Friday, January 17, 2014

Lexicon of Madness -- Insomnia


Insomnia: Difficulty initiating or maintaining sleep. Insomnia is a symptom of both depression and anxiety and is common during periods of high stress, although some patients may report no specific stressors or subjective anxiety. Patients should be reassured that they are probably getting more sleep than they realize, and that sleeping for less than 6 hours a day does not have any long-term negative effects. They must practice good sleep hygiene: 1) the sleeping environment must be quiet, dark, and cool; 2) they must rise at the same time each morning, no matter how much sleep they got during the night; 3) they must absolutely avoid any daytime napping; 4) if they fail to fall asleep within 10 minutes of getting into bed, they should rise and perform some boring activity (e.g., folding laundry) until they are tired enough to sleep; 5) the bedroom must be used only for sleeping and sex; 6) there should be no television in the bedroom, and the patient should not engage in any screentime (t.v., texting, computer, etc.) in the hour before bedtime; 7) they should perform a relaxing pre-bedtime ritual (e.g., taking a warm bath, reading, or progressive muscle relaxation); 8) they should avoid "sleeping in" on weekends, instead rising at the same time as during the work week; 9) they should avoid strenuous exercise within 4 hours of bedtime; and, 10) they should avoid caffeine (in all forms, including chocolate), within 6 hours of bedtime. Satisfying sexual activity can help induce sleep, particularly in men. Many cases of insomnia are precipitated by anxiety over uncompleted tasks -- that report you need to write, or that difficult phone call you have been putting off. Completing the unfinished business in your life will help you sleep better. Other cases of insomnia appear to be self-inflicted punishment (sleep deprivation happens to be one of the most common methods of torture). Patients feel guilty about something they have done (or failed to do). They should considering making amends, or if that is not possible, confessing their transgression to a trustworthy, neutral person. If medications such as benzodiazapines or Ambien are prescribed, they should be used for no more than two weeks, because of the risk of tolerance and dependence. "Rebound insomnia" should be expected when these medications are discontinued.

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