar disorder
DysthymiaDysthymia
AnxietyAnxiety
Psychosis including Psychosis including
schizophreniaschizophrenia
Medical Causes of InsomniaMedical Causes of Insomnia
PainPain
NeuropathyNeuropathy
FibromyalgiaFibromyalgia
Osteoarthritis Osteoarthritis
Rheumatoid arthritisRheumatoid arthritis
Chronic back painChronic back pain
CardiovascularCardiovascular
Congestive heart Congestive heart
failurefailure
DyspneaDyspnea
Nocturnal anginaNocturnal angina
PulmonaryPulmonary
COPDCOPD
AsthmaAsthma
Obstructive Sleep apneaObstructive Sleep apnea
Mixed Sleep apneaMixed Sleep apnea
Obesity-hypoventilation Obesity-hypoventilation
SyndromeSyndrome
GastrointestinalGastrointestinal
GastroEsophageal GastroEsophageal
Reflux Disease Reflux Disease
(GERD)(GERD)
PainPain
NeuropathyNeuropathy
FibromyalgiaFibromyalgia
Osteoarthritis Osteoarthritis
Rheumatoid arthritisRheumatoid arthritis
Chronic back painChronic back pain
CardiovascularCardiovascular
Congestive heart Congestive heart
failurefailure
DyspneaDyspnea
Nocturnal anginaNocturnal angina
PulmonaryPulmonary
COPDCOPD
AsthmaAsthma
Obstructive Sleep apneaObstructive Sleep apnea
Mixed Sleep apneaMixed Sleep apnea
Obesity-hypoventilation Obesity-hypoventilation
SyndromeSyndrome
GastrointestinalGastrointestinal
GastroEsophageal GastroEsophageal
Reflux Disease Reflux Disease
(GERD)(GERD)
Medical Causes of InsomniaMedical Causes of Insomnia
GenitourinaryGenitourinary
Benign Prostatic Benign Prostatic
HypertrophyHypertrophy
NocturiaNocturia
IncontinenceIncontinence
Endocrine/MetabolicEndocrine/Metabolic
Hormonal disruptionsHormonal disruptions
MenopauseMenopause
Thyroid diseaseThyroid disease
Endocrine hormone-Endocrine hormone-
secreting tumorssecreting tumors
NeurologicNeurologic
Alzheimer’sAlzheimer’s
Huntington’sHuntington’s
Parkinson’sParkinson’s
Central Sleep apneaCentral Sleep apnea
SeizuresSeizures
Headaches (cluster, Headaches (cluster,
migraine)migraine)
Fatal Familial Insomnia Fatal Familial Insomnia
(yes, it is fatal, and (yes, it is fatal, and
familial)familial)
You’d already know about You’d already know about
it if it is in your familyit if it is in your family
GenitourinaryGenitourinary
Benign Prostatic Benign Prostatic
HypertrophyHypertrophy
NocturiaNocturia
IncontinenceIncontinence
Endocrine/MetabolicEndocrine/Metabolic
Hormonal disruptionsHormonal disruptions
MenopauseMenopause
Thyroid diseaseThyroid disease
Endocrine hormone-Endocrine hormone-
secreting tumorssecreting tumors
NeurologicNeurologic
Alzheimer’sAlzheimer’s
Huntington’sHuntington’s
Parkinson’sParkinson’s
Central Sleep apneaCentral Sleep apnea
SeizuresSeizures
Headaches (cluster, Headaches (cluster,
migraine)migraine)
Fatal Familial Insomnia Fatal Familial Insomnia
(yes, it is fatal, and (yes, it is fatal, and
familial)familial)
You’d already know about You’d already know about
it if it is in your familyit if it is in your family
DyssomniaDyssomnia
Dyssomnias are sleep disorders Dyssomnias are sleep disorders
characterized by insomnia, excessive characterized by insomnia, excessive
sleepiness, or abnormal sleep-wake timingsleepiness, or abnormal sleep-wake timing
Sleep DisordersSleep Disorders
Restless LegsRestless Legs
Trouble falling asleep Trouble falling asleep
Patient very aware of movement/sensationsPatient very aware of movement/sensations
Periodic Limb Movement DisorderPeriodic Limb Movement Disorder
Unrefreshing sleep, hypersomniaUnrefreshing sleep, hypersomnia
Leg contractions during stages 1 & 2Leg contractions during stages 1 & 2
Patient usually unaware of movementPatient usually unaware of movement
Dyssomnias are sleep disorders Dyssomnias are sleep disorders
characterized by insomnia, excessive characterized by insomnia, excessive
sleepiness, or abnormal sleep-wake timingsleepiness, or abnormal sleep-wake timing
Sleep DisordersSleep Disorders
Restless LegsRestless Legs
Trouble falling asleep Trouble falling asleep
Patient very aware of movement/sensationsPatient very aware of movement/sensations
Periodic Limb Movement DisorderPeriodic Limb Movement Disorder
Unrefreshing sleep, hypersomniaUnrefreshing sleep, hypersomnia
Leg contractions during stages 1 & 2Leg contractions during stages 1 & 2
Patient usually unaware of movementPatient usually unaware of movement
Intrinsic DyssomniaIntrinsic Dyssomnia
Psychophysiological Psychophysiological
insomnia insomnia
Sleep state Sleep state
misperception misperception
Idiopathic insomnia Idiopathic insomnia
Narcolepsy Narcolepsy
Hypersomnia Hypersomnia
Recurrent, idiopathic, Recurrent, idiopathic,
post-traumaticpost-traumatic
Restless legs Restless legs
syndromesyndrome
Obstructive sleep Obstructive sleep
apnea syndromeapnea syndrome
Central sleep apnea Central sleep apnea
syndrome syndrome
Central alveolar Central alveolar
hypoventilation hypoventilation
syndromesyndrome
Periodic limb Periodic limb
movement disordermovement disorder
Intrinsic sleep Intrinsic sleep
disorder NOSdisorder NOS
Psychophysiological Psychophysiological
insomnia insomnia
Sleep state Sleep state
misperception misperception
Idiopathic insomnia Idiopathic insomnia
Narcolepsy Narcolepsy
Hypersomnia Hypersomnia
Recurrent, idiopathic, Recurrent, idiopathic,
post-traumaticpost-traumatic
Restless legs Restless legs
syndromesyndrome
Obstructive sleep Obstructive sleep
apnea syndromeapnea syndrome
Central sleep apnea Central sleep apnea
syndrome syndrome
Central alveolar Central alveolar
hypoventilation hypoventilation
syndromesyndrome
Periodic limb Periodic limb
movement disordermovement disorder
Intrinsic sleep Intrinsic sleep
disorder NOSdisorder NOS
Extrinsic DyssomniaExtrinsic Dyssomnia
Inadequate sleep Inadequate sleep
hygiene hygiene
Environmental sleep Environmental sleep
disorderdisorder
Altitude insomnia Altitude insomnia
Adjustment sleep Adjustment sleep
disorder disorder
Insufficient sleep Insufficient sleep
syndromesyndrome
Limit-setting sleep Limit-setting sleep
disorder disorder
Sleep-onset association Sleep-onset association
disorderdisorder
Food allergy insomniaFood allergy insomnia
Nocturnal eating Nocturnal eating
(drinking) syndrome (drinking) syndrome
Hypnotic-dependent Hypnotic-dependent
sleep disorder sleep disorder
Stimulant-dependent Stimulant-dependent
sleep disordersleep disorder
Alcohol-dependent Alcohol-dependent
sleep disordersleep disorder
Toxin-induced sleep Toxin-induced sleep
disorderdisorder
Extrinsic sleep Extrinsic sleep
disorder NOS disorder NOS
Inadequate sleep Inadequate sleep
hygiene hygiene
Environmental sleep Environmental sleep
disorderdisorder
Altitude insomnia Altitude insomnia
Adjustment sleep Adjustment sleep
disorder disorder
Insufficient sleep Insufficient sleep
syndromesyndrome
Limit-setting sleep Limit-setting sleep
disorder disorder
Sleep-onset association Sleep-onset association
disorderdisorder
Food allergy insomniaFood allergy insomnia
Nocturnal eating Nocturnal eating
(drinking) syndrome (drinking) syndrome
Hypnotic-dependent Hypnotic-dependent
sleep disorder sleep disorder
Stimulant-dependent Stimulant-dependent
sleep disordersleep disorder
Alcohol-dependent Alcohol-dependent
sleep disordersleep disorder
Toxin-induced sleep Toxin-induced sleep
disorderdisorder
Extrinsic sleep Extrinsic sleep
disorder NOS disorder NOS
Circadian DyssomniaCircadian Dyssomnia
Time zone change (jet lag) syndrome Time zone change (jet lag) syndrome
Shift work sleep disorder Shift work sleep disorder
Irregular sleep-wake patternIrregular sleep-wake pattern
Delayed sleep phase syndromeDelayed sleep phase syndrome
Advanced sleep phase syndromeAdvanced sleep phase syndrome
Non-24-hour sleep-wake disorder Non-24-hour sleep-wake disorder
Circadian rhythm sleep disorder NOS Circadian rhythm sleep disorder NOS
Shifts with age (adolescent or elderly)Shifts with age (adolescent or elderly)
Time zone change (jet lag) syndrome Time zone change (jet lag) syndrome
Shift work sleep disorder Shift work sleep disorder
Irregular sleep-wake patternIrregular sleep-wake pattern
Delayed sleep phase syndromeDelayed sleep phase syndrome
Advanced sleep phase syndromeAdvanced sleep phase syndrome
Non-24-hour sleep-wake disorder Non-24-hour sleep-wake disorder
Circadian rhythm sleep disorder NOS Circadian rhythm sleep disorder NOS
Shifts with age (adolescent or elderly)Shifts with age (adolescent or elderly)
ParasomniasParasomnias
Parasomnias are sleep disorders characterized Parasomnias are sleep disorders characterized
by abnormal behavioral or physiological events by abnormal behavioral or physiological events
which occur during sleep or during sleep-wake which occur during sleep or during sleep-wake
transitions.transitions.
