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26.04.2014

Medications for chronic insomnia, treating fatigue naturally - Review

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Renew Your Subscription and List Your Practice for Free!Chronic pain sufferers are using our pain specialist directory to find pain specialists in your area. Currently, classifications for insomnia are available in two references, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the International Classification of Sleep Disorders, Second Edition (ICSD-2).2,5 Both identify various subtypes of insomnia, with the DSM-IV classifying insomnia as either a primary disorder or secondary to some underlying cause. There are numerous secondary causes of insomnia ranging from underlying mental disorders, other general medical conditions, or those that are related to a substance or medication.6,7 Patients with chronic pain syndrome or degenerative diseases may have trouble sleeping because of their pain.
Insomnia also can be drug induced, especially by substances that result in central nervous system (CNS) stimulation.
In a National Institutes of Health (NIH) statement on insomnia, various risk factors for insomnia were highlighted.11 The first was age, with rates of insomnia increasing in older patients.
A 2008 Clinical Guideline for the Evaluation and Management of Chronic Insomnia provides recommendations for the assessment and treatment of patients with insomnia.7 Patients presenting with insomnia should have a detailed history taken to identify any medical, psychiatric, or substance-related factors that may be contributing to their insomnia.
In patients experiencing pain or those with chronic pain, careful assessment is required in order to determine how well the pain itself is being managed.9 The presence of comorbid psychiatric disorders also should be considered. Insomnia should be treated when the condition affects daytime functioning, the patient’s overall health, or sleep quality.7 The first step for treatment is the identification and management of comorbid conditions that are associated with insomnia, such as depression or chronic pain, followed by the modification of behaviors or medications (see Table 2) that can worsen insomnia. Understanding insomnia and how it can most effectively be treated continues to challenge psychiatrists and other clinicians. This column provides information on how and why insomnia develops, as well as on its treatment, focusing primarily on behavioral interventions. Behavioral treatments for insomnia can be very effective for many patients, but there are substantial challenges to clinicians desiring to use these treatments. Sleep hygiene is a critical element of importance for all patients, including those receiving hypnotic medications. Age is a factor in development of insomnia, but not because we need less sleep as we age or even that sleep drive and sleep depth are reduced with age. Personality traits may also play a significant contributory role in the development of insomnia, based on this model. A wide range of events and stimuli may precipitate an insomnia episode in susceptible individuals.
As a consequence of the development of insomnia, patients may make various changes in their habits and routines to try to compensate for their sleep loss and greater difficulties falling asleep. Understanding how insomnia develops may provide opportunities to treat insomnia at early stages and prevent progression to chronic insomnia. Understanding how insomnia develops is also important when insomnia has become established as a chronic condition. Various behavioral therapies have demonstrated efficacy in the treatment of chronic insomnia.9 Research supports the hypothesis that non-pharmacologic therapies can be very effective in the treatment of insomnia, and an effort should be made to include behavioral therapies in the treatment of every patient with insomnia. Operationally, sleep restriction involves an initial limitation of time in bed to an amount close to the number of hours that the insomnia patient reports having slept. Stimulus control therapy (SCT), originally described by Bootzin and colleagues,11 has become so widely utilized in the behavioral treatment of insomnia that many practitioners do not appreciate that it defines a specific and universal approach to the treatment of insomnia. CBT, demonstrated to be effective in the treatment of depression, has also demonstrated efficacy in multiple research studies as a treatment for insomnia.12-14 Typically, CBT attempts to address maladaptive behaviors and thought patterns that plague insomniac patients. Treatment for sleep deprivation may include non restorative treatment, for example, growing better rest propensities or psychotherapy, and here and there pharmaceuticals.


