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INSOMNIA

classified according to the nature of sleep disruption and the duration of the complaint

difficulty falling asleep (sleep onset insomnia), frequent or sustained awakenings (sleep maintenance

insomnia), or early morning awakenings (sleep offset insomnia).*though most insomnia patients present

with two or more of these symptoms*

present with persistent sleepiness/fatigue despite sleep of adequate duration (nonrestorative sleep)

the duration of the symptom influences diagnostic and therapeutic considerations.

lasting one to several nights (within a single episode) is termed transient insomnia and is typically the

result of situational stress or a change in sleep schedule or environment (e.g., jet lag disorder).

Short-term insomnia lasts from a few days to 3 weeks.

Long-term insomnia, or chronic insomnia, lasts for months or years and, in contrast with short-terminsomnia, requires a thorough evaluation of underlying causes

Chronic insomnia is often a waxing and waning disorder, with spontaneous or stressor-induced

exacerbations.

All insomnias can be exacerbated and perpetuated by behaviors that are not conducive to initiating or

maintaining sleep. (Inadequate sleep hygiene)

Many patients with chronic insomnia have no clear, single identifiable underlying cause for their

difficulties with sleep.

Rather, such patients often have multiple etiologies for their insomnia, which may evolve over the years.

In addition, the chief sleep complaint may change over time, with initial insomnia predominating at one

point, and multiple awakenings or nonrestorative sleep occurring at other times.

Subsyndromal psychiatric disorders (e.g., anxiety and mood complaints) negative conditioning to the sleep environment (psychophysiologic insomnia) amplification of the time spent awake (paradoxical insomnia) physiologic hyperarousal poor sleep hygiene (see above) may all be present

Alcohol and antihistamines are the most commonly used nonprescription sleep aids

Alcohol - help with sleep onset but is associated with sleep disruption during the night and can escalate

into abuse, dependence, and withdrawal in the predisposed individual.

Antihistamine - the primary active ingredient in most over-the-counter sleep aids, may be of benefit

when used intermittently but often produce rapid tolerance and may have multiple side effects

(especially anticholinergic), which limit their use, particularly in the elderly.

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Benzodiazepine-receptor agonists are the most effective and well-tolerated class of medications for

insomnia.