Sleep, tiredness, lack of energy: heart sink symptoms

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1 Sleep, tiredness, lack of energy: heart sink symptoms Abstract Problematic sleep is a widespread issue and insomnia is the commonest complaint. The diagnosis of insomnia requires thorough history-taking and management should always include education about adopting suitable sleep hygiene measures and psycholological approaches before prescribing hypnotic medication. Untreated insomnia frequently becomes chronic, is a risk factor for mood disorders and can prove challenging to treat effectively. Dr Natasha Bijlani MBBS, MRCPsych Correspondence: Dr Natasha Bijlani Consultant Psychiatrist, Priory Hospital Roehampton, London SW15 5JJ natashabijlani@ priorygroup.com Keywords Insomnia, Sleep hygiene, Non-pharmacological strategies, Hypnotics. Introduction And miles to go before I sleep, And miles to go before I sleep. Robert Frost, Stopping by Woods on a Snowy Evening (1923) Sleep is an essential function of our lives and we cannot function properly without it. All mammals sleep and indeed, all living creatures, including plants have a natural sleep-wake cycle. Many aspects of sleep remain quite mysterious but in the 24/7 modern world that we live in, the importance of sleep is being marginalised more and more with quite serious consequences for our physical and mental health, social and family life and eventually, productivity in the workplace which in turn impacts on the economy. Sleep deprivation causes tiredness and can lead to accidents. There are several recent examples of devastation caused by the results of insomnia including the nuclear disaster at Chernobyl, the environmentally damaging oil spill by the Exxon Valdez and the loss of the Space Shuttle Challenger. While most of us are aware of the importance of quality sleep as part of a healthy lifestyle, we often struggle to balance the demands of work, family duties and desires for leisure. Sleep disorders are varied, multifactorial, universal and affect millions worldwide. Insufficient sleep leads to tiredness but not all fatigue can be resolved by adequate sleep and is often disease- or substance- based. Insomnia is the commonest complaint about sleep. It is clinically defined as the inability to initiate or maintain sleep or to obtain good sleep quality despite adequate opportunity to do so, accompanied by significant daytime consequences of poor sleep (American Academy of Sleep Medicine, 2005). It is estimated that insomnia affects 1 in 5 adults and 1 in 3 women. Insomnia is highly subjective and individual sleep requirements vary considerably. However, it is generally accepted that those who regularly sleep either more than 8.5 hours or less than 3.5 hours per night, face an increase in mortality risk of around 15% higher than those who average 7 hours sleep per night. Disturbed sleep is affected by many factors but increasing age and Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1):

2 female gender predominate for complaints of insomnia and restless leg syndrome while the prevalence of obstructive sleep apnoea is greater in men. Children and adolescents can also be affected by inappropriate sleep schedules and sleep deprivation. Unfortunately, despite the extent of the problem, insomnia remains unrecognised by many health professionals. It is frequently considered a symptom rather than a true disease and after the challenge of trying to assess when the symptoms are severe enough to need treatment, the next clinical dilemma is how to effectively manage the complaint. Diagnosis of insomnia Insomnia is defined in three diagnostic systems: the International Classification of Mental and Behavioural Disorders (ICD-10; World Health Organisation, 1993); the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000); and the second edition of the International Classification of Sleep Disorders (ICSD-2; American Academy of Sleep medicine, 2005). There are individual differences in terminology but all three systems differentiate between the symptoms of difficulty initiating sleep, difficulty maintaining sleep, early morning awakening and non-restorative sleep. ICD-10 is probably the most practical and useful in general practice and a summary of the diagnostic criteria is shown in Table 1. All four criteria must be satisfied to make a diagnosis. Insomnia can be secondary to medical, psychiatric or environmental conditions but one should never assume this. A detailed description of all the possible aetiological factors for insomnia is beyond the scope of this article but should be considered thoroughly before making a diagnosis of non-organic insomnia as identification will be able to guide treatment options. The differential diagnosis of sleep disorders presents even greater challenges than other clinical disorders because of these numerous possible influences on sleep. More than 80 sleep disorders are described in the ICSD-2, with many overlapping symptoms among some of them. Difficulty initiating sleep, which is a common symptom of insomnia, could be the result of an anxiety disorder, restless legs or issues with circadian rhythm. Interrupted sleep may Table 1: Summary of ICD-10 description of Non Organic Insomnia A Difficulty falling asleep/maintaining sleep/nonrefreshing sleep B The sleep disturbance occurs at least x3 per week for at least 2 months C The sleep disturbance results in marked personal distress or interferes with functioning D No other know causative factors (eg medical illness, substance misuse disorder or effects of medication) are present be caused by recurrent nightmares, sleep apnoea or