How is insomnia?

Insomnia can be divided into primary and secondary according to the etiology.

1. Primary insomnia

Usually, there is no clear cause, or insomnia symptoms still exist after the possible causes of insomnia are ruled out, which mainly include three types: psychophysiological insomnia, idiopathic insomnia and subjective insomnia. The diagnosis of primary insomnia lacks specific indicators, mainly exclusive diagnosis. When the symptoms of insomnia still exist after the possible causes of insomnia are eliminated or cured, it can be considered as primary insomnia. Psychophysiological insomnia can be traced back to the influence of a certain or long-term event on the stability of patients' limbic system function, and the imbalance of limbic system function eventually leads to the disorder of brain sleep function and insomnia.

2. Secondary insomnia

Including insomnia caused by physical diseases, mental disorders and drug abuse. And insomnia related to sleep apnea and sleep dyskinesia. Insomnia often occurs simultaneously with other diseases, and sometimes it is difficult to determine the causal relationship between these diseases and insomnia. Therefore, in recent years, the concept of comorbid insomnia has been put forward to describe those insomnia accompanied by other diseases.

treat cordially

1. Overall goal

Make the reasons as clear as possible to achieve the following objectives:

(1) Improve sleep quality and/or increase effective sleep time;

(2) Restoring social function and improving patients' quality of life;

(3) reduce or eliminate the risk of somatic diseases related to insomnia or comorbidity with somatic diseases;

(4) Avoid the negative effects of drug intervention.

2. Intervention methods

Interventions for insomnia mainly include drug treatment and non-drug treatment. For patients with acute insomnia, medication should be taken early. For patients with subacute or chronic insomnia, whether primary or secondary, psychological and behavioral therapy should be supplemented by drug therapy, even those insomnia patients who take sedative and hypnotic drugs for a long time. The effective psychological and behavioral therapy for insomnia is mainly cognitive behavioral therapy (CBT-I).

At present, there are relatively few professional resources that can engage in psychological and behavioral therapy in China, and not many people have professional qualifications in this field. Simply using CBT-I will also face compliance problems, so drug intervention still occupies the dominant position in insomnia treatment. Other non-drug therapies besides psychobehavioral therapy, such as diet therapy, aromatherapy, massage, homeopathy, phototherapy, etc. , lack of convincing large sample control study. Chinese medicine has a long history of treating insomnia, but it is difficult to evaluate it with modern evidence-based medicine because of the special individualized medical model. The importance of sleep health education should be emphasized, that is, psychological and behavioral therapy, drug therapy and traditional drug therapy should be carried out on the basis of establishing good sleep hygiene habits.

3. Drug treatment of insomnia

Although there are many kinds of hypnotics, most of them are not aimed at treating insomnia. Although antihistamines (such as diphenhydramine), melatonin and valerian extracts have hypnotic effects, the existing clinical research evidence is limited and they are not suitable as routine drugs for insomnia. Alcohol (ethanol) cannot be used to treat insomnia. Non-benzodiazepines are recommended for general treatment, such as eszopiclone, zolpidem, zolpidem controlled-release tablets, zolpidem and so on. Benzodiazepines used to treat insomnia are complex and diverse, including: estazolam, fludiazepam, Quezepam, temazepam, triazolam, alprazolam, clonazepam, diazepam and lorazepam. At present, lamivudine, Tasmilton, agomelatine and various antidepressants are the first choice for insomnia treatment, so it is suggested that you must go to a specialist and take the medicine according to the doctor's prescription.

4. Physical therapy

Repetitive transcranial magnetic stimulation (TMS) is a new non-drug therapy for insomnia, and it is a new technique to give repetitive magnetic stimulation to specific parts of human skull. Repetitive transcranial magnetic stimulation can affect the stimulation of local and function-related distal cortical function, realize the regional reconstruction of cortical function, and have obvious effects on neurotransmitters and their transmission in the brain, various receptors in different brain regions, including 5- hydroxytryptamine and other receptors, and the expression of genes regulating neuronal excitability. Can be combined with drugs to quickly block the occurrence of insomnia, and is especially suitable for treating insomnia during lactation, especially insomnia caused by postpartum depression.

5. Drug therapy for patients with special types of insomnia

(1) Non-drug therapy is the first choice for elderly patients with insomnia, such as sleep hygiene education, with special emphasis on accepting CBT-I(I-level recommendation). When the treatment of the primary disease can not alleviate the symptoms of insomnia or can not comply with non-drug treatment, drug treatment can be considered. Non-benzodiazepines or melatonin receptor agonists are recommended for elderly patients with insomnia (level II recommendation). Caution should be exercised when using benzodiazepines. If ataxia, confusion, abnormal movement, hallucination, respiratory depression and other symptoms occur, benzodiazepines should be stopped immediately and properly handled. At the same time, we should pay attention to accidental injuries such as falls caused by taking benzodiazepines. The dosage of drug therapy for elderly patients should start from the minimum effective dosage, short-term application or intermittent treatment is not recommended, and adverse drug reactions should be closely observed during medication.

