Medical conditions, sleep disturbance

Avoid medications that may cause sleep disturbance Optimise treatment of conditions that may contribute to insomnia... 

Although we are focusing on the primary sleep disorders, sleep disturbance quite often occurs as a symptom of another illness. Depression, anxiety, and substance abuse can impair the quality of sleep, though in the setting of chronic insomnia, other psychiatric disorders account for less than 50% of cases. Nightmares are a frequent complication of post-traumatic stress disorder (PTSD), and pain, endocrine conditions, and a host of medical illnesses can produce sleep problems. Thus, when discussing insomnia or hypersomnia, we are well advised to remember that these can be either a symptom of a psychiatric syndrome, a medical illness, or a sleep disorder. 

The diagnosis of depression still rests primarily on the clinical interview. Major depressive disorder (MDD) is characterized by depressed mood most of the time for at least 2 weeks and/or loss of interest or pleasure in most activities. In addition, depression is characterized by disturbances in sleep and appetite as well as deficits in cognition and energy. Thoughts of guilt, worthlessness, and suicide are common. Coronary artery disease, diabetes, and stroke appear to be more common in depressed patients, and depression may considerably worsen the prognosis for patients with a variety of comorbid medical conditions. 

Insomnia secondary to a general medical condition, especially with pain- or sleep-disordered breathing Circadian rhythm disturbance Periodic limb movement disorder Restless legs syndrome... 

Medical conditions based in nearly all physiological systems can produce coincident sleep disturbances and sleep deprivation. This includes disorders of the cardiovascular (chronic heart failure), pulmonary (asthma), gastrointestinal (hepatic failure), renal (urinary tract infections, polyuria), endocrine (diabetes, hypothyroidism, hyperthyroidism), and neurological (Parkinson s disease,... 

Using a conceptual model such as that presented here (Fig. 1) could facilitate the diagnosis and appropriate treatment of sleep disturbances in a number of different medical disorders. This may ultimately result in improvements in daytime functioning, quality of life, and better management of the primary medical condition. 

A sleep disorder that is not endogenous or due to a medical condition or substance-related condition is categorized as not otherwise specified. Restless leg syndrome and periodic limb movements are two sleep disturbances that do not meet criteria for any of the other sleep disorders. 

A 10-year-old boy with ADHD, oppositional defiant disorder, and generalized and separation anxiety disorders started taking OROS methylphenidate 18 mg/day and fluoxetine 10 mg/day. Four days later, he had an acute episode of intense hallucinations 3 hours after taking the medications. His mother reported that the visual hallucinations lasted about 1 hour and the tactile hallucinations more than 2 hours. Two days later he had a similar episode. His mother withdrew the medications for 10 days, during which time he was symptom free. When OROS methylphenidate 18 mg/day monotherapy was restarted he did not report any hallucinations. Mirtazapine 15 mg/day was added for symptoms of anxiety and sleep disturbances. During the next 2 months his condition improved and he had no further hallucinations. 

Insomnia is characterized as being primary where there is no obvious medical or psychiatric cause. It is a common clinical problan wherein 10-20% of people have chronic insomnia, characterized by trouble sleeping more than three nights a week. It has been directly linked to numerous impacts on individuals such as daytime fatigue, inattention, irritability, poor mood, and reduced energy levels. Consequently, they have reduced productivity, higher woik absenteeism, and an increased risk of depression or substance abuse. There is also a greater risk of traffic and woik-related accidents. Furthermore, studies have shown direct links between circadian rhythm disturbance and an increased risk in health problems, such as diabetes, metabolic disorders and depression. Insomnia is considered secondary if it is caused by external factors such as health conditions, for example, cancer, heart problems, depression, asthma, arthritis, or pain, or as a side effect of medication, or a substance, such as alcohol. 

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