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Sleep Hygiene 101 Table 1 Sleep Hygiene Guidelines Used at Washington University Sleep Medicine Center 1. Go to bed only when sleepy. 2. Use the bed only for sleeping. Do not read, watch television, or eat in bed. 3. If unable to sleep, get up and move to another room. Stay up until you are definitely sleepy and then return to bed. 4. Set the alarm and get up at the same time every morning, regardless of how much you have slept through the night. 5. Do not nap. 6. Do not exercise just before going to bed. 7. Do not engage in stimulating activity just before bed. 8. Avoid caffeine in the afternoon. 9. Do not drink alcohol close to bedtime. 10. Eliminate clocks in the bedroom. 11. Before bedtime, schedule a period to review stressful events of the day. 12. Promote relaxation and sleep by focusing on quiescent tasks that occupy the mind such as reading, watching television, or listening to music. Table 2 Amount of Caffeine in Common Beverages Beverage Amount of caffeine 1 cup of brewed coffee 100–150 mg 1 cup of instant coffee 85–100 mg 1 cup of tea 65–75 mg 12 ounces of cola 40–75 mg 1 cup of cocoa 50 mg sensitivity to changes in their sleep schedules and minute amounts of external stimuli. They have exaggerated physiological responses to even small amounts of stimulants (caffeine, nicotine), alcohol, exercise, excitement, or strong environmental disruptions, such as noise, shift work, and ambient light. It is thought that these persons’ circadian control centers (suprachiasmatic nucleus) (10) also seem to be sensitive to even minimal variations in their sleep schedules or to daytime napping (1). Others who suffer from inadequate sleep hygiene insomnia because of psychological or physical illness or because of an innate predisposition, may have a particularly low tolerance to the effects of even infrequent sleep deprivation and, in good faith, in an attempt to remedy the situation may resort to such poor sleep hygiene behaviors as extra naps or bedtime alcohol. A combination of behaviors that are nonconducive sleep and an innate physiological hyperarousal leads to the development of poor sleep hygiene insomnia (11,12).
102 Attarian CLINICAL MANIFESTATIONS The main clinical symptom of inadequate sleep hygiene is insomnia. Other symptoms may include dysphoric mood, fatigue, irritability, occasional hypersomnia, and poor concentration. The time course of poor sleep hygieneinduced sleep problems may vary from self-limiting and transient, to occasional or even frequent but intermittent, or persistent. It may be the cause of insomnia or may exacerbate an already existing one or itself may be the result of a pre-existing primary or secondary insomnia. The insomnia may be sleeponset, sleep maintenance, or terminal resulting in early morning awakenings. In some cases, it may present as irregular sleep patterns. The activities that constitute poor sleep hygiene and lead to poor sleep hygiene insomnia usually are common activities of daily life, which produce sleep disturbances in people with an innate susceptibility. Behaviors that are considered nonconducive to sleep include caffeine intake late in the afternoon or evening, alcohol intake at night (often in an attempt to self-medicate), psychological stress or excitement in the evening, obsessive clock watching while awake at night, exercise or smoking late at night or close to bedtime, use of the bed for activities unrelated to sleep (other than sex), variable bedtime and rise time, going to bed when not sleepy, poorly regulated comfort measures in the bedroom such as temperature, light, noise, uncomfortable bed, pets, and family members or housemates who may engage in behaviors that are disruptive to one’s sleep (13). Usually, in addition to an innate susceptibility, a combination of these behaviors and extrinsic factors is needed, any one of which might be considered acceptable behavior in most people. Case 1 A 46-year-old engineer presented with the complaint of sleep maintenance insomnia. The patient had a bedtime between 10 and 11 PM, and had no difficulty initiating sleep. He reporting awakening everyday at around 3 AM. He subsequently was unable to return to sleep for the rest of the morning. This problem was of about 2–3 years in duration. Over-the-counter hypnotics did not help. The patient denied pain, worry, or anxiety at night. He had no history of snoring or witnessed apneas, falling asleep unintentionally during the day, or any caffeine intake after an early morning cup of coffee. He denied any neurovegetative symptoms of anxiety and depression. He was taking Zestril and Lipitor. The patient’s exam was normal and his Beck’s Depression Inventory score was 4 (not depressed). When further questioned, he revealed that he drinks on a nightly basis and over the past several years has three glasses of wine or some other type of liquor just before going to bed. He does this out of habit and denied having had problems falling asleep prior to engaging in this nightly alcohol consumption. He was asked to reduce his alcohol intake and to drink lesser amounts earlier in the evening. At the next visit, 6 weeks later, his insomnia was resolved.
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Clinical Handbook of Insomnia Edite
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C URRENT CLINICAL NEUROLOGY Daniel
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© 2004 Humana Press Inc. 999 River
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Series Editor’s Introduction The
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x Foreword nervous system hypersomn
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Contents Series Editor’s Introduc
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Contributors HRAYR P. ATTARIAN, MD
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2 Attarian et al.
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4 Attarian et al. until the 1970s t
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6 Attarian et al. Table 2 Diagnosti
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8 Attarian et al. Duration of Illne
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10 Attarian et al. REFERENCES 1. Ma
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12 Attarian Another study in Austri
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14 Attarian even less well studied.
