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10.05.2014

Causes and effects of insomnia and other sleeping disorders, depression mood disorder - How to DIY

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A sleep disorder or somnipathy includes a range of problems in sleeping patterns like lack of sleep, snoring, sleep apnea, sleep deprivation, restless legs syndrome, bedwetting and others.
There are a number of sleep disorders and the symptoms of sleep disorder may vary accordingly.
Insomnia is a disorder characterized by chronic sleep disturbance associated with daytime disability or distress, such as memory impairment and fatigue, that occurs despite adequate opportunity for sleep.
In this Clinical Information Supplement, Thomas Roth, PhD, describes the nature of insomnia and its pathophysiology. Insomnia is a symptom-based diagnosis.3 Patients with insomnia experience one or more sleep-related complaints, including difficulty falling asleep, difficulty staying asleep, early-morning awakenings, and sleep that is nonrestorative or not adequately restorative (Slide 1).
The disparity between the prevalence in the general population and that in the clinical population may be explained by the risk factors associated with insomnia. The other major comorbidity, besides the medical conditions associated with dyspnea and pain, is depression.
Although 30% of patients with a medical disorder have insomnia, one must consider the fact that 70% do not. While most people experience a decline in body temperature at night, this is not as consistently seen among insomniacs.
The sleep systems in patients with insomnia are relatively normal, but the individuals are hyperaroused, as reflected in catecholamines, brain metabolism, and body metabolism. People who experience sleep difficulty often report problems with daily functioning and quality of life. Several epidemiologic studies1-7 have used cross-sectional analysis or longitudinal data to compare people with insomnia to normal sleepers in an effort to determine the specific impairments and alterations in quality of life associated with insomnia. Findings from cross-sectional studies show a strong correlation between insomnia and impairment. An enlightening study by Katz and McHorney2 compared the SF-36 findings in a group of patients with severe insomnia to those in a group of patients with major depression and a group of patients with congestive heart failure.
Longitudinal data demonstrate that people with insomnia experience increased absenteeism and decreased productivity in their work roles.
There are limitations to our knowledge of how treatments for insomnia affect the impairments and risks associated with the disorder.8 Examinations of some measures of daytime function have produced negative findings. At the National Institutes of Health (NIH) State-of-the-Science Consensus Conference on insomnia, held in June 2005 in Washington, DC, the Federal government addressed insomnia and its associated problems for the first time in >20 years. Other forms of behavioral treatment may be administered in the clinician’s office, however. Sleep restriction and stimulus control are other behavioral treatments for sleep disorders. Likewise, increasing exposure to bright light during the day and avoiding exposure to it during the night contribute to good sleep hygiene. Patients with insomnia should engage in relaxing activities as part of their sleep preparation ritual. Over the years, patients have used a variety of products, alone or in concert with behavioral changes and modifications, to induce sleep (Slide 4). Laudanum, a combination of opium and alcohol, has been around for over 100 years, and was used extensively during the American Civil War, when it was available at every corner grocery store.
The selective melatonin receptor agonist ramelteon is a recent addition to the sleep-agent armamentarium and is also approved by the FDA for the treatment of insomnia. In the process of shifting away from chloral hydrates and barbiturates and adopting more efficacious hypnotic products, doctors began prescribing long-acting benzodiazepines like flurazepam and quazepam (Slide 7).10-12 However, these medications have extremely long half-lives, meaning they have a very high risk of producing residual sedation in patients. Many clinicians use other agents from the benzodiapine class of drugs, such as lorazepam, temazepam, and alprazolam, as hypnotics.
Currently, the nonbenzodiazepines and ramelteon are the newest pharmacologic treatments for insomnia patients.
Q: Most clinicians, particularly psychiatrists, are trained to think about insomnia as a symptom of another disorder. E-newsletter Opt-inSent no more than 2–3 times each month, our E-Newsletter brings you recent findings and commentary from the psychiatric literature.
People who experience chronic pain often times find their issues are compounded by the additional troubles that come with insomnia and sleeping disorders. Chart showing sleep issues included in insomniaThe term, 'insomnia includes all types of sleeping issues. Awakening during the night and waking up earlier than wanted; however, are also frequent issues. Unfortunately the, 'quieting,' of a person's environment might cause issues for people with chronic pain because the only thing left for their brain to concentrate on is the experience of pain.
