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Defining Insomnia 5 Table 1 Diagnostic Criteria for Primary Insomnia A. Difficulty initiating or maintaining sleep for at least 1 month. B. The disrupted sleep and the associated daytime fatigue causes clinically significant distress and impaired functioning. C. The sleep disturbance cannot be attributed to any other sleep disorder. D. The sleep disturbance cannot be attributed to any other psychiatric disorder. E. The sleep disturbance cannot be attributed to any other medical disorder or substance abuse. Adapted from ref. 8. tinct diagnostic entity from insomnia that is a secondary symptom of an underlying medical and/or psychiatric condition. The APA specifies a duration criteria of 1 month and stipulates that the diagnosis be made when the predominant complaint is difficulty initiating or maintaining sleep or nonrestorative sleep. In either case, the complaint must be associated with significant distress and daytime impairment, and not due to other medical, psychiatric, or sleep disorders. Table 1 lists the diagnostic criteria for primary insomnia. AASM: ICSD-R AASM’s nosology, the ICSD-R, does not have a distinct category of primary insomnia but instead discusses three free-standing insomnia disorders: psychophysiological insomnia, idiopathic insomnia, and sleep state misperception (9). PSYCHOPHYSIOLOGICAL INSOMNIA The ICSD-R definition of psychophysiological insomnia is directly tied to the etiologic underpinnings of the disorder. Psychophysiological insomnia is described as “a disorder of somatized tension and learned sleep-preventing associations that results in a complaint of insomnia and associated decreased functioning during wakefulness” (9). “Somatized tension” refers to either the patient’s subjective sense of, or objective measures of, somatic hyperarousal while attempting to sleep. Somatic arousal is characterized by peripheral nervous system activity that is commonly marked by increased muscle tension, rapid heart rate, sweating, and so on. “Learned sleep-preventing associations” refers to the pattern of pre-sleep arousal that appears to be classically conditioned to the bedroom environment, where intrusive pre-sleep cognitions, racing thoughts, and rumination are often taken as indicators of pre-sleep arousal. Table 2 presents the diagnostic criteria for psychophysiological insomnia. IDIOPATHIC, OR CHILDHOOD-ONSET, INSOMNIA This condition presents as a chronic, serious inability to initiate and maintain sleep, which can often be traced back to the first few weeks of life (10). Sleep latency (i.e., the time it takes to fall asleep after going to bed) may be very long, and sleep is riddled with awakenings. Daytime features typically include decreased
6 Attarian et al. Table 2 Diagnostic Criteria for Psychophysiological Insomnia A. Complaint of insomnia together with a complaint of decreased functioning during wakefulness. B. Learned sleep-preventing associations that include the following: 1. Trying too hard to sleep 2. Conditioned arousal to bedroom or sleep-related activities C. Evidence for somatized tension. D. On polysomnography there is 1. Increased sleep latency 2. Reduced sleep efficiency 3. An increased number and duration of awakenings, E. The sleep disturbance cannot be attributed to any other medical disorder. F. Other sleep disorders can co-exist. Minimal Criteria: A plus B. Adapted from ref. 9. Table 3 Diagnostic Criteria for Idiopathic Insomnia A. Complaint of insomnia together with a complaint of decreased functioning during wakefulness. B. The insomnia is long standing with onset in childhood and sometimes even at birth. C. Relentless insomnia invariant through periods of both good and bad emotional adaptation. D. On polysomnography there is 1. Increased sleep latency 2. Reduced sleep efficiency 3. An increased number and duration of awakenings E. The sleep disturbance cannot be attributed to any other medical disorder. F. Other sleep disorders can co-exist. Minimal Criteria: A plus B plus E. Adapted from ref. 9. attention and vigilance, low levels of energy and concentration, and deterioration of mood that is usually described as grim and subdued rather than obviously depressed or anxious. The presumed underlying neurological abnormality may vary from mild to severe, so the range of insomnia encountered also may vary from mild (essentially, the patient is a light sleeper) to severe and incapacitating. In mild or moderate idiopathic insomnia, psychological functioning is remarkably intact. In severe cases, daytime functioning may be severely disrupted, and the affected patient may be unable to hold a job. During childhood and adolescence, idiopathic insomnia is often associated with such neurological signs as dyslexia and hyperactivity. In many cases, diffuse, nonspecific abnormalities are seen on an electroencephalogram (EEG) (9). Table 3 lists the diagnostic criteria for idiopathic insomnia.
