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INTRODUCTION

Disorders of sleep are among the most common problems seen by clinicians. More than one-half of adults experience at least intermittent sleep disturbances, and 50–70 million Americans suffer from a chronic sleep disturbance.

APPROACH TO THE PATIENT Sleep Disorders

Pts may complain of (1) difficulty in initiating and maintaining sleep (insomnia); (2) excessive daytime sleepiness, fatigue, or tiredness; (3) behavioral phenomena occurring during sleep [sleepwalking, rapid eye movement (REM) behavioral disorder, periodic leg movements of sleep, etc.]; or (4) circadian rhythm disorders associated with jet lag, shift work, and delayed sleep phase syndrome. A careful history of sleep habits and reports from the sleep partner (e.g., heavy snoring, falling asleep while driving) are a cornerstone of diagnosis. Pts with excessive sleepiness should be advised to avoid all driving until effective therapy has been achieved. Completion of a day-by-day sleep-work-drug log for at least 2 weeks is often helpful. Work and sleep times (including daytime naps and nocturnal awakenings) as well as drug and alcohol use, including caffeine and hypnotics, should be noted each day. Objective sleep laboratory recording is necessary to evaluate specific disorders such as sleep apnea and narcolepsy.

INSOMNIA

Insomnia, or the complaint of inadequate sleep, may be subdivided into difficulty falling asleep (sleep onset insomnia), frequent or sustained awakenings (sleep maintenance insomnia), early morning awakenings (sleep offset insomnia), or persistent sleepiness/fatigue despite sleep of adequate duration (nonrestorative sleep). An insomnia complaint lasting one to several nights is termed transient insomnia and is typically due to situational stress or a change in sleep schedule or environment (e.g., jet lag). Short-term insomnia lasts from a few days up to 3 weeks; it is often associated with more protracted stress such as recovery from surgery or short-term illness. Long-term (chronic) insomnia lasts for months or years and, in contrast to short-term insomnia, requires a thorough evaluation for underlying causes. Chronic insomnia is often a waxing and waning disorder, with spontaneous or stress-induced exacerbations.

All insomnias can be exacerbated and perpetuated by behaviors that are not conducive to initiating or maintaining sleep. Inadequate sleep hygiene is characterized by a behavior pattern prior to sleep, and/or a bedroom environment, that is not conducive to sleep. In preference to hypnotic medications, the pt should attempt to avoid stressful activities before bed, reserve the bedroom environment for sleeping, and maintain regular rising times.

Adjustment Insomnia (Acute Insomnia)

Acute insomnia can occur after a change in the sleeping environment (e.g., in an unfamiliar hotel or hospital bed) or before or after a significant life event or anxiety-provoking situation. Treatment is symptomatic, with intermittent use of hypnotics and resolution of the underlying stress.

Psychophysiologic Insomnia

These pts are preoccupied with a perceived inability to sleep adequately at night. Rigorous attention should be paid ...

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