Handbook of Insomnia: Chapter 4 Flashcards

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Questions and Answers

What are lifestyle adjustments?

Lifestyle adjustments are often crucial for successful treatment and prevention of insomnia.

What is sleep hygiene?

Sleep hygiene is generally considered a good adjunctive addition to sleep restriction, stimulus control, relaxation therapy, and cognitive behavioral therapy (CBT), but has not been proven to be efficacious as a stand-alone treatment.

Exercising too close to sleep initiation can contribute to arousal that interferes with sleep.

True

What are considered examples of behavioral therapy?

Stimulus control therapy, sleep restriction, progressive muscle relaxation. Signup and view all the answers

How is Cognitive Behavioral Therapy (CBT) for insomnia usually structured?

Behavioral therapy is often combined with sleep education, sleep hygiene, and cognitive interventions into multi-modal CBT. Signup and view all the answers

What is the basis of stimulus control in treating insomnia?

It is based on the theory that insomnia is perpetuated by repeated association of the bedroom with poor sleep, as well as worrying, planning, or recreation. Signup and view all the answers

What are the most common stimulus control instructions?

<ol> <li>Do not use the bed or bedroom for anything but sleep (or sex). 2. Go to bed only when ready to sleep. 3. Leave the bed and do something in another room if sleep onset is greater than 15 minutes. 4. Return to bed only when feeling a strong sleep urge. 5. If you do not fall asleep quickly upon returning to bed, start over at Step 3 as many times as is necessary. 6. Use an alarm to awaken at the same time every morning. 7. Do not nap during the day.</li> </ol> Signup and view all the answers

What is sleep restriction?

It involves reducing total time in bed to more accurately reflect the amount of time spent sleeping on a typical night. Signup and view all the answers

What is the theory behind sleep compression?

It is an alternative approach where reduction in time in bed is done incrementally (e.g., 15-30 minutes per session) to decrease anxiety about losing sleep. Signup and view all the answers

What does relaxation therapy focus on?

It is based on the theory that people with insomnia have elevated levels of physiological and mental arousal that can inhibit sleep. Signup and view all the answers

What is progressive muscle relaxation (PMR)?

Patients alternate between tensing and relaxing different muscle groups throughout the body for approximately 20-45 seconds. Signup and view all the answers

What does the cognitive model of insomnia propose?

It posits that patients with insomnia tend to 'over focus' on sleep and have distorted beliefs about sleep and its impact on daytime performance. Signup and view all the answers

What are the steps involved in cognitive therapy for insomnia?

<ol> <li>The clinician works with the patient to identify their sleep-interfering thoughts. 2. Challenging the validity of those thoughts. 3. Replacing them with more sleep-conducive thoughts.</li> </ol> Signup and view all the answers

What is pharmacotherapy in the context of treating insomnia?

It should be supplemented with behavioral and cognitive therapies where possible and carries a risk of dependence and residual daytime impairment. Signup and view all the answers

What are the three main classes of medications currently used to treat insomnia?

<ol> <li>Benzodiazepine receptor agonists (BzRAs), 2. Non-benzodiazepine hypnotics, 3. Antidepressants.</li> </ol> Signup and view all the answers

What are benzodiazepine receptor agonists commonly used for?

They are commonly used pharmaceutical treatments when first-line cognitive behavioral therapy for insomnia (CBT-I) fails or is unavailable. Signup and view all the answers

What is Gamma-aminobutyric acid (GABA)?

It is the primary inhibitory neurotransmitter in the central nervous system of mammals and appears to inhibit monoaminergic arousal centers in the brain. Signup and view all the answers

Which receptors have been the primary target in insomnia and why?

In insomnia, GABA*A receptors have been the primary target because they appear to control sedation and muscle relaxation. Signup and view all the answers

What are the effects of BzRAs?

BzRAs resulted in reduced sleep onset latency and wake time after sleep onset, increasing total sleep time and continuity, and were less lethal than barbiturates in overdose. Signup and view all the answers

BzRAs can lead to tolerance and withdrawal symptoms.

True Signup and view all the answers

What are non-benzodiazepine hypnotics and their characteristics?

They are newer drugs that are more specific in their receptor affinity, reducing the number of receptors by approximately 25%. Signup and view all the answers

What have been some negative side effects of non-benzodiazepine hypnotics?

Negative side effects include rebound insomnia, subjective ratings suggestive of abuse potential, anxiety, sleep-related eating disorder, and short-term memory decrements. Signup and view all the answers

What is zolpidem used for?

Improving sleep-onset latency and total sleep time, but not middle-of-the-night awakenings. Signup and view all the answers

What is the effect of zaleplon?

Effective for significantly reducing sleep latency but not total sleep time. Signup and view all the answers

How does eszopiclone aid sleep?

It improves sleep-onset latency, wake time after sleep onset, and total sleep time. Signup and view all the answers

What are melatonin receptor agonists?

Analogues of melatonin that bind to and activate the melatonin receptor. Signup and view all the answers

What does ramelteon do?

It is a melatonin receptor agonist, with high affinity for MT1 and MT2 subtypes. Signup and view all the answers

What role does melatonin play in sleep?