Chart showing causes of long-term insomniaIf the issue remains, a non-pharmacologic treatment should be implemented. A number of medical disorders such as hyperthyroidism, congestive heart failure, dementia, rheumatologic diseases, asthma, chronic obstructive pulmonary disease and gastroesophageal reflux disease may also cause insomnia.
Definition: InsomniaInsomniaA sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired.
As the medicines are prescribed according to the problem and individual needs of the patient. Roth is director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit, and clinical professor of psychiatry at the University of Michigan School of Medicine in Ann Arbor.
Krystal is director of the Sleep Research and Insomnia Program at Duke University School of Medicine in North Carolina. Lieberman is professor of family medicine at Jefferson Medical College, Thomas Jefferson University, in Philadelphia, Pennsylvania, and speaker of the house of the Medical Society of Delaware in Newark, Delaware. A disorder is a condition  which exhibits morbidity mediated by some kind of pathophysiology. Some of the greatest risk factors for insomnia are age and psychiatric disorders (Slide 3). On the other hand, it is very clear that shift work contributes to insomnia by causing changes in circadian rhythm. It is important for clinicians to understand that while insomnia interacts with other medical disorders, it is not necessarily caused by them. It is now known that sleep loss and sleep fragmentation causes pain and increased inflammatory response. Several studies in the medical literature demonstrate that insomnia increases the risk of depression by a factor of 5. Hyperarousal overrides these normal sleep systems and causes insomnia, which then interacts with the comorbid medical and psychiatric disorders.
While impairment and decreased quality of life are included among the criteria for the diagnosis of insomnia, the nature and degree of these impairments are difficult to ascertain. In another type of study, patients with insomnia receive insomnia-specific therapies and are followed to determine how their function and quality of life improve. Compared to normal sleepers, people who meet insomnia criteria have impaired quality of life. The striking results indicated that people with insomnia had more impairment in areas of vitality, general health, and physical ability to function than those with congestive heart failure and those with major depression. Breslau and colleagues5 looked at a group of patients who met insomnia criteria at baseline and a group of people without insomnia. In a study by Suka and colleagues,6 4,794 male workers from one company in Japan were diagnosed with insomnia at initial evaluation and followed for 4 years. As there is a tendency not to publish negative findings, it is not known how often studies fail to find therapeutic effects. In four of these studies, people completed morning self-ratings that indicated their alertness or ability to function had significantly improved after insomnia treatment. Two of the major chronic insomnia treatment endorsements came out of that conference: First, cognitive-behavioral therapy (CBT) for insomnia is effective and should be utilized.
The role of CBT in insomnia is to challenge the dysfunctional beliefs and misconceptions about sleep held by a person with insomnia (Slide 2).2 One of the cornerstones of CBT for insomnia is to stop the patient from focusing too much on the time.
Other CBT techniques that require less training and are thus more easily delivered include relaxation training, in which patients are taught to reduce their physiologic and cognitive arousal at bedtime. Patients with insomnia should exercise in the morning or, at the very latest, by early afternoon.
Although they are safer than some of the other substances mentioned, they still carry certain hazards and risks. These are safer than the aforementioned mentioned products, but they also have drawbacks and side effects. Even the intermediate-acting agents, such as estazolam and temazepam, have half-lives long enough to cause risk of residual sedation.
National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute, National Institutes of Health.
Lieberman: There have been no solid studies to indicate that primary sleep disorders can be treated by treating depression. Clinicians may look very hard for an underlying psychiatric disorder or for an associated medical problem—even an acute stressor.
Roth: The National Institutes of Health (NIH) realized that insomnia is not a symptom, but rather a chronic disorder.


Krystal: When treatment is started, one does not know how long a patient will have insomnia.
Many of these shift workers have dysfunctional sleeping patterns, such as napping during the daytime and adopting a normal sleep-wake cycle on weekends.
Of the people who report experiencing chronic pain, approximately 15% of the overall population in America and half of seniors, around 65% report experiencing sleep disorders such as non-restorative or disrupted sleep.
People will often times report that one of their primary pain management tools during the day is the ability to distract themselves from the pain they experience by staying busy with other tasks such as hobbies, crafts, watching television, reading, or interacting with other people. People who experience chronic pain often experience less deep sleep, more arousals and awakenings during the night, as well as less efficient sleep. It is important for a health care provider to look for the underlying cause of a person's sleep issue and to treat the condition.
Short-term insomnia might be caused by pain, acute stress, medications, environmental changes, the withdrawal of sedatives, or stimulant use.
