DIAGNOSIS OF INSOMNIA:
Long trivialized or minimized to the point of being absent from the reasons for consultation and medical examinations, insomnia nevertheless proves to be a serious condition because of its impact on quality of life. Sleep multiple roles come largely in the physical and mental health of individuals, including alertness and memory and intellectual abilities.
Insomnia, the most common sleep disorders, can only be defi ned by quantifiable factors, measurable as sleep duration, rhythm or distribution in the day. Indeed, sleep has a significant individual physiological variability, especially according to the age.
To judge from sleep, the diagnosis should focus more on the quality of the recovery, the comfort of the next day and the subjective experience of the past night. Insomnia can be defined by a sleep perceived as difficult to obtain, insufficient or non recovery.
His clinical reality is diverse: difficulty falling asleep, nighttime awakenings, too early awakenings or decrease in sleep efficiency, often accompanied by arousals.
Etiological research of insomnia:
Insomnia often mentioned at the end of consultation and sometimes unnoticed by the patient, must be sought from signs such as fatigue complaints, decreased concentration, or symptoms suggestive of depressive series.
If the will of an immediate restoration of the patient’s part to the success of hypnotic medications, it is nevertheless important, before any treatment, to take time, possibly to see the patient, to establish a positive diagnosis and etiologic insomnia .
The treatment of insomnia begins with the identification of the quality and quantity of sleep, including through the sleep diary filled out by the patient, which allows relative objectification of the course of the night. It is important to observe the habits of sleep, without underestimating the knowledge that patients have, but still trying to be systematic in the investigation because sometimes they commit unwittingly gross errors.
If necessary, this identification can be done through polysomnography, which used wisely, advanced distortion between a sleep perception and reality, landmark fragmentation during the first sleep, explaining a feeling of difficulty in falling asleep, a problem of intermittent awakenings and finally above shows the composition and organization of sleep which in some cases has diagnostic significance.
In the elderly:
Insomnia generally identified as adults nevertheless exist other time of life. They are too often ignored or trivialized, the elderly frequently having physiologically impaired sleep continuity and gradual disruption of the sleep-wake rhythm.
Frequently, their etiologies are the same as those of insomnia adult subject.
Insomnia increases with advancing age, especially due to neurological factors, and toxic drug. Note also the factors due to stress or psychiatric pathologies linked to moments of loss, mourning and denial characteristic of this period of life and conducive to the underlying conditions of activation.
Vigilance is required, insomnia, once installed, accentuates the deterioration of memory and intellectual abilities.
In children:
In the child, insomnia is usually the fact of infancy or adolescence. Apart consecutive insomnia to serious pathologies, we do not note sleep disorder during the latency period. As a teenager can start an intrinsic insomniac pathology, but the cause is frequently a phase delay rather than insomnia.
In infants, environmental causes, preventing a sufficiently soothing atmosphere for a good sleep and a good course of the night, are the most common: relationship problem with parent, presence of a depressed parent, anxious, phobic.Organic causes can also be found: ear infections, skin diseases, gastro-esophageal reflux, seizures, encephalopathy, allergy to cow’s milk, malnutrition, colic.
Differential diagnosis:
Somatic and psychological examination, sometimes polysomnography, is necessary to screen for insomnia, find the source and eliminate other diseases responsible for arousal disorders.
These diseases can be directly related to sleep as restless leg syndrome and restless sleep apnea or be in the form of sleep disturbances on the distribution of the nycthémère such as circadian rhythm disorders. Finally, they may take the form of parasomnia, disorders observed during sleep but not exactly a decrease in the quantity or quality of sleep.
This distinction is important in order not to falsely diagnose patients with such disorders as insomnia or depressed and treated, to the detriment of effective specific treatment, with drugs that can aggravate their problems.
CLASSIFICATION OF INSOMNIA:
It is important to distinguish between transient insomnia and chronic insomnia.
Transient insomnia:
Transient insomnia, occasional or short-term, extend over a period of a few nights to three weeks, affecting 30 to 40% of the population. They almost always belong to the group of so-called extrinsic insomnia which in the classifi cation International
sleep disorders, are twelve in number.
They are reaction insomnia due to poor sleep hygiene (excitations, irregular bedtimes or lift, naps too many, jet lag, shift work), environmental factors (noise, temperature, light conditions change) to altitude, to stress, to a conflict (of adjustment insomnia), for occasional physical stress or to stop a hypnotic treatment (rebound insomnia).
They present the risk of the chronic insomnia bed if they were neglected or badly treated.
Chronic insomnia:
The so-called chronic insomnia lasts more than three weeks and have different etiologies.
Somatic pathological etiology:
These insomnia can be symptomatic of a somatic pathology causing sleep disorders that generally are not specific: increased sleep latency, increased the number and duration of nocturnal awakenings, decreased efficiency sleep.
They may be due to the following conditions:
– Neurological: head trauma, epilepsy (in which sleep architecture can be disrupted);
– Degenerative neurological Parkinson syndrome Shy Drager, progressive supranuclear palsy, olivopontocerebellar cerebellar atrophy, Huntington’s disease, ALS, in September;
– Vascular: Ischemic or Alzheimer-type;
– Infectious: prion diseases as fatal familial insomnia, Creutzfeldt-Jacob fibrillary chorea Morvan or HIV infections;
– Metabolic: diabetes, hyperthyroidism;
– Cardiac: pressure, heart failure;
– Itchy.