Parasomnias typically do not cause insomnia or Parasomnias typically do not cause insomnia or
excessive sleepiness, but some are dangerous excessive sleepiness, but some are dangerous
to the patient or others. to the patient or others.
Most are “normal” if done while awakeMost are “normal” if done while awake
More common in children than adultsMore common in children than adults
Most do not require therapyMost do not require therapy
Parasomnias are sleep disorders characterized Parasomnias are sleep disorders characterized
by abnormal behavioral or physiological events by abnormal behavioral or physiological events
which occur during sleep or during sleep-wake which occur during sleep or during sleep-wake
transitions.transitions.
Parasomnias typically do not cause insomnia or Parasomnias typically do not cause insomnia or
excessive sleepiness, but some are dangerous excessive sleepiness, but some are dangerous
to the patient or others. to the patient or others.
Most are “normal” if done while awakeMost are “normal” if done while awake
More common in children than adultsMore common in children than adults
Most do not require therapyMost do not require therapy
Parasomnias ContinuedParasomnias Continued
Arousal disorders:Arousal disorders:
Confusional arousalsConfusional arousals
SleepwalkingSleepwalking
Sleep terrors Sleep terrors
Sleep-wake Sleep-wake
transition disorders:transition disorders:
Rhythmic movement Rhythmic movement
disorderdisorder
Sleep startsSleep starts
Sleep talkingSleep talking
Nocturnal leg cramps Nocturnal leg cramps
Parasomnias Parasomnias
usually associated usually associated
with REM sleep:with REM sleep:
Nightmares Nightmares
Sleep paralysisSleep paralysis
Impaired sleep-related Impaired sleep-related
penile erectionspenile erections
Sleep-related painful Sleep-related painful
erections erections
REM sleep-related sinus REM sleep-related sinus
arrest REM sleep arrest REM sleep
behavior disorderbehavior disorder
Arousal disorders:Arousal disorders:
Confusional arousalsConfusional arousals
SleepwalkingSleepwalking
Sleep terrors Sleep terrors
Sleep-wake Sleep-wake
transition disorders:transition disorders:
Rhythmic movement Rhythmic movement
disorderdisorder
Sleep startsSleep starts
Sleep talkingSleep talking
Nocturnal leg cramps Nocturnal leg cramps
Parasomnias Parasomnias
usually associated usually associated
with REM sleep:with REM sleep:
Nightmares Nightmares
Sleep paralysisSleep paralysis
Impaired sleep-related Impaired sleep-related
penile erectionspenile erections
Sleep-related painful Sleep-related painful
erections erections
REM sleep-related sinus REM sleep-related sinus
arrest REM sleep arrest REM sleep
behavior disorderbehavior disorder
Parasomnias ContinuedParasomnias Continued
Parasomnias NOSParasomnias NOS
Sleep bruxism (tooth grinding)Sleep bruxism (tooth grinding)
Sleep enuresis (bed-wetting)Sleep enuresis (bed-wetting)
Sleep-related abnormal swallowing syndrome Sleep-related abnormal swallowing syndrome
Nocturnal paroxysmal dystomia Nocturnal paroxysmal dystomia
Sudden unexplained nocturnal death syndrome Sudden unexplained nocturnal death syndrome
Primary snoring Primary snoring
Infant sleep apnea Infant sleep apnea
Congenital central hypoventilation syndrome Congenital central hypoventilation syndrome
Sudden infant death syndrome Sudden infant death syndrome
Benign neonatal sleep myoclonus Benign neonatal sleep myoclonus
Other parasomnia NOSOther parasomnia NOS
Parasomnias NOSParasomnias NOS
Sleep bruxism (tooth grinding)Sleep bruxism (tooth grinding)
Sleep enuresis (bed-wetting)Sleep enuresis (bed-wetting)
Sleep-related abnormal swallowing syndrome Sleep-related abnormal swallowing syndrome
Nocturnal paroxysmal dystomia Nocturnal paroxysmal dystomia
Sudden unexplained nocturnal death syndrome Sudden unexplained nocturnal death syndrome
Primary snoring Primary snoring
Infant sleep apnea Infant sleep apnea
Congenital central hypoventilation syndrome Congenital central hypoventilation syndrome
Sudden infant death syndrome Sudden infant death syndrome
Benign neonatal sleep myoclonus Benign neonatal sleep myoclonus
Other parasomnia NOSOther parasomnia NOS
Pharmacologic Causes of InsomniaPharmacologic Causes of Insomnia
AntidepressantsAntidepressants
SteroidsSteroids
DecongestantsDecongestants
CaffeineCaffeine
Coffee, tea, Coffee, tea,
chocolatechocolate
AlcoholAlcohol
NicotineNicotine
AntihypertensivesAntihypertensives
AnticholinergicsAnticholinergics
HormonesHormones
AntineoplasticsAntineoplastics
CNS stimulantsCNS stimulants
MiscellaneousMiscellaneous
Dilantin, sinemetDilantin, sinemet
AntidepressantsAntidepressants
SteroidsSteroids
DecongestantsDecongestants
CaffeineCaffeine
Coffee, tea, Coffee, tea,
chocolatechocolate
AlcoholAlcohol
NicotineNicotine
AntihypertensivesAntihypertensives
AnticholinergicsAnticholinergics
HormonesHormones
AntineoplasticsAntineoplastics
CNS stimulantsCNS stimulants
MiscellaneousMiscellaneous
Dilantin, sinemetDilantin, sinemet
Behavioral CausesBehavioral Causes
Poor sleep hygiene (more later)Poor sleep hygiene (more later)
PsychophysiologicPsychophysiologic
Learned behaviorLearned behavior
Worring about getting to sleep/Worring about getting to sleep/
trying too hard to sleeptrying too hard to sleep
Leads to increased anxiety and arousalLeads to increased anxiety and arousal
Perpetuates insomniaPerpetuates insomnia
Poor sleep hygiene (more later)Poor sleep hygiene (more later)
PsychophysiologicPsychophysiologic
Learned behaviorLearned behavior
Worring about getting to sleep/Worring about getting to sleep/
trying too hard to sleeptrying too hard to sleep
Leads to increased anxiety and arousalLeads to increased anxiety and arousal
Perpetuates insomniaPerpetuates insomnia
DiagnosisDiagnosis
The medical interview is everythingThe medical interview is everything
focus on underlying causesfocus on underlying causes
Sleep partner should be present for the Sleep partner should be present for the
interview if possibleinterview if possible
Full medication list is requiredFull medication list is required
Be prepared to ask very direct questions Be prepared to ask very direct questions
about substances and alcohol useabout substances and alcohol use
The medical interview is everythingThe medical interview is everything
focus on underlying causesfocus on underlying causes
Sleep partner should be present for the Sleep partner should be present for the
interview if possibleinterview if possible
Full medication list is requiredFull medication list is required
Be prepared to ask very direct questions Be prepared to ask very direct questions
about substances and alcohol useabout substances and alcohol use
Medical InterviewMedical Interview
Current state of complaintCurrent state of complaint
Onset, duration, frequency of insomniaOnset, duration, frequency of insomnia
Sleep history… is the trouble with:Sleep history… is the trouble with:
falling asleep?falling asleep?
maintaining sleep?maintaining sleep?
not being able to go back to sleep once up?not being able to go back to sleep once up?
early awakenings?early awakenings?
not feeling rested?not feeling rested?
Current state of complaintCurrent state of complaint
Onset, duration, frequency of insomniaOnset, duration, frequency of insomnia
Sleep history… is the trouble with:Sleep history… is the trouble with:
falling asleep?falling asleep?
maintaining sleep?maintaining sleep?
not being able to go back to sleep once up?not being able to go back to sleep once up?
early awakenings?early awakenings?
not feeling rested?not feeling rested?
Medical InterviewMedical Interview
Daytime consequencesDaytime consequences
can you function/stay awake to drive?can you function/stay awake to drive?
Do you experience (or bed-partner report):Do you experience (or bed-partner report):
Leg or arm jerking while asleep?Leg or arm jerking while asleep?
Loud snoring/gasping/choking, or stopping Loud snoring/gasping/choking, or stopping
breathing when asleep?breathing when asleep?
Uncomfortable feelings in your legs that Uncomfortable feelings in your legs that
go away with moving them?go away with moving them?
Daytime consequencesDaytime consequences
can you function/stay awake to drive?can you function/stay awake to drive?
Do you experience (or bed-partner report):Do you experience (or bed-partner report):
Leg or arm jerking while asleep?Leg or arm jerking while asleep?
Loud snoring/gasping/choking, or stopping Loud snoring/gasping/choking, or stopping
breathing when asleep?breathing when asleep?
Uncomfortable feelings in your legs that Uncomfortable feelings in your legs that
go away with moving them?go away with moving them?
Sleep HabitsSleep Habits
Usual bedtimeUsual bedtime
Usual morning awakening timeUsual morning awakening time
Time spent in bed awake prior to sleeping, Time spent in bed awake prior to sleeping,
and following the onset of sleepand following the onset of sleep
Estimated time spent asleepEstimated time spent asleep
Do you take anything to make you sleep?Do you take anything to make you sleep?