We welcome well-informed remarks relevant to the article, as well as your advice, criticism and unique insights.
Almost all of us experience problems in sleeping at some point of time in our lives but if this continues for long, take medical advise.
Any one of these latter symptoms must be present with the sleep-related complaint, and must occur despite adequate opportunity for sleep. Familial aggregation is a risk factor, suggesting that there is a genetic basis for this disorder.
The majority of patients with medical disorders such as rheumatoid arthritis or neuropathic pain do not have insomnia.
Patients with a history of depression are also at a greater risk of relapse if they have insomnia.
In addition,  Perlis and colleagues11 showed that these patients experience increased high-frequency electroencephalogram. Derivation of Research Diagnostic Criteria for Insomnia: Report of an American Academy of Sleep Medicine Workgroup.
National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder.
Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. One important question is whether insomnia causes alterations in physiology or behavior that might lead to longer-term adverse consequence. They report that they do not feel as well overall, and they do not feel like they are able to function as well. They had comparable impairments to those with congestive heart failure and major depression in other important subscales, such as emotional role and mental health.
A 1997 retrospective analysis by Simon and VonKorff3 compared a database of ~2,000 primary care patients with insomnia to controls. The incidence of hypertension increased in those who had difficulty initiating sleep or staying asleep compared with those who did not meet have insomnia. Another problem is that studies of daytime function, quality of life, and associated psychiatric and medical conditions have widely variable measures and methodologies.
The relationship between insomnia and health-related quality of life in patients with chronic illness. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Nightly treatment of primary insomnia with eszopiclone for six months: Effect on sleep, quality of life and work limitations.
In one variation of this technique, patients are taught progressive muscular relaxation, in which they relax the muscles of their body, starting with the feet and working toward the head, until they fall asleep.
Patients should not try to catch up on sleep during the weekends, but rather set their own internal clock to consistently go to bed at a certain time and wake up at a certain time.
Exposure to a 150-watt light bulb during a nighttime lavatory visit can cause difficulty sleeping in very susceptible patients. A warm bath and socks are just two ways that patients can reduce core body temperature to predispose themselves to sleep. Patients are best treated with the nonpharmacologic behavioral interventions outlined above, such as CBT and relaxation training. Ever since the 2005 NIH State-of-the-Science Consensus Conference on insomnia, all drugs approved by the Food and Drug Administration have been indicated for the long-term therapy of insomnia. And after a patient starts pharmacologic treatment, one will not know if the patient still does have insomnia. And there are some people whose anxiety is such that it is difficult to change their behavior.
Back pain is the most common type of chronic pain issue and is the most prevalent medical disorder in industrialized societies. In getting ready for bed it is common to attempt to eliminate distractions or other influences in efforts to relax and start to fall asleep. When they try to fall asleep; however, there are no other distractions available to them to concentrate on except for the pain they experience. The first task is usually to figure out the duration of the insomnia the person experiences. If the cause cannot be resolved, a health care provider will usually treat insomnia with medication on a short-term basis. Depression is a common cause of insomnia in seniors, many times resulting in early awakening, and is best treated with medications that have sedative side effects. Comments are moderated and will not appear until approved, please note we do not verify information posted in the comments section.
Insomnia can be classified as transient, acute, or chronic.Transient insomnia lasts for less than a week. Insomnia can be a cause of underlying disease like stress, anxiety, depression, or an underlying health condition.
Pain conditions and depression are commonly associated with insomnia, either as secondary or comorbid conditions. The clinical subpopulation that does have insomnia is composed of patients with a predisposition for it. The more medical conditions they have, the greater the number of precipitants, and the greater their likelihood of developing insomnia.
Other medical disorders commonly associated with insomnia include arthritis and other chronic pain syndromes, congestive heart failure, cerebral vascular disease, chronic pulmonary disease, Parkinson’s disease, dementia, gastroesophageal reflux, and renal failure (Slide 6). As is the case with treating other comorbid conditions, treatment of insomnia diminishes illness severity and improves response to antidepressant treatment. Nofzinger and colleagues8 demonstrated increased brain metabolism in the arousal centers in the brain, indicating that insomnia does not result from broken sleep systems but from over-engaged arousal systems (Slide 7).
Lushington and colleagues12 demonstrated that those with insomnia experience an increase in body temperature, and Stepanski and colleagues13 indicated that insomniacs also experience increased heart rate—both at night and during the day. In a study involving 261 insomnia patients and 101 controls, Zammit and colleagues1 employed the 36-item Short Form (SF-36) Health Survey, a well-validated epidemiologic measure of quality of life. There were significant differences in the groups’ ratings of their social disability, ability to fulfill roles, number of days of limited activity, and number of days spent in bed.