(2) Lack of information on the safety of sedative and hypnotic drugs used by pregnant women during pregnancy and lactation. Because zolpidem has no teratogenic effect in animal experiments, it can be taken for a short time if necessary (recommended by grade ⅳ). Care should be taken when using sedative-hypnotic drugs and antidepressants during lactation to avoid drugs affecting babies through breast milk. Non-drug intervention is recommended to treat insomnia (I-level recommendation). The existing experiments show that transcranial magnetic stimulation is a promising method to treat insomnia during pregnancy and lactation, but the exact effect needs further large-scale observation.

(3) Perimenopausal and menopausal patients For perimenopausal and menopausal women with insomnia, we should first identify and treat common diseases that affect sleep in this age group, such as depression, anxiety, sleep apnea syndrome, etc., and give necessary hormone replacement therapy according to symptoms and hormone levels. The insomnia symptoms of these patients are the same as those of ordinary adults.

(4) Benzodiazepines should be used with caution in patients with respiratory diseases, chronic obstructive pulmonary disease (COPD) and sleep apnea-hypopnea syndrome due to their adverse reactions such as respiratory depression. Non-benzodiazepine drug receptors have strong selectivity, and the incidence of residual effect is low the next morning. Zolpidem and zopiclone have not found any adverse respiratory reactions in patients with stable COPD, but the efficacy of zaleplon in the treatment of insomnia with respiratory diseases has not been determined.

Insomnia is the chief complaint of elderly patients with sleep apnea, and the number of patients complicated with sleep apnea is increasing. Zolpidem and other short-acting drugs can reduce the occurrence of central sleep apnea, and the application of noninvasive ventilator can improve compliance and reduce the possibility of inducing obstructive sleep apnea. Benzodiazepines are prohibited in patients with obvious hypercapnia and decompensated restrictive ventilation dysfunction in acute exacerbation of COPD. When necessary, benzodiazepines can be used with the support of mechanical ventilation (invasive or noninvasive) and closely monitored. Melatonin receptor agonist Rameltone can be used to treat patients with sleep-disordered breathing accompanied by insomnia, but further research is needed.

(5) Patients with mental disorders often suffer from insomnia. Psychiatric practitioners should treat and control primary diseases and treat insomnia symptoms according to the principle of specialization. Depression is often co-morbid with insomnia and cannot be treated in isolation to avoid falling into a vicious circle. The recommended combination therapy includes: ①CBT-I therapy: CBT-I is used to treat insomnia and hypnotic antidepressants (such as doxepin, amitriptyline and mirtazapine); ② Antidepressants: antidepressants (single drug or combined drug) plus sedative and hypnotic drugs, such as non-benzodiazepines or melatonin receptor agonists (recommended by Grade III). It should be noted that the use of antidepressants and sleeping pills may aggravate sleep apnea syndrome and periodic leg movements. When patients with anxiety disorder suffer from insomnia, anti-anxiety drugs are mainly used, and sedative and hypnotic drugs are added before going to bed if necessary. When schizophrenic patients suffer from insomnia, antipsychotic drugs should be chosen as the main treatment, and sedative and hypnotic drugs can be supplemented to treat insomnia when necessary.

6. Psychobehavioral therapy for insomnia

The essence of psychobehavioral therapy is to change patients' belief system, give full play to their self-efficacy, and then improve insomnia symptoms. To achieve this goal, professional doctors often need to participate. Psychobehavioral therapy has a good effect on adult primary insomnia and secondary insomnia, which usually includes sleep hygiene education, stimulation control therapy, sleep restriction therapy, cognitive therapy and relaxation therapy. These methods can be used alone or in combination to treat primary or secondary insomnia in adults.

(1) Sleep Health Education Most insomniacs have bad sleep habits, which destroy normal sleep patterns and form wrong sleep concepts, thus leading to insomnia. Sleep hygiene education is mainly to help insomnia patients understand the important role of bad sleep habits in the occurrence and development of insomnia, analyze and find out the causes of bad sleep habits, and establish good sleep habits. Generally speaking, sleep health education needs to be carried out simultaneously with other psychological and behavioral therapy methods, and it is not recommended to take sleep health education as an isolated intervention method.

