According to a survey, 42.5% of the world’s population suffers from insomnia to varying degrees. The prevalence of insomnia among adults is 57%, and 51% of people aged 30 to 50 have insomnia. The most predominant insomnia symptom is difficulty maintaining sleep (44%), followed by difficulty falling asleep (33%). Only 21% of insomnia patients sought medical care, and only a minority of them sought help from specialists in psychiatry, psychology and neurology. Seventy-three percent of patients had never taken medication or used other methods to improve their sleep.
Insomnia is probably one of the most common complaints in both clinical practice and daily life.
So how do doctors make the correct diagnosis of insomnia?
1. Based on the medical criteria for insomnia.
Doctors determine whether a patient has clinically significant insomnia by focusing on the following aspects:
(1) Insomnia symptoms The presence of unsatisfactory quality and/or quantity of sleep, which can be manifested as difficulty in falling asleep, difficulty in maintaining sleep (easy to wake up, dreamy, early awakening, etc.), and inability to regain energy from sleep.
(2) Exclusion of sleep deprivation The above sleep symptoms occur in the presence of adequate sleep opportunities and a good sleep environment. The main reason for emphasizing this point is to exclude sleep deprivation. In modern social life, it is quite common to reduce sleep time for work, study and recreation, etc. The unsatisfactory quality and quantity of sleep in this case is not insomnia. It is not advisable to prescribe hypnotic drugs for the treatment of insomnia, but rather to guide the establishment of good sleep hygiene habits.
(3) The presence of daytime symptoms, i.e., a decrease in sleep quality that causes significant distress or affects normal social or occupational functioning.
(4) The duration of the disease should be at least 3 times a week for more than 1 month. Patients who present to the clinic with insomnia as the main complaint can generally meet this criterion. The diagnosis of “transient” or “acute” insomnia should be made carefully on the basis of a comprehensive assessment to exclude relevant physical and mental diseases.
2. Make a diagnosis of “etiology” of insomnia as far as possible.
Sleep is a high-level function of the brain, and in a certain sense, the occurrence of insomnia can be regarded as a manifestation of brain dysfunction, the causes of which can be complex and varied. This is a prerequisite for the physician to develop a targeted treatment plan.
The clinical assessment should be comprehensive and detailed, including the process of insomnia onset and evolution, the patient’s sleep hygiene habits, the patient’s personality and cognitive characteristics, physical health status, and emotional reactions are the basic information to be collected.
Analysis of insomnia characteristics:
(1) Early stage insomnia, i.e., difficulty in falling asleep as the first symptom, is commonly associated with psychophysiological insomnia, insomnia associated with anxiety disorders and insomnia induced by some somatic diseases or drug treatment;
(2) Middle insomnia, i.e., easy to wake up after sleep and dreamy, is common in insomnia related to anxiety disorders, sleep disordered breathing, periodic limb movement disorder, etc;
(3) Insomnia at the end of the night, i.e. early awakening, is most common in insomnia related to depressive disorders;
(4) In case of unsatisfactory sleep quality, such as sleep disorder, restless legs syndrome, periodic limb movement disorder, etc., when there is no significant decrease in sleep time throughout the night, the sleep quality is unsatisfactory when there is no relief after waking up.
Characteristic analysis:
Anxious, competitive, detail-oriented, the pursuit of perfection personality characteristics, in the event of stressful events prone to psychophysiological insomnia, and in the insomnia occurred, the patient often quickly formed excessive concern about sleep and excessive worry about the consequences of insomnia, which increases the level of anxiety, aggravating insomnia and prone to chronicity.
Polysomnography is a basic auxiliary examination for sleep disorders. For patients who are still not satisfied with the quality of sleep after systematic treatment, especially if sleep disorders such as sleep disordered breathing, restless legs syndrome and periodic limb movement disorder are suspected, polysomnography should be performed.
Problems to be noted in the treatment of insomnia
Psychotherapy and medication are both important
Since the causes of insomnia are complex and varied, the general principle of treatment is to give equal importance to psycho-behavioral and other non-pharmacological treatments as well as pharmacological treatments. There is no one “cure-all” for insomnia, nor is there a “cure-all” for all insomnia patients, so doctors should try to avoid the idea of relying solely on medication to treat insomnia.
In addition, doctors should be careful to avoid simply emphasizing the health hazards or serious consequences of insomnia, especially in patients with a relatively short course of the disease, so as not to unnecessarily increase the patient’s anxiety and excessive concern about insomnia. It must be understood that long-term insomnia can affect the health of the body, but it may also be the result of health damage.
