Sleeplessness (insomniya)

Description:

The frustration which is characterized by disturbance of backfilling or maintenance of a dream is considered Insomniya. Moreover, the unsatisfactory quality of a dream causing physical and emotional symptoms in the afternoon that exerts impact on social and cognitive activity is characteristic of an insomniya.

Insomniya represents the widespread frustration difficult for diagnosis and treatment demanding development of accurate strategy and planning. Sleeplessness, whether it be a symptom, a syndrome or independent frustration, has serious professional, social effects and imposes a considerable economic burden on society. The Brazilian association of a dream developed new recommendations about diagnosis and treatment of sleeplessness at adults and children who were published in the Arquivos de Neuro-Psiquiatria magazine (2010; 68 (4): 666-675). In work the general questions concerning dream problems and also methods of clinical and psychosocial assessment, diagnosis, choice and purpose of drug and psychotherapeutic treatment are discussed.

In November, 2008 at the initiative of the Brazilian society of somnologists in São Paulo various specialists in the field of dream medicine were invited to discuss creation of new recommendations about diagnosis and treatment of an insomniya. On this action such subjects were considered: clinical and psychosocial verification of the diagnosis, recommendation about carrying out a polisomnografiya, pharmacological treatment, behavioural and cognitive therapy, the accompanying pathology and sleep disorders at children.

Types of sleeplessness (insomniya):

1. Adaptation insomniya (acute insomniya). This frustration of a dream arises against the background of acute stress, the conflict or change of an environment. The increase in the general activation of a nervous system complicating entry into a dream at evening backfilling or night awakenings is a consequence. At this form of sleep disorders it is possible to define the reason which caused them with big confidence, the adaptation insomniya lasts no more than three months.

2. Psychophysiological insomniya. If sleep disorders remain for longer term, they "acquire" psychological disturbances, the most characteristic of which is formation of "fear of a dream". At the same time the somatized tension increases in the evening when the patient tries "to force" to fall asleep rather that leads to aggravation of sleep disorders and strengthening of concern the next evening.

3. Psevdoinsomniya. The patient claims that he sleeps very little or does not sleep absolutely, however when carrying out a research, objektiviziruyushchy a dream picture, existence of a dream in the quantity exceeding subjectively felt is confirmed. Here the major simptomoobrazuyushchy factor is the disturbance of perception of own dream connected, first of all, with features of feeling of time at night (the wakefulness periods are well remembered at night, and the dream periods — on the contrary, amnezirutsya), and fixing on the problems of own health connected with a sleep disorder.

4. Idiopathic insomniya. Sleep disorders at this form of an insomniya are noted from children's age, and other reasons of their development are excluded.

5. Insomniya at mental disorders. 70% of patients with mental disorders of a neurotic row have problems of initiation and maintenance of a dream. Quite often the sleep disorder acts as the main "simptomoobrazuyushchy" radical because of which, according to the patient, and numerous "vegetative" complaints (a headache, fatigue, heartbeat, deterioration in sight etc.) develop and social activity is limited.

6. Insomniya owing to disturbance of hygiene of a dream. At this form of an insomniya of a problem with a dream arise against the background of the activity leading to increase in activation of a nervous system during the periods preceding laying. It can be the use of coffee, smoking, exercise and mental stress in the evening or other activity interfering initiation and maintenance of a dream (laying in various time of day, use of bright light in a bedroom, a situation, inconvenient for a dream).

7. Behavioural insomniya of children's age. Arises when at children the wrong associations or installations connected with a dream form (for example, the need to fill up only at a motion desease, unwillingness to sleep in the bed), and in attempt to move away them or to correct the active resistance of the child leading to reduction of time of a dream is shown.

8. Insomniya at somatopathies. Displays of many diseases of internals or a nervous system are followed by disturbance of a night dream (hungry pains at a peptic ulcer, night arrhythmias, painful neuropathies etc.).