The contents of sleep hygiene education include: ① Avoid using irritating substances (coffee, strong tea or smoking, etc.). A few hours before going to bed (usually after 4 pm); Don't drink before going to bed, alcohol will interfere with sleep; ③ Exercise regularly, but avoid strenuous exercise before going to bed; 4 Do not eat, drink or eat food before going to bed; ⑤ Don't do mental work or watch exciting books and movies at least 1 hour before going to bed; ⑥ Bedroom environment should be quiet and comfortable, with appropriate light and temperature; ⑦ Keep regular work and rest; 8 It is not advisable to read, watch TV or eat in bed after staying in bed; Pet-name ruby conditional foot washing or bathing before going to bed.

(2) Tension, nervousness and anxiety in relaxation therapy are common factors inducing insomnia. Relaxation therapy can alleviate the adverse effects caused by the above factors, so it is the most commonly used non-drug therapy for insomnia, and its purpose is to reduce the alertness in bed and reduce nighttime awakening. Skills training to reduce arousal and promote night sleep includes gradually relaxing muscles, guiding imagination and abdominal breathing training. Patients should practice relaxation training 2 ~ 3 times a day after the plan, and the environment should be clean and quiet, and should be carried out under the guidance of professionals at the initial stage. Relaxation therapy can be used as an independent intervention for insomnia (recommended by grade I).

(3) Stimulation control therapy Stimulation control therapy is a set of behavioral intervention measures to improve the interaction between sleep environment and sleep tendency (drowsiness), restore the function of bed rest as a sleep signal, make patients fall asleep easily, and rebuild the biological rhythm of sleep-awakening. Stimulation control therapy can be used as an independent intervention (I recommend it). Specific content: ① only sleep when you are sleepy; 2 If you can't sleep in bed for 20 minutes, you should get up and leave the bedroom, engage in some simple activities, and then go back to the bedroom to sleep when you are sleepy; ③ Don't do activities unrelated to sleep in bed, such as eating, watching TV, listening to the radio and thinking about complex problems. No matter how long you slept the night before, you should keep getting up regularly; ⑤ Avoid taking a nap during the day.

(4) Sleep restriction therapy Many insomniacs try to increase the chances of sleeping by increasing the time in bed, but it often backfires, further reducing the quality of sleep. Sleep restriction therapy improves sleep efficiency by shortening the waking time in bed and increasing the driving ability to fall asleep. The specific contents of the recommended sleep restriction therapy are as follows (level II recommendation): ① Reduce the bed rest time to match the actual sleep time, and only when the sleep efficiency of 1 week exceeds 85% can the bed rest time 15 ~ 20 minutes be increased; ② When the sleep efficiency is lower than 80%, the bed rest time will be reduced by 15 ~ 20 minutes, while when the sleep efficiency is between 80% and 85%, the bed rest time will remain unchanged; ③ Avoid taking a nap during the day and keep a regular time to get up.

(5) Cognitive behavioral therapy for insomnia patients often fears insomnia itself, pays too much attention to the adverse consequences of insomnia, and often feels nervous when approaching sleep, worrying about not sleeping well. These negative emotions further worsen sleep, and the aggravation of insomnia in turn affects the mood of patients, forming a vicious circle. The purpose of cognitive therapy is to change patients' cognitive bias towards insomnia and irrational beliefs and attitudes towards sleep problems. Cognitive therapy is usually combined with stimulus control therapy and sleep restriction therapy to form CBT-I to treat insomnia. The basic contents of cognitive behavioral therapy are: ① keeping reasonable sleep expectation; Don't blame all the problems on insomnia; (3) To fall asleep naturally and avoid excessive subjective intention to fall asleep (forcing yourself to fall asleep); 4 don't pay too much attention to sleep; Don't feel depressed because you didn't sleep well all night; ⑥ Tolerance of culture to insomnia. CBT-I is usually a combination of cognitive therapy and behavioral therapy (stimulus control therapy, sleep restriction therapy), and can also be supplemented by relaxation therapy and sleep health education. CBT-I is the core of psychological and behavioral therapy for insomnia (first-class recommendation)

(6) Comprehensive intervention of insomnia ① Drug intervention: The short-term efficacy of drugs in the treatment of insomnia has been confirmed by clinical trials, but long-term application still needs to bear potential risks such as adverse drug reactions and addiction. CBT-I not only has short-term curative effect, but also can be maintained for a long time in follow-up observation. CBT-I combined with non-benzodiazepines can gain more advantages, and the latter can be changed to intermittent treatment to optimize the effect of this combined treatment. ② Recommend combination therapy (level II recommendation): CBT-I combined with non-benzodiazepines or melatonin receptor agonists is the first choice. If the symptoms improve in a short time, gradually stop using non-benzodiazepines, otherwise use non-benzodiazepines intermittently, and maintain CBT-I intervention during the whole treatment period (level II recommendation).