This document discusses insomnia and normal sleep patterns. It provides details on: 1) The stages of the normal sleep cycle and how sleep needs change throughout life from childhood to older age. 2) Insomnia as a common sleep disorder defined by difficulties initiating or maintaining sleep that impairs daytime functioning. 3) Factors that can cause insomnia like medical conditions, medications, and psychiatric disorders. 4) Treatments for insomnia including sleeping pills, cognitive behavioral therapy, sleep restriction, stimulus control, and improving sleep hygiene.

1. IINNSSOOMMNNIIAA
Dr. SHERIF SAAD
M.D. Psychiatry

2. Sleep is Essential to Our
Overall Health and Well-
Being
• Key to our health, performance, safety
and quality of life
• As essential a component as good
nutrition and exercise to
optimal health
• Essential to our ability to perform both cognitive
and physical tasks, engage fully in life and
function in an effective, safe and productive way

3. Normal Sleep and Normal
Aging: Our Internal Clock
• The biological clock resides in
the brain
• It helps regulate when we feel
sleepy and when we are alert
• It works in tandem with light
and dark, and our body
temperature and hormones

4. Sleep stages
• We cycle through the stages of sleep
about every 90 minutes during the
night, in the same order
• Most dreaming occurs during the
second half of the night, as REM sleep
lasts longer and longer
– Stage 1: Very light sleep
– Stage 2: Light sleep
– Stage 3: Deeper sleep
– Stage 4: Very deep sleep, most
restorative
– Stage 5: REM sleep, when we dream

5. The Sleep Cycle in
Adults
Awake
Stages
Hours in Sleep
REM
REM
REM
REM
REM
0 1 2 3 4 5 6 7 8
1
2
3
4

6. Sleep throughout life
• Childhood and adolescence
– Sleep needs range from 18 hrs a day for
infants to about 9 hrs a day for teenagers
• Adulthood
– Amount of deep sleep drops dramatically
between age 20 and 40, and average sleep
time is 7.5 hours
– Women’s reproductive cycles affect sleep
• Especially pregnancy (sleepier first trimester)
• Also affected by menstrual cycle (sleepier second
half of cycle)

7. Sleep in middle age
Sleep becomes lighter and nighttime awakenings
become more frequent and last longer
Often wake up after 3 hours of sleep
Menopause may lead to hot flashes that interrupt
sleep repeatedly
Breathing problems may begin, especially among
overweight people
Physically active adults sleep more soundly than
their sedentary peers.
About 20% of sleep time is spent in dreaming

8. Sleep among older adults
• Little deep sleep, but dreaming still 20%
• Dozens of awakenings during the night
• Falling asleep takes longer
• Despite the above, over a 24-hour period
older adults accumulate the same amount of
total sleep as younger people
– Older adults more likely to nap during the day
• Older adults do need the same amount of
sleep as they did when they were younger

9. Normal Sleep and Normal
Aging: Less Deep Sleep

11. Sleep Disorders (ICSD
2)
1. Insomnia.
2. Sleep Related Breathing Disorders.
3. Hypersomnia.
4. Cicadian Rhythm Sleep Disorder.
5. Parasomnia.
6. Sleep related Movement Disorder.

13. Insomnia
A common sleep problem
• Insomnia is defined as:
Difficulty initiating sleep,
maintaining sleep, final
awakenings that occur much
earlier than desired or sleep that
is non-restorative and of poor
quality and result in impairment
in daytime function.

14. Insomnia
A common sleep problem
• People with insomnia may have
– Trouble falling asleep
– Many awakenings during the night,
with difficulty going back to sleep
– Fitful sleep
– Daytime drowsiness
• During the day, people with
insomnia may be
– Anxious and irritable
– Forgetful, with difficulty concentrating

15. Types of Insomnia
• Transient: Less than 2 weeks
• Intermittent: Repetitive episodes of
transient insomnia
• Chronic: Continuing difficulty with sleep

16. Chronic insomnia
• Complaint of poor sleep causing
distress or impairment for 6 months
or longer
• Average less than 6.5 hours sleep
per day
• Or 3 episodes per week of:
– Taking longer than 30 minutes to fall asleep
– Waking up during the night for at least an hour
• Not accounted for by another sleep
disorder, mental disorder, medical condition
or substance use.