1.The right medication
In order to improve insomnia symptoms of drug therapy, should be preferred to hypnotic drugs with a short half-life. Our current clinical choices are benzodiazepines midazolam and triazolam, as well as non-benzodiazepines zolpidem, zopiclone, zaleplon and so on. The principle of using these drugs is to use them intermittently and in sufficient quantity as needed, and they should not be used continuously for a long time, nor is it recommended to exceed the maximum recommended dose.
In general, the safety of these drugs is good, and the risk of tolerance and dependence is low under reasonable use. However, in some special groups of people, such as the elderly or people with combined physical diseases, the first dose may induce blurred consciousness arousal disorder, in which the patient may sit up, wave his hands and feet, get out of bed and move around, such as pushing open the window, etc. 1~2 hours after taking the drug. The patient usually has no memory afterwards. Once this happens, family members around the patient are often very frightened and do not know how to respond.
Therefore, for elderly, weak patients, when the condition requires the administration of hypnotic drugs, the first dose should be given the minimum recommended dose, and explain to the patient and family members that if this happens, the most important thing is to avoid the patient’s accident, while not overly nervous, the drug metabolism usually does not leave other more serious problems, but also should not be used again the drug.
For patients with depression and anxiety, even if they do not meet the diagnostic criteria for depression and anxiety disorders, they can combine appropriate antidepressants and anxiolytics, and after achieving better results, they can be used for a longer period of time, such as more than 3 months, according to the needs of the condition. If the depression or anxiety is serious or complicated, it is recommended to refer to psychiatry for further treatment as soon as possible.
Some antipsychotic drugs with strong sedative effects, such as olanzapine, quetiapine, clozapine, etc., are sometimes used to treat insomnia. The indications for the use of antipsychotics for insomnia should be strictly controlled with caution, and it is recommended to use them only for insomnia patients with psychotic symptoms, bipolar disorder, and depression that is not satisfactorily treated with antidepressants alone. This is because, for other types of insomnia, antipsychotic drugs also have the problem of tolerance, that is, the hypnotic effect will decrease after repeated use; secondly, the pharmacological mechanism of these drugs is relatively complex, and the risk of adverse reactions is also high, and the long-term effects on patients after use are difficult to predict.
2. Psycho-behavioral treatment
The role of psycho-behavioral therapy is very important in insomnia, especially in chronic insomnia with a duration of more than 6 months, because medication alone cannot change the negative perceptions and attitudes of patients who are overly worried about the consequences of insomnia and overly concerned about sleep problems.
In addition to general sleep hygiene education, some specific psycho-behavioral treatment techniques are more effective.
(1) Stimulus control therapy Limiting other activities in the bedroom and bed, i.e., not doing things other than sleeping and sex in the bedroom and bed, is aimed at correcting the negative conditioned reflexes formed by the patient regarding sleep time and environmental factors, and re-establishing the conditioned reflexes between the bed and bedroom and fast sleep.
(2) Relaxation training Commonly used progressive muscle relaxation training techniques are used to reduce the patient’s high level of arousal at night and during the day by practicing contraction tension and relaxation of different muscle groups throughout the body.
(3) Sleep restriction treatment The patient’s subjective perceived sleep time is used as the basis for gradually reducing the time spent in bed in order to improve sleep efficiency and thus prolong sleep time.
In conclusion, we should not treat patients with insomnia as the main complaint, but should give them a more comprehensive assessment and formulate a “holistic” treatment plan based on a reasonable diagnosis, in order to improve the quality of sleep and the quality of life of patients.
Attachment: 13 principles of dealing with insomnia.
1, sleep time has a great deal of individual differences, as long as you do not feel sleepy during the day, it proves that the sleep time has been sufficient.
2, doze off before going to bed, do not care too much about the time to go to bed.
3, reasonable use of light to obtain a good sleep.
4.Avoid taking stimulating food and control the intake of liquid drinks before going to bed.
5.Fix the daily waking time.
6.Regular three meals.
7.If you want to take a lunch break, sleep for 20-30 minutes before 3pm.
8, sleep with severe snoring, apnea, leg muscle twitching or ants walking feeling is to pay attention to prompt medical attention.
9, rely on alcohol instead of hypnotic drugs often aggravate insomnia.
10, insomnia, to try to relax themselves. Sometimes some methods such as active imagination, brain ineffective work, etc. may help sleep.
11, in the night under the condition of sufficient sleep, but still appear in the daytime irresistible sleepiness should promptly seek medical advice.
12.It is safe to take hypnotic drugs under the guidance of a doctor.
13.Scientific exercise can reduce the occurrence of insomnia.