Do you drink to help you go to sleep?Do you drink to help you go to sleep?
What else do you do in your bedroom?What else do you do in your bedroom?
Usual bedtimeUsual bedtime
Usual morning awakening timeUsual morning awakening time
Time spent in bed awake prior to sleeping, Time spent in bed awake prior to sleeping,
and following the onset of sleepand following the onset of sleep
Estimated time spent asleepEstimated time spent asleep
Do you take anything to make you sleep?Do you take anything to make you sleep?
Do you drink to help you go to sleep?Do you drink to help you go to sleep?
What else do you do in your bedroom?What else do you do in your bedroom?
Sleep HabitsSleep Habits
Anything disruptive to sleep?Anything disruptive to sleep?
InfantsInfants
NoisesNoises
LightsLights
Snoring partnerSnoring partner
Partner with different bed/wake timesPartner with different bed/wake times
TVTV
PetsPets
Not feeling safe where you sleepNot feeling safe where you sleep
Anything disruptive to sleep?Anything disruptive to sleep?
InfantsInfants
NoisesNoises
LightsLights
Snoring partnerSnoring partner
Partner with different bed/wake timesPartner with different bed/wake times
TVTV
PetsPets
Not feeling safe where you sleepNot feeling safe where you sleep
Sleep Habits (bad!)Sleep Habits (bad!)
Do you consume: nicotine, caffeine, alcohol, Do you consume: nicotine, caffeine, alcohol,
other stimulants, decongestants prior to other stimulants, decongestants prior to
bedtime? Half lives are important!bedtime? Half lives are important!
tt1/21/2 nicotine = 1 hour, t nicotine = 1 hour, t1/21/2 caffeine = 6 hours, caffeine = 6 hours,
tt1/21/2 alcohol depends on how much you’ve had alcohol depends on how much you’ve had
Do you smoke/eat when you wake up, or Do you smoke/eat when you wake up, or
perform other tasks like cleaning?perform other tasks like cleaning?
Do you check the clock when you wake up?Do you check the clock when you wake up?
What is your pre-bedtime routine: exercise, What is your pre-bedtime routine: exercise,
work, TV, eating?work, TV, eating?
Do you consume: nicotine, caffeine, alcohol, Do you consume: nicotine, caffeine, alcohol,
other stimulants, decongestants prior to other stimulants, decongestants prior to
bedtime? Half lives are important!bedtime? Half lives are important!
tt1/21/2 nicotine = 1 hour, t nicotine = 1 hour, t1/21/2 caffeine = 6 hours, caffeine = 6 hours,
tt1/21/2 alcohol depends on how much you’ve had alcohol depends on how much you’ve had
Do you smoke/eat when you wake up, or Do you smoke/eat when you wake up, or
perform other tasks like cleaning?perform other tasks like cleaning?
Do you check the clock when you wake up?Do you check the clock when you wake up?
What is your pre-bedtime routine: exercise, What is your pre-bedtime routine: exercise,
work, TV, eating?work, TV, eating?
Half-lives: why you can’t go to sleep at Half-lives: why you can’t go to sleep at
10pm if your last coffee was at noon.10pm if your last coffee was at noon.
0
10
20
30
40
50
60
70
80
90
100
12 noon 6pm 12 midnight 6am
% caffeine still in
body
10pm if your last coffee was at noon.10pm if your last coffee was at noon.
0
10
20
30
40
50
60
70
80
90
100
12 noon 6pm 12 midnight 6am
% caffeine still in
body
What’s New With You?What’s New With You?
Medical issuesMedical issues
Medication changesMedication changes
Lifestyle issuesLifestyle issues
Work stressWork stress
School stressSchool stress
Financial stressFinancial stress
Relationship changes/stressRelationship changes/stress
Complaints from partnerComplaints from partner
Medical issuesMedical issues
Medication changesMedication changes
Lifestyle issuesLifestyle issues
Work stressWork stress
School stressSchool stress
Financial stressFinancial stress
Relationship changes/stressRelationship changes/stress
Complaints from partnerComplaints from partner
Physical ExamPhysical Exam
For primary insomnia there are no For primary insomnia there are no
characteristic exam findingscharacteristic exam findings
Evaluate for symptoms/findings that Evaluate for symptoms/findings that
suggest an underlying explanationsuggest an underlying explanation
For primary insomnia there are no For primary insomnia there are no
characteristic exam findingscharacteristic exam findings
Evaluate for symptoms/findings that Evaluate for symptoms/findings that
suggest an underlying explanationsuggest an underlying explanation
Sleep DiariesSleep Diaries
Usually kept daily for 1-2 weeksUsually kept daily for 1-2 weeks
Help delineate variability in sleep from Help delineate variability in sleep from
day-to-dayday-to-day
May identify contributing factorsMay identify contributing factors
May help patient more accurately May help patient more accurately
perceive sleepperceive sleep
Usually kept daily for 1-2 weeksUsually kept daily for 1-2 weeks
Help delineate variability in sleep from Help delineate variability in sleep from
day-to-dayday-to-day
May identify contributing factorsMay identify contributing factors
May help patient more accurately May help patient more accurately
perceive sleepperceive sleep
Sleep DiariesSleep Diaries
BedtimeBedtime
Time to sleep Time to sleep
onsetonset
Number of Number of
awakeningsawakenings
Time out of bed in Time out of bed in
morningmorning
Total sleep time Total sleep time
(estimated)(estimated)
Use of sleep Use of sleep
medications or medications or
other substancesother substances
Quality of sleepQuality of sleep
Daytime symptomsDaytime symptoms
Caffeine logCaffeine log
Exercise logExercise log
BedtimeBedtime
Time to sleep Time to sleep
onsetonset
Number of Number of
awakeningsawakenings
Time out of bed in Time out of bed in
morningmorning
Total sleep time Total sleep time
(estimated)(estimated)
Use of sleep Use of sleep
medications or medications or
other substancesother substances
Quality of sleepQuality of sleep
Daytime symptomsDaytime symptoms
Caffeine logCaffeine log
Exercise logExercise log
Sample Sleep DiarySample Sleep Diary
Example Sleep PatternsExample Sleep Patterns
6.0 hours
Yes
2+
45
Depression
Or anxiety
~5.5 hours7.5 hoursTotal Time
Asleep
YesNo
Early
Morning
Awakenings
62Awakenings
4510Sleep onset
(minutes)
InsomniaNormal
6.0 hours
Yes
2+
45
Depression
Or anxiety
~5.5 hours7.5 hoursTotal Time
Asleep
YesNo
Early
Morning
Awakenings
62Awakenings
4510Sleep onset
(minutes)
InsomniaNormal
Treatment GoalsTreatment Goals
Alleviate underlying problemsAlleviate underlying problems
Prevent progression from acute to chronicPrevent progression from acute to chronic
Improve quality of lifeImprove quality of life
Treat depressionTreat depression
Treat medical conditionsTreat medical conditions
Limit all medications whenever possibleLimit all medications whenever possible
Alleviate underlying problemsAlleviate underlying problems
Prevent progression from acute to chronicPrevent progression from acute to chronic
Improve quality of lifeImprove quality of life
Treat depressionTreat depression
Treat medical conditionsTreat medical conditions
Limit all medications whenever possibleLimit all medications whenever possible
Acute InsomniaAcute Insomnia
Often does not require treatmentOften does not require treatment
Should be treated when:Should be treated when:
Daytime consequences warrant treatmentDaytime consequences warrant treatment
Episodes last more than a few daysEpisodes last more than a few days
Episodes become predictableEpisodes become predictable
Treating acute insomnia may help Treating acute insomnia may help
promote sleep hygienepromote sleep hygiene
Get a sleep diary from the patientGet a sleep diary from the patient
Often does not require treatmentOften does not require treatment
Should be treated when:Should be treated when:
Daytime consequences warrant treatmentDaytime consequences warrant treatment
Episodes last more than a few daysEpisodes last more than a few days
Episodes become predictableEpisodes become predictable
Treating acute insomnia may help Treating acute insomnia may help
promote sleep hygienepromote sleep hygiene
Get a sleep diary from the patientGet a sleep diary from the patient
Chronic InsomniaChronic Insomnia
Usually requires many different Usually requires many different
approachesapproaches
Treat underlying condition firstTreat underlying condition first
May need behavioral and May need behavioral and
pharmacologic therapypharmacologic therapy
Treatment should be collaborativeTreatment should be collaborative
Get a sleep diary from the patientGet a sleep diary from the patient
Usually requires many different Usually requires many different
approachesapproaches
Treat underlying condition firstTreat underlying condition first
May need behavioral and May need behavioral and
pharmacologic therapypharmacologic therapy
Treatment should be collaborativeTreatment should be collaborative
Get a sleep diary from the patientGet a sleep diary from the patient
Sleep HygieneSleep Hygiene
Hygiene: from where is the term derived?Hygiene: from where is the term derived?
Hygeia (also Hygea, Hygia, Hygieia) This Hygeia (also Hygea, Hygia, Hygieia) This
is derived from the name of the Greek is derived from the name of the Greek
goddess of health known as Hygeia the goddess of health known as Hygeia the
daughter of Aesculapius/Asklepios and daughter of Aesculapius/Asklepios and
sister to Panacea. While her father and sister to Panacea. While her father and
sister were connected with the treatment sister were connected with the treatment
of existing disease Hygeia was regarded of existing disease Hygeia was regarded
as being concerned with the preservation as being concerned with the preservation
of good health or the prevention of of good health or the prevention of
disease. disease.
Hygiene: from where is the term derived?Hygiene: from where is the term derived?
