Common symptoms are difficulty in falling asleep, decreased sleep quality andSleep timeDecreased memory and attention.
Now?clinical medicineScientific understanding of insomnia has limitations, but clinical physicians have begun toclinical research , Defining Insomnia, 2012Chinese Medical AssociationNeurologybranchSleep disordersBased on the existingEvidence based medicineEvidence, the Guidelines for Diagnosis and Treatment of Insomnia in Chinese Adults has been formulated, in which insomnia means that patients are dissatisfied with sleep time and/or quality and affect daytimesocial functionA subjective experience of.
TCM disease name
insomnia
Foreign name
insomnia
Visiting department
Neurology Department, Psychopsychology Department
Common causes
Mental pressure, psychosocial factors, some chronic diseases, etc
common symptom
Difficult to fall asleep, low sleep quality, easy to wake up;Forgetfulness, daytime sleepiness
Usually, there is no clear cause of insomnia, or insomnia symptoms still remain after eliminating the causes that may cause insomnia, mainly includingpsychophysiological insomnia 、idiopathic insomnia andsubjective insomnia 3 types.The diagnosis of primary insomnia lacks specific indicators and is mainly an exclusive diagnosis.When the possible cause of insomnia is excluded or cured, it can be considered as primary insomnia when there are still insomnia symptoms.Psychophysiological insomnia can be traced to a certain or long-term event to the patient's brainLimbic systemThe influence of functional stability and the imbalance of marginal system function eventually lead to the disorder of brain sleep function and insomnia.
Including due toSomatic disease、Mental disorders、drug abuseInsomnia caused by, andSleep disordered breathing, SleepDyskinesiaAnd other related insomnia.Insomnia often occurs at the same time as other diseases, and sometimes it is difficult to determine the relationship between these diseases and insomniacausal relationship, so it is proposed in recent yearsComorbidityThe concept of sexual insomnia is used to describe insomnia accompanied by other diseases.
clinical manifestation
Announce
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The clinical manifestations of insomnia patients mainly include the following aspects:
1. Obstacles in sleep process
Difficulty in falling asleep, decreased sleep quality and reduced sleep time.
memory function Decline, attention function decline, and planning function decline, resulting in daytime sleepiness and reduced working ability, which is easy to occur during the day when work stopsLethargyPhenomenon.
The total sleep time is reduced, usually less than 6 hours.
On the basis of the above symptoms, accompanied by daytimedysfunction。Sleep related daytime functional damage includes: ① fatigue or general discomfort; ②Attention, attention maintenance orMemory loss；③The ability to study, work and (or) socialize decreases; ④Emotional fluctuations orEasily provoked；⑤Sleeping in the daytime; ⑥Loss of interest and energy; ⑦Error tendency increases during work or driving; ⑧Tension, headachedizzy, or other somatic symptoms related to sleep loss; ⑨Excessive attention to sleep.
Insomnia can be divided into: ① acute insomnia, duration<1 month; ②SubacuteInsomnia, duration ≥ 1 month,<6 months; ③chronic insomnia , course of disease ≥ 6 months.
ClinicianIt is necessary to carefully inquire about the medical history, including the specific sleep condition, medication history and possibleMaterial dependenceCondition, physical examination and mental examinationmentalityassessment.The specific content of sleep status data acquisition includes insomnia manifestations, work and rest patterns, sleep related symptoms, and the impact of insomnia on daytime function.Can be accessed viaSelf assessment scaleTools, family sleep records, symptom screening forms, mental screening tests and family member statements were used to collect medical history data.The recommended collection process of medical history (1~7 are necessary evaluation items, 8 are recommended evaluation items) is as follows:
(4) Review the overall sleep status in the past 2-4 weeks, including the sleep latency (the time from the beginning of going to bed to falling asleep), the number of awakenings during sleep, duration and total sleep time.It should be noted that the average should be used when asking the above parametersEstimated value, it is not suitable to regard the sleep condition and experience of a single night asDiagnostic basis；Body motion is recommendedSleep detectorSleep assessment was carried out every 7 days;
(5) Sleep quality assessment can be carried out byPittsburgh Sleep Quality Index(PSQJ) questionnaire and other scale tools. It is recommended to use the body motion sleep detector for sleep assessment every 7 daysBlood oxygenMonitor blood oxygen at night;
(6) Evaluate daytime function through consultation or with the help of scale tools to exclude other diseases that impair daytime function;
(7) It is carried out for patients who are homesick during the day, combined with consultation to screen for sleep disordered breathing and othersSleep disorders；
(8) Before the first systematic evaluation, it is better for patients and their families to help complete a 2-week sleep diary, record the daily bedtime, and estimatesleep latency , record the number of awakening times at night and the time of each awakening, and record the total time from going to bed to getting upBed time, according to awakening in the morningTime estimationActual sleep time, calculatingSleep efficiency(i.e. actual sleep time/bedtime × 100%), record abnormal symptoms at night（Abnormal breathing, behavior, sports, etc.), daytime energy andsocial functionThe degree of impact and lunch break.Daily medication and self experience.
