Chapter 028. Sleep Disorders (Part 7) Psychophysiologic Insomnia Persistent psychophysiologic insomnia is a behavioral disorder in which patients are preoccupied with a perceived inability to sleep adequately at night. This sleep disorder begins like any other acute insomnia; however, the poor sleep habits and sleep-related anxiety ("insomnia phobia") persist long after the initial incident. Such patients become hyperaroused by their own efforts to sleep or by the sleep environment, and the insomnia becomes a conditioned or learned response. Patients may be able to fall asleep more easily at unscheduled times (when not trying) or outside the home environment. Polysomnographic recording in patients with psychophysiologic insomnia reveals an objective sleep disturbance, often with an abnormally long sleep latency; frequent nocturnal awakenings; and an increased amount of stage 1 transitional sleep. Rigorous attention should be paid to improving sleep hygiene, correction of counterproductive, arousing behaviors before bedtime, and minimizing exaggerated beliefs regarding the negative consequences of insomnia. Behavioral therapies are the treatment modality of choice, with intermittent use of medications. When patients are awake for >20 min, they should read or perform other relaxing activities to distract themselves from insomnia-related anxiety. In addition, bedtime and wake time should be scheduled to restrict time in bed to be equal to their perceived total sleep time. This will generally produce sleep deprivation, greater sleep drive, and, eventually, better sleep. Time in bed can then be gradually expanded. In addition, methods directed towards producing relaxation in the sleep setting (e.g., meditation, muscle relaxation) are encouraged. Adjustment Insomnia (Acute Insomnia) This typically develops after a change in the sleeping environment (e.g., in an unfamiliar hotel or hospital bed) or before or after a significant life event, such as a change of occupation, loss of a loved one, illness, or anxiety over a deadline or examination. Increased sleep latency, frequent awakenings from sleep, and early morning awakening can all occur. Recovery is generally rapid, usually within a few weeks. Treatment is symptomatic, with intermittent use of hypnotics and resolution of the underlying stress. Altitude insomnia describes a sleep disturbance that is a common consequence of exposure to high altitude. Periodic breathing of the Cheyne-Stokes type occurs during NREM sleep about half the time at high altitude, with restoration of a regular breathing pattern during REM sleep. Both hypoxia and hypocapnia are thought to be involved in the development of periodic breathing. Frequent awakenings and poor quality sleep characterize altitude insomnia, which is generally worse on the first few nights at high altitude but may persist. Treatment with acetazolamide can decrease time spent in periodic breathing and substantially reduce hypoxia during sleep. Comorbid Insomnia Insomnia Associated with Mental Disorders Approximately 80% of patients with psychiatric disorders describe sleep complaints. There is considerable heterogeneity, however, in the nature of the sleep disturbance both between conditions and among patients with the same condition. Depression can be associated with sleep onset insomnia, sleep maintenance insomnia, or early morning wakefulness. However, hypersomnia occurs in some depressed patients, especially adolescents and those with either bipolar or seasonal (fall/winter) depression (Chap. 386). Indeed, sleep disturbance is an important vegetative sign of depression and may commence before any mood changes are perceived by the patient. Consistent polysomnographic findings in depression include decreased REM sleep latency, lengthened first REM sleep episode, and shortened first NREM sleep episode; however, these findings are not specific for depression, and the extent of these changes varies with age and symptomatology. Depressed patients also show decreased slow-wave sleep and reduced sleep continuity. In mania and hypomania, sleep latency is increased and total sleep time can be reduced. Patients with anxiety disorders tend not to show the changes in REM sleep and slow-wave sleep seen in endogenously depressed patients. Chronic alcoholics lack slow-wave sleep, have decreased amounts of REM sleep (as an acute response to alcohol), and have frequent arousals throughout the night. This is associated with impaired daytime alertness. The sleep of chronic alcoholics may remain disturbed for years after discontinuance of alcohol usage. Sleep architecture and physiology are disturbed in schizophrenia (with a decreased amount of stage 4 sleep and a lack of augmentation of REM sleep following REM sleep deprivation); chronic schizophrenics often show day-night reversal, sleep fragmentation, and insomnia. . Chapter 028. Sleep Disorders (Part 7) Psychophysiologic Insomnia Persistent psychophysiologic insomnia is a behavioral. show decreased slow-wave sleep and reduced sleep continuity. In mania and hypomania, sleep latency is increased and total sleep time can be reduced. Patients with anxiety disorders tend not to. in bed to be equal to their perceived total sleep time. This will generally produce sleep deprivation, greater sleep drive, and, eventually, better sleep. Time in bed can then be gradually expanded.