Dyssomnia

FIGURE 72-1. Algorithm for treatment of dyssomnias. (BZDRA, benzodiazepine receptor agonist CPAP, continuous positive airway pressure.) (Adapted and reprinted with permission from Jermain DM, Sleep disorders. IntJann M, ed. Pharmacotherapy Self-Assessment Program, 2nd ed. Kansas City, MO, American College of Clinical Pharmacy, 1995 139-154.)... 

Symptoms of withdrawal include depression, altered mental status, drug craving, dyssomnia, and fatigue. Duration of withdrawal from methamphetamine ranges from 3 to 24 days, but these individuals are usually not in acute distress. Occurrence of delirium suggests withdrawal from another drug (e.g., alcohol). 

Narcolepsy is sometimes termed a dyssomnia, but whatever classification is used, it essentially represents an intrusion of REM sleep into wakefulness. Narcolepsy is comprised of a quartet of potential symptoms, but only a few individuals exhibit all four narcolepsy symptoms. The most common symptom of narcolepsy is the sleep attack. Sleep attacks consist of an irresistible urge to fall asleep and can occur several times each day. Patients with narcolepsy usually feel refreshed and energized after a 10-20 minute nap however, their sleepiness returns after just a few hours. 

Psychological Factors Affectinq,a,Med, ca,l,Cg,nd Sleep Disorders Dyssomnias... 

The sleep disorders are categorized into primary disorders (i.e., dyssomnias and parasomnias), those related to another mental disorder, those related to a general medical disorder, and those that are substance induced. Like anxiety, disturbances of sleep affect nearly all of us at one time or another. Also like... 

The International Classification of Sleep Disorders lists 88 types, with insomnia the most prominent symptom for many of these (17). Chronic insomnia is the most common sleep problem for which patients consult practitioners (18) and usually reflects psychological/ behavioral disturbances ( 19). Differences in treatment recommendations support the distinction between DSM-IV and the International Classification for Sleep Disorders ( 20). The DSM-IV divides primary disorders into two major groups the dyssomnias (in which the predominant disturbance is the amount, quality, or timing of sleep) and the parasomnias (in which the predominant disturbance is an abnormal event occurring during sleep) (7). 

Dyssomnias consist of problems associated with the amount, quality or timing of sleep, whereas parasomnias involve pathological, behavioral, or psychological events that occur with sleep, specific sleep stages, or sleep-wake transitions (see also Chapter 11). The other two categories usually require treatment of the mental or physical condition that has created the sleep disturbance. For all categories, the short-term use of hypnotics may play a role. 

More evidence is needed to evaluate the use of valerian in children. One study using a combination product of valerian root extract and lemon balm leaf extract found that symptoms of dyssomnia or pathological restlessness might decrease in children under age 12 (27). 

Muller SF, Klement S. A combination of valerian and umun balm is effective in the treatment of restlessness and dyssomnia in children. Phytomedicine 2006 13 383-387. 

A decision analysis for dyssomnias is shown in Figure 71-1. Patients with short-term or chronic insomnia should be evaluated after 1 week of therapy to assess for drug efficacy, adverse effects, and adherence to nonpharmacologic recommendations. Patients should be instructed to keep a sleep diary. The diary requires daily recording of bedtime, wake time, latency of sleep onset, number and duration of awakenings, medication ingestion, naps, and an index of sleep quality. 

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