Hygeia (also Hygea, Hygia, Hygieia) This Hygeia (also Hygea, Hygia, Hygieia) This
is derived from the name of the Greek is derived from the name of the Greek
goddess of health known as Hygeia the goddess of health known as Hygeia the
daughter of Aesculapius/Asklepios and daughter of Aesculapius/Asklepios and
sister to Panacea. While her father and sister to Panacea. While her father and
sister were connected with the treatment sister were connected with the treatment
of existing disease Hygeia was regarded of existing disease Hygeia was regarded
as being concerned with the preservation as being concerned with the preservation
of good health or the prevention of of good health or the prevention of
disease. disease.
Sleep Hygiene--BasicsSleep Hygiene--Basics
Don’t spend excessive time in bed, Don’t spend excessive time in bed,
including daytime napping.including daytime napping.
Get into bed when sleepy.Get into bed when sleepy.
Maintain a regular sleep/wake scheduleMaintain a regular sleep/wake schedule
Bed is for sleep and sex only, not TV!Bed is for sleep and sex only, not TV!
Increase exercise and fitnessIncrease exercise and fitness
Avoid caffeine and nicotine at least 4-6 Avoid caffeine and nicotine at least 4-6
hours before going to bed.hours before going to bed.
Don’t spend excessive time in bed, Don’t spend excessive time in bed,
including daytime napping.including daytime napping.
Get into bed when sleepy.Get into bed when sleepy.
Maintain a regular sleep/wake scheduleMaintain a regular sleep/wake schedule
Bed is for sleep and sex only, not TV!Bed is for sleep and sex only, not TV!
Increase exercise and fitnessIncrease exercise and fitness
Avoid caffeine and nicotine at least 4-6 Avoid caffeine and nicotine at least 4-6
hours before going to bed.hours before going to bed.
Sleep Hygiene--BasicsSleep Hygiene--Basics
Never use alcohol to go to sleep.Never use alcohol to go to sleep.
It induces sleep, but causes frequent awakeningsIt induces sleep, but causes frequent awakenings
Decreases REM sleep, increases stages 3 & 4Decreases REM sleep, increases stages 3 & 4
Chronic use causes insomnia, which can persist up to Chronic use causes insomnia, which can persist up to
a year after cessation of all drinkinga year after cessation of all drinking
Avoid excessive liquids or a heavy meal in the Avoid excessive liquids or a heavy meal in the
evening.evening.
Minimize noise, light, and temperature extremes Minimize noise, light, and temperature extremes
during sleep.during sleep.
Move alarm clock away from bed if it is Move alarm clock away from bed if it is
distractingdistracting
Never use alcohol to go to sleep.Never use alcohol to go to sleep.
It induces sleep, but causes frequent awakeningsIt induces sleep, but causes frequent awakenings
Decreases REM sleep, increases stages 3 & 4Decreases REM sleep, increases stages 3 & 4
Chronic use causes insomnia, which can persist up to Chronic use causes insomnia, which can persist up to
a year after cessation of all drinkinga year after cessation of all drinking
Avoid excessive liquids or a heavy meal in the Avoid excessive liquids or a heavy meal in the
evening.evening.
Minimize noise, light, and temperature extremes Minimize noise, light, and temperature extremes
during sleep.during sleep.
Move alarm clock away from bed if it is Move alarm clock away from bed if it is
distractingdistracting
Sleep Hygiene--RelaxationSleep Hygiene--Relaxation
Plan a relaxation period before bed, Plan a relaxation period before bed,
develop a bedtime routine.develop a bedtime routine.
Attempts to address somatic and cognitive Attempts to address somatic and cognitive
arousalarousal
Relaxation Therapy:Relaxation Therapy:
Progressive muscle relaxationProgressive muscle relaxation
EMG BiofeedbackEMG Biofeedback
MeditationMeditation
Imagery trainingImagery training
Self-hypnosisSelf-hypnosis
Diaphragmatic breathingDiaphragmatic breathing
Plan a relaxation period before bed, Plan a relaxation period before bed,
develop a bedtime routine.develop a bedtime routine.
Attempts to address somatic and cognitive Attempts to address somatic and cognitive
arousalarousal
Relaxation Therapy:Relaxation Therapy:
Progressive muscle relaxationProgressive muscle relaxation
EMG BiofeedbackEMG Biofeedback
MeditationMeditation
Imagery trainingImagery training
Self-hypnosisSelf-hypnosis
Diaphragmatic breathingDiaphragmatic breathing
Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction
If unable to fall asleep within an If unable to fall asleep within an
acceptable amount of time (15-20 min), acceptable amount of time (15-20 min),
leave the bedroom, engage in a relaxing leave the bedroom, engage in a relaxing
activity until sleepy, and then return to activity until sleepy, and then return to
bed. This is called sleep restrictionbed. This is called sleep restriction
Repeat as necessary.Repeat as necessary.
Boring activities (reading the phone book) Boring activities (reading the phone book)
count. TV/video games doesn’t count as count. TV/video games doesn’t count as
relaxing or boring—the flashing lights relaxing or boring—the flashing lights
stimulate the brain.stimulate the brain.
If unable to fall asleep within an If unable to fall asleep within an
acceptable amount of time (15-20 min), acceptable amount of time (15-20 min),
leave the bedroom, engage in a relaxing leave the bedroom, engage in a relaxing
activity until sleepy, and then return to activity until sleepy, and then return to
bed. This is called sleep restrictionbed. This is called sleep restriction
Repeat as necessary.Repeat as necessary.
Boring activities (reading the phone book) Boring activities (reading the phone book)
count. TV/video games doesn’t count as count. TV/video games doesn’t count as
relaxing or boring—the flashing lights relaxing or boring—the flashing lights
stimulate the brain.stimulate the brain.
Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction
Sleep Restriction TherapySleep Restriction Therapy
Track average total sleep time per nightTrack average total sleep time per night
Spend Spend onlyonly this amount of time in bed; this amount of time in bed;
minimum being 4.5 hours.minimum being 4.5 hours.
Once 90% of time in bed is spent asleep Once 90% of time in bed is spent asleep
(sleep efficiency), increase total time in (sleep efficiency), increase total time in
bed by 15 minutes every 5-7 days. bed by 15 minutes every 5-7 days.
Sleep Restriction TherapySleep Restriction Therapy
Track average total sleep time per nightTrack average total sleep time per night
Spend Spend onlyonly this amount of time in bed; this amount of time in bed;
minimum being 4.5 hours.minimum being 4.5 hours.
Once 90% of time in bed is spent asleep Once 90% of time in bed is spent asleep
(sleep efficiency), increase total time in (sleep efficiency), increase total time in
bed by 15 minutes every 5-7 days. bed by 15 minutes every 5-7 days.
Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction
If sleep efficiency falls to less than 80%, If sleep efficiency falls to less than 80%,
decrease time in bed by 15 minutesdecrease time in bed by 15 minutes
Work set, daytime hours (whenever Work set, daytime hours (whenever
possible).possible).
As sleep consolidation improves, time in As sleep consolidation improves, time in
bed (and asleep) increases.bed (and asleep) increases.
Creates a mild state of sleep deprivation, Creates a mild state of sleep deprivation,
and thus promotes more rapid sleep onset and thus promotes more rapid sleep onset
and more efficient sleep.and more efficient sleep.
If sleep efficiency falls to less than 80%, If sleep efficiency falls to less than 80%,
decrease time in bed by 15 minutesdecrease time in bed by 15 minutes
Work set, daytime hours (whenever Work set, daytime hours (whenever
possible).possible).
As sleep consolidation improves, time in As sleep consolidation improves, time in
bed (and asleep) increases.bed (and asleep) increases.
Creates a mild state of sleep deprivation, Creates a mild state of sleep deprivation,
and thus promotes more rapid sleep onset and thus promotes more rapid sleep onset
and more efficient sleep.and more efficient sleep.
