insomnia

The common symptoms are difficulty in falling asleep, decreased sleep quality and sleep time, and decreased memory and attention.

Now there are limitations in the understanding of insomnia in clinical medical science. However, clinicians have begun to define insomnia according to clinical research. In 2012, the sleep disorders group of Neurology branch of Chinese Medical Association formulated “guidelines for the diagnosis and treatment of adult insomnia in China” based on the existing evidence of evidence-based medicine, in which insomnia refers to patients’ understanding of sleep time and (or) quality Quantity dissatisfaction is a subjective experience that affects daytime social function.

pathogeny

Insomnia can be divided into primary and secondary according to the etiology.

  1. Primary insomnia

There are three types of insomnia: psychophysiological insomnia, idiopathic insomnia and subjective insomnia. The diagnosis of primary insomnia lacks specific indicators, which is mainly an exclusive diagnosis. When the possible cause of insomnia is eliminated or cured, it can be considered as primary insomnia. Psychophysiological insomnia can be traced back to the influence of a certain or long-term event on the functional stability of limbic system. The imbalance of limbic system eventually leads to the disorder of brain sleep function and insomnia.

  1. Secondary insomnia

It includes insomnia caused by physical diseases, mental disorders and drug abuse, as well as insomnia related to sleep disordered breathing and sleep dyskinesia. Insomnia often occurs at the same time with other diseases, sometimes it is difficult to determine the causal relationship between these diseases and insomnia, so in recent years, the concept of comorbid insomnia was proposed to describe those insomnia accompanied by other diseases.

The main clinical manifestations of insomnia patients are as follows:

  1. Sleep disorders

Sleep difficulty, sleep quality and sleep time decreased.

  1. Daytime cognitive impairment

The decline of memory function, attention function and planning function lead to daytime drowsiness and decreased work ability, and daytime sleepiness is easy to occur when stopping work.

  1. Dysfunction of autonomic nerve in limbic system and its surroundings

Cardiovascular system performance for chest tightness, palpitation, blood pressure instability, peripheral vasoconstriction and expansion disorders; digestive system performance for constipation or diarrhea, stomach bloating; exercise system performance for neck and shoulder muscle tension, headache and low back pain. Emotional control ability is reduced, easy to be angry or unhappy; men are prone to impotence, women often have sexual dysfunction and other performance.

  1. Other systemic symptoms

Short term weight loss, immune dysfunction and endocrine dysfunction are easy to occur.

treatment

  1. overall objectives

The etiology should be defined as far as possible to achieve the following objectives:

(1) Improve sleep quality and / or increase effective sleep time;

(2) To restore social function and improve the quality of life of patients;

(3) Reduce or eliminate the risk of physical disease or co disease associated with insomnia;

(4) Avoid the negative effects of drug intervention.

  1. intervention mode

The intervention measures of insomnia mainly include drug therapy and non drug treatment. For the patients with acute insomnia, it is advisable to use drug treatment in early stage. For subacute or chronic insomnia, whether it is primary or secondary, it should be assisted with psychological behavior treatment while drug treatment is applied, even for those who have been taking sedative hypnotic drugs for a long time. The effective psychotherapy for insomnia is cognitive behavior therapy (cbt-i).

At present, there are relatively few professional resources that can be engaged in psychological behavior treatment in China. There are not many professional qualification certification in this field. It is also faced with compliance problems if cbt-i is used alone. Therefore, drug intervention still occupies the leading position of insomnia treatment. There are no convincing large sample control studies in non drug treatment except for psychological behavior therapy, such as diet therapy, aromatherapy, massage, homeopathy, and light therapy. Traditional Chinese medicine has a long history in the treatment of insomnia, but it is difficult to evaluate it with modern evidence-based medicine due to its special individualized medical model. The importance of sleep health education should be emphasized, that is, on the basis of establishing good sleep hygiene habits, psychological behavior therapy, drug therapy and traditional medical treatment should be carried out.

  1. drug treatment of insomnia

Although there are many kinds of hypnotic drugs, most of them are not mainly used for insomnia. At present, the main drugs for insomnia include benzodiazepine receptor agonists

(benzodiazepineceptoragonists, bzras), melatonin receptor agonists and antidepressants with hypnotic effects. Although antihistamine drugs (such as pheniramine), melatonin and valerian extract have hypnotic effects, there is limited evidence in clinical research, which is not suitable for insomnia. General treatment recommendations: eszopiclone, zolpidam, zolpidem Cr, zopiclone. The drugs for insomnia are complex and various, including estazolam, flurazepam, quarkepam, temazepam, triazolam, alprazolam, clodiazepxide, diazepam, lorazepam, midazolam, zolpidan Zolpidem Cr, zopiclone, eszopiclone and zaleplon, ramelteon, temetrone (tasimelteon), agomelatin, tricyclic antidepressants, selective 5-tryptamine reuptake inhibitors (SSRIs), 5-hydroxytryptamine and demethylation SNRIs, mirtazapine and trazodone were used in the study. Because some drugs are likely to rely on, it is not generally recommended to take them for a long time.