2. Scale evaluation
(1) Systematic review of medical history: It is recommended to use the Cornell Health Index to conduct a semi quantitative review of medical history and current situation, and obtain basic data supporting evidence in terms of relevant body and emotion.
(2) Sleep quality scale evaluation: insomnia severity index;Pittsburgh sleep index;Fatigue severity scale;Quality of lifeQuestionnaire;Sleep belief and attitude questionnaire, and Epworth sleep scale assessment.
(3) Emotion includes self rating and other rating insomnia related scale: Beck;Depression Scale;State trait anxiety questionnaire.
3. Cognitive function assessment
Note that IVA-CPT is recommended for functional evaluation;Memory function recommendedWechsler Memory Scale。
4. Objective evaluation
Insomniacs are more likely to have bias in their self-evaluation of sleep status, and they need to take objective evaluation methods to screen when necessary.
(1) Sleep monitoring
OvernightPolysomnography(PSG) is mainly used for the evaluation and differential diagnosis of sleep disorders.PSG can be evaluated in the differential diagnosis of chronic insomnia patients.Multiple sleep latency test forNarcolepsyAnd excessive daytime sleep.KinesisRecorderIt can be used as an alternative method to evaluate the total sleep time andSleep mode。Finger pulse blood oxygen monitoring can understand the blood oxygen during sleep, and should be carried out before and after treatment. Before treatment, it is mainly used to diagnose whether there is hypoxia during sleep, and during treatment, it is mainly used to judge the effect of drugs on breathing during sleep.
Event relatedevoked potentialExamination can provide diagnosis of emotional and cognitive dysfunctionObjective indicators。Neurological functionImagingOpen up a new field for the diagnosis and differential diagnosis of insomnia. Due to the expensive equipmentclinical practice It cannot be popularized in China.
(2) Restore social function and improve the quality of life of patients;
(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 mode
InsomniacInterventionsIt mainly includes drug treatment and non drug treatment.For patients with acute insomnia, it is advisable to use drugs early.For patients with subacute or chronic insomnia, whether primary or secondary, psychological treatment should be supplemented with medicationBehavior therapy, even those who have taken sedation for a long timesodium amytal The same is true of insomniacs.The main effective psychological and behavioral treatment methods for insomnia areCognitive behavioral therapy（CBT-I）。
At present, the professional resources that can engage in psychological and behavioral therapy are relatively scarce in China, and there are professionals in this fieldQualificationThere are not many people, and simply using CBT-I will also faceComplianceProblem, so drug intervention still occupies the place of insomnia treatmentleading role 。Other non psychotherapymedication, such asDietotherapy、Aromatherapy, massageHomeopathy、PhototherapyThere is no convincing large sample control study.Traditional Chinese MedicineTreat insomniaHas a long history, but is limited by special individualizationmedical modelIt is difficult to evaluate with modern evidence-based medicine model.The importance of sleep health education should be emphasized, that is, on the basis of establishing good sleep hygiene habits, psychological and behavioral treatment, drug treatment andtraditional medicine treatment.
Repetitive transcranial magnetic stimulationIt is a new non drug scheme for insomnia treatment,Transcranial magnetic stimulationIt is a new technology of giving magnetic stimulation to a specific part of the human skull, which refers to the process of giving repeated stimulation to a specific cortical part.Repetitive transcranial magnetic stimulation can affect the stimulation of local and functionally related remote cortical functions, achieve regional reconstruction of cortical functions, andNeurotransmitterAnd its transmission, differenceBrain regionMultiple receptors including 5-hydroxytryptamine and its regulationneuronExcitatorygene expressionIt has obvious influence.It can be compared with drugsCombined treatmentQuickly block the occurrence of insomnia, especially suitable for insomnia treatment of women during lactation, especiallyPostpartum depressionInsomnia caused by.
