Insomnia

Insomnia means having trouble sleeping at night, staying asleep, or both. It's one of the most common sleep disorders. One night of poor sleep doesn’t mean you’re living with insomnia.  Episodes of insomnia that last a few days at a time are called short-term (acute) insomnia. Ongoing (chronic) insomnia is often diagnosed when you have ongoing problems with sleep.  An insomnia or sleep disorder diagnosis requires these sleep troubles to also cause daytime impairments, such as sleepiness or difficulty concentrating that is affecting your daily life.  A further workup from sleep medicine or other provider may be warranted but ask Andrea about options today. 

Insomnia is listed as a sleep-wake disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, revised text (DSM-5-TR). The condition has three primary symptoms.

• Challenges falling asleep (onset insomnia): inability to fall asleep beyond 20-30 minutes

• Inability to maintain sleep (middle insomnia): frequent waking during the night after sleep onset beyond 20-30 minutes, and difficulty returning to sleep after midnight waking

• Early-morning wakefulness (late insomnia): waking at least 30 minutes before the desired time and before sleep reaches 6.5 hours (often accompanied by an inability to resume sleep at all)

While only these symptoms are present in the DSM-5-TR for insomnia, how those symptoms are present and how long you experience them are important for determining whether you have the condition.

Because not everyone requires the same amount of sleep, Andrea will consider what your ideal sleep duration may be, based on factors such as your past sleep history, age, and activity level.

Under a DSM-5-TR insomnia diagnosis, insomnia sleep disturbances are those that impact your daily function and negatively affect you socially, occupationally, or in other important areas of life.

The primary symptoms will involve at least one of the following:

1. difficulty falling asleep

2. challenges maintaining sleep

3. inability to fall back asleep after an early morning wake up

These three symptoms define an insomnia diagnosis, regardless of type. How those symptoms manifest in your daily life is often unique.

You may experience:

• daytime sleepiness

• fatigue

• irritability

• mood fluctuations

• declining work or school performance

• difficulty concentrating

• lack of focus

• memory lapses

• erratic sleep schedules

• excessive napping

• spending more time in bed

• preoccupation with being unable to sleep

• decreased energy

• anxiety

• depression

• emotional reactivity

• muscle pain

• headache

• gastrointestinal upset

Several factors can influence how insomnia affects your thoughts and actions. If you’re living with insomnia disorder and major depressive disorder, for example, you may find symptoms of low mood are more prevalent for you.

Not everyone shows symptoms that directly reflect the severity of sleep disturbance.

You may experience insomnia for years, most nights of the week, but outwardly show minimal signs to those around you.

Other sleep disorders

The DSM-5-TR lists several sleep disorders in addition to insomnia. This includes:

• hypersomnolence disorder

• narcolepsy

• obstructive sleep apnea hypopnea

• central sleep apnea

• sleep-related hypoventilation

• circadian rhythm sleep-wake disorders

• non-rapid eye movement sleep arousal disorders

• nightmare disorder

• rapid eye movement sleep behavior disorder

• restless legs syndrome

• substance or medication-induced sleep disorder

• parasomnias

• other or unspecified sleep disorder

All these sleep disorders have their own criteria that set them apart from insomnia. A further workup may be warranted to fully diagnose and treat these. Ask Andrea about options.

Andrea conducts a thorough psychiatric diagnostic evaluation during your ADHD screening. She reviews your medical and mental health history, as well as your family history. She also asks about your childhood, academic performance, work, and social interactions, looking for symptoms of ADHD.

Additionally, she has you complete a symptom rating scale.

Andrea uses the information gathered during your evaluation and screening to develop a diagnostic impression and determine whether you meet the criteria for an ADHD diagnosis. Sometimes a neuropsychological evaluation with formal testing is required; patients would be referred out to a specialist for that.

New Patient Intake/Diagnostic Evaluation appointments are typically 60-75 minutes long.

Follow up visits are 15-25 minutes.

There are a variety of ways to improve your sleep habits to improve your sleep issues.  Healthy sleep habits are the basis for a restorative sleep.  You can take steps to improve your sleep habits. First, make sure that you give yourself enough time to sleep. With enough sleep each night, you may find that you're happier and more productive during the day.

To improve your sleep habits, it also may help to:

• Make your bedroom sleep friendly. Sleep in a cool, quiet, dark place. Avoid watching TV or looking at electronic devices, as the light from these sources can disrupt your sleep-wake cycle.

• Go to sleep and wake up around the same time each day, even on the weekends. If you can, avoid night shifts, a schedule that changes, or other things that may disrupt your sleep schedule. This can be challenging for new parents or shift workers. Learn more tips to help you get good-quality sleep and prevent problems over time.

• Avoid caffeine, nicotine, and alcohol close to your bedtime. Although alcohol can make it easier to fall asleep, it can cause you to have a sleep that tends to be lighter than normal. This makes it more likely that you will wake up during the night.

• Get regular physical activity during the daytime (at least 5 to 6 hours before going to bed). Exercising close to bedtime can make it harder to fall asleep.

• Avoid naps, especially in the afternoon. This may help you sleep longer at night.

• Eat meals on a regular schedule and avoid late-night dinners.

• Limit how much fluids you drink close to bedtime. This may help you sleep longer without having to use the bathroom.

• Learn new ways to manage stress. Follow a routine that helps you wind down and relax before bed. For example, read a book, listen to soothing music, or take a hot bath.