Sleep Hygiene—Cognitive Therapy Sleep Hygiene—Cognitive Therapy
Cognitive Therapy works to change beliefs Cognitive Therapy works to change beliefs
about insomnia:about insomnia:
Misconceptions about the causesMisconceptions about the causes
Performance anxiety and loss of control over Performance anxiety and loss of control over
the ability to sleepthe ability to sleep
Unrealistic sleep expectationsUnrealistic sleep expectations
Identify and replace dysfunctional beliefs and Identify and replace dysfunctional beliefs and
attitudes about sleepattitudes about sleep
For example, questioning the idea that you must For example, questioning the idea that you must
sleep 8 hours to function effectivelysleep 8 hours to function effectively
Cognitive Therapy works to change beliefs Cognitive Therapy works to change beliefs
about insomnia:about insomnia:
Misconceptions about the causesMisconceptions about the causes
Performance anxiety and loss of control over Performance anxiety and loss of control over
the ability to sleepthe ability to sleep
Unrealistic sleep expectationsUnrealistic sleep expectations
Identify and replace dysfunctional beliefs and Identify and replace dysfunctional beliefs and
attitudes about sleepattitudes about sleep
For example, questioning the idea that you must For example, questioning the idea that you must
sleep 8 hours to function effectivelysleep 8 hours to function effectively
Behavioral TherapiesBehavioral Therapies
Reliable and enduring improvements for Reliable and enduring improvements for
chronic insomniacschronic insomniacs
Sleep latency insomniacs fell asleep faster Sleep latency insomniacs fell asleep faster
than 81% of untreated controlsthan 81% of untreated controls
Sleep maintenance insomniacs slept longer Sleep maintenance insomniacs slept longer
than 74% of untreated controlsthan 74% of untreated controls
May be used in combination with other May be used in combination with other
techniques or medicationstechniques or medications
Reliable and enduring improvements for Reliable and enduring improvements for
chronic insomniacschronic insomniacs
Sleep latency insomniacs fell asleep faster Sleep latency insomniacs fell asleep faster
than 81% of untreated controlsthan 81% of untreated controls
Sleep maintenance insomniacs slept longer Sleep maintenance insomniacs slept longer
than 74% of untreated controlsthan 74% of untreated controls
May be used in combination with other May be used in combination with other
techniques or medicationstechniques or medications
Stimulus Control TherapyStimulus Control Therapy
Based on premise that insomnia is a Based on premise that insomnia is a
conditioned response based on cues conditioned response based on cues
associated with sleepassociated with sleep
Trains the brain to associate the bed / Trains the brain to associate the bed /
bedroom with sleepbedroom with sleep
Leave the bedroom if not sleeping within Leave the bedroom if not sleeping within
15-20 minutes15-20 minutes
Effective for sleep onset and sleep-Effective for sleep onset and sleep-
maintenancemaintenance
Based on premise that insomnia is a Based on premise that insomnia is a
conditioned response based on cues conditioned response based on cues
associated with sleepassociated with sleep
Trains the brain to associate the bed / Trains the brain to associate the bed /
bedroom with sleepbedroom with sleep
Leave the bedroom if not sleeping within Leave the bedroom if not sleeping within
15-20 minutes15-20 minutes
Effective for sleep onset and sleep-Effective for sleep onset and sleep-
maintenancemaintenance
Other TherapiesOther Therapies
Regular exerciseRegular exercise
Helpful if timed in the late afternoonHelpful if timed in the late afternoon
Any exercise, regardless of time of day, helpsAny exercise, regardless of time of day, helps
Promotes sleep depth and qualityPromotes sleep depth and quality
May be stimulating if done in closer to May be stimulating if done in closer to
bedtimebedtime
PhototherapyPhototherapy
Exposure to daytime bright light is helpful in Exposure to daytime bright light is helpful in
treating those with slow or fast circadian treating those with slow or fast circadian
cyclescycles
May be especially helpful in the elderlyMay be especially helpful in the elderly
Regular exerciseRegular exercise
Helpful if timed in the late afternoonHelpful if timed in the late afternoon
Any exercise, regardless of time of day, helpsAny exercise, regardless of time of day, helps
Promotes sleep depth and qualityPromotes sleep depth and quality
May be stimulating if done in closer to May be stimulating if done in closer to
bedtimebedtime
PhototherapyPhototherapy
Exposure to daytime bright light is helpful in Exposure to daytime bright light is helpful in
treating those with slow or fast circadian treating those with slow or fast circadian
cyclescycles
May be especially helpful in the elderlyMay be especially helpful in the elderly
What works best?What works best?
Multicomponent cognitive behavior Multicomponent cognitive behavior
therapy works better than both placebo therapy works better than both placebo
and pharmacotherapy (medicines) in short and pharmacotherapy (medicines) in short
and long term cases.and long term cases.
Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy
and pharmacotherapy for insomnia: a randomized controlled trial and direct and pharmacotherapy for insomnia: a randomized controlled trial and direct
comparison. comparison. Arch Intern MedArch Intern Med. 2004; 164: 1888-1896. 2004; 164: 1888-1896
Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for
insomnia: a meta-analysis of treatment efficacy. insomnia: a meta-analysis of treatment efficacy. Am J PsychiatrAm J Psychiatr. 1994; 151: . 1994; 151:
1172-1180.1172-1180.
Murtagh DR, Greenwood KM. Identifying effective psychological treatments Murtagh DR, Greenwood KM. Identifying effective psychological treatments
for insomnia: a meta-analysis. for insomnia: a meta-analysis. J Consult Clin PsycholJ Consult Clin Psychol. 1995; 63:79-89.. 1995; 63:79-89.
Multicomponent cognitive behavior Multicomponent cognitive behavior
therapy works better than both placebo therapy works better than both placebo
and pharmacotherapy (medicines) in short and pharmacotherapy (medicines) in short
and long term cases.and long term cases.
Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy
and pharmacotherapy for insomnia: a randomized controlled trial and direct and pharmacotherapy for insomnia: a randomized controlled trial and direct
comparison. comparison. Arch Intern MedArch Intern Med. 2004; 164: 1888-1896. 2004; 164: 1888-1896
Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for
insomnia: a meta-analysis of treatment efficacy. insomnia: a meta-analysis of treatment efficacy. Am J PsychiatrAm J Psychiatr. 1994; 151: . 1994; 151:
1172-1180.1172-1180.
Murtagh DR, Greenwood KM. Identifying effective psychological treatments Murtagh DR, Greenwood KM. Identifying effective psychological treatments
for insomnia: a meta-analysis. for insomnia: a meta-analysis. J Consult Clin PsycholJ Consult Clin Psychol. 1995; 63:79-89.. 1995; 63:79-89.
If you have to use drugs: If you have to use drugs:
Pharmacotherapy GuidelinesPharmacotherapy Guidelines
Use the lowest Use the lowest therapeutictherapeutic dose dose
Use for the shortest duration Use for the shortest duration
necessarynecessary
Discontinue medication graduallyDiscontinue medication gradually
Be alert for rebound insomniaBe alert for rebound insomnia
Use agents with short half-lives to Use agents with short half-lives to
minimize daytime sedationminimize daytime sedation
Pharmacotherapy GuidelinesPharmacotherapy Guidelines
Use the lowest Use the lowest therapeutictherapeutic dose dose
Use for the shortest duration Use for the shortest duration
necessarynecessary
Discontinue medication graduallyDiscontinue medication gradually
Be alert for rebound insomniaBe alert for rebound insomnia
Use agents with short half-lives to Use agents with short half-lives to
minimize daytime sedationminimize daytime sedation
Drugs that make you sleepDrugs that make you sleep
Drugs that make you sleep are called Drugs that make you sleep are called
“hypnotics”.“hypnotics”.
There are many types of hypnotics:There are many types of hypnotics:
Sedating antihistamines (over the counter)Sedating antihistamines (over the counter)
Herbals (over the counter)Herbals (over the counter)
Benzodiazepines (prescription/controlled)Benzodiazepines (prescription/controlled)
Benzodiazepine-Like (prescription/controlled)Benzodiazepine-Like (prescription/controlled)
Melatonin receptor agonists (prescription)Melatonin receptor agonists (prescription)
Antidepressants (prescription)Antidepressants (prescription)
Antipsychotics (prescription)Antipsychotics (prescription)
Drugs that make you sleep are called Drugs that make you sleep are called
“hypnotics”.“hypnotics”.
There are many types of hypnotics:There are many types of hypnotics:
Sedating antihistamines (over the counter)Sedating antihistamines (over the counter)
Herbals (over the counter)Herbals (over the counter)
Benzodiazepines (prescription/controlled)Benzodiazepines (prescription/controlled)
Benzodiazepine-Like (prescription/controlled)Benzodiazepine-Like (prescription/controlled)
Melatonin receptor agonists (prescription)Melatonin receptor agonists (prescription)
Antidepressants (prescription)Antidepressants (prescription)
Antipsychotics (prescription)Antipsychotics (prescription)
Over the Counter Medicines—FDA Over the Counter Medicines—FDA
approved and regulatedapproved and regulated
Sedating antihistamines: Sedating antihistamines:
diphenhydramine (Benadryl) and diphenhydramine (Benadryl) and
doxylaminedoxylamine
Nighttime Sleep Aid Nighttime Sleep Aid
Sleep Aid Liqui-Gels Sleep Aid Liqui-Gels
Maxium Strength Unisom Nighttime Sleep AidMaxium Strength Unisom Nighttime Sleep Aid
Tylenol PMTylenol PM
approved and regulatedapproved and regulated
Sedating antihistamines: Sedating antihistamines:
diphenhydramine (Benadryl) and diphenhydramine (Benadryl) and
doxylaminedoxylamine
Nighttime Sleep Aid Nighttime Sleep Aid
Sleep Aid Liqui-Gels Sleep Aid Liqui-Gels
Maxium Strength Unisom Nighttime Sleep AidMaxium Strength Unisom Nighttime Sleep Aid
Tylenol PMTylenol PM
OTC Medicines—FDA approved OTC Medicines—FDA approved
and regulatedand regulated
Sedating antihistamines continued:Sedating antihistamines continued:
Not addictive, but tolerance develops Not addictive, but tolerance develops
quicklyquickly
Daytime sleepiness, anticholinergic side Daytime sleepiness, anticholinergic side
effects commoneffects common
Dry mouth, constipation, urinary retention, Dry mouth, constipation, urinary retention,
memory impairment, confusion (dries up memory impairment, confusion (dries up
sinuses if post nasal drip is what keeps you sinuses if post nasal drip is what keeps you
up)up)
and regulatedand regulated
Sedating antihistamines continued:Sedating antihistamines continued:
Not addictive, but tolerance develops Not addictive, but tolerance develops
quicklyquickly
Daytime sleepiness, anticholinergic side Daytime sleepiness, anticholinergic side
effects commoneffects common
Dry mouth, constipation, urinary retention, Dry mouth, constipation, urinary retention,
memory impairment, confusion (dries up memory impairment, confusion (dries up
sinuses if post nasal drip is what keeps you sinuses if post nasal drip is what keeps you
up)up)
OTC Medicines--herbalsOTC Medicines--herbals
Not FDA regulated:Not FDA regulated:
Valerian rootValerian root
Used for anxiety, and as a sleep aidUsed for anxiety, and as a sleep aid
Dosing uncertainDosing uncertain
Powerful odorPowerful odor
Kava-kavaKava-kava
Can cause liver failureCan cause liver failure
Dosing uncertain Dosing uncertain
Sateia MJ, Nowell PD. Insomnia. Sateia MJ, Nowell PD. Insomnia. LancetLancet. 2004; 364:1959-1973. 2004; 364:1959-1973
Not FDA regulated:Not FDA regulated:
Valerian rootValerian root
Used for anxiety, and as a sleep aidUsed for anxiety, and as a sleep aid
Dosing uncertainDosing uncertain
Powerful odorPowerful odor
Kava-kavaKava-kava
Can cause liver failureCan cause liver failure
Dosing uncertain Dosing uncertain
Sateia MJ, Nowell PD. Insomnia. Sateia MJ, Nowell PD. Insomnia. LancetLancet. 2004; 364:1959-1973. 2004; 364:1959-1973
OTC Medicines--herbalsOTC Medicines--herbals
Melatonin—hormone made by the pituitary Melatonin—hormone made by the pituitary
gland in the brain (at night/when dark)gland in the brain (at night/when dark)
Best for shift work/jet lag; shifts sleep to dark Best for shift work/jet lag; shifts sleep to dark
hourshours
Schenck CH, Mahowald MW, Sack RL. Assessment and management of Schenck CH, Mahowald MW, Sack RL. Assessment and management of
insomnia JAMA 2003;289:2475-2479.insomnia JAMA 2003;289:2475-2479.
