Insomnia (insomnia)

Insomnia - "repeated violations of initiation, duration, consolidation or quality of sleep, occurring despite the availability of sufficient time and conditions for sleep and manifested by violations of daily activities of various types."

In this definition it is necessary to identify the main features, namely:

• persistent nature of sleep disorders (they occur for several nights);
• the possibility of developing a variety of types of disturbances in the structure of sleep;
• the availability of sufficient time to provide sleep in a person (for example, insomnia can not be considered a lack of sleep in the intensively working members of an industrial society);
• occurrence of disturbances in daytime functioning in the form of decreased attention, mood, daytime sleepiness, vegetative symptoms, etc.

[1]

Epidemiology of insomnia

Insomnia is the most common sleep disorder, its frequency in the general population is 12-22%. The frequency of disturbances in the "sleep-wakefulness" cycle in general and insomnia in particular among neurological patients is very high , although they often go to the background on the background of massive neurological disorders.

The frequency of insomnia in certain neurological diseases. See also: Sleep and other diseases

Diseases	Frequency of sleep disorders,%
	Subjective	Objective
Stroke (acute period)	45-75	100
Parkinsonism	60-90	Up to 90
Epilepsy	15-30	Up to 90
Headache	30-60	Up to 90
Dementia	15-25	100
Neuromuscular diseases	Up to 50	?

Undoubtedly, insomnia more often develops in older age groups, which is due to both the physiological age-related changes in the sleep-wake cycle and the high prevalence of somatic and neurological diseases that can cause sleep disturbances (arterial hypertension, chronic pain, etc.).

[2], [3], [4], [5], [6], [7]

Causes of insomnia

The causes of insomnia are manifold: stress, neurosis; mental disorders; somatic and endocrine-metabolic diseases; taking psychotropic drugs, alcohol; toxic factors; organic brain damage; syndromes arising in a dream (sleep apnea syndrome, motor disorders in sleep); pain syndromes; external adverse conditions (noise, etc.); shift work; change of time zones; disturbances in sleep hygiene, etc.

[8], [9], [10], [11], [12], [13]

Symptoms of insomnia

The clinical phenomenology of insomnia includes presumptive, intrasomal and post-somnolent disorders.

• Presomnic disorders - the difficulty of starting a dream. The most common complaint is the difficulty of falling asleep; in the long course, pathological rituals of going to sleep, as well as "fear of bed" and fear of "non-occurrence of sleep" can form. The desire to sleep disappears as soon as the patients find themselves in bed: painful thoughts and memories appear, motor activity increases in an effort to find a comfortable posture. The coming drowsiness is interrupted by the slightest sound, by the physiological myoclonias. If falling asleep in a healthy person occurs within a few minutes (3-10 minutes), in patients it is sometimes delayed up to 2 hours or more. In a polysomnographic study, a significant increase in the time of falling asleep, frequent transitions from the first and second stages of the first cycle of sleep to wakefulness are noted.
• Intrasomatic disorders include frequent nocturnal awakenings, after which the patient can not sleep for a long time, and sensations of superficial sleep. Awakenings are caused both by external (primarily noise) and internal factors (intimidating dreams, fears and nightmares, pain and vegetative shifts in the form of breathing disorders, tachycardia, increased motor activity, urge to urinate, etc.). All these factors can awaken healthy people, but in patients the threshold of awakening is sharply reduced and the process of falling asleep is difficult. Reduction in the threshold of awakening is largely due to insufficient depth of sleep. Polysomnographic correlates of these sensations are an increased representation of superficial sleep (stages I and II of the FMS), frequent awakenings, long periods of wakefulness within the dream, reduction of deep sleep (δ-sleep), an increase in motor activity.
• Postmodern disorders (arising in the immediate period after awakening) - early morning awakening, decreased efficiency, a sense of "brokenness", dissatisfaction with sleep.

Forms of insomnia

In everyday life, the most common cause of sleep disorders - adaptive insomnia - is a sleep disorder that occurs when acute stress, conflict, or environmental changes occur. As a result of these factors, the overall activity of the nervous system increases, making it difficult to enter into sleep at nightfall or nightly awakenings. With this form of sleep disorders, you can determine with great certainty the cause that caused it. The duration of the adaptive insomnia does not exceed 3 months.

If sleep disturbances persist for a longer period, they are joined by psychological disorders (most often, the formation of a "fear of sleep"). At the same time, the activation of the nervous system increases in the evening hours, when the patient tries to "force" himself to fall asleep more quickly, which leads to aggravation of sleep disturbances and worsening anxiety the next evening. This form of sleep disorders is called psychophysiological insomnia.