Benzodiazepine narcotics, for example, triazolam (Halcion), estazolam, lorazepam (Ativan), temazepam (Restoril), flurazepam, and quazepam (Doral) and non-benzodiazepine tranquilizers, for example, zolpidem (Ambien, Intermezzo), eszopiclone (Lunesta), and zaleplon (Sonata) are medications that can help prompt rest. As previously mentioned, depression and anxiety are common in patients with chronic pain and may further exacerbate sleep disturbances and insomnia. If medications that are associated with insomnia cannot be discontinued or switched, consideration should be given to adjusting the timing of administration. NIH state of the science conference statement on manifestations and management of chronic insomnia in adults statement. Evidence-based recommendations for the assessment and management of sleep disorders in older persons.
Vertical Health Media, LLC disclaims any liability for damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. Erman is clinical professor in the Department of Psychiatry at the University of California, San Diego School of Medicine, is a staff scientist for the Scripps Research Institute Department of Neuropharmacology, and is the president of Pacific Sleep Medicine Services. Insomnia may be acute or chronic, but the majority of patients presenting for evaluation to treating physicians complain of chronic insomnia. The origins of chronic insomnia are usually much more complex, with contributions from predisposing, precipitating, and perpetuating factors.
It also recognizes that chronic insomnia is maintained (unintentionally) by maladaptive coping strategies (perpetuating factors). The presence of concomitant medical illnesses is the largest contributing factor to increased rates of insomnia seen with increased age.
Insomnia patients are often anxious, and may develop fixations about the amount and quality of sleep that they obtain and the impact they believe it will have on daytime function.
For example, using the Spielman model,2-4 if physicians and therapists recognize that premorbid traits predisposing to development of insomnia exist, they may be more aggressive in treating stress and instructing patients on avoidance of key stressors capable of provoking insomnia.
Identification of elements that have contributed to the development of insomnia, and educating the patient about the roles that behavior and conditioning have played in this process, should help physicians and patients understand that behavioral therapies combined with pharmacologic interventions are useful treatment options. Some of the elements from these specific therapies may also be incorporated in a more global approach to the treatment of insomnia using cognitive-behavioral therapy (CBT). This restriction is based on assumption that most insomnia patients underestimate the amount of sleep that they have obtained.
These disturbances develop over long periods of time, become an entrenched part of the insomniac’s thought and behavior patterns, and exacerbate insomnia severity. Education in sleep hygiene is always beneficial to patients, even for those who feel they fully understand how to improve their sleep. For example, clinicians should discuss computer use with their patients; using a computer when one cannot sleep involves motor activity, cognitive activation, and light exposure, all of which will interfere with the capacity to fall asleep.
Some elements of the sleep history include characterization of the primary complaint (eg, difficulty falling asleep vs awakenings vs poor sleep), frequency and duration of insomnia, identification of nocturnal symptoms, impact on daytime activities and functioning, and any past or current treatments and responses. Most insomnia can be related, at least in part, to comorbid medical and psychiatric conditions, which may play a role in any of these three contributory realms. These patients maintain a state of excessive arousal (out of context with their need for arousal in their sleep or relaxation environment) that interferes with their capacity to sleep.
Thus, a person may be prone to insomnia due to trait characteristics, may experience a trenchant or short-term insomnia as a consequence of precipitating stresses, and may develop a persistent and chronic insomnia as a consequence of pathologic coping strategies and poor sleep hygiene.


Thought processes of this sort clearly contribute to the development of insomnia, and are excellent targets for cognitive therapy as part of an overall treatment program. Parental demands, care-giving for a spouse or parent, or arousal related to a bed-partner’s sleep tendencies, schedule, or habits may all contribute to increased risk of developing insomnia. Examples of disorders that could precipitate insomnia include arthritis flares, angina, prostatism, hyperthyroidism, and irritable bowel syndrome.
If stressors are neutralized or insomnia symptoms are quickly and effectively treated, patients may revert to their pre-morbid, non-insomniac state.
If they are limited to the 5 hours, for example, which they report they have been receiving, their sleep will be restricted. Although it is helpful for many patients, some of its components, such as getting up from bed and going to another room if unable to sleep, may increase levels of arousal and make it extremely hard for patients to be able to return to sleep when they return to their bedroom. These disturbances tend to develop no matter how the insomnia originally developed, and include behavioral and cognitive elements that interfere with the patient’s ability to relax and fall asleep.
Another common habit exhibited by insomniacs is a tendency to look at clocks when they have trouble sleeping.
Others may report sleeping for 90–120 minutes over the course of the day, but have difficulty understanding that this reduces sleep drive at night, making entry into sleep and sustained sleep more difficult. Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. Likewise they can be hazardous on the off chance that you bring them with liquor or different medications that discourage the focal sensory system. A physical exam also is recommended to identify risk factors for other sleeping disorders (eg, sleep apnea), such as obesity, increased neck circumference, and upper airway anatomical changes.
If interventions are not made until perpetuating elements have developed, the insomnia condition is more likely to become chronic. Insomniacs will attempt to process the information provided by the clock in the middle of the night; this is always a negative phenomenon. They can bring about morning drowsiness, albeit reactions are for the most part less extreme with the non-benzodiazepines.
The Insomnia Answer: A Personalized Program for Identifying and Overcoming the Three Types of Insomnia. A solution oral shower called Zolpimist, which contains Ambien’s dynamic fixing, can be utilized for transient treatment of sleep deprivation. An example of a sleep questionnaire is the Insomnia Severity Index, a 7-item rating to assess patients’ perceptions of insomnia. The promotion of a natural state of relaxation which encourages sleep in the hours before bedtime, along with avoiding physical activity or exercise in the evening hours, can help create an environment favorable for sleep.



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