What is insomnia?

Insomnia can be categorized as primary and secondary according to its cause.

1. Primary insomnia

There is usually a lack of a clear cause of insomnia, or insomnia symptoms remain after the exclusion of possible causes of insomnia, including psychophysiological insomnia, idiopathic insomnia and subjective insomnia of three types. The diagnosis of primary insomnia lacks specific indicators and is mainly a diagnosis of exclusion. When the causes of insomnia are excluded or cured, the remaining insomnia symptoms can be considered as primary insomnia. Psychophysiological insomnia in the clinical found that its etiology can be traced to a certain or long-term events on the patient's brain limbic system function stability, limbic system function imbalance ultimately led to the brain sleep function disorders, insomnia occurs.

2. Secondary insomnia

Includes insomnia caused by somatic diseases, mental disorders, drug abuse, and insomnia related to sleep breathing disorders and sleep movement disorders. Insomnia often occurs simultaneously with other diseases, and sometimes it is difficult to determine the causal relationship between these diseases and insomnia, so in recent years, the concept of *** disease insomnia (comorbid insomnia) was proposed to describe those insomnia that accompanies other diseases at the same time.

Treatment

1. Overall goals

To clarify the cause of the disease as much as possible, and to achieve the following goals:

(1) to improve the quality of sleep and/or to increase the effective duration of sleep;

(2) to restore social functioning and to improve the patient's quality of life;

(3) to reduce or eliminate the risk of insomnia-associated somatic disorders or of somatic disease*** risk of disease;

(4) avoiding the negative effects of pharmacologic interventions.

2. Intervention methods

Intervention measures for insomnia mainly include pharmacological and non-pharmacological treatments. For patients with acute insomnia, it is advisable to apply medication at an early stage. For patients with subacute or chronic insomnia, whether primary or secondary, the application of medication should be supplemented with psycho-behavioral therapy, even for those who have been taking sedative hypnotic drugs for a long time. Effective psycho-behavioral treatments for insomnia are mainly cognitive behavioral therapy (CBT-I).

Currently, there is a relative lack of professional resources to engage in psycho-behavioral therapy in China, and there are not many people with professional qualifications in this area, and the use of CBT-I will also face compliance problems, so the drug interventions are still dominant in the treatment of insomnia. Non-pharmacological treatments other than psycho-behavioral treatments, such as diet therapy, aromatherapy, massage, homeopathy, light therapy, etc., lack convincing large-sample controlled studies. Traditional Chinese medicine has a long history of treating insomnia, but is confined to a special individualized medical model that makes it difficult to be evaluated using modern evidence-based medical models. The importance of sleep health education, i.e., psycho-behavioral therapy, medication and traditional medicine treatment based on the establishment of good sleep hygiene habits, should be emphasized.

3. Pharmacologic treatment of insomnia

Although there is a wide variety of drugs with hypnotic effects, the main purpose of most of them is not to treat insomnia. Antihistamines (e.g., diphenhydramine), melatonin, and valerian extract, although hypnotic, have limited clinical evidence and should not be used routinely for insomnia. Alcohol (ethanol) should not be used to treat insomnia. Non-benzodiazepines are recommended for general treatment: e.g., eszopiclone, zolpidem, zolpidem controlled-release, zopiclone, etc. Benzodiazepines for the treatment of insomnia are complex and numerous, and include: eszopiclone, flurazepam, quazepam, temazepam, triazolam, alprazolam, alprazolam, and other medications. alprazolam, chlordiazepoxide, diazepam, lorazepam, midazolam, etc. However, because of the potential for dependence, long-term use of these drugs is generally not recommended. Nowadays, such as Ramelteon (ramelteon), Tesmelteon (tasimelteon in phase III clinic), Agomelatin (agomelatin) and various antidepressants are recommended as the first choice of medication for the treatment of insomnia, so it is recommended that you must go to a specialist in the treatment of insomnia, and take the medication according to the prescription issued by the physician.