A special form of insomnia is pseudo-insomnia (formerly called a distorted perception of sleep, or sleep agnosia) in which the patient claims to be completely awake, but objective research confirms that he has enough sleep (6 hours or more). Pseudo-insomnia is caused by a disturbance in the perception of one's own sleep, associated primarily with the peculiarities of the sense of time at night (periods of wakefulness at night are well remembered, and sleep periods, on the contrary, are amnesed), and fixation on their own health problems associated with sleep disorders.

Insomnia can develop and against the background of inadequate sleep hygiene, that is, the characteristics of human life, which lead to increased activation of the nervous system (drinking coffee, smoking, physical and mental stress in the evening), or conditions that prevent the onset of sleep (stacking at different times of the day , the use of bright light in the bedroom, uncomfortable for the sleeping environment). Similar to this form of sleep disturbance, behavioral insomnia of childhood, caused by the formation in children of incorrect associations associated with sleep (for example, the need to fall asleep only with motion sickness), and when trying to eliminate or correct them, there is an active resistance of the child, leading to a reduction in sleep time.

Of the so-called secondary (associated with other diseases) sleep disorders, insomnia is most frequently observed in disorders of the psychic sphere (in the old way - in diseases of the neurotic circle). In 70% of patients with neuroses, there are disorders of initiation and maintenance of sleep. Often, sleep disturbance is the main symptom-forming factor, because of which, according to the patient, numerous vegetative complaints (headache, fatigue, visual impairment, etc.) develop and social activity is limited (for example, they think that they can not work , since they do not get enough sleep). Particularly great is the role in the development of insomnia anxiety and depression. Thus, with various depressive disorders, the frequency of disturbances in night sleep reaches 100% of cases. Polysomnographic correlates of depression are considered shortening of the latent period of FBS (<40 min - hard, <65 min - "democratic" criterion), decrease in the duration of δ-sleep in the first cycle of sleep, a-δ-sleep. Increased anxiety is most often manifested by presumptive disorders, and as the disease progresses - and intrasomnicheskimi and postsomnicheskim complaints. Polysomnographic manifestations with high anxiety are non-specific and are determined by prolonged sleep, an increase in surface stages, motor activity, waking time, a decrease in the duration of sleep, and deep stages of slow sleep.

Complaints on sleep disorders are also very common in patients with somatic diseases, such as hypertension, diabetes, etc.

A special form of insomnia are sleep disorders associated with a disorder of the biological rhythms of the body. At the same time, the "internal clock", giving a signal for the onset of sleep, provides preparation for the onset of sleep either too late (for example, at 3-4 hours of the night), or too early. Accordingly, at the same time, either falling asleep when a person tries unsuccessfully to fall asleep at a socially acceptable time, or a morning awakening that comes too early in the time of the day (but at the "right" time according to the internal clock) is violated accordingly. A common case of sleep disturbance due to a disorder of biological rhythms is the "reactive retardation syndrome" - insomnia, which develops with rapid movement through several time zones in one direction or another.

[14], [15], [16]

The course of insomnia

With the flow, acute (<3 weeks) and chronic (> 3 weeks) insomnia are isolated. Insomnia lasting less than 1 week is called transient. Chronization of insomnia is promoted by persistence of stress, depression, anxiety, hypochondriacal setting, alexithymia (difficulty of differentiation and description of one's own emotions and sensations), irrational use of hypnotic drugs.

Consequences of insomnia

Isolate the social and medical consequences of insomnia. The first have a great public sound, primarily in connection with the problem of daytime sleepiness. This concerns, in particular, the problem of driving vehicles. It is shown that the effect on concentration of attention and reaction speed is 24 hours sleep deprivation equivalent to a 0.1% alcohol concentration in the blood (the intoxication state is confirmed at a blood ethanol concentration of 0.08%). The medical consequences of insomnia are being actively studied at the present time. It is shown that insomnia is associated with psychosomatic diseases - arterial hypertension, chronic gastritis, atopic dermatitis, bronchial asthma, etc. The effect of lack of sleep in the children's population is especially pronounced: first of all, in the form of impaired ability to learn and behave in the team.

