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Primary Insomnia: How to Manage It Effectively

Primary insomnia is quite common. The International Classification of Sleep Disorders defines primary insomnia as a syndrome that includes psychophysiological insomnia, paradoxical insomnia, and idiopathic insomnia. Primary insomnia is defined as difficulty falling asleep (sleep onset insomnia), difficulty staying asleep (mid-sleep awakening, early morning awakening), or chronic non-restorative sleep that lasts more than three weeks despite adequate sleep opportunity and results in impaired daytime functioning. There are no known psychiatric disorders, medical conditions, or substance use disorders that explain primary insomnia. Primary insomnia is a non-organic sleep disorder with an unknown aetiology that primarily affects middle-aged females. Recent research points to the hyperarousal hypothesis of primary insomnia. Non-restorative sleep may be excluded from the definition of primary insomnia in the near future.

10% to 40% of adults have intermittent insomnia, and 15% have long-term sleep problems. This article examines the classification, differential diagnosis, and treatment options for insomnia. OVID and the key words “insomnia,” “sleeplessness,” “behaviour modification,” “herbs,” “medicinal,” and “pharmacologic therapy” were used in a MEDLINE search. Articles were chosen for their relevance to the topic. A careful sleep history, review of medical history, review of medication use (including over-the-counter and herbal medications), family history, and screening for depression, anxiety, and substance abuse are all part of the evaluation of insomnia. Treatment should be tailored to the nature and severity of the symptoms. When compared to drug therapies, nonpharmacologic treatments are more effective and have fewer side effects. Initially, medications like diphenhydramine, doxylamine, and trazodone can be used, but patients may not tolerate their side effects. Newer medications with short half-lives and few side effects include zolpidem and zaleplon. Both are approved for short-term use in the treatment of insomnia.

Many people have trouble sleeping. According to a Gallup poll conducted in 1995, 49% of adults were dissatisfied with their sleep at least 5 nights per month.

1 According to population-based studies, 10% to 40% of American adults have intermittent insomnia, and 10% to 15% have long-term sleep problems.

2 Insomnia has been linked to decreased work performance as well as an increase in motor vehicle accidents and hospitalisation rates.

3 The annual cost of lost productivity and insomnia-related accidents is estimated to be more than $100 billion.

4 The goal of this review is to provide a current overview of insomnia classification, differential diagnosis, and treatment options. OVID and the key words “insomnia,” “sleeplessness,” “behaviour modification,” “herbs,” “medicinal,” and “pharmacologic therapy” were used in a MEDLINE search. Two of the authors reviewed the abstracts (ENR, SLP). The articles were then chosen based on their relevance to the topical review.

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Insomnia is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)5 as a complaint about the quantity, quality, or timing of one’s sleep at least three times per week for at least one month. Sleep is classified into two types: rapid eye movement (REM) sleep and non-REM sleep. Non-REM sleep is divided into four stages, each of which gets progressively deeper. Stages 3 and 4, deep restorative sleep, are also referred to as slow wave sleep. Reduced time spent in stages 3 and 4 reduces sleep quality. REM sleep is the fifth stage of sleep. 6 According to research, insomnia is defined as a sleep latency (time taken to fall asleep) greater than 30 minutes, a sleep efficiency (time asleep/time in bed) less than 85%, or a sleep disturbance occurring more than three times per week.

Insomnia is classified as a dyssomnia by the International Classification of Sleep Disorders.

8 Insomnia (difficulties initiating or maintaining sleep) and excessive sleep are examples of dyssomnias (hypersomnia). Several insomnia-related complaints are difficult to categorise. Patients with sleep state misperception insomnia complain of not sleeping for an extended period of time despite no objective evidence of difficulty sleeping. Some patients sleep less because of work or social obligations (self-imposed short total sleep time), while others sleep less because they are naturally short sleepers and require less sleep.

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