5. Drug treatment for patients with special types of insomnia
The elderly patients with insomnia preferred non drug treatment, such as sleep health education, especially CBT-I (Level I recommendation).When the treatment for the primary disease cannot alleviate the insomnia symptoms or cannot comply with non drug treatment, drug treatment can be considered.Non BZDs (non benzodiazepines) or melatonin receptor agonists (Grade II recommendation) are recommended for elderly insomnia patients.BZDs are required（BenzodiazepineClass) should be taken with cautionAtaxia、Vagueness of consciousness, abnormal movement, hallucinationRespiratory depressionThe drug should be stopped immediately and properly handled, and attention should be paid to the problems caused by taking BZDsMuscular tensionLowering may lead to falls, etcAccidental injury。The dosage of medication for elderly patients should beMinimum effective doseStart, short-term application or adoptionIntermittent therapy, do not advocate large doseAdministration, close observation is required during medicationAdverse drug reactions。
There is a lack of data on the safety of sedative and hypnotic drugs used by pregnant womenAnimal experimentNone inTeratogenic effectIf necessary, it can be taken for a short time (recommended for Grade IV).Use of sedative and hypnotic drugs during lactation andAntidepressantCare should be taken to avoid drugs affecting infants through milk. Non drug intervention is recommended to treat insomnia (Level I recommendation).Existing experiments show that transcranial magnetic stimulation is a promising method to treat insomnia in pregnancy and lactation, but the exact effect needs further large sample observation.
For perimenopausal and menopausal women with insomnia, it is necessary to first identify and deal with this problemage groupCommon diseases affecting sleep, such asDepressive disorder, anxiety disorder andSleep apnea syndromeAnd give necessaryHormone replacement therapyThe treatment of insomnia symptoms of this part of patients is the same as that of ordinary adults.
BZDs due to respiratory depressionAdverse reactions, onChronic obstructive pulmonary disease（COPD）、Sleep apnea hypopnea syndromeUse with caution in patients.Non BZDs receptor has strong selectivity and residual effect in the next morningincidence rateLow. Insomniacs who use zolpidem and zopiclone to treat mild and moderate COPD in stable stage have not been foundrespiratory function Adverse reactions were reported, but the efficacy of zaleplon on insomnia patients with respiratory diseases has not yet been determined.
old ageSleep ApneaPatients can lose sleep forChief complaintThe number of patients with complex sleep disordered breathing increases, and the use of short-term sleep promoting drugs such as zolpidem alone can reduceCentral sleep apneaOccurs onNon invasive ventilatorSimultaneous application of treatment can improveComplianceTo reduce the possibility of inducing obstructive sleep apnea.yesHypercapniaObvious acute exacerbation of COPDRestrictive ventilatory dysfunctionBZDs are forbidden for patients in decompensation period, and can bemechanical ventilation Support (invasive or non-invasive) simultaneous application and close monitoring.Melatonin receptor agonist Remelton can be used for treatmentSleep disordered breathingPatients with insomnia, but further research is needed.
(5) Patients with comorbid mental disorders
Insomnia often exists in patients with mental disorders, which should be controlled byPsychiatry DepartmentThe licensed doctors treat and control the primary disease according to the specialized principle, and treat insomnia symptoms at the same time.Depressive disorder is often associated with insomnia. It cannot be treated alone to avoid the dilemma of entering a vicious circle. The recommended combination treatment methods include:
Antidepressants (single or combined) plus sedative hypnotics, such as non BZDs or melatonin receptor agonists (recommended for Level III).It should be noted that the use of antidepressants and hypnotics may aggravate sleep apnea syndrome and periodic leg movements.When patients with anxiety disorder have insomniaAntianxiety drugsMainly, add sedative and hypnotic drugs before going to bed when necessary.SchizophreniaWhen patients have insomnia, they should mainly choose antipsychotic drugs, and if necessary, sedative hypnotic drugs can be used to treat insomnia.
6. Psychological and behavioral treatment of insomnia
The essence of psychotherapy is to change the patient'sBelief system, play its roleSelf efficacyTo improve insomnia symptoms.To achieve this goal, professional doctors are often required to participate.Psychobehavioral therapy has good effects on adult primary insomnia and secondary insomnia, usually including sleep health educationStimulus controlTherapySleep restriction therapy, cognitive therapy andRelaxation therapy。These methods are used independently or in combination for the treatment of adult primary or secondary insomnia
(1) Sleep health education
Most of the insomniacs have adverse effectsSleep habits, disrupt the normal sleep pattern, and form a sleepMisconception, leading to insomnia.Sleep health 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 the reasons for forming bad sleep habits, and establish good sleep habits.Generally speaking, sleep health education needs to be carried out at the same time as other psychological and behavioral treatment methods, and it is not recommended to use sleep health education as an isolated intervention.