pain due to any one of a number of possible causes. Frequently, patients are not always aware of symptoms that occur while they are asleep such as breathing issues, snoring and leg movements. Sleep disorders are associated with high rates of psychiatric comorbidities and such individuals represent the largest subgroup of insomnia complaints. Almost 90% of people with depressive disorder have insomnia (and frequently, insomnia may be the presenting complaint), but 5-10% can experience hypersomnia. In generalised anxiety disorder, 20-30% patients report initial insomnia. Sleep abnormalities also occur in panic disorder, schizophrenia, post-traumatic stress disorder, dementia and in those who abuse substances. A selection of causes for insomnia secondary to medical conditions is outlined in Table 2. True secondary insomnia requires historical evidence as well as certainty that without the medical condition, the insomnia would not have developed. It might be useful to consider the insomnia and the underlying medical problem as coexisting and comorbid rather than causative and then to treat each separately. Thus, for practical purposes, one could differentiate between: Absolute secondary insomnia (caused by another medical issue) Partial insomnia (influenced by the coexisting disorder) and Comorbid insomnia (actually independent) Assessment of insomnia Insomnia can be transient or persistent. Table 3. illustrates the three broad types of insomnia and possible causes, depending on the duration it has lasted. A thorough history is essential to make a definitive diagnosis. Apart from the obvious question about the Table 2: Some causes of insomnia secondary to medical conditions Difficulty falling asleep: Anxiety, depressive disorder Restless leg syndrome Any painful, uncomfortable condition CNS lesions Any of the conditions below Difficulty remaining asleep: Sleep apnoea syndromes Restless leg syndrome/ nocturnal myoclonus Dietary factors Direct substance effects (incl. alcohol) Substance interactions Endocrine or metabolic disorders Infections Neoplastic conditions Painful conditions Brainstem or hypothalamic lesions or disease Ageing 52 Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1): 51 58

3 Table 3: Types of insomnia based on duration of symptoms and suggested management 1. Transient (1-6 nights) 2. Short-term (1-3 weeks) 3. Long-term (weeks, months, or years) Short hospital stays or jet-lag Usually requires no treatment or 2-3 doses of a hypnotic No need for tapering or withdrawal Stress caused by moving house, bereavement, job loss or certain substances or medications ntermittent hypnotic dose regime recommended Use the lowest effective dose for the shortest period of time Chronic hospitalisation, elderly, shift working Intermittent dose regime perceived cause of poor sleep, ask whether the patient has initial insomnia, interrupted sleep, early morning waking or unrefreshing sleep. You should ask how many hours sleep they regularly get, what their expectations of good sleep are and how long they have been having problems with their sleep. Ask whether there have been other times in their life when they ve had difficulties with sleep and whether anyone has ever complained about their snoring. Your questions should include a systematic review to exclude medical causes, a medication history, (prescribed and over the counter preparations), recreational drug use and amounts of caffeine, cola and other psychoactive substances consumed. Their activity level, daytime naps and psychological state should also be asked about. A record of their thoughts and cognitive phenomena during sleep latency could provide useful clues to aid management strategies. If possible, corroborative history from their bed partner should be sought. The British Association of Psychopharmacology (2010) has produced an excellent consensus statement on the management of insomnia, which includes a practical algorithm on diagnosis and the document can be accessed online. There are many physiological assessment methods available in specialist sleep clinics including polysomnograpy, electroencephalography, neuroimaging and event-related potentials. In the general practice setting, a sleep diary is a useful tool and resource which records an individual s sleep and wake times with related information such as activity levels, substances (including meals) consumed and their timing, interruptions in sleep, daytime naps, stressors and mood. It can provide valuable objective evidence to aid diagnosis, direct and later chart progress with treatment. Data should usually be collected for 2 to 3 weeks if any meaningful interpretations are to be made. Specialized software for creating sleep logs is also available and online services can be used to track daily sleep patterns An example of a simple sleep diary is shown (Espie 2006 see Figure 1). Data should usually be collected for 2 to 3 weeks. Items 1-3 on the sample diary record total sleep time and items 4-7 record time spent in bed. The average of the total sleep time for each seven day period should be divided by the average of the total time spent in bed for each corresponding week. Multiply the answer by 100 to get an estimate of sleep efficiency. The aim is to increase sleep efficiency to as close to 100% as possible by restricting the time spent in bed to approximate to average sleep length, (ie the actual amount of time actually spent asleep, rather than trying to fall asleep), to enable the actual sleep duration to expand. In patients with insomnia, a sleep diary can not only provide information about sleep patterns but also compensatory behaviours that