4. Physical therapy

Repetitive transcranial magnetic stimulation is a new type of non-pharmacological treatment for insomnia, which is a new technology that gives repetitive magnetic stimulation to a specific part of the human skull. Repetitive transcranial magnetic stimulation can affect the stimulation of local and functionally relevant remote cortex function, to achieve regional reconstruction of cortical function, and on the brain neurotransmitters and their transmission, a variety of receptors in different brain regions, including 5-hydroxytryptamine and other receptors and the regulation of neuronal excitability of the expression of genes has a significant impact. It can be combined with drugs to rapidly block the onset of insomnia, and is especially suitable for the treatment of insomnia during breastfeeding in women, especially insomnia caused by postpartum depression.

5. Pharmacological treatment of patients with special types of insomnia

(1) Elderly patients Elderly insomnia patients preferred non-pharmacological treatments, such as sleep hygiene education, with particular emphasis on acceptance of the CBT-I (Class I recommendation). When treatment for the primary disease does not relieve insomnia symptoms or when non-pharmacologic treatment cannot be complied with, pharmacologic treatment can be considered. Non-benzodiazepines or melatonin receptor agonists are recommended for elderly patients with insomnia (Class II recommendation). Caution should be exercised when benzodiazepines must be used. If ****typical dysarthria, confusion, paradoxical movements, hallucinations, or respiratory depression occurs, the medication should be discontinued immediately and managed appropriately, and attention should be paid to the fact that decreased muscle tone caused by the administration of benzodiazepines may lead to accidental injuries such as falls. Elderly patients should start from the smallest effective dose, short-term application or intermittent therapy, do not advocate the administration of large doses of drugs, the use of drugs need to be closely observed in the process of adverse drug reactions.

(2) Pregnant and lactating patients There is a lack of information on the safety of sedative-hypnotic drugs for women during pregnancy, and since zolpidem has no teratogenic effects in animal experiments, it can be taken for a short period of time if necessary (Class IV recommendation). Sedative-hypnotic drugs as well as antidepressants should be used with caution during breastfeeding to avoid the drugs affecting the infant through breast milk, and non-pharmacological interventions are recommended for the treatment of insomnia (Class I recommendation). Existing experiments suggest that transcranial magnetic stimulation is a promising treatment for insomnia during pregnancy and lactation, but the exact effect needs to be further observed in large samples.

(3) Perimenopausal and menopausal patients For perimenopausal and menopausal women with insomnia, common disorders affecting sleep in this age group, such as depressive disorders, anxiety disorders, and sleep apnea syndromes, should be identified and treated first, and necessary hormone replacement therapy should be given according to the symptoms and hormone levels, and the treatment of insomnia in this part of the patient is the same as that for the general adult.

(4) Patients with respiratory diseases Benzodiazepines are used with caution in patients with chronic obstructive pulmonary disease (COPD) and sleep apnea hypoventilation syndrome due to their adverse effects such as respiratory depression. Non-benzodiazepines are highly receptor selective and have a low incidence of next-morning residual effects. Respiratory adverse effects have not been reported in insomniacs with mild to moderate COPD treated with zolpidem and zopiclone in the stabilized phase, but the efficacy of zaleplon in insomniacs with respiratory disorders has not been established.

Elderly patients with sleep apnea can have insomnia as the main complaint, with an increase in complex sleep breathing disorders. The use of short-acting sleep-promoting drugs, such as zolpidem alone, can reduce the incidence of central sleep apnea, and its application along with noninvasive ventilatory therapy can improve compliance and reduce the possibility of inducing obstructive sleep apnea. Benzodiazepines are contraindicated in patients with acute exacerbations of COPD with significant hypercapnia and in the decompensated phase of restrictive ventilatory dysfunction, and can be applied along with mechanical ventilation support (invasive or noninvasive) and closely monitored if necessary. The melatonin receptor agonist ramelteon may be used to treat patients with sleep apnea combined with insomnia, but further studies are needed.