9. Insomniya connected with reception of medicines or other substances. The insomniya arising at abuse of somnolent drugs and alcohol is most widespread. At the same time development of a syndrome of accustoming (the need for increase in a dose of drug for obtaining the same clinical effect) and dependences is noted (development of a withdrawal at the termination of administration of drug or reduction of its dose).

Associated diseases:

1. A syndrome of an obstructive apnoea in a dream.
In 1973 Guileminolt and colleagues described communication of sleeplessness and obstructive apnoea during sleep; this phenomenon began to be called "a syndrome of an obstructive night apnoea". Relationship between these two widespread sleep disorders is complex and up to the end is not clear. The increased frequency of disorders of breath at patients with an insomniya in comparison with the general population is traced. Weight of symptoms of sleeplessness is directly connected with weight of an apnoea, defining thus their komorbidnost. Listein and colleagues showed that the considerable number of individuals, especially advanced age, has a combination of these two states: not diagnosed syndrome of a night apnoea and sleeplessness. Thus, the polisomnografiya can help to find the significant disturbances of breath connected with an insomniya.
Women in peri-and the post-menopausal period have sleeplessness in comparison with women of fertile age more often. Replacement hormonal therapy (estrogen and progesterone) allows to improve quality of a dream and favorably influences symptoms of a syndrome of an obstructive night apnoea. Benzodiazepines cause sedation, decrease in a muscle tone of respiratory tracts and reduction of ventilation of the lungs that leads to an anoxemia. In this regard in the presence of a syndrome of an obstructive night apnoea purpose of drugs of this group is not recommended. Use of various devices for improvement of passability of respiratory tracts (for example, based on creation of positive pressure of air) also negatively influences quality of a dream, especially in the period of an adaptation phase.

2. Fibromyalgia.
Patients with fibromyalgia complain of constant fatigue, physical weakness, a dream without feeling of rest and diffusion muscular pain. Usually at such patients the constant feeling of fatigue is combined with sleep disorders.

3. Disturbances of circadian rhythms.
The syndrome of an otstrochenny phase of a dream as private option of frustration of a circadian rhythm is characterized by a delay of backfilling and morning awakening. These states usually begin at children's age or youth and extremely seldom incorrectly are considered as sleeplessness, in particular an idiopathic insomniya.

4. Syndrome of uneasy legs and periodic movements of extremities.
The syndrome of uneasy legs is characterized by the touch frustration which are preferential affecting the lower extremities which especially often arise before withdrawal to a dream, causing thus difficulties of backfilling. The periodic movements of extremities are often associated during sleep with a syndrome of uneasy legs, lead to fragmentation of a dream and influence its quality. The periodic movements of the lower extremities can arise during sleep irrespective of existence of a syndrome of uneasy legs. Thus, their influence on a dream profile, communication with sleeplessness and drowsiness have to be carefully analyzed in each case in the afternoon.

Non-drug treatment of sleeplessness (insomniya):

Cognitive and behavioural therapy.
Today cognitive and behavioural therapy is the standard in treatment of primary insomniya. It should not be applied independently but only in combination with pharmacological therapy. Cognitive and behavioural therapy has advantages before drug treatment as it is accompanied by smaller risk of development of side effects at prolonged use. This type of therapy is carried out during the limited period, by from 4 to 8 sessions. It is a focal and directive method of therapy at which the patient plays an active role and assumes a part of responsibility for treatment. Cognitive and behavioural therapy can individually be carried out or in groups.
During therapy the training, behavioural and cognitive interventions, according to theoretical model of the sleeplessness offered by Spiyelman are carried out. Proceeding their this model, lead three main groups of factors to an insomniya: contributing, provoking and fixing. Main objectives of cognitive and behavioural therapy are the provoking and fixing factors. Main technicians following: hygiene of a dream, an incentive - the controlling therapy, restriction of the time spent in a bed and time of a dream, the equipment of a relaxation, cognitive restructuring, paradoxical aspirations and cognitive therapy at disturbances of perception of a dream.