maintain the insomnia. Information from the diary is crucial in the cognitive behavioural treatment of insomnia and monitoring of treatment progress. When insomnia becomes chronic, the original reasons for poor sleep become less important compared to behaviour and lifestyle. Many chronic insomniacs do not have any underlying medical, psychiatric or behaviour disorder and for others, the treatment of the underlying condition which seems a possible causative factor for the insomnia may have no effect on the treatment of the insomnia. Chronic insomnia itself may lead to the development of a mood disorder. People with chronic insomnia often want to know why they cannot sleep but a better question to ask them is: what is keeping them awake? Treatment options Non-pharmacological A number of interventions have been suggested and tried in the management of insomnia. By the time individuals present for professional help however, the problem has often become complex and chronic with various maladaptive behaviours around sleep and expectations of sleep. The demands of our 24 hour society have led to most people marginalising sleep and expecting an instant solution to their symptoms, usually in the form of a pill. Education and sleep hygiene The best initial approach is to spend some time explaining the importance of sleep and its functions. Remind your patient that achieving a satisfactory sleep cycle will take time and effort, particularly if they have had the problem for a long time. Assuming there are no obvious psychiatric or medical conditions affecting sleep, your sleep history should have already provided information about appropriate sleep hygiene interventions for your patient such as a regular bedtime routine, a comfortable bedroom environment, avoiding stimulants, exercise or rich Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1):

4 SLEEP DIARY Please complete this sleep diary in the morning when you wake up Sunday Monday Tuesday Wednesday Thursday Friday Saturday 1. At what time did you go to bed last night? 2. How long did it take you to fall asleep (hours)? 3. What time did you rise from bed this morning? Total Divide by 7 4. How many hours between going to bed and getting up? 5. How many times did you wake up during the night? Total time in bed 6. How long were you awake during the night? (total hours, including 2.) Total Divide by 7 7. About how long did you sleep altogether (hours)? (4-6) 8. How many sleeping pills did you take to help you sleep? Total sleep time 9. How much alcohol did you take last night? Figure 1: Example of Sleep Diary. 54 Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1): 51 58

5 food near bedtime and incorporating regular relaxation techniques into their daily schedule. Ask about daytime naps and activity levels as occasionally people seem to have unrealistic expectations of sleep. Adjustments required will differ for individuals and your approach will need to be tailored to match your patients expectations and abilities. Relaxation A variety of methods can be taught to help relax the mind and body to help with sleep onset in those whom cognitive or physiological arousal affects sleep. Techniques include progressive muscular relaxation, visualisation/ imagery methods and meditation. The key to success is practice, and it is recommended that the exercises are initially practised well away from bedtime, (when anxiety will usually be excessive) until sufficient confidence and skill is achieved in obtaining desired levels of relaxation. Stimulus control or the 10 minute rule This method was suggested by Bootzin & Nicassioin 1978 and is based on operant conditioning principles. It boasts a success rate of 70% in patients with sleeponset insomnia. All non-sleep activities apart from sex, are forbidden in the bedroom. The patient should be instructed to get out of bed if they cannot fall asleep within minutes and to do some boring, mundane activity for the next minutes instead. They can then return to bed and attempt to sleep. If they cannot fall asleep within another minutes, they should get up again and repeat the cycle until they are eventually able to fall asleep within minutes. This method requires strong will power and persistence, as results can take a week or two to achieve, while resisting the urge for daytime naps or delaying wake-up times in the morning during the temporary period of tiredness due to sleeplessness. Simple management of excessive worry If mental activation (eg my mind won t switch off ) is a regular problem, patients need to set a regular thinking/ worry time after the evening meal. They could be advised to draw two columns on a page and to list their worries on the left side with corresponding possible actions that could be taken for each worry on the right, with an appropriate time scale of when each of the issues could practically be dealt with. They should then be instructed to fold the paper and put it away in their bedside drawer, thereby symbolically deferring the reasons for anxiety until a later date, and hopefully allowing for the immediate restful onset of sleep. Sleep restriction This method focuses on restricting the time spent in bed to those actually spent asleep rather than lying awake and feeling frustrated, as many insomniacs tend to do. The therapist and client decide on an agreed bedtime and wake up time which must be adhered to strictly. A sleep diary can be very useful in improving sleep efficiency with this method although an initial increase in daytime sleepiness can reduce compliance. Sleep compression This is a similar approach to sleep restriction but takes longer as the agreed time