For insomnia not related to shift work/jet lag, For insomnia not related to shift work/jet lag,
there is NO convincing evidence it works.there is NO convincing evidence it works.
Silber MH, Chronic insomnia. Silber MH, Chronic insomnia. N Engl J Med. N Engl J Med. 2005;353:803-8102005;353:803-810
Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of
primary insomnia with melatonin: a double-blind, placebo-controlled, crossover primary insomnia with melatonin: a double-blind, placebo-controlled, crossover
study. study. J Psychiatry Neurosc.J Psychiatry Neurosc. 2003; 28: 191-196 2003; 28: 191-196
Melatonin—hormone made by the pituitary Melatonin—hormone made by the pituitary
gland in the brain (at night/when dark)gland in the brain (at night/when dark)
Best for shift work/jet lag; shifts sleep to dark Best for shift work/jet lag; shifts sleep to dark
hourshours
Schenck CH, Mahowald MW, Sack RL. Assessment and management of Schenck CH, Mahowald MW, Sack RL. Assessment and management of
insomnia JAMA 2003;289:2475-2479.insomnia JAMA 2003;289:2475-2479.
For insomnia not related to shift work/jet lag, For insomnia not related to shift work/jet lag,
there is NO convincing evidence it works.there is NO convincing evidence it works.
Silber MH, Chronic insomnia. Silber MH, Chronic insomnia. N Engl J Med. N Engl J Med. 2005;353:803-8102005;353:803-810
Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of
primary insomnia with melatonin: a double-blind, placebo-controlled, crossover primary insomnia with melatonin: a double-blind, placebo-controlled, crossover
study. study. J Psychiatry Neurosc.J Psychiatry Neurosc. 2003; 28: 191-196 2003; 28: 191-196
Prescription Medicines: Prescription Medicines:
BenzodiazepinesBenzodiazepines
Non-selectivelyNon-selectively bind to the bind to the
benzodiazepine-GABA (Gamma-benzodiazepine-GABA (Gamma-
AminoButyric Acid) receptor complex in AminoButyric Acid) receptor complex in
the brainthe brain
Effective in inducing, maintaining, and Effective in inducing, maintaining, and
consolidating sleep; and in decreasing consolidating sleep; and in decreasing
daytime consequences of insomniadaytime consequences of insomnia
BenzodiazepinesBenzodiazepines
Non-selectivelyNon-selectively bind to the bind to the
benzodiazepine-GABA (Gamma-benzodiazepine-GABA (Gamma-
AminoButyric Acid) receptor complex in AminoButyric Acid) receptor complex in
the brainthe brain
Effective in inducing, maintaining, and Effective in inducing, maintaining, and
consolidating sleep; and in decreasing consolidating sleep; and in decreasing
daytime consequences of insomniadaytime consequences of insomnia
Prescription Medicines: Prescription Medicines:
BenzodiazepinesBenzodiazepines
Side effects include daytime drowsiness, Side effects include daytime drowsiness,
anterograde amnesia, impairments in anterograde amnesia, impairments in
memory and psychomotor performance.memory and psychomotor performance.
Addiction, habituation, tolerance, rebound Addiction, habituation, tolerance, rebound
insomnia, withdrawal symptoms, anxiety insomnia, withdrawal symptoms, anxiety
can all occur with benzo usecan all occur with benzo use
When combined with alcohol, When combined with alcohol,
benzodiazepines can be deadly.benzodiazepines can be deadly.
Increases fall risk in the elderly (and Increases fall risk in the elderly (and
concomitant hip fractures)concomitant hip fractures)
BenzodiazepinesBenzodiazepines
Side effects include daytime drowsiness, Side effects include daytime drowsiness,
anterograde amnesia, impairments in anterograde amnesia, impairments in
memory and psychomotor performance.memory and psychomotor performance.
Addiction, habituation, tolerance, rebound Addiction, habituation, tolerance, rebound
insomnia, withdrawal symptoms, anxiety insomnia, withdrawal symptoms, anxiety
can all occur with benzo usecan all occur with benzo use
When combined with alcohol, When combined with alcohol,
benzodiazepines can be deadly.benzodiazepines can be deadly.
Increases fall risk in the elderly (and Increases fall risk in the elderly (and
concomitant hip fractures)concomitant hip fractures)
Prescription Medicines: Prescription Medicines:
BenzodiazepinesBenzodiazepines
No one medicine in the class works any No one medicine in the class works any
better than any other medicine.better than any other medicine.
Those with a short half-life work better for Those with a short half-life work better for
those who have trouble falling asleepthose who have trouble falling asleep
Those with a longer half-life work better for Those with a longer half-life work better for
those who cannot stay asleepthose who cannot stay asleep
No benzodiazepine is FDA approved for No benzodiazepine is FDA approved for
chronicchronic use (think vioxx)! use (think vioxx)!
BenzodiazepinesBenzodiazepines
No one medicine in the class works any No one medicine in the class works any
better than any other medicine.better than any other medicine.
Those with a short half-life work better for Those with a short half-life work better for
those who have trouble falling asleepthose who have trouble falling asleep
Those with a longer half-life work better for Those with a longer half-life work better for
those who cannot stay asleepthose who cannot stay asleep
No benzodiazepine is FDA approved for No benzodiazepine is FDA approved for
chronicchronic use (think vioxx)! use (think vioxx)!
Presciption Medicines: Presciption Medicines:
Benzodiazepines—how they workBenzodiazepines—how they work
Generic name (brand)--duration/onset of effectsGeneric name (brand)--duration/onset of effects
used forused for
Triazolam (Halcion) – short/rapidTriazolam (Halcion) – short/rapid
sleep onset insomnia; pregnancy category Xsleep onset insomnia; pregnancy category X
Estazolam (ProSom) – intermed/rapid Estazolam (ProSom) – intermed/rapid
both sleep onset and maintenance insomnia; preg category Xboth sleep onset and maintenance insomnia; preg category X
Temazepam (Restoril) – intermed/slowTemazepam (Restoril) – intermed/slow
Sleep maintenance; pregnancy category XSleep maintenance; pregnancy category X
Flurazepam (Dalmane) – long/intermedFlurazepam (Dalmane) – long/intermed
Sleep maintenance—active metabolite for over 100 hours; XSleep maintenance—active metabolite for over 100 hours; X
Quazepam (Doral) – long/intermedQuazepam (Doral) – long/intermed
Sleep maintenance—active metabolite for over 100 hoursSleep maintenance—active metabolite for over 100 hours
Benzodiazepines—how they workBenzodiazepines—how they work
Generic name (brand)--duration/onset of effectsGeneric name (brand)--duration/onset of effects
used forused for
Triazolam (Halcion) – short/rapidTriazolam (Halcion) – short/rapid
sleep onset insomnia; pregnancy category Xsleep onset insomnia; pregnancy category X
Estazolam (ProSom) – intermed/rapid Estazolam (ProSom) – intermed/rapid
both sleep onset and maintenance insomnia; preg category Xboth sleep onset and maintenance insomnia; preg category X
Temazepam (Restoril) – intermed/slowTemazepam (Restoril) – intermed/slow
Sleep maintenance; pregnancy category XSleep maintenance; pregnancy category X
Flurazepam (Dalmane) – long/intermedFlurazepam (Dalmane) – long/intermed
Sleep maintenance—active metabolite for over 100 hours; XSleep maintenance—active metabolite for over 100 hours; X
Quazepam (Doral) – long/intermedQuazepam (Doral) – long/intermed
Sleep maintenance—active metabolite for over 100 hoursSleep maintenance—active metabolite for over 100 hours
Prescription Medicines: Prescription Medicines:
Benzodiazepine InformationBenzodiazepine Information
10-15% of users take them regularly for 10-15% of users take them regularly for
more than a year (not FDA approved)more than a year (not FDA approved)
Many patients (not all) develop physical Many patients (not all) develop physical
dependence and/or tolerancedependence and/or tolerance
Once an effective dose is established, Once an effective dose is established,
higher doses typically only increase side higher doses typically only increase side
effectseffects
Sudden withdrawal can be dangerous to Sudden withdrawal can be dangerous to
the patientthe patient
Benzodiazepine InformationBenzodiazepine Information
10-15% of users take them regularly for 10-15% of users take them regularly for
more than a year (not FDA approved)more than a year (not FDA approved)
Many patients (not all) develop physical Many patients (not all) develop physical
dependence and/or tolerancedependence and/or tolerance
Once an effective dose is established, Once an effective dose is established,
higher doses typically only increase side higher doses typically only increase side
effectseffects
Sudden withdrawal can be dangerous to Sudden withdrawal can be dangerous to
the patientthe patient
Prescription Medicines: Prescription Medicines:
Benzodiazepine ContraindicationsBenzodiazepine Contraindications
Pregnant women (most are category X)Pregnant women (most are category X)
Untreated sleep-related breathing disorderUntreated sleep-related breathing disorder
Alcohol or substance abuseAlcohol or substance abuse
Patients who might need to awaken and Patients who might need to awaken and
function during their normal sleep periodfunction during their normal sleep period
Parents, doctors, fire-fighters, etc.Parents, doctors, fire-fighters, etc.