After that interval, there was a much greater incidence of major depression, anxiety, and alcohol and drug dependence problems in those who had insomnia. These studies show that reported sleepiness, number of naps, and time spent napping all decreased following treatment, while ability to carry out professional activity increased. Although effective, the application of CBT as a wide-spread treatment is hampered by its availability (since specialized training is required) and its lack of consistent coverage by medical insurance carriers.
Other relaxation methods may be commonly available in the community, such as relaxation sessions, transcendental meditation, yoga, and biofeedback. While most patients realize that coffee and cola drinks contain caffeine, many do not know that tea, many non-cola soft drinks, and chocolate do, as well. Usually, hypnotics should be prescribed only if good sleep hygiene principles and cognitive interventions are not sufficient to allow patients to get a good night’s sleep.
People without any insomnia at all were asked whether they have difficulty sleeping when they experience stress. Because of that ambiguity and the absence of data, I do trial tapers every couple of months. First, if you get them to sleep 8 hours during the day, which is itself an incredible challenge, they still will have difficulty staying awake at work and driving home because they are trying perform these activities in a downside of the circadian rhythm. We use the cognitive interventions first, and then we use pharmacotherapeutic agents for awakening or increased alertness, and to help with sleep. However, before one decides that a patient has insomnia, one should make sure that the patient has adequate opportunity to sleep. Perhaps not surprisingly, people with chronic back pain frequently report significant interference with sleep.In a recent study it was discovered that around two-thirds of people with chronic back pain experienced a sleep disorder.


Doing so might include making the room quiet, trying to get comfortable, turning off the lights, eliminating other noises, and then starting to try to fall asleep. The chronic pain issues may be a significant intrusion into a good night's sleep and disrupt the usual stages of sleep.
The non-restorative sleep pattern might cause depressed mood, diminished energy, fatigue, and a worsening pain experience during the day. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe depression, or by stress. In addition, a greater incidence of anxiety, alcohol and drug dependence, and cardiovascular disease is found in people with insomnia. Lieberman III, MD, MPH, provides an overview of therapeutics utilized in patients with insomnia, including behavioral therapies and pharmacologic options. However, the 30% sleep disturbance prevalence does not account for the population suffering from insomnia. Age is the greatest risk factor for insomnia; however, the reason elderly people experience increased risk of insomnia is not due to a breakdown of their sleep systems. However, the fact that the incidence of insomnia is not 100% among patients who have three or four medical disorders indicates that medical disorders themselves are not responsible for causing insomnia. Virtually every medical disorder can be associated with insomnia because most medical disorders require an arousal response. Fava and colleagues7 demonstrated that patients with comorbid insomnia and depression experience a quicker, more effective antidepressant response when treated with a sleep agent and antidepressant combination than when treated with either a sleep agent or antidepressant alone. The results demonstrated that people with insomnia differ from normal sleepers in their vitality, their emotional role, their health, and their physical role.
The results showed that insomnia was correlated with global impairments in patients’ ability to live their lives (Slide 3). While these associations cannot be construed as hard and fast proof, it is notable that the positive findings occurred despite poor or inconsistent methodology (Slide 6). Consequently, in some areas, there is a shortage of cognitive-behavioral therapists and an inability to access them because of insurance policies. Similarly, stimulus control ensures that patients restrict their psychological associations with the bed to just sleep and sexual activity.
Alcohol makes people sleepy, but it has a short half-life, and as it is metabolized the body produces neurotoxins that are irritants to the central nervous system. It turns out that those people who have more disturbed sleep in stressful circumstances, in age- and sex-matched controls, have an ~11-fold increased risk of developing insomnia in the future. I think both problems must be treated based on their individual symptomatologies, and one cannot be considered secondary to the other, though this was common in the past. However, comorbid insomnia is very different from secondary insomnia, in which a condition or disorder is the primary cause of insomnia. The decision of the NIH indicates that there is a role for chronic therapy, but for whom and under what circumstances depend very much on the patient, just as in determining treatment for patients with depressive disorders. These shift workers will have worse sleep hygiene, too, because their sleeping environment will be affected by daylight. But this is only after we have ensured that our patient is pretty well versed in what other things they need to do to help themselves. And as long as there is a plan to taper that medication over the course of three weeks, before the full benefit of behavioral therapy kicks in, you still seem to get full benefit of the behavioral therapy.