Hygiene of a dream. It is the educational intervention containing the main information about the habits connected with a dream and its hygiene. Hygiene of a dream includes instructions for definition of regular time of withdrawal to a dream: to go to a bed only when there is a drowsiness and not to use a bed for attempts to fall asleep; during day not to worry about the forthcoming situation of backfilling; to control the time; to avoid reception of the stimulating products (coffee, cigarettes, medicines, black tea, the cook - Coca and chocolate); to avoid an alcohol abuse before going to bed; to limit reception of liquid for the night. Also here recommendations of rather evening meal (easy food) not later than in two hours prior to a dream enter and regular physical activity it is preferential in the first half of day, and also concerning a condition of a bedroom (comfort, temperature, noise and stress factors), it is important that in it it was silent, rather fresh air, it is pure and removed.

Control of incentives. The main objective – to train patients with sleeplessness how to choose the dream rhythm which was more suitable for them – wakefulness, to reduce wakefulness time at night and to control time spent in a bedroom/bed. The main instructions for patients the following: to go to bed only having felt drowsiness; to avoid any activity in a bed except a dream and occupations sex; at inability to fall asleep the patient should rise and go to other room, where to be engaged in the weakening activity at weak lighting and to return to a bed only when he will feel drowsiness again; to keep certain time for awakening throughout 7 days of the week irrespective of, output it or the working day; not to sleep and not to lay down for day, in a bedroom is not, not to read, not to work, not to watch TV and not to use the computer.

Therapy by restriction of a dream. The purpose of this type of therapy – to normalize a dream through restrictions of time which the patient spends in beds to the average time of a dream (a number of hours which he really sleeps) on the basis of information obtained from the diary of a dream. This equipment creates an easy condition of a deprivation of a dream that can result in drowsiness in the afternoon. However it normalizes a dream, facilitating backfilling process, improving quality of a dream and reducing stage of latency of backfilling and its variability between nights. It is not recommended to sleep less than 4-5 hours, it is also necessary to do correction of time spent in a bed according to efficiency of this method for patients. If the patient reached 90% of efficiency, it is necessary to add 15 minutes by the time of stay to beds if efficiency is less than 85% – to take away 15 minutes.

Technicians of a relaxation. These technicians are directed to showing to patients as they are strained and excessively vigilant for day and even night. Today the most studied method of treatment of sleeplessness is the equipment of a gradual relaxation. Patients learn to strain/relax the main groups of muscles consistently and at the same time to pay attention to corporal feelings during tension and relaxation.

Cognitive restructuring. This type of therapy is generally directed to the cognitive symptoms leading to synchronization of sleeplessness. Interaction happens to beliefs of the patient, his thoughts, false opinions, irrational beliefs concerning a dream and their effects, the false ideas concerning the sleeplessness reasons, disbelief in practice, improving a dream, and own ability to fall asleep. The idea consists in making the patient responsible for sleeplessness symptoms, reminding him that our thoughts connected with certain events substantially define our feelings which we experience in connection with these events.
Paradoxical intentions. This equipment allows to reduce the level of the alarm of expectation connected with fear of impossibility to fall asleep. Since that moment when the patients having sleeplessness arrive at an idea that lost the natural ability to fill up, they receive instructions – going to bed, to try not to fall asleep. It promotes relaxation and saves from a burden of obligatory backfilling. In an effect process of backfilling is facilitated.

Cognitive therapy at inadequate perception of a dream. This option of therapy is connected with relationship between subjective perception of the patient of the general duration of a dream and its true duration established by means of a polisomnografiya. It becomes with the purpose to provide to the patient the objective information about the efficiency of his dream established by method of a polisomnografiya and to convince him that he sleeps longer, than he thinks. This equipment also helps the patient to relax, convincing him that duration of a dream is sufficient, and thanks to it backfilling happens easier.