[17], [18], [19], [20], [21], [22], [23], [24]

Diagnosis of insomnia

The basic principles of diagnosing insomnia are as follows: an evaluation of the individual chronobiological stereotype of a person (owl / lark, short / long-lasting), which is probably genetically determined; accounting of cultural characteristics (siesta in Spain), professional activities (night and shift work); study of the features of the clinical picture, the data of psychological research, the results of polysomnography; assessment of concomitant diseases (somatic, neurological, mental), toxic and medicinal effects.

[25], [26], [27], [28], [29], [30], [31], [32], [33]

Treatment of insomnia

Non-medicinal treatments for insomnia include observing sleep hygiene, psycho-, phototherapy (treatment with bright white light), encephalophony ("brain music"), acupuncture, biological feedback, physiotherapy.

An important and integral component of the treatment of any form of insomnia is the observance of sleep hygiene, which implies the following recommendations.

• Go to bed and get up at the same time.
• Exclude daytime sleep, especially in the afternoon.
• Do not drink tea or coffee for the night.
• Reduce stressful situations, mental stress, especially in the evening.
• Organize physical activity in the evening, but no later than 2 hours before bedtime.
• Regularly use water procedures before bedtime. You can take a cool shower (slight cooling of the body is one of the elements of the physiology of falling asleep). In some cases, let's say a warm shower (comfortable temperature) to a feeling of mild muscle relaxation. Use of contrasting water procedures, excessively hot or cold baths is not recommended.

Medicinal insomnia treatment

Ideally, treatment of a disease that causes insomnia, which in most cases is one of the manifestations of a particular pathology, is necessary. Nevertheless, in most cases, the detection of the etiologic factor is difficult or the causes of insomnia in a particular patient are numerous and can not be eliminated. In such cases, it is necessary to limit the appointment of symptomatic therapy, that is, hypnotics. Historically, many drugs of different groups were used as hypnotics: bromides, opium, barbiturates, neuroleptics (mainly phenothiazine derivatives), antihistamines, etc. A significant step in the treatment of insomnia was the introduction into the clinical practice of benzodiazepines - chlordiazepoxide (1960), diazepam (1963) , oxazepam (1965); At the same time, the drugs of this group have a lot of negative effects (addiction, dependence, the need for a constant increase in the daily dose, withdrawal syndrome, aggravation of sleep apnea, loss of memory, attention, reaction time, etc.). In this regard, new sleeping pills have been developed. Widely used drugs group "three Z" - zopiclone, zolpidem, zaleplon (agonists of various subtypes of receptors GABA-ergic receptor postsynaptic complex). Great importance in the treatment of insomnia is given melatonin (melaxen) and melatonin receptor agonists.

The basic principles of medicinal treatment of insomnia are as follows.

• The predominant use of short-lived drugs, such as zaleplon, zolpidem, zopiclone (presented in order of increasing half-life).
• To avoid the formation of addiction and dependence, the duration of prescription of hypnotics should not exceed 3 weeks (optimally - 10-14 days). During this time, the doctor must find out the causes of insomnia.
• Patients of older age groups should be prescribed a half (in relation to patients of middle age) daily dose of hypnotics; it is important to consider their possible interaction with other drugs.
• In the presence of even minimal suspicions of sleep apnea syndrome as a cause of insomnia and the impossibility of its polysomnographic verification, doxylamine and melatonin can be used.
• In the event that subjective dissatisfaction with sleep, the objectively recorded duration of sleep exceeds 6 hours, the use of sleeping pills is unreasonable (psychotherapy is indicated).
• Patients who receive long-term hypnotic drugs should undergo a "medical vacation", which allows to reduce the dose of the drug or replace it (especially in the case of benzodiazepines and barbiturates).
• It is advisable to use sleeping pills on demand (especially preparations of the "three Z" group).

When prescribing hypnotics, neurological patients should consider the following aspects.

• Mainly elderly patients.
• Limited possibilities for the use of agonists of various receptor subtypes of GABA-ergic receptor postsynaptic complex (in diseases caused by muscle pathology and neuromuscular transmission).
• A higher incidence of sleep apnea syndrome (2-5 times greater than in the general population).
• A greater risk of developing side effects of hypnotics (especially benzodiazepines and barbiturates, which often causes complications such as ataxia, mnestic disorders, drug parkinsonism, dystonic syndromes, dementia, etc.).

If insomnia is associated with depression, the use of antidepressants is optimal for the treatment of sleep disorders. Of particular interest are antidepressants that have a hypnotic effect without sedation, in particular, agonists of cerebral melatonin receptors type 1 and 2 (agomelatine).