Psychiatric disease etiology:
Psychiatric disorders can occur in the following forms:
– mood disorders :
– Mania: insomnia is one of the first symptoms,
– Melancholic depression insomnia in the second part of the night,
– Neurotic depression: difficulty falling asleep and night wakings;
– Schizophrenia: Organization of sleep disorders, constant shifts in sleep onset giving anarchic appearance to sleep;
– Neurotic disorders: difficulty falling asleep, nighttime awakenings, even “panic attacks” caused by nocturnal anxiety component of these diseases;
– Post-traumatic pathologies: insomnia and recurring nightmares.
Drug etiology:
Some treatments can also induce chronic insomnia.
You have to think whether the patient is taking psychostimulants amphetamine or not, some disinhibitory antidepressants or stimulants, anti-Parkinson, theophylline and β-2-agonists, high-dose corticosteroids or thyroid hormone.
If for taking psychotropic drugs, a study of the impact on sleep and alertness was conducted, this is not always the case with other classes of drugs, we must be careful especially during drug combinations and properly assess the risk-benefit ratio.
Intrinsic insomnia:
Some chronic insomnia are primary insomnia. Not related to psychiatric or organic disease, the cause seems to come from the organization or the patient’s functional organization. They are also called intrinsic insomnia.
They are three in number:
– Poor sleep perception. The patient, although he seems to sleep properly, complained in a quasi hypochondriac not get enough sleep;
– Idiopathic insomnia. It begins in childhood and continues throughout life; so bad constitutional sleep;
– Psychophysiological insomnia. The most common, it represents about 25% of all insomnia and is found more in women than in men. It usually appears in the aftermath of an event loaded with a stressful or emotional component.
The patient complains of difficulty falling asleep, night wakings, light sleep and non-recovery, and their repercussions in the day: fatigue, feeling of being half asleep, impaired intellectual capacity, concentration difficulties, troubles memory, mood disorders, irritability, susceptibility, kink, gloom, of tears.
These patients have more somatic problems in the same population of good sleepers, drink alcohol and drugs, often starting in hypnogenic goal.
Although psychologists have not spotted profile of an insomniac personalities, some signs are commonly found: a high frequency of depressive or anxious hypochondriacal character, vulnerability to stress, a tendency to internalize conflict.
MANAGEMENT OF INSOMNIA:
In cases of insomnia, and mainly in the extrinsic insomnia, it should remind patients the basics of sleep hygiene.
Once an established etiologic diagnosis, we would obviously prefer an etiological treatment: treatment of painful somatic or respiratory diseases, neurological diseases, although sometimes concomitant symptomatic treatment of insomnia is necessary.
Non-drug treatments:
Non-drug treatments should be used in priority.
There may be behavioral treatments that are based on conditioning techniques such as relaxation training, systematic desensitization, biofeedback, stimulus control or paradoxical intention. These treatments are reserved in priority to psychophysiological insomnia to fall asleep and used in addition to support other types of insomnia.
Analytic psychotherapy and psychoanalysis are quite appropriate, insomnia is a symptom whose treatment requires a comprehensive support.
In cases of stress, support psychotherapeutic
without medication is indicated.
Herbal medicine can also be prescribed.
Some plants, valerian, passionflower, orange blossom, St. John’s wort (when a depressive component is identified), can be used in cases of transient insomnia, early in the treatment of chronic insomnia, medication before or during relay withdrawal of sleeping medications.
Drug treatments:
Drug treatments are frequently used in all forms of insomnia, though they are not, in principle, prescribed to children or adolescents.
In adults, they can be used in certain cases of occasional insomnia in chronic insomnia, temporarily, to relieve the patient in parallel with behavioral or psychoanalytic assumption, finally, in the longer term, in combination with treatments etiologic in cases of somatic pathologies.
In psychiatric pathologies, insomnia being linked to causal condition, it will therefore be treated with neuroleptics in schizophrenia, certain antidepressants in depressed, benzodiazepines in anxious.
While these medications are effective, for a time anyway, but not without drawbacks.
The most used are benzodiazepines: short half-lives for insomnia to fall asleep, medium or long half-lives in the maintenance insomnia.
The risks of chronic benzodiazepine use are now well known, they are however less if the dose is low, and use batch can avoid dependency. In severe or organic insomnia, continued treatment may be considered, however, it must then weigh the risk / benefit and use the minimum effective dose. Prescription is a half dose in the elderly.
The non-benzodiazepine benzodiazepine receptor ligands are used mainly in sleep onset insomnia, regardless of their cause, with similar rules although the risks are lower.
Antidepressants are not only used for depressed, some of which can advantageously replace benzodiazepines especially in drug-seeking patients or help with withdrawal in benzodiazepine.
Prevention:
Preventing insomnia passes through a sleep learning. Sleep, instinctual behavior, works with innate common data to the species, but also depends on how the parents weave the child’s ties to sleep during the weaning period, characterized by change of sleeping distribution in nycthémère.
This learning is directly related to the quality of the parent-child relationship, but also the psychological structure of the adult and his own relationship with sleep. The adult must fearlessly by exorcising the fear of separation, hatred, death wishes, agree to let the child fall asleep, sleep up around the halo of pleasure, passing him the opportunity to find himself sleeping and tranquility.
We must learn to find peace within himself to agree to drift off to sleep.