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<strong>Insomnia</strong> in Psychiatric Disorders 133 Table 3 Diagnostic Criteria for Generalized Anxiety Disorder Worries and anxieties over several events and activities for 50% of the time or more for at least 6 months. The person experiences difficulty or trouble trying to control these feelings. In addition to the above there are at least three of the symptoms listed below for 50% of the time or more for at least 6 months. • Feels restless, edgy, keyed up • Tires easily • Trouble concentrating • Irritability • Increased muscle tension • Trouble sleeping (initial insomnia or restless, unrefreshing sleep) The cause of the anxiety and the worry is not an aspect of another psychiatric illness. The anxiety is not the symptom of another medical condition. The anxiety is not the symptom of another psychiatric condition. The symptoms cause clinically important distress or impair work, social, or personal functioning. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision. Copyright © 2000 American Psychiatric Association Test of patients with GAD (4). There are similarities between psychophysiologic insomnia and GAD in both their clinical presentation and the polysomnographic changes. If anxiety permeates most aspects of functioning, a GAD is the usual diagnosis. In contrast, if anxiety is focused almost exclusively on poor sleep and its consequences on daytime functioning, psychophysiologic insomnia is the typical diagnosis (17). On the other hand, patients with GAD experience pervasive anxiety during the day, which interferes with their level of functioning well beyond the consequences of poor sleep (10). In contrast with GAD, sleep efficiency improves on the second night in patients with psychophysiologic insomnia when their nighttime sleep polysomnogram (PSG) is recorded in the sleep lab 2 nights in a row (4). Treatment Benzodiazepines like Alprazolam and Clonazepam continue to play a major role in the management of GAD. SSRI antidepressant medications like fluoxetine, paroxetine, sertraline, and a tricyclic antidepressant like Imipramine are found to be valuable options in the treatment of GAD. Cognitive-behavioral therapy should be strongly considered as an important tool in the treatment of GAD and the related insomnia.
134 Karaz Table 4 Diagnostic Criteria for Panic Disorder The patient suddenly develops a severe fear or discomfort that peaks within 10 minutes. During this discrete episode, four or more of the following symptoms occur: • Choking sensation • Chills or hot flashes • Chest pain or other chest discomfort • Fear of dying • Dizzy, lightheaded, faint, or unsteady • Derealization (feeling unreal) or depersonalization (feeling detached from self) • Fears of loss of control or becoming insane • Heart pounds, races, or skips beats • Nausea or other abdominal discomfort • Numbness or tingling • Sweating • Shortness of breath or smothering sensation • Trembling Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Text Revision. Copyright © 2000 American Psychiatric Association Panic Disorder Sleep disturbances have been reported in 70% of patient’s with panic disorder (18). The panic attack is characterized by a sudden, intense fear or terror of dying. Symptoms include dizziness, choking, palpitation, trembling, chest pain, or discomfort, and sweating (4). Symptoms of panic attack as listed in the DSM-IV is shown in Table 4. Panic disorder can be associated with sudden awakening from sleep. Nocturnal panic attacks present with similar symptoms to daytime panic. Palpitation, dyspnea, and flushing are the most frequent symptoms of nocturnal panic attacks (18). Polysomnographic monitoring of nocturnal panic demonstrates an abrupt awakening with a sensation of panic out of stage 2 or 3 sleep. It also presents with marginally increased SL and decreased sleep efficiency. Obstructive sleep apnea (OSA) may lead to awakening with panic-like symptoms. OSA usually presents with symptoms of snoring, sleepiness, and the absence of daytime anxiety, which distinguishes OSA from panic disorder (4). Night terrors, which also emerge from non-rapid eye movement (NREM) sleep are usually followed by no recollection of the events and there is no daytime panic symptoms. Nightmares differ from panic attacks as they usually cluster around the early morning and contain much more mental content (4). It is important to note that panic disorder is associated with major depression in 50 to 94% of patients (18). This comorbidity could result in alteration of the presentation of insomnia symptoms.
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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
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50 Attarian 27. Polo-Kantola, P., E
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52 Garcia
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54 Garcia association is known as s
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56 Fig. 1. A sleep log used in chil
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58 Garcia the reality that the tend
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60 Fig. 2. Actigraph recording in a
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62 Garcia neurodevelopmental disabi
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64 Garcia 35. Czeisler, C., kronaue
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66 Garcia
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68 Attarian showed similar degrees
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70 Attarian agitation and hence the
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72 Attarian Affective disorder is s
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74 Attarian and Drug Administration
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76 Fig. 2. Sleep log after treatmen
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78 Attarian 18. Bonnet, M. H. and A
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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 and 118: 100 Attarian EPIDEMIOLOGY There are
Page 119 and 120: 102 Attarian CLINICAL MANIFESTATION
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: 132 Karaz He felt hopeless that his
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
Page 169 and 170: 152 Duntley 34. Cartwright, R. (197
Page 171 and 172: 154 Perlis et al.
Page 173 and 174: 156 Perlis et al. Fig. 1. A schemat
Page 175 and 176: 158 Perlis et al. ditioned arousal
Page 177 and 178: 160 Perlis et al. subjected to empi
Page 179 and 180: 162 Perlis et al. effect), (3) may
Page 181 and 182: 164 Perlis et al. Cognitive Therapy
Page 183 and 184: 166 Perlis et al. Table 2 Cognitive
Page 185 and 186: 168 Perlis et al. Perhaps more impo
Page 187 and 188: 170 Perlis et al. 28. Carskadon, M.
Page 189 and 190: 172 Perlis et al.
Page 191 and 192: 174 Attarian Secondary Insomnias Re
Page 193 and 194: 176 Attarian 50 years of age who sl
Page 195 and 196: 178 Attarian Antidepressants Becaus
Page 197 and 198: 180 Attarian The use of benzodiazep
Page 199 and 200: 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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