allowed in bed is gradually reduced, which has the advantage of being less drastic and therefore easier to adjust to. Cognitive behaviour therapy (CBT) Cognitive behavioural therapy (CBT) has been shown to improve sleep quality, reduce hypnotic drug use and improve health-related quality of life among long-term hypnotic users with chronic sleep difficulties. It involves a versatile range of relatively simple, brief and effective strategies that can be utilised in primary care, with either individual or group delivery and even via the self-help route. It is well known that beliefs, attitudes and maladaptive behaviours worsen the sleep of chronic insomniacs. Core techniques of CBT can be extremely helpful in treating insomnia in motivated patients. CBT is based on the assumption that out thoughts affect our feelings which in turn affect our actions. If we can learn to change our thoughts, then we can also alter our feelings and behaviours in sequence. CBT can be used to help individuals recognise that they can function adequately on less sleep than they think they need, that they probably sleep more than they realise, that they can manage their stresses more effectively and shows them how to become more responsible for their thoughts during the day so that sleep improves. Evidence for long-term effects of CBT for insomnia is more difficult to assess but treatment gains are generally maintained or increased with continued application. Pharmacological Psychotropic substances have been used for insomnia since ancient times and have included alcohol, opiates and herbal substances. Bromides and barbiturates were widely prescribed until their potential for abuse, dependence and fatal consequences in overdose became apparent. Pharmacological treatments for insomnia tend to be the ready treatment of choice for most doctors and the preference of most insomniacs and they certainly constitute big business for the pharmaceutical industry, generating massive profits. Although hypnotics provide short term relief, they cannot cure insomnia, they can make the problem worse by creating tolerance if used regularly and of course can have side effects. Long-term users of hypnotics have been shown to overestimate the benefits although it is now becoming accepted that long term treatment with hypnotics may be useful in a very small number of patients. One study (Poyares D et al2004), demonstrated that after a period of rebound symptoms immediately following withdrawal, many chronic users returned to the same sleep pattern they had before they started using the hypnotic. 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6 meta analysis by Glass et al 2005, revealed that the clinical benefits associated with hypnotics are found to be small in the elderly and actually out shadowed by adverse effects in some. The most common insomnia treatments are over the counter (OTC) agents and alcohol while prescription hypnotics are taken by just 6% chronic insomniacs. With data from various studies, it can be assumed that around 10-20% of chronic insomniacs regularly take prescription hypnotics, especially benzodiazepines and benzodiazepine receptor agonists (BZs/BZRAs). However, the clinical picture is complicated by the concomitant use of alcohol and various OTC agents for hypnotic purposes. Herbal substances The public has access to a vast array of alternative and over-the-counter remedies for sleep but there is a considerable amount of ignorance and misinformation about the safety of these substances. These substances, particularly herbal ones, are usually inexpensive, readily available and are frequently perceived as being safer than prescribed hypnotics. Valerian is a commonly used OTC. It is made from the roots of a perennial flowering plant but many studies have found no significant differences between valerian and placebo either in healthy individuals or in persons with general sleep disturbance or insomnia. Additionally, valerian can cause stomach aches and anxiety and is known to be hepatotoxic with regular use. It should not be used in people who are already taking medication for depression, insomnia or anxiety or by pregnant women. As with most OTC preparations, there are no long term safety studies to support the use of these agents in insomnia. Antihistamines Sedative antihistamines such as diphenhydramine (Nytol) and promethazine (Phenergan) are commonly used as hypnotics and a number of them are available without prescription. Doses of between 50mg to 100mg for diphenhydramine and between 25mg to 50mg for promethazine are recommended. They can cause dry mouth and other anticholinergic side effects. Their relatively long half lives compared to Z drugs is beneficial in patients with interrupted sleep and early morning awakening but this property can also lead to debilitating daytime drowsiness in some people and tolerance can occur within a few days of regular use. These drugs are not suited for the long-term treatment of chronic insomnia. They should be avoided in individuals taking cardiovascular medications, those who have cognitive impairment or urinary hesitancy or retention. Chloral hydrate This drug has a low therapeutic efficacy and a narrow therapeutic window with rapid development of tolerance and although there is some evidence for a moderate effect in the short-term treatment of insomnia, there is no adequate assessment of long-term use. It can lead to unpleasant taste, gastrointestinal problems, nausea, vomiting as well as nightmares, light headedness and ataxia. Overdosing is highly dangerous and can be fatal and its use in insomnia is not recommended. Melatonin Melatonin is