TABLE 19.7 Precipitating factors for insomnia
• nonprescription drugs such as caffeine or alcohol. Alcohol reduces the time to onset of sleep but disrupts sleep later in the night Regular and excessive consumption disrupts sleep continuity; insomnia is a key feature of alcohol withdrawal. Excessive intake of caffeine and theophylline, either in tea.coffee or cola drinks.also contributes to sleeplessness.
• parting treatment with certain anridepresionts. especially seroton in reuptake inhibitors (e.g. fluoxetine, fluvoxammel, or monoamine uptake inhibitors;sleep disruption is likely to resolve after' 3—4 weeks.
• other drugs which increase central noradrenergic and serotonergic activity include >,'.'• '.:;.'•" such as amphetamine, cocaine and methylphenidate and syrftpoihomrrtTetics such as the [^-adrenergic agonist salbutamol and associated compounds.
• wiihdrawal from hypnotic drugs; this is usually short-lived.
• treatment with ¡-¡-adrenoceptor Wodtcrs may disrupt sleep, perhaps because of their serotonergic action; a [1-blocking drug which crosses blood-brain barrier less readily is preferred, e.g. atenolol.
Psychological: hyperarousal due to
• the need to be vigjlíiní at night e.g. because of sick relatives or young children
• pnrn. in which case adequate analgesia will improve sleep
• coughing or wheezing: adequate control of asthma with stimulating drugs as above, may paradoxically improve sleep by reducing waking duo to breathlessness
• respiratory and cardiovascular disorders
• need to urinate; this may be affected by timing of diuretic medication
• neurological disorders, e.g. stroke, movement disorders
• periodic leg movements of sleep (frequent jerks or twitches during the descent into deeper sleep}, rarely reduce subjective sloop quality but are more likely to causo them in the subject's sleeping partner.
• Pationts with depressive illnesses often have difficulty falling asleep at night and complain of restless, disturbed and unrefreshing sleep, and early morning waking.Wlien therr sleep is analysed by polysomnography, time to sleep onset is indeed prolonged, and there is a tendency for more REM sleep to occur in the first part o( the night, with reduced deep quiet sleep in the first hour or so after sleep onset and increased awakenings during the night.They may wake early in the morning and fail to get back to sleep again.
• Anxiety disorders may cause patients to complain about their sleep, cither because there is a reduction in sleep continuity or because normal periods of nocturnal waking are somehow less well tolerated. Nocturna panic attacks can make pationts fearful of going off to sleep
• Bipolar pationts in the hypomamc or manic phase will sleep loss than usual and sometimes changes in sleep pattern can bo an early warning that an episode is imminent.
Disruption of circadian rhythm
Shift work,jel lag and irregular routine can cause insomnia, in that patients cannot sleep when they wish to.
bedroom is associated with not sleeping and automatic negative thoughts about the sleeping process occur in the evening. Cognitive behavioural therapy is helpful in dealing with 'psychophysiological' insomnia and together with education and sleep hygiene measures as above is the treatment of choice for long-term primary insomnia. Cognitive behavioural therapists are specially trained in changing behaviour and thoughts about sleep, particularly concentrating on learned sleep-incompatible behaviours and automatic negative thoughts at bedtime. The availability of these therapies is often limited and some patients are unwilling or unable to engage with them. Drug therapy may:
• relieve short-term insomnia when precipitating causes cannot be improved
• prevent progression to a long-term problem by establishing a sleep habit
• interrupt the vicious cycle of anxiety about sleep itself.
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