Sleep disturbances. Insomnia. Psychophysiological insomnia

Sleep disorders are common. It has been estimated that approximately 10 million Americans have visited a doctor at least once for sleep. Such patients complain of three types of disorders: insomnia, drowsiness during the day, and pathological events occurring in a dream — movements, sensations, or complex behavioral reactions. 

In the international classification of sleep disorders (International Classification of Sleep Disorders – ICSD ) consists of 84 violations. All these disorders are divided into 4 main categories: dissomnia – difficulty falling asleep and maintaining sleep, as well as disorders accompanied by increased drowsiness; parasomnia disorders associated with somatic or mental disorders; imaginary sleep disturbances. To simplify the diagnosis of sleep disorders, this chapter uses the classification adapted from ICSD, based on differential diagnostic criteria.  

Insomnia is defined as the patient’s inability to fall asleep or a feeling of poor sleep. There are three main types of insomnia – psychophysiological insomnia, idiopathic insomnia and impaired awareness (perception of state) of sleep. 

Psychophysiological insomnia

1. The course of psychophysiological insomnia . A patient suffering from psychophysiological insomnia does not sleep enough at night, which interferes with his subsequent daily activity, work or study. Already in the afternoon, he begins to worry about whether he can fall asleep. Lying in bed, he tries to sleep, focusing on his efforts. If the patient goes to bed in an unfamiliar environment, for example, at a party or even in another room of his house, his dream paradoxically improves. Somatized stress associated with the time of falling asleep and the subject of sleep is noted. It is very difficult to conduct differential diagnosis of psychophysiological insomnia and generalized anxiety. In the latter case, anxiety violates all types of daily activity of the patient to a greater extent than his sleep. It should also conduct differential diagnosis with affective disorders. 

2. Treatment and prognosis of psychophysiological insomnia . Most patients require a comprehensive individual approach. Treatment consists of teaching the patient the rules of sleep hygiene, conducting behavioral therapy, and using sleeping pills. Although pharmacological drugs play a significant role in the treatment of insomnia, their use is not the core method in the fight against insomnia. In addition, they are not recommended for long-term use. Treatment includes compulsory sleep hygiene at the same time as behavior correction and sleeping pills for 3-4 weeks. If after such a course of treatment there is no positive dynamics in the patient’s condition, then it is necessary to consult a specialist in sleep problems and conduct night polysomnography. 

Behavioral therapy of psychophysiological insomnia . Four basic principles of sleep hygiene are highlighted. First, the observance of circadian rhythms and the structure of sleep and wakefulness.

Secondly, it is the presence of the correct psychological attitudes to sleep (sleep psychology is often disturbed with age). Thirdly, it is the exclusion of exposure to exogenous factors that can affect sleep – smoking, the use of caffeine (coffee, tea) and alcohol. Fourth, it is the exclusion of factors that can cause awakening.  

Of the methods of behavioral therapy in the treatment of insomnia, the relaxation technique, stimulus control therapy and sleep restriction therapy are most often used. Relaxation methods include progressive muscle relaxation, biological feedback, deep breathing, pharmacological agents, fantasy management and other techniques for controlling cognitive awakening. First, the patient is taught these methods on an outpatient basis, then he should be daily for 20-30 minutes. to do at home, usually before bedtime. Incentive control therapy is considered particularly effective for treating insomnia. The goal of therapy is to create strong associations of the bedroom with the patient’s sleep. 

Therapy of sleep restriction is that every night the patient’s sleep duration is limited to several hours, until the patient learns to use the time allotted to him for sleep. 

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