Page 1 and 2: Clinical Handbook of Insomnia Edite
Page 3 and 4: C URRENT CLINICAL NEUROLOGY Daniel
Page 5 and 6: © 2004 Humana Press Inc. 999 River
Page 8: Series Editor’s Introduction The
Page 11 and 12: x Foreword nervous system hypersomn
Page 14 and 15: Contents Series Editor’s Introduc
Page 16: Contributors HRAYR P. ATTARIAN, MD
Page 19 and 20: 2 Attarian et al.
Page 21: 4 Attarian et al. until the 1970s t
Page 25 and 26: 8 Attarian et al. Duration of Illne
Page 27 and 28: 10 Attarian et al. REFERENCES 1. Ma
Page 29 and 30: 12 Attarian Another study in Austri
Page 31 and 32: 14 Attarian even less well studied.
Page 33 and 34: 16 Attarian communities. A structur
Page 35 and 36: 18 Attarian 5. Sutton, D. A., Moldo
Page 37 and 38: 20 Attarian 53. Kageyama, T., Kabut
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Page 41 and 42: 24 Bonnet and Arand Table 1 Reporte
Page 43 and 44: 26 Bonnet and Arand On the day spen
Page 45 and 46: 28 Bonnet and Arand SUMMARY These m
Page 47 and 48: 30 Bonnet and Arand chronic caffein
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Page 51 and 52: 34 Bonnet and Arand The Development
Page 53 and 54: 36 Bonnet and Arand ACKNOWLEDGMENT
Page 55 and 56: 38 Bonnet and Arand 45. Bonnet, M.
Page 57 and 58: 40 Attarian Table 1 Types of Insomn
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Page 61 and 62: 44 Fig. 1. Example of a 1-week slee
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Page 65 and 66: 48 Attarian Fig. 4. Algorithm. (Use
Page 67 and 68: 50 Attarian 27. Polo-Kantola, P., E
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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,
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82 Attarian was confirmed by resear
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84 Attarian times worrying about th
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86 Attarian insomnia or for other s
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88 Attarian
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90 Duntley tion systems found that
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92 Duntley Case 1 A 36-year-old fem
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94 Fig. 2. The objective amount of
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96 Duntley PROGNOSIS AND COMPLICATI
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98 Duntley
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100 Attarian EPIDEMIOLOGY There are
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102 Attarian CLINICAL MANIFESTATION
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104 Attarian DIAGNOSTIC WORKUP The
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106 Attarian 13. Hauri, P. J. (1998
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108 Plotkin
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110 Plotkin quality of sleep. Ultim
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112 Plotkin of the therapeutic effi
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114 Plotkin months or years. The ef
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116 Plotkin associated somatic disc
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118 Plotkin Table 1 Causes of Secon
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120 Plotkin Table 1 (continued) Lew
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122 Plotkin REFERENCES 1. Foley, D.
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124 Plotkin 48. Marchetti, F., Rome
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126 Plotkin
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128 Karaz Table 1 DSM-IV Diagnoses
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130 Karaz poor. Focusing only on th
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132 Karaz He felt hopeless that his
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134 Karaz Table 4 Diagnostic Criter
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136 Karaz complained of feeling anx
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138 Karaz other physicians avoided
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140 Karaz 17. Attarian, H. P. (2000
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142 Duntley disorders has been conf
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144 Duntley itance. A recent study
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146 Duntley The patient’s primary
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148 Duntley return to sleep. He tos
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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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