Overview.
Insomnia is a state of unsatisfactory quality and quantity of sleep that lasts for a considerable period of time and is the main form of sleep disorder. Nonorganic insomnia is the term used by the International Classification of Diseases, 10th edition (ICD-10), to refer to a group of sleep disorders in which emotional factors serve as the primary etiology or main trigger. Currently, there are several new classifications as research on insomnia progresses. Insomnia is a very common complaint in clinical practice and is also very common in the general population, with more than 1/3 of the population likely to experience different forms of insomnia in their lifetime; it can occur at any age and is more common in women, the elderly and in groups with psychosocial dysfunction and poor socioeconomic status.
Etiology
1. Physical factors, such as pain, itching, cough, wheezing, nocturia, vomiting and diarrhea.
2. Environmental factors, such as changes in living habits, changes in the living environment, sound and light stimulation, etc.
3. Biological factors, such as coffee, strong tea and withdrawal reactions to central stimulants and certain drugs.
4. Genetic factors.
5. Other neurological and psychiatric disorders, such as nervousness, anxiety and fear, worry and insomnia.
Symptoms
Difficulty in falling asleep, or waking up frequently at night, difficulty in maintaining sleep, or poor sleep treatment. In addition, when going to sleep, often feel nervous, anxious, worried or depressed, and thoughts can not fall asleep. Adverse emotions cause patients to have a biased perception of time, feeling that the time before falling asleep is so long and the time after falling asleep is so short. They often think too much about getting enough sleep, personal problems, health conditions, and even death. Upon waking, they often feel drained, and during the day they feel anxious, depressed, irritable, and overly preoccupied with themselves. Some patients may have a loss of sleepiness.
Examination
Sleep electroencephalography reveals prolonged latency to sleep, shortened sleep duration, increased physiologic awakenings during sleep, and a relative increase in REM sleep periods.
Diagnosis
1. Complaints of difficulty falling asleep, or difficulty maintaining sleep, or inability to regain energy or unsatisfactory quality of sleep after sleep, and occurs in the presence of adequate sleep opportunities and a favorable sleep environment.
2. preoccupation with sleep problems day and night and excessive worry about the consequences of insomnia.
3. There are some symptoms related to unsatisfactory sleep at night during the day, such as feeling obvious distress, easy fatigue, lack of motivation, unstable and irritable mood, etc., or some adverse effects on daily work, study and life.
4. Sleep disturbance occurs at least three times a week and lasts for one month or more.
Differential Diagnosis
1. Episodic sleep disorder
The sleep attacks of episodic narcolepsy are irresistible, and the duration of the attacks is short, not more than 15-20 minutes each time, and there can be a long period of mental stimulation after the attacks, which is often accompanied by one or more additional symptoms, such as sudden collapse, sleep paralysis, and hallucinations before going to sleep, and the duration of sleep is shortened at night. The sleep attacks of narcolepsy can often be prevented by the patient’s efforts, and the sleep lasts for a long time after the attack, without additional symptoms, and the night sleep is prolonged, and it can be in the state of Moet and Chandon when waking up.
2. Sleep apnea syndrome
In addition to the symptoms of excessive daytime sleepiness, narcolepsy caused by this syndrome also has a history of nocturnal apnea, typical intermittent snoring, obesity, hypertension, impotence, cognitive deficits, nocturnal hyperactivity and hyperhidrosis, morning headache and ataxia.
3. Organic narcolepsy
It is common in organic brain diseases, metabolic disorders, poisoning, endocrine abnormalities, post-radiation syndrome, etc. The causative factors can be found through the patient’s history, clinical manifestations, body and corresponding laboratory tests.
Treatment
Insomnia requires comprehensive treatment including psychotherapy and medication. The goal of treatment is not simply to prolong the sleep time, but to improve the subjective satisfaction with the quality and quantity of sleep and the quality of life.
1. Psychotherapy
Psychotherapy should be the basic program for the treatment of insomnia, and the goal is to correct the patient’s bad cognition about sleep and bad sleep hygiene habits.
(1) General psychological support therapy and health education on sleep knowledge, the main points are to help patients recognize the individual differences in the need for sleep time, establish and adhere to a routine that conforms to the law of “waking up during the day and going to sleep at night”, and to avoid bad sleep habits.
(2) Cognitive behavioral therapy is an effective treatment for insomnia with sufficient evidence-based medical evidence. According to the specific conditions of the patients, cognitive remediation training with stimulus control, relaxation therapy, anti-intention control, sleep restriction and other behavioral therapies are used to carry out systematic psychotherapy.
2.Drug therapy
Drug therapy plays an important role in reducing the pain of patients in the acute stage and improving the compliance of psychotherapy. However, long-term medication should be avoided, especially for chronic insomnia patients, long-term medication is often ineffective and can lead to drug dependence. Some long-term drug users will also appear hypnotic drug insomnia.
Commonly used drugs are: short, medium-acting benzodiazepines, melatonin and antidepressants with sedative effects. For patients with predominantly difficulty falling asleep, zolpidem, dexzopiclone (or zopiclone), zaleplon and other short-acting drugs are preferred. For patients with light sleep and easy awakening, eszopiclone may be used. For those judged to be accompanied by anxiety and depression after careful clinical evaluation, antidepressants such as trazodone, mirtazapine, doxepin, etc., which have some sedative effect, may be used, and the dosage is generally lower than that used in the treatment of anxiety and depressive disorders.