A survey shows that 42, 5% of people worldwide have insomnia problems of varying degrees. The prevalence of insomnia in adults is 57%. 51% of people aged 30 – 50 have insomnia. The most predominant insomnia symptom is difficulty maintaining sleep (44%), followed by difficulty falling asleep (33%). Only 21% of insomnia patients seek medical attention, and only a minority of them seek help from specialists in psychiatry, psychology and neurology. 73% of patients have never taken medication or used other methods to improve their sleep. Insomnia is probably one of the most common complaints, both in clinical practice and in daily life.
So how do doctors make the correct diagnosis of insomnia?
1. Based on the medical criteria for insomnia
Physicians determine whether a patient has clinically significant insomnia by focusing on the following aspects.
(1) Insomnia symptoms exist in the form of unsatisfactory sleep quality and/or quantity, which can be manifested as difficulty in falling asleep, difficulty in maintaining sleep (easy to wake up, dreamy, early awakening, etc.), and inability to recover 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. Emphasis on this point is mainly to exclude sleep deprivation. In modern social life, it is quite common to have reduced sleep time for work, study and recreation, etc. The unsatisfactory quality and quantity of sleep that occurs in this case is not insomnia. It is not advisable to simply prescribe hypnotic drugs for treatment, but rather to guide the establishment of good sleep hygiene habits.
(3) The presence of daytime symptoms, i.e., the decline in sleep quality brings significant distress or affects normal social and occupational functions.
(4) The criteria for the duration of the disease should also be at least 3 times a week for more than 1 month. Occasionally, we can see patients with insomnia lasting less than one month and seek consultation. 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, and in many cases it may be difficult to clarify the cause of insomnia clinically. 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 common in 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 whistling disorder, periodic limb movement disorder, etc;
(3) Insomnia at the end of the night, i.e., early awakening, is most commonly associated with insomnia related to depressive disorders;
(4) In the case of unsatisfactory sleep quality such as non-relaxation and lack of mental clarity after waking up without a significant reduction in sleep time throughout the night, special sleep disorders such as sleep whistling disorder, restless legs syndrome and periodic limb movement disorder should be excluded.
Characteristic analysis.
Anxious, competitive, detail-oriented, and perfection-seeking personality characteristics are prone to psychophysiological insomnia when encountering stressful events, and after insomnia occurs, patients often quickly develop excessive concern about sleep and excessive worry about the consequences of insomnia, which increases the level of anxiety, aggravates insomnia and makes it easy to be chronic.
Polysomnography is a basic adjunct to sleep disorders and should be performed in patients who are still unsatisfied with sleep quality after systematic treatment, especially if sleep disorders such as sleep whistling disorder, restless legs syndrome, periodic limb movement disorder are suspected.
Problems to be noted in insomnia treatment
Psychotherapy and medication are important together
Since the causes of insomnia are complex and varied, the general principle of treatment is to give equal importance to non-pharmacological treatment such as psycho-behavioral treatment and pharmacological treatment. 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 the pharmacological treatment of insomnia symptoms, hypnotic drugs with a short half-life should be preferred. Our current clinical choices are midazolam and triazolam in benzodiazepines, and zolpidem, zopiclone and zaleplon in non-benzodiazepines. The principle of using these drugs is to use them intermittently and in sufficient quantity as needed, and they are generally not suitable for long-term continuous use, nor are they recommended to exceed the maximum recommended dose.
In general, these drugs have a good safety profile, and the risk of tolerance and dependence is small under the premise of reasonable use. However, in some special populations, such as the elderly or those with combined physical illnesses, the first dose may induce ambiguous arousal disorder, in which patients may sit up, wave their hands and feet, or get out of bed and move around such as pushing open windows, etc. 1 – 2 hours after taking the drug. The duration is a few minutes or ten minutes, and the patient usually has no memory afterwards. Once this happens, the family members around the patient are often very scared 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 such a situation occurs, the most important thing is to avoid accidents in patients, while there is no need to be overly nervous, the drug metabolism usually does not leave other more serious problems, but also should not use the drug again.
For patients with depression and anxiety, even if they do not meet the diagnostic criteria for depression and anxiety disorders, appropriate antidepressants and anxiolytics can be combined, 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 and anxiety are more serious or complicated, early referral to psychiatry for further treatment is recommended.
Some antipsychotic drugs with stronger sedative effects, such as olanzapine, quetiapine, clozapine and others, are sometimes used to treat insomnia. Treatment of insomnia with antipsychotic drugs should be strictly controlled with a cautious attitude to the indications, and it is recommended to use them only for insomnia patients with psychotic symptoms, bipolar disorder and depression that are not satisfactorily treated with antidepressants alone. This is because, for other types of insomnia, antipsychotic drugs also have the problem of tolerance, i.e., the hypnotic effect will decrease after several consecutive uses; 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 education on sleep hygiene, some specific psycho-behavioral treatment techniques have more definite efficacy.
(1) Stimulus control therapy restricts other activities in the bedroom and bed, i.e., does not do things other than sleep and sex in the bedroom and bed, with the aim of 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 rapid sleep.
(2) Progressive muscle relaxation training techniques commonly used in relaxation training reduce the patient’s high level of arousal state at night and during the day by practicing contraction tension and relaxation of different muscle groups throughout the body.
(3) Sleep restriction therapy is based on the patient’s subjective perceived sleep time, and gradually shortens 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.
13 principles for dealing with insomnia.
1, sleep time has a great deal of individual differences, as long as you do not feel sleepy during the day to prove 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, inhalation pause, leg muscle twitching or ants walking feeling and other phenomena 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 doctors.
13.Scientific exercise can reduce the occurrence of insomnia.