It helps regulate the circadian clock and is normally secreted during periods of darkness. Signup and view all the answers

What are antidepressants used for?

They are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Signup and view all the answers

What are tricyclic antidepressants (TCAs) commonly used for?

They are the most common antidepressants used off-label as insomnia medications. Signup and view all the answers

Nonprescription treatments are recommended for insomnia.

False Signup and view all the answers

What are some emerging treatments for insomnia?

Suvorexant, Tasimelteon. Signup and view all the answers

What is orexin?

It is a neurotransmitter that appears to promote wakefulness through excitation of dopamine, norepinephrine, histamine, and acetylcholine systems. Signup and view all the answers

What does suvorexant do?

It is a dual orexin receptor antagonist which appears to improve sleep efficiency by inhibiting wakefulness. Signup and view all the answers

What is tasimelteon used for?

It is being investigated for sleep disorders and shows increased sleep efficiency. Signup and view all the answers

Study Notes

Treating Insomnia

Lifestyle adjustments are essential for effective treatment and prevention of insomnia.
Sleep hygiene complements treatments like sleep restriction, stimulus control, relaxation therapy, and Cognitive Behavioral Therapy (CBT), but lacks standalone efficacy.
Exercising close to bedtime can hinder sleep, while earlier workouts may promote better rest.
Behavioral Therapy includes empirically validated techniques based on the behavioral model of insomnia.
Examples of behavioral therapy methods: stimulus control therapy, sleep restriction, and progressive muscle relaxation.
CBT for insomnia combines behavioral therapy with sleep education and cognitive strategies for a comprehensive approach.
Behavioral Therapy (BT), alone or combined with Cognitive Therapy (CT) and Sleep Hygiene (SH), effectively addresses both primary insomnia and insomnia linked to other disorders.
Stimulus Control aims to break the association between the bedroom and poor sleep, minimizing distractions and anxieties.
Key stimulus control instructions emphasize using the bed only for sleep, limits on time spent in bed, and actions to take when unable to sleep.
Sleep restriction reduces time in bed to match actual sleep duration, addressing the tendency to prolong time awake in bed.
Sleep compression gradually reduces time in bed, helping to alleviate sleep anxiety.
Relaxation therapy teaches self-guided practices like imagery, meditation, and biofeedback to combat elevated arousal levels.
Progressive muscle relaxation (PMR) involves sequential muscle tensing and relaxation to promote physical ease.
The cognitive model of insomnia suggests that patients often fixate on sleep and hold distorted sleep-related beliefs negatively affecting daytime performance.
Cognitive Therapy involves identifying negative sleep thoughts, challenging their validity, and substituting them with sleep-promoting thoughts.
Cognitive therapy is typically integrated with other validated treatments as its standalone efficacy is not yet supported.
Pharmacotherapy remains the most frequently used treatment for insomnia.
Medication should be paired with behavioral and cognitive therapies to reduce dependence risks and daytime impairments.
Main medication classes for insomnia include: benzodiazepine receptor agonists (BzRAs), non-benzodiazepine hypnotics, and antidepressants.
BzRAs are commonly prescribed when first-line CBT interventions are ineffective.
Gamma-aminobutyric acid (GABA) is a key inhibitory neurotransmitter affecting sleep regulation.
GABA*A receptors are primarily targeted in insomnia treatment due to their role in sedation and muscle relaxation.
BzRAs reduce sleep latency and increase total sleep time while being considered less lethal than barbiturates in overdose situations.
However, BzRAs can lead to tolerance, rebound insomnia upon withdrawal, and daytime residual effects.
Non-benzodiazepine hypnotics are newer drugs that act more selectively on GABA receptors, with a lower side effect profile but still a potential for dependence.
Negative side effects of non-benzodiazepine hypnotics may include rebound insomnia and other cognitive issues.
Zolpidem is effective for sleep latency and total sleep time; Zaleplon is notable for sleep latency but not overall sleep time; Eszopiclone improves both sleep onset and wake time.
Melatonin receptor agonists, like Ramelteon, help regulate the circadian clock by mimicking natural melatonin secretion during darkness.
Antidepressants, particularly tricyclics (TCAs), are often utilized off-label for insomnia with variable effects on sleep.
Nonprescription treatments such as antihistamines can lead to rapid tolerance and are not recommended for insomnia management.
Emerging treatments include Suvorexant and Tasimelteon, targeting orexin regulation and melatonin receptor activation, respectively.
Orexin promotes wakefulness through several neurotransmitter systems, and is affected by sleep deprivation.
Suvorexant, a dual orexin receptor antagonist, improves sleep efficiency by decreasing wakefulness.
Tasimelteon shows promise for enhancing sleep efficiency and reducing disturbances, particularly in circadian rhythm-related disorders.

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Test your knowledge on key concepts from Chapter 4 of the Handbook of Insomnia. This quiz focuses on essential terms like lifestyle adjustments and sleep hygiene that are crucial for managing and preventing insomnia. Perfect for students or anyone interested in improving their understanding of sleep health.