(5) Patients with mental disorders of **** disease Insomnia is often present in patients with mental disorders, and should be treated and controlled by a licensed psychiatrist according to specialty principles, along with the treatment of insomnia symptoms. Depressive disorders are often associated with insomnia *** disease, and should not be treated in isolation so as not to enter a vicious circle of dilemma, the recommended combination of treatments include: ① CBT-I treatment: CBT-I treatment of insomnia at the same time as the application of antidepressants with hypnotic effect (eg, doxepin, amitriptyline, mirtazapine, etc.); ② Antidepressant: antidepressant (single or combination) plus sedative-hypnotic drugs, such as non-benzodiazepine drugs or melatonin receptor agonists (Class III recommendation). It is important to note that the use of antidepressants and hypnotic medications has the potential to exacerbate sleep apnea syndrome and periodic leg movements. In the presence of insomnia in patients with anxiety disorders, anti-anxiety medications are the mainstay, with the addition of sedative-hypnotic medications at bedtime if necessary. Schizophrenic patients with insomnia, should choose antipsychotic drug treatment mainly, if necessary, can be supplemented with sedative hypnotic drugs to treat insomnia.

6. Psycho-behavioral treatment of insomnia

The essence of psycho-behavioral treatment is to change the patient's belief system, to play its self-efficacy, and then improve the symptoms of insomnia. The involvement of a medical professional is often necessary to accomplish this goal. Psychobehavioral treatments work well for adults with primary and secondary insomnia, and typically include sleep hygiene education, stimulus control therapy, sleep restriction therapy, cognitive therapy, and relaxation therapy. These methods are used independently or in combination for the treatment of primary or secondary insomnia in adults

(1) Sleep hygiene education Most insomnia patients have poor sleep habits that disrupt normal sleep patterns and form misconceptions about sleep, leading to insomnia. Sleep hygiene education is mainly to help insomnia patients recognize the important role of bad sleep habits in the occurrence and development of insomnia, analyze and find the reasons for the formation of bad sleep habits, and establish good sleep habits. Generally speaking, sleep hygiene education needs to be carried out at the same time with other psycho-behavioral treatments, and it is not recommended to apply sleep hygiene education as an isolated intervention.

The content of sleep hygiene education includes: ① avoid using excitatory substances (coffee, strong tea or smoking, etc.) a few hours before bedtime (usually after 4:00 p.m.); ② don't drink alcohol before bedtime, as alcohol can interfere with sleep; ③ regular physical exercise, but avoid strenuous exercise before bedtime; ④ don't eat and drink or eat food that is not easy to digest; ⑤ don't do excitable mental work or watch excitatory food at least an hour before bedtime; and ⑤ don't do excitable mental work or watch excitatory food at least an hour before bedtime. Brain work or watch books and film programs that can easily cause excitement; ⑥ bedroom environment should be quiet, comfortable, appropriate light and temperature; ⑦ to maintain a regular work and rest time; ⑧ bed should not be in bed to read, watch TV, eat, etc.; ⑨ before going to bed to have the conditions to wash their feet or take a bath.

(2) relaxation therapy Stress, tension and anxiety are common factors that induce insomnia. Relaxation therapy can alleviate the adverse effects of these factors, and is therefore the most commonly used non-pharmacological therapy for the treatment of insomnia, with the aim of decreasing alertness while in bed and reducing nighttime awakenings. Technique training to reduce arousal and promote nighttime sleep includes progressive muscle relaxation, guided imagery, and abdominal breathing exercises. Patients who plan to perform relaxation training should insist on practicing two to three times a day in a clean, quiet environment, initially under professional supervision. Relaxation therapy can be used as a stand-alone intervention in the treatment of insomnia (level I recommendation).