Monitor those with hepatic, renal, or Monitor those with hepatic, renal, or
pulmonary disease; and use with cautionpulmonary disease; and use with caution
Benzodiazepine ContraindicationsBenzodiazepine Contraindications
Pregnant women (most are category X)Pregnant women (most are category X)
Untreated sleep-related breathing disorderUntreated sleep-related breathing disorder
Alcohol or substance abuseAlcohol or substance abuse
Patients who might need to awaken and Patients who might need to awaken and
function during their normal sleep periodfunction during their normal sleep period
Parents, doctors, fire-fighters, etc.Parents, doctors, fire-fighters, etc.
Monitor those with hepatic, renal, or Monitor those with hepatic, renal, or
pulmonary disease; and use with cautionpulmonary disease; and use with caution
Prescription Medicines: Prescription Medicines:
Benzodiazepine-LikeBenzodiazepine-Like
Benzodiazepine-Like medicines Benzodiazepine-Like medicines selectivelyselectively
bind to the benzo-GABA receptor.bind to the benzo-GABA receptor.
The benzos we learned about before are non-The benzos we learned about before are non-
selective; there should be fewer side effects selective; there should be fewer side effects
with the Benzo-Like meds than true benzos.with the Benzo-Like meds than true benzos.
Exact mechanism of action is unknownExact mechanism of action is unknown
Help people go to sleep (sleep latency), Help people go to sleep (sleep latency),
and stay asleep (sleep maintenance).and stay asleep (sleep maintenance).
Benzodiazepine-LikeBenzodiazepine-Like
Benzodiazepine-Like medicines Benzodiazepine-Like medicines selectivelyselectively
bind to the benzo-GABA receptor.bind to the benzo-GABA receptor.
The benzos we learned about before are non-The benzos we learned about before are non-
selective; there should be fewer side effects selective; there should be fewer side effects
with the Benzo-Like meds than true benzos.with the Benzo-Like meds than true benzos.
Exact mechanism of action is unknownExact mechanism of action is unknown
Help people go to sleep (sleep latency), Help people go to sleep (sleep latency),
and stay asleep (sleep maintenance).and stay asleep (sleep maintenance).
Prescription Medicines: Prescription Medicines:
Benzodiazepine-LikeBenzodiazepine-Like
Eszopiclone (Lunesta)—intermed/rapidEszopiclone (Lunesta)—intermed/rapid
Sleep maintenance (metallic taste); pregnancy category CSleep maintenance (metallic taste); pregnancy category C
Zolpidem (Ambien)—short/rapidZolpidem (Ambien)—short/rapid
Sleep latency; side effects include: sleepwalking, sleep-Sleep latency; side effects include: sleepwalking, sleep-
related eating disorder; pregnancy category B (?C)related eating disorder; pregnancy category B (?C)
Zolpidem controlled release (Ambien CR)—Zolpidem controlled release (Ambien CR)—
intermed/rapidintermed/rapid
Sleep latency, sleep maintenance; pregnancy category CSleep latency, sleep maintenance; pregnancy category C
Zaleplon (Sonata)—ultrashortZaleplon (Sonata)—ultrashort
Sleep latency, can take in the middle of the night if you Sleep latency, can take in the middle of the night if you
awaken; pregnancy category Cawaken; pregnancy category C
Benzodiazepine-LikeBenzodiazepine-Like
Eszopiclone (Lunesta)—intermed/rapidEszopiclone (Lunesta)—intermed/rapid
Sleep maintenance (metallic taste); pregnancy category CSleep maintenance (metallic taste); pregnancy category C
Zolpidem (Ambien)—short/rapidZolpidem (Ambien)—short/rapid
Sleep latency; side effects include: sleepwalking, sleep-Sleep latency; side effects include: sleepwalking, sleep-
related eating disorder; pregnancy category B (?C)related eating disorder; pregnancy category B (?C)
Zolpidem controlled release (Ambien CR)—Zolpidem controlled release (Ambien CR)—
intermed/rapidintermed/rapid
Sleep latency, sleep maintenance; pregnancy category CSleep latency, sleep maintenance; pregnancy category C
Zaleplon (Sonata)—ultrashortZaleplon (Sonata)—ultrashort
Sleep latency, can take in the middle of the night if you Sleep latency, can take in the middle of the night if you
awaken; pregnancy category Cawaken; pregnancy category C
Prescription Medicines: Prescription Medicines:
Benzodiazepine-LikeBenzodiazepine-Like
Zolpidem (Ambien) and Zaleplon (Sonata)Zolpidem (Ambien) and Zaleplon (Sonata)
Zolpidem t ½ = 2.5 hours; no residual Zolpidem t ½ = 2.5 hours; no residual
effects if taken 5 hours before awakening; effects if taken 5 hours before awakening;
works well for freq. awakenings; Preg. B, works well for freq. awakenings; Preg. B,
and generally regarded safe in nursingand generally regarded safe in nursing
Zaleplon t ½ = 1 hour; no residual effects Zaleplon t ½ = 1 hour; no residual effects
if taken > 2 hours before awakening; if taken > 2 hours before awakening;
works well for terminal insomnia; Preg. Cworks well for terminal insomnia; Preg. C
Relatively new = relatively expensiveRelatively new = relatively expensive
Benzodiazepine-LikeBenzodiazepine-Like
Zolpidem (Ambien) and Zaleplon (Sonata)Zolpidem (Ambien) and Zaleplon (Sonata)
Zolpidem t ½ = 2.5 hours; no residual Zolpidem t ½ = 2.5 hours; no residual
effects if taken 5 hours before awakening; effects if taken 5 hours before awakening;
works well for freq. awakenings; Preg. B, works well for freq. awakenings; Preg. B,
and generally regarded safe in nursingand generally regarded safe in nursing
Zaleplon t ½ = 1 hour; no residual effects Zaleplon t ½ = 1 hour; no residual effects
if taken > 2 hours before awakening; if taken > 2 hours before awakening;
works well for terminal insomnia; Preg. Cworks well for terminal insomnia; Preg. C
Relatively new = relatively expensiveRelatively new = relatively expensive
Prescription Medicines: Prescription Medicines:
Melatonin-Receptor AgonistMelatonin-Receptor Agonist
Ramelteon (Rozerem)—short duration: 1-2.5 hrsRamelteon (Rozerem)—short duration: 1-2.5 hrs
Sleep latency, not sleep maintenanceSleep latency, not sleep maintenance
may increase prolactin levels (meaning you may may increase prolactin levels (meaning you may
lactate—typically undesired, especially in men) lactate—typically undesired, especially in men)
Dizziness, nausea, headache all commonDizziness, nausea, headache all common
No dependence, withdrawal, or rebound insomnia!No dependence, withdrawal, or rebound insomnia!
NOT a controlled substanceNOT a controlled substance
New medicine, long-term effects unknown; New medicine, long-term effects unknown;
pregnancy category C, pregnancy category C,
activity not through GABA receptor complexactivity not through GABA receptor complex
Do not take after a high-fat mealDo not take after a high-fat meal
Melatonin-Receptor AgonistMelatonin-Receptor Agonist
Ramelteon (Rozerem)—short duration: 1-2.5 hrsRamelteon (Rozerem)—short duration: 1-2.5 hrs
Sleep latency, not sleep maintenanceSleep latency, not sleep maintenance
may increase prolactin levels (meaning you may may increase prolactin levels (meaning you may
lactate—typically undesired, especially in men) lactate—typically undesired, especially in men)
Dizziness, nausea, headache all commonDizziness, nausea, headache all common
No dependence, withdrawal, or rebound insomnia!No dependence, withdrawal, or rebound insomnia!