  1. physical therapy

Repetitive transcranial magnetic stimulation is a new non drug treatment scheme for insomnia. Transcranial magnetic stimulation is a new technique of magnetic stimulation in specific parts of the head and skull, which refers to the process of repeated stimulation in a specific cortex. Repeated transcranial magnetic stimulation can stimulate the function of the distant cortex, and realize the regional reconstruction of the cortex function. It also has a significant effect on neurotransmitter and its transmission, various receptors in different brain regions, including 5-hydroxytryptamine and gene expression regulating the excitability of neurons. It can be combined with drugs to prevent insomnia, especially for insomnia treatment during lactation, especially insomnia caused by postpartum depression.

  1. drug treatment of special insomnia patients

(1) The elderly insomnia patients prefer non drug treatment, such as sleep health education, especially cbt-i (recommended at level I). When the treatment of primary diseases can not alleviate insomnia symptoms or can not comply with non drug treatment, drug treatment can be considered. The elderly insomnia patients are recommended to use non BZDs (non benzodiazepines) or melatonin receptor agonists (recommended in level II). When BZDs (benzodiazepines) are used, care should be taken when using the drugs. If ataxia, consciousness is blurred, abnormal movement, hallucinations and respiratory inhibition occur, the drugs should be stopped immediately and properly handled. Meanwhile, attention should be paid to the unexpected injury such as falling caused by the decrease of muscle tension caused by BZDs. The drug treatment dose of elderly patients should start with the minimum effective dose, short-term application or intermittent therapy, and do not give large dose. During the course of drug use, the adverse drug reactions should be closely observed.

(2) There is no data on the safety of sedative hypnotic drugs in pregnant women and lactation patients. Because zolpidam has no teratogenic effect in animal experiments, they can be taken in a short period if necessary (recommended for grade IV). In lactation, sedative hypnotic drugs and antidepressants should be cautious to avoid the influence of drugs on infants through milk. Non drug intervention is recommended for insomnia (recommended in level I). The existing experiments show that transcranial magnetic stimulation is a promising method for insomnia in pregnancy and lactation, but the exact effect needs to be further observed in large samples.

(3) For the insomnia women in perimenopause and menopause, the common diseases affecting sleep in this age group, such as depression, anxiety disorder and sleep apnea syndrome, should be identified and dealt with first. According to the symptoms and hormone levels, necessary hormone replacement treatment should be given. The insomnia symptoms of these patients are the same as that of ordinary adults.

(4) BZDs with respiratory diseases are used carefully in COPD and sleep apnea hypopnea syndrome due to adverse reactions such as respiratory inhibition. Non BZDs receptor has strong selectivity and low incidence of secondary morning residual effect. No adverse respiratory response has been reported in insomnia patients with mild and moderate COPD treated with zolpidam and zopiclone. However, the efficacy of zaleplon in insomnia patients with respiratory diseases has not been determined.

The elderly patients with sleep apnea can be complained of insomnia, and the number of complex sleep and respiratory disorders increases. The use of short-term hypnotic drugs such as zolpidam can reduce the occurrence of central sleep apnea. The application of noninvasive ventilator therapy can improve the compliance and reduce the possibility of inducing obstructive sleep apnea. BZDs can be banned in patients with acute exacerbation and compensatory period of restrictive ventilation dysfunction with hypercapnia, and should be used and monitored closely when necessary. Melatonin receptor agonist remierton can be used in the treatment of sleep respiratory disorders and insomnia patients, but further research is needed.

(5) Insomnia is often found in the patients with mental disorders in the patients with comorbidity. The psychiatrists should treat and control the primary disease according to the principle of specialty, and treat insomnia symptoms at the same time. Depression is often associated with insomnia, and it is not allowed to be treated in isolation to avoid the dilemma of vicious circle. The recommended combination treatment methods include: ① cbt-i is used to treat insomnia with hypnotic antidepressants (such as doxepin, amitriptyline, mirtazapine or paroxetine); ② antidepressants (single drug or combination) plus sedative hypnotic drugs, such as non BZ, etc DS drugs or melatonin receptor agonists (recommended for class III). Attention should be paid to the potential for the use of antidepressants and hypnotics to aggravate sleep apnea syndrome and periodic leg movement. When the patients with anxiety disorder have insomnia, anti anxiety drugs are the main drugs, and sedative hypnotics are used before sleep if necessary. When the schizophrenia patients have insomnia, the anti psychotic drugs should be chosen as the main treatment, and the sedative hypnotic drugs can be used to treat insomnia if necessary.