(3) Stimulus control therapy Stimulus control therapy is a set of behavioral interventions to improve the interaction between the sleep environment and the tendency to sleep (drowsiness), to restore the function of bed rest as a sleep-inducing signal, so that the patient can easily fall asleep, and to re-establish the sleep-wake biological rhythms. Stimulus control therapy can be applied as a stand-alone intervention (Level I recommendation). Specifics: ① go to bed only when there is a desire to sleep; ② if you can't fall asleep after 20 minutes in bed, get up and leave the bedroom, you can engage in some simple activities, and then return to the bedroom to sleep when there is a desire to sleep; ③ don't do activities not related to sleep in bed, such as eating, watching TV, listening to the radio and thinking about complex problems; ④ no matter how much sleep you got in the previous night, keep a regular wake-up time; ⑤ avoid naps in the daytime.

(4) Sleep restriction therapy Many insomniacs attempt to increase the chances of sleep by increasing the bedtime, but it often goes against their wishes and makes the quality of sleep further decline. Sleep restriction therapy improves sleep efficiency by shortening the time spent awake in bed and increasing the drive to fall asleep. The specifics of recommended sleep restriction therapy are as follows (Level II recommendation): ① Reduce bedtime to match actual sleep time and increase bedtime by 15 to 20 minutes only if 1-week sleep efficiency exceeds 85%; ② Reduce bedtime by 15 to 20 minutes when sleep efficiency is below 80%, and keep bedtime unchanged when sleep efficiency is between 80 and 85%; ③ Avoid daytime mini-wakefulness. No change; ③ Avoid daytime naps and keep a regular wake-up time.

(5) Cognitive-behavioral therapy Insomnia patients are often afraid of insomnia itself, overly concerned about the adverse consequences of insomnia, often feel nervous and worried about sleeping well when they are approaching sleep, and these negative emotions make sleep deteriorate further, and the aggravation of insomnia in turn affects the patient's mood, and the two form a vicious circle. The purpose of cognitive therapy is to change the patient's cognitive bias towards insomnia and to change the patient's irrational beliefs and attitudes towards sleep problems. Cognitive therapy is often used in conjunction with stimulus control therapy and sleep restriction therapy to form CBT-I for insomnia. The basic contents of cognitive behavioral therapy: ① Maintain reasonable sleep expectations; ② Don't blame all problems on insomnia; ③ Maintain natural sleep and avoid excessive subjective intention to fall asleep (forcing oneself to sleep); ④ Don't pay too much attention to sleep; ⑤ Don't get frustrated because you didn't sleep well one night; ⑥ Cultivate an awareness of the effects of insomnia CBT-I is usually a combination of cognitive and behavioral therapies (stimulus control therapy, sleep restriction therapy), and can be overlaid with relaxation therapy and supplemented with sleep hygiene education. CBT-I is the core of psycho-behavioral treatment for insomnia (Level I recommendation)

(6) Comprehensive Intervention of Insomnia ①Pharmacological Intervention: Short-term efficacy of pharmacological treatment of insomnia has been confirmed by clinical trials, but it has been shown that the short-term efficacy of pharmacological treatment of insomnia has been improved in some cases. The short-term efficacy of insomnia medication has been confirmed by clinical trials, but long-term application still needs to bear the potential risks of adverse drug reactions, addiction, etc. CBT-I not only has short-term efficacy, but also its efficacy can be maintained for a long period of time in the follow-up observation. CBT-I combined with the application of non-benzodiazepines can gain more advantages, and the latter changed to intermittent treatment can optimize the effect of this combination of treatments. ②Recommended combination therapy (level II recommendation): prefer CBT-I and non-benzodiazepines or melatonin receptor agonists) combination therapy, if the short-term symptoms improve then tapering off the non-benzodiazepines, otherwise change the non-benzodiazepines to intermittent medication, and maintain CBT-I intervention throughout the treatment (level II recommendation).