Drug treatment of sleeplessness (insomniya):

Pharmacological treatment of sleeplessness consists in use of hypnotic means which induce a dream, is preferential through impact on the TsNS main brake GAMK-system. In addition use the drugs possessing sedation. Recently the substances influencing melatoninovy receptors began to be applied. Their use is represented the perspective direction in pharmacological treatment of sleeplessness.

The selection agonists hypnotic GAMKA-retseptorov. Zolpidem – derivative imidazopyridine, was synthesized in 1980, is applied since 1990.
It was the first selection agonist of the a1 subtype of GAMK-receptors. It is quickly soaked up (approximately within an hour) and possesses a short elimination half-life (2,5 hours). Its bioavailability is in range of 65-70%. The peak of concentration in plasma is reached in 1,5 hours after reception. Therapeutic range of doses – from 5 to 10 mg. Drug is metabolized in a liver and removed by kidneys.
At patients of advanced age and in case of a renal failure the recommended dose makes 5 mg. In spite of the fact that dream inductors recommend to apply to treatment of chronic sleeplessness for a month, clinical showed testing that zolpidy remains effective and safe at longer reception (for a dose of 10 mg – 35 days). Zolpidem reduces cyclic fluctuations of a pattern of the A1 and A2 type, even at non-constant reception.

Zolpidem of slow release (zolpidy MR) – a new form of drug which is used at patients with difficulties in maintenance of a continuous dream. This form of drug consists of substance with bystry and otstrochenny release that promotes maintenance of constant plasma concentration from 3 to 6 hours after reception. Zolpidem it is also possible to apply changeably, throughout the long period, without effect of a ricochet.
Zopiklon – derivative a tsiklopirrolona, differs from a zolpidem in longer elimination half-life (5,3 hours) and the affinity with receptors of a1 and a2. The recommended dose – from 3,7 to 7,5 mg. The most frequent side effects are shown by postsomnichesky disturbances which can be caused by a long elimination half-life of drug.

Zaleplon – derivative a pyrazolopyrimidine, tropny to a1-receptors. The recommended dose makes 10 mg, an elimination half-life – about one hour. In this regard залеплон it is appointed for induction of a dream as renders small effect on its maintenance. At its reception the withdrawal is possible that it limits its use.

Eszopiklon – derivative a tsiklopirrolona, is isomer of a zopiklon. It is quickly absorbed and has rather long elimination half-life. The dose is selected individually, in the range from 1 to 3 mg, before going to bed.
Indiplon – a pyrazolopyrimidine with similar with zopilpidemy, zopiklony and zaleplony selectivity to a1-receptors. There are two forms of an indiplon: with bystry release (индиплон IR) which recommend at problems with backfilling, and controlled release (индиплон MR) which is appointed to patients with difficulties of maintenance of a continuous dream, the effect remains from 6 to 8 hours. Range of the recommended doses – 15-30 mg, is accepted just before a dream.
Antidepressants. The antidepressive drugs possessing sedative action (доксепин, Trazodonum, миртазапин), are alternative means in treatment of sleep disorders. However double blind randomized researches in which efficiency and safety of this group of drugs would be confirmed still were not conducted. Some tricyclic antidepressants, such as amitriptyline, improve quality and duration of a dream, however can cause drowsiness next day.