18. How common is
insomnia?
• More than half of adults in the U.S. said
they experienced insomnia at least a
few nights a week during the past year
• Nearly one-third said they had insomnia
nearly every night
• Increases with age
• The most frequent health complaint
after pain
• Twice as common in women as in men

19. GUIDELINES FOR TAKING A
SLEEP HISTORY IN INSOMNIA
• Define the specific sleep problem
• Assess the onset and clinical course of the
condition
• Evaluate 24-h sleep/wakefulness patterns
• Assess stressful events and personality patterns
• Determine the presence of anxiety and/or
depression
• Determine the presence of other sleep disorders
• Obtain a family history of sleep and psychiatric
disorders
• Evaluate the medical, psychiatric, and personal
impact of insomnia

20. Conditions that can
cause insomnia
• Hyperthyroidism
• Arthritis or any other painful condition
• Chronic lung or kidney disease
• Cardiovascular disease (heart failure,
CAD)
• Heartburn (GERD)
• Neurological disorders (epilepsy,
Alzheimer’s, headaches, stroke, tumors,
Parkinson’s Disease)
• Diabetes
• Menopause

21. Common drugs that can
cause insomnia
• Alcohol
• Caffeine/chocolate
• Nicotine/nicotine
patch
• Beta blockers
• Calcium channel
blockers
• Bronchodilators
• Corticosteroids
• Decongestants
• Antidepressants
• Thyroid hormones
• Anticonvulsants
• High blood pressure
medications

22. Additional Causes
• Psychiatric disorders
– Especially phobias and panic attacks, bipolar
disorder, depression, and schizophrenia
• Poor sleep habits
• Shift work
• Other sleep disorders
– Circadian rhythm disorders
– Restless legs syndrome
– Periodic limb movement disorder
– Sleep apnea

24. Consequences of
insomnia
• Decreases in mental performance and
motor functioning
• Accidents
• Inability to accomplish daily tasks
• Mood disturbance
– More sadness, depression, and anxiety
• Interpersonal difficulties
– With families, friends, and at work

25. Sleeping pills
• Most common treatment approach
– Drowsiness common the next day
• NOT meant for chronic insomnia
– Effective for short-term (a couple weeks) insomnia
only
• Tolerance and dependency may develop
• Withdrawal, rebound, relapse may occur
• But commonly used, despite the above
– 5-10% of adults have used a benzodiazepine in
past year as a sleep aid
– 10-20% of those over age 65 use sleeping pills

26. 1. BenzodiMazeepidnei clikae:t zioolpindesm, zaleplon,
eszopiclone.
2. MT receptor agonists: melatonin,
ramelteon.
3. Antidepressants: trazodone, mirtazapine.
4. Antihistamines: diphenhydramine.
5. Antipsychotics: olanzapine, clozaril,
quetiapine.
6. Herbal supplements: lavender,
chamomile.

27. Non-drug
treatments
• Cognitive-behavioral therapy (CBT)
– Stimulus control
– Cognitive therapy
– Sleep restriction
– Relaxation training
– Sleep hygiene

28. Cycle of Persistent
Insomnia
MALADAPTIVE HABITS
•Excessive time in bed
•Irregular sleep schedule
•Daytime napping
•Sleep- incompatible activities
AROUSAL
•Emotional
•Cognitive
•Physiologic
CONSEQUENCES
•Mood Disturbances
•Fatigue
•Performance impairments
•Social Discomfort
DYSFUNCTIONAL COGNITIONS
•Worrying over sleep loss
•Ruminating over consequences
•Unrealistic Expectations

29. How to keep track of your
sleep
• Daily sleep diary or sleep log
– Bedtime
– Falling asleep time
– Nighttime awakenings
– Time to get back to sleep
– Waking up time
– Getting out of bed time
– Naps