The contents of sleep hygiene education include:
① Avoid using stimulants (coffeeStrong teaOr smoking); ②Don't drink alcohol before going to bed. Alcohol can interfere with sleep; ③Regular physical exercise, but should be avoided before going to bedStrenuous exercise；④Do not overeat or eat food that is difficult to digest before going to bed; ⑤Not doing anything for at least one hour before going to bed is likely to cause excitementmental labourOr watch books and TV programs that are easy to arouse excitement; ⑥The bedroom environment should be quiet and comfortable, with appropriate light and temperature; ⑦Keep a regular schedule.
(2) Relaxation therapy
Stress, tension and anxiety 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. Its purpose is to reduce alertness and reduceNight Awakening。Skills training to reduce arousal and promote sleep at night includeGradualnessMuscle relaxation, instructional imagination andAbdominal breathing training。After the relaxation training, the patient should insist on practicing 2-3 times a day. The environment should be clean and quiet. At the initial stage, it should be conducted under the guidance of professionals.Relaxation therapy can be used as an independent intervention for insomnia treatment (Level I recommendation).
(3) Stimulation control therapy
Stimulation control therapy is a set of improvementsSleep environmentBehavioral intervention measures that interact with sleep tendency (sleepiness) to restore the function of bedrest as a sleep inducing signal, so that patients can easily fall asleep and re-establish sleep wakeBiological rhythm。Stimulation control therapy can be used as an independent intervention (Level I recommendation).Specific contents: ① Go to bed only when sleepy; ②If you cannot fall asleep after staying in bed for 20 minutes, you should get up and leave the bedroom, engage in some simple activities, and return to the bedroom to sleep when you are sleepy; ③Do not do activities unrelated to sleep in bed, such as eating, watching TV, listeningradioAnd thinkingComplex problemsEtc.; ④No matter how long you slept the night before last, keep a regular time to get up; ⑤Avoid naps during the day.
(4) Sleep restriction therapy
Many insomniacs try to increase the chance of sleeping by increasing the time they stay in bed, but it often backfires and makes the quality of sleep further decline.Sleep restriction therapy increases the number of people who fall asleep by shortening the time they stay awake in bedDriving powerTo improve sleep efficiency.The specific contents of the recommended sleep restriction therapy are as follows (Level II recommendation): ① reduce the bed rest time to make it consistent with the actual sleep time, and increase the bed rest time by 15-20 minutes only when the sleep efficiency of one week exceeds 85%; ②When the sleep efficiency is lower than 80%, the bedridden time will be reduced by 15-20 minutes, and when the sleep efficiency is between 80% and 85%, the bedridden time will remain unchanged; ③Avoid daytime naps and keep a regular wake up time.
(5) Cognitive behavioral therapy
Insomniacs often fear insomnia itself, pay too much attention to the adverse consequences of insomnia, and often feel nervous and worried about not sleeping well when they are close to sleep. These negative emotions further worsen sleep, and the aggravation of insomnia in turn affects patients' emotions, forming a vicious circle.The purpose of cognitive therapy is to change patients' perception of insomniaCognitive bias, change the patient's perception of sleep problemsIrrational beliefAnd attitude.Cognitive TherapyIt is often used together with stimulation control therapy and sleep restriction therapy to form the CBT-I of insomnia.Cognitive behavioral therapyBasic content of: ① maintain reasonable sleep expectation; ②Don't blame insomnia for all problems; ③Keep sleeping naturally and avoid excessive subjective intention to fall asleep (force yourself to fall asleep); ④Don't pay too much attention to sleep; ⑤Don't feel frustrated because you didn't sleep well in the first night; ⑥Cultivation of insomniaTolerance。CBT-I is usually a combination of cognitive therapy and behavioral therapy (stimulation control therapy, sleep restriction therapy), and it can also be combined with relaxation therapy and sleep health education.CBT-I is the core of insomnia psychotherapy (Level I recommendation)
(6) Comprehensive intervention of insomnia：
1) Drug intervention
The short-term efficacy of insomnia has been confirmed by clinical trials, but long-term use still needs to bear adverse drug reactionsAddictionAnd other potential risks.CBT-I not only has short-term efficacy, but also can maintain its efficacy for a long time in follow-up observation.CBT-I combined with non BZDs can gain more advantages, and the latter can optimize the effect of this combined treatment by changing to intermittent treatment.
2) Recommended combinationTreatment mode(Level II recommendation)
The combination of CBT-I and non BZDs (or melatonin receptor agonists) is the first choice. If the symptoms are controlled in a short time, the non BZDs drugs should be gradually stopped. Otherwise, non BZDs should be changed to intermittent drugs, and CBT-I intervention should be maintained throughout the treatment (recommended by Level II).