So, Trazodonum it (is recommended), most likely, is one of the most often appointed drugs for treatment of sleeplessness. It concerns group of selective serotonin reuptake inhibitors and has antagonistic activity to adrenergic a1-receptors, and also serotoninovy receptors 5-HT1A and 5-NT2. Trazodonum slightly oppresses a phase of a REM sleep and improves dream duration. The recommended dose makes 50 mg/days.
Doksepin it (is recommended) – the tricyclic antidepressant having affinity to histamine receptors of H1/H2. Its efficiency at treatment of sleeplessness in small dosages is noted (1-6 mg for the night). Doksepin does not cause the expressed residual anticholinergic effects.
Mirtazapin (possible option) – atypical antidepressive drug. The mechanism of its action consists in increase in adrenergic activity by means of interaction with adrenergic receptors of a2a and nonspecific blockade of the return serotonin reuptake. Mirtazapin has ability to block postsynaptic serotoninovy receptors 5-TH2C, 5-TH2A and 5-TH3 and thus shows sedative and anxiolytic effect. Its expressed antihistaminic action in the form of blockade of H1 receptors explains its expressed somnolent effect which among all antidepressants available today the strongest. The recommended doses – from 7 to 30 mg.
Amitriptyline sedation (possible option) is caused by anticholinergic, antihistaminic and anti-a1 - activity, and also antagonism with 5HT2A-and 5HT2C-receptors, it advances antidepressive and decreases after several weeks of treatment. The recommended therapeutic doses – from 12,5 to 50 mg.
Mianserin (possible option) – atypical antidepressant which somnolent effect is caused by anticholinergic and antihistaminic action. Still the long researches confirming efficiency and safety of a mianserin in treatment of sleeplessness were not conducted.

Valerian drugs. The valerian can be applied in treatment of sleeplessness, can be also used as supportive application during breaks at chronic reception of benzodiazepines. In some researches it is reported that the mechanism of its action is carried out through GAMK-ergichesky system. Action of a valerian can be connected also with other mediator systems, for example receptors of MT1 and MT2 (melatonin), and some subspecies of 5-NT-retseptorov.

Benzodiazepines. These drugs nonspecific interact with a1-and a2-subtypes of postsynaptic receptors of GAMKA and with all subspecies of receptors of g-type. Benzodiazepines increase affinity postsynaptic GAMKA-retseptorov to endogenous GAMK, thus increasing depth and duration of the inhibiting effects by means of increase in number of chloride channels. The Tropnost to a1-receptors causes somnolent action and cognitive effects of these means whereas interaction with a2-receptors is expressed in anxiolytic, anticonvulsant and myorelaxation action. After cancellation of benzodiazepines sleeplessness can renew or the effect of a ricochet with aggravation of symptomatology in comparison with that will be shown that was before treatment. Emergence of alarm and deepening of sleep disorders depend on the identity of the patient. Therefore it is necessary to reduce gradually a dose of benzodiazepines, combining this process with psychological support. Development of an abstinence syndrome at cancellation of these means depends on various factors.
Abuse of drugs develops at long reception more often. Tolerance is reflected in progressive increase in a dose of benzodiazepines and depends on certain factors. However at some patients tolerance against the background of long reception of these drugs does not develop. There are researches which showed existence of correlation between long reception of benzodiazepines and increase in risk of death. Increase in cases of obstructive disturbances during sleep, sedation, less attentive attitude towards itself, falling, confusion, amnesia and another, connected with administration of drug, effects can explain increase in mortality. Benzodiazepines are not recommended for use for the patients abusing alcohol and suffering from alcohol addiction. Especially attentively it is necessary to use these drugs at elderly people, patients with renal, liver and pulmonary failure, and also with mental pathology. Benzodiazepines aggravate obstructive disturbances during sleep, are contraindicated during pregnancy, and also to patients whose activity demands sudden night awakenings and adoption of bystry decisions. From benzodiazepines it is possible to apply clonazepam, midazolam and to estazola. Other drugs are not recommended.
Agonists of melatoninovy receptors. Ramelteon – a new hypnagogue which is applied at treatment of a chronic insomniya. It is the high-selection agonist of MT1-and MT2-receptors. The recommended dose makes 8 mg, drug is quickly absorbed (0,75-0,94 hours), an elimination half-life – 1,3 hours.
Due to the short elimination half-life рамелтеон appoint at initial sleeplessness. It is not effective as means of maintenance of a dream. Ramelteon is safe concerning influence on cognitive processes next day after reception and causes ricochet sleeplessness after the end of long use. Drug also does not cause dependence development.