30. Cognitive Therapy
• Identify beliefs about sleep that
are incorrect
• Challenge their truthfulness
• Substitute realistic thoughts

31. False beliefs about
insomnia
• Misconceptions about causes of insomnia
– “Insomnia is a normal part of aging.”
• Unrealistic expectations: sleep needs
– “I must have 8 hours of sleep each night.”
• Faulty beliefs about insomnia consequences
– “Insomnia can make me sick or cause a mental
breakdown.”
• Misattributions of daytime impairments
– “I’ve had a bad day because of my insomnia.”
– I can’t have a normal day after a sleepless night.”

32. Common Myths about
Insomnia
• Misconceptions about control and
predictability of sleep
– “I can’t predict when I’ll sleep well or
badly.”
• Myths about what behaviors lead to
good sleep
– “When I have trouble getting to sleep, I
should stay in bed and try harder.”

33. Sleep Restriction:
best if done with a
professional
• Cut bedtime to the actual amount of
time you spend asleep (not in bed), but
no less than 4 hours per night
• No additional sleep is allowed outside
these hours
• Record on your daily sleep log the
actual amount of sleep obtained

34. Sleep Restriction
(cont’d)
• Compute sleep efficiency (total time
asleep divided by total time in bed)
• Based on average of 5 nights’ sleep
efficiency, increase sleep time by 15
minutes if efficiency is >85%
• With elderly, increase sleep time if
efficiency >80% and allow 30 minute
nap.

35. Stimulus Control:
You can do this on your
own
• Go to bed only when sleepy
• Use the bed only for sleeping
• If unable to sleep, move to another
room
• Return to bed only when sleepy
• Repeat the above as often as
necessary
• Get up at the same time every morning
• Do not nap

36. Relaxation
training
• More effective than no treatment, but not as
effective as sleep restriction
• More useful with younger compared with
older adults
• Engage in any activities that you find relaxing
shortly before bed or while in bed
– Can include listening to a relaxation tape, soothing
music, muscle relaxation exercises, a pleasant
image

37. Healthy sleep habits
(sleep hygiene)
Avoid alcohol, nicotine, caffeine, chocolate
For several hours before bedtime
Cut down on non-sleeping time in bed
Bed only for sleep and satisfying sex
Avoid trying to sleep
You can’t make yourself sleep, but you can set the stage
for sleep to occur naturally
Avoid a visible bedroom clock with a lighted dial
Don’t let yourself repeatedly check the time!
Can turn the clock around or put it under the bed

38. More healthy sleep
habits
• Expose yourself to bright light at the right time
– Morning, if you have trouble falling asleep at night
– Night, if you want to stay awake longer at night
• Establish a regular sleep schedule
– Get up at the same time 7 days a week
– Go to bed at the same time each night
• Exercise every day - exercise improves sleep!
• Deal with your worries before bedtime
– Plan for the next day before bedtime
– Set a worry time earlier in the evening

39. More healthy sleep
habits
• Adjust the bedroom environment
– Sleep is better in a cool room, around 65 F.
– Darker is better
– If you get up during the night to use the bathroom,
use minimum light
– Use a white noise machine or a fan to drown out
other sounds
– Make sure your bed and pillow are comfortable
– If you have a partner who snores, kicks, etc., you
may have to move to another bed (try white noise
first)

40. Cognitive-Behavioral Therapy (CBT)
Technique Pat ient Symptoms
Stimulus control Delayed sleep onset
Excessive time spent in bed;
Sleep restriction fragmented or poor quality sleep
High physiologic, cognitive, or
Relaxation emotional arousal
Racing or obsessive thoughts around
Cognitive bedtime
Any of the above or general poor sleep
Sleep hygiene education hygiene
Spielman AJ, et al. Psychiatr Clin North Am. 1987; Walsh JK, et al. Insomnia: Assessment and Management in Primary Care. 1998.

43. THANK
YOU
Dr. SHERIF SAAD
M.D. Psychiatry