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16 Attarian communities. A structur
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18 Attarian 5. Sutton, D. A., Moldo
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20 Attarian 53. Kageyama, T., Kabut
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22 Attarian
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24 Bonnet and Arand Table 1 Reporte
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26 Bonnet and Arand On the day spen
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28 Bonnet and Arand SUMMARY These m
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30 Bonnet and Arand chronic caffein
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32 Bonnet and Arand response that a
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34 Bonnet and Arand The Development
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36 Bonnet and Arand ACKNOWLEDGMENT
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38 Bonnet and Arand 45. Bonnet, M.
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40 Attarian Table 1 Types of Insomn
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42 Attarian 15 to 40 seconds. PLMs
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44 Fig. 1. Example of a 1-week slee
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46 Fig. 3. One-week printout of an
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48 Attarian Fig. 4. Algorithm. (Use
Page 67 and 68: 50 Attarian 27. Polo-Kantola, P., E
Page 69 and 70: 52 Garcia
Page 71 and 72: 54 Garcia association is known as s
Page 73 and 74: 56 Fig. 1. A sleep log used in chil
Page 75 and 76: 58 Garcia the reality that the tend
Page 77 and 78: 60 Fig. 2. Actigraph recording in a
Page 79 and 80: 62 Garcia neurodevelopmental disabi
Page 81 and 82: 64 Garcia 35. Czeisler, C., kronaue
Page 83 and 84: 66 Garcia
Page 85 and 86: 68 Attarian showed similar degrees
Page 87 and 88: 70 Attarian agitation and hence the
Page 89 and 90: 72 Attarian Affective disorder is s
Page 91 and 92: 74 Attarian and Drug Administration
Page 93 and 94: 76 Fig. 2. Sleep log after treatmen
Page 95 and 96: 78 Attarian 18. Bonnet, M. H. and A
Page 97 and 98: 80 Attarian 65. Perlis, M., Aloia,
Page 99 and 100: 82 Attarian was confirmed by resear
Page 101 and 102: 84 Attarian times worrying about th
Page 103 and 104: 86 Attarian insomnia or for other s
Page 105 and 106: 88 Attarian
Page 107 and 108: 90 Duntley tion systems found that
Page 109 and 110: 92 Duntley Case 1 A 36-year-old fem
Page 111 and 112: 94 Fig. 2. The objective amount of
Page 113 and 114: 96 Duntley PROGNOSIS AND COMPLICATI
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Page 117: 100 Attarian EPIDEMIOLOGY There are
Page 121 and 122: 104 Attarian DIAGNOSTIC WORKUP The
Page 123 and 124: 106 Attarian 13. Hauri, P. J. (1998
Page 125 and 126: 108 Plotkin
Page 127 and 128: 110 Plotkin quality of sleep. Ultim
Page 129 and 130: 112 Plotkin of the therapeutic effi
Page 131 and 132: 114 Plotkin months or years. The ef
Page 133 and 134: 116 Plotkin associated somatic disc
Page 135 and 136: 118 Plotkin Table 1 Causes of Secon
Page 137 and 138: 120 Plotkin Table 1 (continued) Lew
Page 139 and 140: 122 Plotkin REFERENCES 1. Foley, D.
Page 141 and 142: 124 Plotkin 48. Marchetti, F., Rome
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Page 145 and 146: 128 Karaz Table 1 DSM-IV Diagnoses
Page 147 and 148: 130 Karaz poor. Focusing only on th
Page 149 and 150: 132 Karaz He felt hopeless that his
Page 151 and 152: 134 Karaz Table 4 Diagnostic Criter
Page 153 and 154: 136 Karaz complained of feeling anx
Page 155 and 156: 138 Karaz other physicians avoided
Page 157 and 158: 140 Karaz 17. Attarian, H. P. (2000
Page 159 and 160: 142 Duntley disorders has been conf
Page 161 and 162: 144 Duntley itance. A recent study
Page 163 and 164: 146 Duntley The patient’s primary
Page 165 and 166: 148 Duntley return to sleep. He tos
Page 167 and 168: 150 Duntley Treatment of RLS should
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152 Duntley 34. Cartwright, R. (197
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154 Perlis et al.
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156 Perlis et al. Fig. 1. A schemat
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158 Perlis et al. ditioned arousal
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160 Perlis et al. subjected to empi
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162 Perlis et al. effect), (3) may
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164 Perlis et al. Cognitive Therapy
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166 Perlis et al. Table 2 Cognitive
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168 Perlis et al. Perhaps more impo
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170 Perlis et al. 28. Carskadon, M.
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172 Perlis et al.
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174 Attarian Secondary Insomnias Re
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176 Attarian 50 years of age who sl
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178 Attarian Antidepressants Becaus
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180 Attarian The use of benzodiazep
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182 Attarian to placebo. Zaleplon a
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184 Attarian 3. Wyatt, R. J., Engel
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186 Attarian residual sedation foll
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188 Index Clonidine, 183 CNS arousa
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190 Index Proton pump inhibitors, 1
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Current Clinical Neurology CLINICAL
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