Agomelatin – antidepressant which is an agonist of receptors of MT1 and MT2 and the antagonist of serotoninovy 5-HT2C-retseptorov. Due to the melatoninovy activity агомелатин can be the potential regulator of circadian rhythms at patients with a depression, making thus the contribution to treatment of depressive symptomatology. Drug in dosages of 25-50 mg effectively improves quality of a dream, reduces the period of backfilling and increases a phase of a slow dream.

Other pharmacological means and new perspectives. Perhaps also use of antihistaminic drugs. In treatment of sleeplessness it is not desirable to apply anti-psychotics. New GABA-ergic drugs, such as тиагабин and габоксадол, still are not registered in some countries and were not approved for treatment of insomniya. These substances inhibit the return capture of GAMK and are new perspective means of therapy of insomniya.

Sleeplessness at children's age:

Sleeplessness at children's age is subdivided on behavioural, psychophysiological, the insomniya in special populations connected with certain diseases the sleeplessness and an insomniya caused by the use of medicines.
The most widespread clinical states leading to sleeplessness at children's age, the following: pain syndrome or spasms, otitises, reflux, medicines (stimulators or corticosteroids), night attacks of asthma or laryngospasm. During primary address to the specialist it is necessary to establish accurately the possible reasons of sleeplessness at children. The main type of sleeplessness at children behavioural, but is the diagnosis of an exception.

Behavioural children's sleeplessness.
Behavioural children's sleeplessness arises at 10-30% of children of preschool age. According to the International classification of sleep disorders (ICSD, 2005), various difficulties during the backfilling and maintenance of a dream at children are considered as its main characteristic. This problem can be connected with certain behavioural stereotypes of children or their parents. Behavioural children's sleeplessness is subdivided into two types: frustration of associations and a lack of the constraining mechanisms.

Frustration of associations.
There is a certain quantity of the conditions connected with backfilling process which existence is obligatory in order that the child fell asleep or returned back to a bed after night awakening. The child can independently create positive associations (a pacifier, a rattle or a soft toy) whereas negative associations demand assistance (a small bottle for feeding or a motion desease). Negative incentives also include external irritants (the TV and toys) and various situations (stay in a bed of parents or driving in the car). When the conditions connected with a dream are present, the child falls asleep quickly. However, when they are absent, children often wake up and then long cannot fall asleep again.
Diagnostic criteria of frustration of associations consist in identification of those incentives which slow down backfilling process, and also connected with backfilling that in itself is very problematic and demands considerable efforts. When associative elements are absent, the beginning of a dream is significantly postponed, and the dream has fragmentary character. Night awakenings demand interventions in order that the child fell asleep again.

Lack of the constraining mechanisms.
The lack of the constraining mechanisms can be shown by refusal to go to bed in time determined for this purpose. To a coma of that, postponement of withdrawal to a dream can be carried out through certain requests (feelings of thirst, need to take a bath or to receive one more kiss before going to bed) or additional activity (to watch TV, to read another story). When such children fall asleep, quality of a dream at them normal, with only several awakenings. However children with a lack of the constraining mechanisms usually have the smaller duration of a dream (for 30-60 minutes).
Diagnostic criteria of this type of sleeplessness following: difficulties during the backfilling or maintenance of a dream; postponement/refusal to go to bed in due time or refusal to be returned to a bed during night awakenings; inability of parents to develop suitable behavior of children concerning an otkhozhdeniye to a dream; impossibility to explain sleep disorders with some other reasons, clinical states, neurologic and psychiatric disturbances or reception of medicines.

The sleeplessness connected with neurologic and mental pathology.
The majority of diseases of TsNS can be shown by various options of sleep disorders.