Then it is important to determine the cause of the person's insomnia and to treat the issue if possible.
Its consequences - sleepiness and impaired psychomotor performance, are similar to those of sleep deprivation.Acute insomnia is the inability to consistently sleep well for a period of less than a month. Clinicians must consider whether chronic treatment of insomnia can prevent the relapse of depression or other like conditions.
In all of the different subscales of the survey, quality of life was diminished in the patients with insomnia (Slide 1). While these studies do not prove causality, they show strong association, which is intriguing and worthy of further inquiry. Finally, there are no studies that have had a primary focus on morbidity; a study of the effects of insomnia therapy on morbidities must examine a group of people who have an identified set of morbidities, and then follow them in a method powered to detect those effects. Treatment seems to improve the deficits people with insomnia experience, including those in quality of life, social role, and work performance. The bed should not be used for television watching, dog grooming, stamp collecting, or any other activity executed in hopes of eventually falling asleep. Patients should enhance their sleep environment by reducing ambient noise, keeping the room dark, and having adequate bed covers and sleep surface. These irritants act as stimulating agents that can overwhelm the initial sense of sedation alcohol causes. They know that in cases like patients with recurrent episodes of depression, lifelong pharmacologic therapy is required, so I think they are more easily convinced to use chronic treatments for insomnia. Some interesting data suggest that if you continue insomnia medication long term, the behavioral therapy benefits do not seem to manifest, perhaps because there is no motivation to change behavior.
A troublesome cycle develops in which the person's back pain disrupts their sleep and trouble with sleeping makes the person's pain worse - which in turn makes sleeping harder.
Insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality.
Insomnia patients experience increased metabolic rate, body temperature, and heart rate, and elevated levels of norepinephrine and catecholamines. Finally, the prevalence of insomnia varies among medical practices in the clinical population. However, most studies are powered to determine whether therapies include sleep and are not powered to find the effects on non-sleep outcomes. Effects of treatment on risks for medical and psychiatric disorders have not yet been sufficiently studied. I think the more interesting question is how much of that hyperarousal is due to the insomnia, rather than the cause of insomnia. We do not have as much longitudinal data for chronic treatment of insomnia as we do for depressive disorders.
These problems occur despite adequate opportunity and circumstances for sleep and they must result in problems with daytime function. When air is blocked from entering into the lungs, the individual unconsciously gasps for air and sleep is disturbed. Pharmacologic options for the treatment of insomnia include benzodiazepine hypnotics, a selective melatonin receptor agonist, and sedating antidepressants. For example, insomnia prevalence in geriatric medicine differs from that in athletic medicine.
Clinicians may be trained to infer that a patient’s depression causes their insomnia. Some patients respond to a limited course of therapy; after a while the insomnia is ostensibly cured and the therapy can be withdrawn. Acute insomnia is also known as short term insomnia or stress related insomnia.Chronic insomnia lasts for longer than a month.
However, insomnia may be best treated with cognitive-behavioral therapy and instruction in good sleep hygiene, either alone or in concert with pharmacologic agents.
However, across all medical specialties and all medical clinics, ~50% of patients meet diagnostic criteria for insomnia (Slide 2). However, if insomnia is caused by depression, treating depression should, and does, alleviate sleep disruptions. Chronic therapy has always been an option clinically, but it is now also an option in terms of regulations, both as indicated on medication labels and in terms of clinical guidelines. Studies on the effects of insomnia treatment use variable methodologies or do not publish negative results, and there are currently no studies of treatment focusing on morbidity. There is equally a large body of data indicating that those who suffer from insomnia also experience cognitive hyperarousal, indicating the pathophysiology is not simply biological. People with high levels of stress hormones or shifts in the levels of cytokines are more likely to have chronic insomnia.
Further research is necessary to better understand the effects of insomnia therapies on medical and psychiatric disorders. Krystal presented data from Breslau and colleagues,2 which shows that in the majority of cases, insomnia precedes the depression. However, some patients who have hypertension are treated temporarily and some require lifelong treatment. There are also data that would suggest that if you treat depression, then the more refractory symptom is insomnia. Hence, although it is clear that insomnia often is comorbid, this does not preclude the treatment of insomnia as its own distinct condition. This is appropriate so long as we can make the association between that insomnia and some of the other conditions that these clinicians treat.




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