Insomnia Insomnia

Insomnia in Psychiatric Disorders 139
The older sedative hypnotics like barbiturates are less frequently used due to the
higher risk of dependence and the more severe withdrawal symptoms like withdrawal
seizures.
The benzodiazepines polysomnographic changes include increased TST,
decreased WASO, decreased REM sleep, and increased sleep spindles in stage 2.
Most benzodiazepines decrease the SL and decrease delta sleep (22).
The sedative hypnotics abuse occurs predominantly in the context of
polysubstance abuse (16). Benzodiazepines with rapid onset of action (e.g.,
Alprazolam and Diazepam) are more likely to be abused than the longer onset of
action type of benzodiazepine (Oxazepam or Chlordiazepoxide). Withdrawal from
sedative hypnotics can result in a rebound insomnia or emergence of insomnia as a
new symptom (in prolonged high-dose use). Anxiety is a common withdrawal
symptom, which independently can initiate or worsen insomnia. In evaluating the
risks vs benefits of the sedative hypnotic therapy in patients including those who
have insomnia, it is helpful to distinguish between “drug-seeking behavior” from
“therapy-seeking behavior” (16).
REFERENCES
1. Harvey, A. G. (2001) Insomnia: symptom or diagnosis? Clin. Psychol. Rev. 21(7), 1037–1059.
2. Ohayon, M. M., Caulet, M., and Lemoine, P. (1998) Comorbidity of mental and insomnia disorders
in the general population. Compr. Psychiatry 39 (4), 185–197.
3. Bonnet, M. H. and Arand, D. L. (1999) Diagnosis and treatment of insomnia. Respir. Care Clin.
North Am. 5(3), 333–348.
4. American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders
(4th ed.). American Psychiatric Association, Washington, DC.
5. American Sleep Disorders Association, Diagnostic Classification Steering Committee. (1997)
The international classification of sleep disorders, revised: diagnostic and coding manual. American
Sleep Disorders Association, Rochester, MN.
6. Benca, R. M. (2001) Consequences of insomnia and its therapies. J. Clin. Psychiatry 62(10), 33–38.
7. Hales, S. C., Yudofsky, R. E., and Talbott, J. A., eds (1999) The American Psychiatric Press
Textbook of Psychiatry (3rd ed.). American Psychiatric Press, Inc., Washington, DC.
8. McCall, W.V. (2001) A psychiatric perspective on insomnia. J. Clin. Psychiatry 62(10), 27–32.
9. Naylan, T. C., Metzler, T. J., Schoenfeld, F. B., et al. (2001) Fluvoxamine and sleep disturbances
in posttraumatic stress disorders. J. Traum. Stress 14(3), 461–467.
10. Sadock, B. J. and Sadock V. A. eds. (1999) Kaplan and Sadock’s comprehensive textbook of psychiatry
(7th ed.). Lippincott Williams & Wilkins, Philadelphia, PA, pp. 1380–1384, pp. 1490–1503.
11. Simon, G. E., Heiligenstein, J. H., Grothaus, L., Katon, W., and Revicki, D. (1998) Should anxiety
and insomnia influence antidepressant selection: a randomized comparison of fluoxetine and
imipramine. J. Clin. Psychiatry 59(2), 49–55.
12. Kupfer, D. G. (1999) Pathophysiology and management of insomnia during depression. Ann.
Clin. Psychiatry 11(4), 267–276.
13. Bourdet, C. and Goldenberg, F. (1994) Insomnia and anxiety: Sleep EEG changes. J. Psychosom.
Res. 38(Suppl 1), 93–104.
14. Soldatos, C. R. (1994) Insomnia in relation to depression and anxiety: epidemiologic considerations.
J. Psychosom. Res. 38(Suppl 1) 3–8.
15. Martinez-Gonzalez, D., Obermeyer, W. H., and Benca, R. M. (2002) Comorbidity of insomnia
with medical and psychiatric disorders. Prim. Psychiatry 9(8), 37–49.
16. Kryger, M. H., Roth, T., and Dement, W. C., eds. (2000) Principles and practice of sleep medicine
(3rd ed.), WB Saunders, Philadelphia, PA, pp. 642, 1128, 1134–1135.