Sleep disorders/PGS (VPL)

Insomnia is one of the most common subj. difficulties in primary care. Sleep is perceived by people as an important sign of health. For physician-patient communication, it is important not to underestimate insomnia.

Etiologically, a wide range of causes: also neurological or psychiatric disease (whose other symptoms the patient may not even report - he does not want or does not notice them).

Proper management of short-term insomnia can prevent more intractable chronic insomnia.

Definitions
Insomnia is def. as sleep disturbance, interrupted sleep or/and early awakening - if it lasts at least a month, at least 3 times a week.

The patient usually starts to worry (too much) about the consequences of insomnia, fears sleep, decreases his/her performance at work and in contact with people, general fatigue. Dangers include a lowered alertness threshold, repeated falling asleep during the day, inattention, even microsleeps, and the risk of accidents, e.g. when driving.

May be accompanied by unpleasant vegetative and somatic symptoms.

Epidemiology
One of the most common disorders. More common with age.

Acute insomnia has been encountered by almost everyone, chronic insomnia by tens of percent of the population (usually 20% - estimate 5-35%).

Increasingly
 * accelerating pace of life,
 * increasing average age of the population,
 * irregular sleep-wake patterns.

Etiology and pathogenesis
The most common cause of insomnia is stress. The body responds normally to an unpleasant event with insomnia (it should return to normal after the event has subsided, otherwise it would fixate the wrong sleep patterns: patterns of behaviour >> worry >> thinking >> cognitive activity and waking). Insomnia is thus maintained and developed.

Electrophysiologically, insomnia is an increased susceptibility to waking. Rapid activity corresponding to wakefulness-cognitive activity is present on waking.

Classification
Basic diagnostic clues for insomnia
 * difficulty falling asleep
 * frequent waking - at night
 * early waking - in the morning
 * non-restorative sleep affecting daytime activities - with various somatic complaints
 * duration of difficulties for more than a month - at least 3 times a week.

Classification of insomnia' the most detailed is ICSD-2 (i.e. International Classification of Sleep Disorders - 2... modified in 2005), the most common is based on ICD-10

It is simplistically divided into primary and secondary.

Primary insomnia
 * F51.03 - Psychophysiological insomnia - pathol. patterns
 * F51.02 - Paradoxical insomnia ("sleep misperception")
 * F51.01 - Acute insomnia
 * Z72.821 - Insomnia due to improper sleep hygiene

Secondary insomnia'
 * Obstructive sleep apnoea (OSA, SAS)
 * Restless Legs Syndrome (RLS)
 * Displaced sleep phase (forward or delayed)

According to ICSD-2 still:
 * F51.04 - Idiopathic insomnia
 * F51.05 - Insomnia due to mental disorder
 * F51.00 - Insomnia not caused by drugs or other substances or known physiological conditions, non-specific' (non-organic) insomnia


 * G47.00 - Organic, physiological insomnia, nonspecific
 * G47.02 - Insomnia caused by drugs or other substances'
 * G47.03 - Insomnia caused by somatic disease


 * Z73.81 - Behavioural insomnia in childhood