NOT a controlled substanceNOT a controlled substance
New medicine, long-term effects unknown; New medicine, long-term effects unknown;
pregnancy category C, pregnancy category C,
activity not through GABA receptor complexactivity not through GABA receptor complex
Do not take after a high-fat mealDo not take after a high-fat meal
Prescription Medicines: Prescription Medicines:
Other Drugs (antidepressants)Other Drugs (antidepressants)
Amitriptyline (Elavil)Amitriptyline (Elavil)
Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and
serotonin uptake in the CNS—pregnany category Cserotonin uptake in the CNS—pregnany category C
Doxepin (Adapin)Doxepin (Adapin)
Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and
serotonin uptake in the CNS—pregnancy category Cserotonin uptake in the CNS—pregnancy category C
Trazadone (Desyrel)Trazadone (Desyrel)
sedating antidepressant (non-TCA/non SSRI)—cat. Csedating antidepressant (non-TCA/non SSRI)—cat. C
Mirtazapine (Remeron)Mirtazapine (Remeron)
Sedating antidepressant, antagonizes alpha2-Sedating antidepressant, antagonizes alpha2-
adrenergic and serotonin 5-HT2 receptors (tetracyclic)adrenergic and serotonin 5-HT2 receptors (tetracyclic)
—pregnancy category C—pregnancy category C
Other Drugs (antidepressants)Other Drugs (antidepressants)
Amitriptyline (Elavil)Amitriptyline (Elavil)
Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and
serotonin uptake in the CNS—pregnany category Cserotonin uptake in the CNS—pregnany category C
Doxepin (Adapin)Doxepin (Adapin)
Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and
serotonin uptake in the CNS—pregnancy category Cserotonin uptake in the CNS—pregnancy category C
Trazadone (Desyrel)Trazadone (Desyrel)
sedating antidepressant (non-TCA/non SSRI)—cat. Csedating antidepressant (non-TCA/non SSRI)—cat. C
Mirtazapine (Remeron)Mirtazapine (Remeron)
Sedating antidepressant, antagonizes alpha2-Sedating antidepressant, antagonizes alpha2-
adrenergic and serotonin 5-HT2 receptors (tetracyclic)adrenergic and serotonin 5-HT2 receptors (tetracyclic)
—pregnancy category C—pregnancy category C
Prescription Medicines: Prescription Medicines:
Other Drugs (antidepressants)Other Drugs (antidepressants)
Antidepressants only work well if patient is Antidepressants only work well if patient is
depressed; otherwise, trazadone and elavil depressed; otherwise, trazadone and elavil
work, but not as well as Ambien (Benzo-Like).work, but not as well as Ambien (Benzo-Like).
Should not be used in combination as a sleep Should not be used in combination as a sleep
aid if the patient is taking some other form of aid if the patient is taking some other form of
antidepressant.antidepressant.
Antidepressants used as sleep aids are not Antidepressants used as sleep aids are not
addicting.addicting.
Antipsychotics should only be used in psychotic Antipsychotics should only be used in psychotic
patients or occasionally the elderly in an patients or occasionally the elderly in an
institutional setting, if they cannot tolerate other institutional setting, if they cannot tolerate other
medicinesmedicines
Other Drugs (antidepressants)Other Drugs (antidepressants)
Antidepressants only work well if patient is Antidepressants only work well if patient is
depressed; otherwise, trazadone and elavil depressed; otherwise, trazadone and elavil
work, but not as well as Ambien (Benzo-Like).work, but not as well as Ambien (Benzo-Like).
Should not be used in combination as a sleep Should not be used in combination as a sleep
aid if the patient is taking some other form of aid if the patient is taking some other form of
antidepressant.antidepressant.
Antidepressants used as sleep aids are not Antidepressants used as sleep aids are not
addicting.addicting.
Antipsychotics should only be used in psychotic Antipsychotics should only be used in psychotic
patients or occasionally the elderly in an patients or occasionally the elderly in an
institutional setting, if they cannot tolerate other institutional setting, if they cannot tolerate other
medicinesmedicines
If all else failsIf all else fails
If your bed partner sleeps well, but keeps If your bed partner sleeps well, but keeps
you up by snoring, moving, coughing, etc., you up by snoring, moving, coughing, etc.,
sleep in a different bed or in a different sleep in a different bed or in a different
room. room.
If your bed partner sleeps well, but keeps If your bed partner sleeps well, but keeps
you up by snoring, moving, coughing, etc., you up by snoring, moving, coughing, etc.,
sleep in a different bed or in a different sleep in a different bed or in a different
room. room.
SummarySummary
Be alert for symptoms of insomnia and Be alert for symptoms of insomnia and
depressiondepression
Determine specific type of sleep problemDetermine specific type of sleep problem
Make a differential diagnosisMake a differential diagnosis
Don’t neglect behavioral therapiesDon’t neglect behavioral therapies
Pay attention to onset of action/duration of Pay attention to onset of action/duration of
effect of all medicines usedeffect of all medicines used
Teach ALL insomniacs proper sleep Teach ALL insomniacs proper sleep
hygienehygiene
Be alert for symptoms of insomnia and Be alert for symptoms of insomnia and
depressiondepression
Determine specific type of sleep problemDetermine specific type of sleep problem
Make a differential diagnosisMake a differential diagnosis
Don’t neglect behavioral therapiesDon’t neglect behavioral therapies
Pay attention to onset of action/duration of Pay attention to onset of action/duration of
effect of all medicines usedeffect of all medicines used
Teach ALL insomniacs proper sleep Teach ALL insomniacs proper sleep
hygienehygiene
ReferencesReferences
1) AAFP and American Academy of Sleep Medicine 1) AAFP and American Academy of Sleep Medicine
Monograph “Strategies for Managing Insomnia” 1999Monograph “Strategies for Managing Insomnia” 1999
2) Roth T, Roehrs T. Insomnia: Epidemiology, 2) Roth T, Roehrs T. Insomnia: Epidemiology,
characteristics, and consequences. characteristics, and consequences. Clin CornerstoneClin Cornerstone
2003;5(3):5-152003;5(3):5-15
3) Neubauer DN. Pharmacologic approaches to the 3) Neubauer DN. Pharmacologic approaches to the
treatment of chronic insomnia. treatment of chronic insomnia. Clin CornerstoneClin Cornerstone
2003;5(3):16-272003;5(3):16-27
4) Smith MT, Neubauer DN. Cognitive behavior therapy 4) Smith MT, Neubauer DN. Cognitive behavior therapy
for chronic insomnia. for chronic insomnia. Clin CornerstoneClin Cornerstone 2003;5(3):28-40 2003;5(3):28-40
5) Kupfer DJ, Reynolds CF. Management of Insomnia. 5) Kupfer DJ, Reynolds CF. Management of Insomnia.
NEJM 1997;336:341-46NEJM 1997;336:341-46
1) AAFP and American Academy of Sleep Medicine 1) AAFP and American Academy of Sleep Medicine
Monograph “Strategies for Managing Insomnia” 1999Monograph “Strategies for Managing Insomnia” 1999
2) Roth T, Roehrs T. Insomnia: Epidemiology, 2) Roth T, Roehrs T. Insomnia: Epidemiology,
characteristics, and consequences. characteristics, and consequences. Clin CornerstoneClin Cornerstone
2003;5(3):5-152003;5(3):5-15
3) Neubauer DN. Pharmacologic approaches to the 3) Neubauer DN. Pharmacologic approaches to the
treatment of chronic insomnia. treatment of chronic insomnia. Clin CornerstoneClin Cornerstone
2003;5(3):16-272003;5(3):16-27
4) Smith MT, Neubauer DN. Cognitive behavior therapy 4) Smith MT, Neubauer DN. Cognitive behavior therapy
for chronic insomnia. for chronic insomnia. Clin CornerstoneClin Cornerstone 2003;5(3):28-40 2003;5(3):28-40
5) Kupfer DJ, Reynolds CF. Management of Insomnia. 5) Kupfer DJ, Reynolds CF. Management of Insomnia.
NEJM 1997;336:341-46NEJM 1997;336:341-46
ReferencesReferences
6) National Center on Sleep Disorders Research… 6) National Center on Sleep Disorders Research…
Insomnia: Assessment and Management in Primary Insomnia: Assessment and Management in Primary
Care. NIH/NHLBI, 1998: 1-16Care. NIH/NHLBI, 1998: 1-16
7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine. 7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine.
1998;19:157-681998;19:157-68
8) Simon GE, VonKorff M. Prevalence, burden, and 8) Simon GE, VonKorff M. Prevalence, burden, and
treatment of insomnia in primary care. treatment of insomnia in primary care. Am J PsychiatryAm J Psychiatry
1997;154:1417-14231997;154:1417-1423
9) Krystal AD. Insomnia in women. 9) Krystal AD. Insomnia in women. Clin CornerstoneClin Cornerstone
2003;5(3):41-502003;5(3):41-50
10) Ward SH, Ward LD. The evaluation and 10) Ward SH, Ward LD. The evaluation and
management of insomnia in primary care. management of insomnia in primary care. Patient CarePatient Care. .
July 2006;40:46-55.July 2006;40:46-55.
11) Gritz BF. “Overview of Insomnia” CME-TAFP 11) Gritz BF. “Overview of Insomnia” CME-TAFP
Primary Care Lecture Series. Dec 6, 2006.Primary Care Lecture Series. Dec 6, 2006.
6) National Center on Sleep Disorders Research… 6) National Center on Sleep Disorders Research…
Insomnia: Assessment and Management in Primary Insomnia: Assessment and Management in Primary
Care. NIH/NHLBI, 1998: 1-16Care. NIH/NHLBI, 1998: 1-16
7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine. 7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine.
1998;19:157-681998;19:157-68
8) Simon GE, VonKorff M. Prevalence, burden, and 8) Simon GE, VonKorff M. Prevalence, burden, and
treatment of insomnia in primary care. treatment of insomnia in primary care. Am J PsychiatryAm J Psychiatry
1997;154:1417-14231997;154:1417-1423
9) Krystal AD. Insomnia in women. 9) Krystal AD. Insomnia in women. Clin CornerstoneClin Cornerstone
2003;5(3):41-502003;5(3):41-50
10) Ward SH, Ward LD. The evaluation and 10) Ward SH, Ward LD. The evaluation and
management of insomnia in primary care. management of insomnia in primary care. Patient CarePatient Care. .
July 2006;40:46-55.July 2006;40:46-55.
11) Gritz BF. “Overview of Insomnia” CME-TAFP 11) Gritz BF. “Overview of Insomnia” CME-TAFP
Primary Care Lecture Series. Dec 6, 2006.Primary Care Lecture Series. Dec 6, 2006.
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