Andrea Skrocki may also recommend other ways to relax, including massage therapy, meditation, or yoga. 

Talk to Andrea about over the counter and prescription medicines that may disrupt your sleep (for example, some cold and allergy medicines).

Therapies

Light therapy

Light therapy involves sitting in front of a light box, which produces bright light similar to sunlight. Light visors and light glasses may also be effective. Light therapy may help adjust the amount of melatonin your body needs to make to reset your sleep-wake cycle.

Orofacial therapy

Exercises for your mouth and facial muscles, also called orofacial therapy, may help treat sleep apnea in children and adults. This therapy helps improve the position of your tongue and strengthens the muscles that control your lips, tongue, upper airway, and face.

Cognitive behavioral therapy for insomnia (CBT-I)

CBT-I is a 6- to 8-week treatment plan to help you learn how to fall asleep faster and stay asleep longer. This is usually recommended as the first treatment option for long-term insomnia and can be very effective.

Medicines

If you are having trouble falling asleep or staying asleep and improving your sleep habits and other therapies have not helped, Andrea can talk to you about medicines to help you sleep. Many of these medicines have side effects and should not be taken long term.

Prescription medicines

Some prescription medicines used to treat other health conditions can also increase your risk of developing sleep conditions.

• Benzodiazepine receptor agonists are medicines such as zolpidem, zaleplon, and eszopiclone. Side effects may include anxiety. Rare side effects may include having severe allergic reactions or doing activities while asleep such as walking, eating, or driving.

• Melatonin receptor agonists are medicines such as ramelteon. Side effects can include dizziness and fatigue. Some people experience the rare side effects of doing activities while they are asleep, like walking, eating, or driving; or they may have severe allergic reactions.

• Orexin receptor antagonists such as suvorexant are not recommended for people who have narcolepsy. Rare side effects may include doing activities while asleep such as walking, eating, or driving; or not being able to move or speak for several minutes while going to sleep or waking up.

• Benzodiazepines may be prescribed for insomnia if other treatments and medicines have not worked. Talk to Andrea about the side effects of these medicines, which can include dizziness, confusion, and muscle weakness. Benzodiazepines can also interact dangerously with other medicines. They can be habit-forming and should be taken for only a few weeks.

Off-label medicines

• In some cases, healthcare providers may prescribe medicines that are commonly used for other health conditions but are not approved by the U.S. Food and Drug Administration (FDA) to treat insomnia. Some of these medicines include antidepressants, antipsychotics, and anticonvulsants.

• Over the counter (OTC) medicines and supplements

Make sure to tell Andrea about any OTC products that you are taking.

• OTC products that contain antihistamines are sold as sleep aids. Although these products might make you sleepy, talk to your provider before taking them, as antihistamines can be unsafe for some people.

• Melatonin supplements are lab-made versions of the sleep hormone melatonin. Many people take melatonin supplements to improve their sleep. These supplements are not regulated by the U.S. Food and Drug Administration like medicines. Because of this, the dose and purity of these supplements can vary between brands. Talk with Andrea about how to find safe, effective melatonin supplements, and about possible side effects or medicine interactions, especially if you are pregnant or trying to become pregnant. Side effects of melatonin may include excess sleepiness, headaches, high blood pressure, low blood pressure, stomach upsets, and worsening symptoms of depression.

Devices

Continuous positive airway pressure (CPAP)

• CPAP is a device that uses mild air pressure to keep your airways open while you sleep. A CPAP machine includes a mask that fits over your nose or your nose and mouth with straps that position the mask. It also includes a tube that connects the mask to the machine’s motor and a motor that blows air into the tube.

Oral devices

• Oral devices are devices that you wear in your mouth while you sleep. These are often custom-made by a dentist or orthodontist (a dentist who specializes in correcting teeth or jaw problems) to fit your mouth or jaw. Oral devices hold your jaw or tongue in a position that helps keep your airway open. You may need an oral device if you have mild sleep apnea or if your apnea happens only when you are lying on your back. If you have sleep apnea, your primary care provider may prescribe an oral device if you do not want to use CPAP or cannot tolerate CPAP.

There are two types of oral devices that work differently to open the upper airway while you sleep. Some hybrid devices have features of both types.

1. Mandibular advancement devices cover the upper and lower teeth and hold the jaw in a position that prevents it from blocking the upper airway.

2. Tongue retaining devices are mouthpieces that hold the tongue in a forward position to prevent it from blocking the upper airway.

Procedures

For the treatment of sleep apnea, if a CPAP or other oral devices do not work, you may need surgery.

• Adenotonsillectomy surgery removes the tonsils and adenoids.

• Surgery to place an implant may help monitor your breathing patterns and control certain muscles that open your airways during sleep. Other types of implants, called nerve stimulators, can help control your tongue muscles while you sleep. This helps prevent your tongue from blocking your airway.

• Surgery to remove some soft tissue from your mouth and throat can make your upper airway bigger.

• A maxillary or jaw advancement surgery moves your upper jaw (maxilla) and lower jaw (mandible) forward. This helps make your upper airway bigger.

As you can see, there are many ways to treat and improve sleep.  Don’t suffer, or make your partner suffer by your poor sleep.  Talk with Andrea about options today. 

Psychopharmacological genetic testing (PGT) can be order and is covered by some insurance carriers to determine how you metabolize certain medications. This can be helpful if you have failed or had serious side effects on medications in the past. If you have questions, or want to order this test, ask Andrea for more details.