  1. psychological behavior treatment of insomnia

The essence of psychological behavior therapy is to change the belief system of patients, to play their own efficacy, and to improve insomnia symptoms. To achieve this goal, the participation of professional doctors is often required. Psychological behavior therapy has good effects on primary insomnia and secondary insomnia in adults, including sleep health education, stimulation control therapy, sleep restriction therapy, cognitive therapy and relaxation therapy. These methods or combinations are used independently or in combination for the treatment of primary or secondary insomnia in adults

(1) Sleep health education most insomnia patients have bad sleep habits, destroy normal sleep patterns, form the wrong concept of sleep, thus leading to insomnia. Sleep health education is mainly to help insomnia patients understand the important role of bad sleep habits in the occurrence and development of insomnia, analyze and find out the reasons for the formation of bad sleep habits, and establish good sleep habits. Generally speaking, sleep health education needs to be carried out at the same time as other psychological behavior treatment methods. It is not recommended to use sleep health education as an isolated intervention method.

The contents of sleep health education include:

① Avoid using excitatory substances (coffee, tea or smoking) for hours before sleep (generally after 4 p.m.); ② do not drink before sleep, alcohol can interfere with sleep; ③ regular physical exercise, but avoid violent exercise before sleep; ④ do not eat food that is difficult to digest before sleep; ⑤ do not do mental labor or observation which is easy to cause excitement within 1 hour before sleep Read books and TV programs that are easy to arouse excitement; ⑥ the bedroom environment should be quiet and comfortable, and the light and temperature are suitable; ⑦ keep regular working and rest time.

(2) Stress, tension and anxiety are common factors that induce insomnia. Relaxation therapy can alleviate the adverse effects of the above factors, so it is the most common non drug therapy for insomnia, which aims to reduce the alertness and night awakening when sleeping in bed. Training techniques to reduce arousal and promote night sleep include progressive muscle relaxation, guided imagination and abdominal breathing training. Patients should practice 2-3 times a day after relaxation training. The environment should be clean and quiet. At the beginning, they should be conducted under the guidance of professional personnel. Relaxation therapy can be used as an independent intervention for insomnia (recommended in level I).

(3) Stimulation control therapy is a set of behavioral intervention measures to improve the interaction between sleep environment and sleep tendency (sleep intention). It can restore the function of sleeping as the signal of inducing sleep, make the patient easy to sleep and reconstruct the sleep wake biological rhythm. Stimulation control therapy can be used as an independent intervention (recommended at level I). Specific contents: ① only go to bed when you have sleep; ② if you can’t sleep in bed for 20 minutes, you should get up and leave the bedroom, and you can do some simple activities, and return to the bedroom when you have sleep; ③ don’t do activities unrelated to sleep in bed, such as eating, watching TV, listening to radio and thinking about complex problems; ④ no matter how long you sleep the night before and then, keep regular The time to get up; ⑤ avoid napping in the daytime.

(4) Sleep restriction therapy many insomnia patients try to increase sleep opportunities by increasing their bedtime, but often do not do what they wish, but make sleep quality further decline. Sleep restriction therapy can improve sleep efficiency by shortening the sleeping time and increasing the driving ability of sleeping. The recommended sleep restriction therapy is as follows (recommended in level II): ① reduce the sleeping time to make it conform to the actual sleep time, and only if the sleep efficiency of one week exceeds 85%, it can increase the sleeping time of 15-20 minutes; ② when the sleep efficiency is lower than 80%, the sleeping time of 15-20 minutes will be reduced; if the sleep efficiency is between 80% and 85%, the bed time will not be kept Change; ③ avoid daytime nap and keep the rule of time to get up.

(5) Cognitive behavior therapy often fear insomnia itself, pay too much attention to the adverse consequences of insomnia, often feel nervous and worry about sleep when they are near sleep. These negative emotions make sleep worse, and the aggravation of insomnia in turn affects the mood of patients, which forms a vicious circle. The purpose of cognitive therapy is to change the cognitive deviation of insomnia and the irrational belief and attitude of patients about sleep problems. Cognitive therapy is often used in combination with stimulation control therapy and sleep restriction therapy to form cbt-i of insomnia. The basic contents of cognitive behavioral therapy are as follows: ① keep reasonable sleep expectation; ② do not blame all problems on insomnia; ③ keep sleeping naturally and avoid excessive subjective intention to sleep (forcing yourself to sleep); ④ don’t pay too much attention to sleep; ⑤ do not have frustration because you don’t sleep well for one night; 6) cultivate tolerance to the effect of insomnia. Cbt-i is usually a combination of cognitive therapy and behavioral therapy (stimulation control therapy, sleep restriction therapy), and it can also be combined with relaxation therapy and sleep health education. Cbt-i is the core of insomnia psychological behavior therapy (recommended at level I)

(6) Comprehensive intervention of insomnia: 1) the short-term effect of drug intervention on insomnia has been confirmed by clinical trials, but long-term application still needs to bear the potential risks of adverse drug reactions and addiction. Cbt-i has not only short-term effect, but also can be maintained for a long time in follow-up observation. Cbt-i combined with non BZDs can gain more advantages, and the latter can optimize the effect of this combination treatment by changing the intermittent treatment. 2) The recommended combination therapy (recommended in level II) is to combine cbt-i and non BZDs (or melatonin receptor agonist). If the symptoms are controlled in a short period, stop the non BZDs gradually, otherwise, change non BZDs to intermittent medication, and maintain cbt-i intervention (Level II recommendation).