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22.08.2014

Symptoms and treatments of insomnia, tinnitus masking treatment - For You

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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.
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.
Numerous specific behavioral therapies have been described in the past, including sleep restriction, relaxation therapies, and stimulus control therapy.
Sleep restriction therapy was initially described by Spielman and colleagues10 and is based on an assumption that sleep deprivation will promote a stronger drive to fall and remain asleep. 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. CBT includes various techniques to alter dysfunctional sleep cognitions, beliefs, attitudes, and expectations. 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. Diagnosis of insomnia must be concluded by a physician based on the patient's reported signs and symptoms before treatment options can be pursued. In addition, patients with insomnia are evaluated with the help of medical history and a sleep history. Treatment of insomnia may involve treatment of the underlying medical disorder, if any are detected during diagnosis. Diagnosing sleep insomnia and its cause is the most important step in restoring healthy sleep. 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. Clinicians must be educated in how to use behavioral treatment modalities, and must be able to identify which patients are most likely to benefit from their use. 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. The disruption of sleep seen in association with depression, anxiety disorders, bipolar disorder, obsessive-compulsive disorder, or psychotic disorders may interact with the personality traits of these patients to increase anxiety and concern about sleep.5,6 Social factors may also be contributory to this process.
As sleep becomes more elusive, efforts to fall asleep may become more intensified, as is the level of arousal and anxiety the continued failure to sleep generates.
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. This technique requires a compliant patient, careful record keeping and record analysis by patient and therapist, and recognition that at least several weeks will be required before significant changes will be observed by the patient.
SCT consists of a series of five instructions given to patients to strengthen their capacity to fall asleep at night and to improve their capacity to sleep on a regular basis in their own bedroom. These disturbances develop over long periods of time, become an entrenched part of the insomniac’s thought and behavior patterns, and exacerbate insomnia severity.
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. Many patients who report that they use caffeine to help them become more alert and functional in the morning are relieved when informed that caffeine in the morning and early afternoon may not impact nighttime sleep.
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. Patients must be motivated to accept these treatments, especially since they may not experience immediate relief.
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. The bed and bedroom, which ideally are associated with comfort, pleasure, and relaxation, become increasingly associated with pain, arousal, and anxiety.


If stressors are neutralized or insomnia symptoms are quickly and effectively treated, patients may revert to their pre-morbid, non-insomniac state. 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. CBT is designed to interrupt the self-fulfilling nature of these beliefs and behaviors, and provides patients with coping skills to prevent or minimize recurrence of sleep disturbances after treatment. Core elements, such as attempting to maintain regular bedtime and awakening hours, may seem obvious, but linking these activities to the importance of strongly entrained circadian rhythms may provide an intellectual base that allows the patient to make a greater effort to maintain such a regular pattern. 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. Being able to treat sleep insomnia reduces the amount of individuals suffering from sleep insomnia. Disclaimer: Reliance on information, material, advice, or other linked or recommended resources, received from Anthony Cain, shall be at your sole risk, and Anthony Cain assumes no responsibility for any errors, omissions, or damages arising. Other efforts or strategies to promote sleep may ensue, further disrupting normal sleep patterns and habits. If interventions are not made until perpetuating elements have developed, the insomnia condition is more likely to become chronic. Examples of maladaptive behaviors include irregular sleep-wake patterns, frequent daytime naps, clock watching, and going to bed at too early an hour.
Insomniacs will attempt to process the information provided by the clock in the middle of the night; this is always a negative phenomenon. Users of this website are encouraged to confirm information received with other sources, and to seek local qualified advice if embarking on any actions that could carry personal or organisational liabilities. Among maladaptive thought patterns are trying too hard to fall asleep (which provokes greater arousal), pathologic anxiety generated by the immediate inability to fall asleep, and excessive worry about sleep loss and its possible next day consequences. A positive alternative would be sleeping through the night and awakening on one’s own or with a morning alarm. The Insomnia Answer: A Personalized Program for Identifying and Overcoming the Three Types of Insomnia. Managing people and relationships are sensitive activities; the free material and advice available via this website do not provide all necessary safeguards and checks.



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