an endogenous hormone secreted by the pineal gland, and levels peak as darkness falls, leading to onset of sleep at night. It is widely used for jet lag but is probably not as effective in secondary sleep disorders. Because it is contained naturally in some foods, it is allowed to be sold in the USA as a dietary supplement and is not controlled by the FDA as other drugs are. Consequently, doses listed on preparations obtained over the counter may not be accurate and most such preparations contain amounts much higher than naturally occur in the body. This could be harmful for people with heart-related problems, hypertension and stroke as well as for women of child-bearing age. It is also available as a prescription only medication as ramelteon (in the USA) and Circadin, a prolonged release formulation (in the UK and Europe). Both these drugs are melatonin receptor agonists. Recommended doses are 3 to 6mg for OTC melatonin, 8 to 16mg for ramelteon and 2mg for Circadin. Circadin is specifically indicated for insomnia in those over 55 years old. The main side effects seem to be sore throat, headache and nasopharyngitis. Caution is urged in liver disease. There are no reports for dependence, abuse or withdrawal symptoms and it seems to be well tolerated but onset of action is probably slower than seen with classic hypnotics such as benzodiazepines. There are some, as yet unsubstantiated, concerns that it may worsen nocturnal asthma and seizure control, and cause changes in blood pressure and fertility. It is unclear whether there are long-term benefits for patients with chronic insomnia. L-tryptophan L-tryptophan is an essential amino-acid which is metabolised to serotonin in the brain and it can result in mild to moderate improvement of sleep continuity with reductions in sleep latency and nocturnal wake times. Recommended doses range from 500 to 1000mg and with a half-life of just 1-2 hours, it does not lead to next day sedation. It can be used for short-term relief of insomnia. Benzodiazepines and benzodiazepine receptor agonists (BZs and BZRAs) These are the most widely prescribed type of medication for insomnia and are shown in Table 4. These drugs act on GABA-A receptors (which are the most widely spread receptors in inhibitory synapses) and shorten sleep latency, reduce nocturnal wake times and prolong sleep times. Substances with shorter half-lives exert their effects mainly in the first half of the night and are usually not effective in sleep maintenance whereas substances with long half-lives act throughout the night and may result in daytime sedation as well. Many of these drugs lead to suppression of REM sleep. Regular use of BZs leads to tolerance, dependence, 56 Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1): 51 58

7 Table 4: Benzodiazepines commonly used as hypnotics Benzodiazepine Approx equivalent dose to diazepam 5mg Chlordiazepoxide 15mg Flurazepam mg Loprazolam 0.5-1mg Lorazepam 0.5mg Nitrazepam 0.1-1mg Oxazepam 15mg Temazepam 10mg abuse and withdrawal. Together with the likelihood of memory disturbance, hangover effects, unwanted muscle relaxation leading to increased likelihood of psychomotor incoordination falls and an increase in mortality, they are not recommended for long term use. The BZRAs available in the UK are Zopiclone, Zolpidem and Zaleplon and are recommended in NICE Guidelines as the first line pharmacological treatment for treatment of severe insomnia which interferes with normal daily life. They should be used for short periods, in strict accordance with licensed indications and cost considerations and one should only switch to another drug with a higher cost in those patients who experience side effects. Suggested doses for these and a list of other commonly used hypnotics are shown in Table 5. Other non-evidence based pharmacological treatments The sedative effects of anxiolytics, antidepressants, antipsychotics and anticonvulsants are often harnessed to help with sleep in patients who have either not responded, shown a partial response or ceased responding to recommended hypnotics. Most of these drugs increase sleep continuity but there is very little evidence to support this approach. Managing chronic insomnia Once insomnia becomes chronic, it is best to treat it as an independent issue, apart from any co-morbid condition that might be influencing it. Many chronic insomniacs have no underling medical, psychiatric or behavioural disorder and for others, treatment of the underlying condition may have no effect on their insomnia. Chronic insomnia itself is a risk factor for the subsequent development of a mood disorder and if it already coexists with a mood disorder, treatment of the insomnia seems to foster a quicker response to antidepressants and result in a greater reduction in the risk for suicide. By the time patients present to doctors seeking help, the problem is usually chronic, complex and multifactorial. Maladaptive behaviours around sleep are common and often unrecognised by patients. A subsequent reduced confidence in the ability to initiate and maintain sleep may worsen the problem. The National Institute of Mental Health (2005) suggests that clinicians consider diagnosing comorbid insomnia rather than secondary insomnia and thus treat insomnia as a separate entity from any other coexisting diagnosis that may be influencing sleep. BzRAs are declared as being safe and efficacious but more long term studies are required and there is no consensus as yet on long-term pharmacologic treatment. Long-term use of BzRAs can be considered in selected patients if they are effective and there is no evidence of dependence or abuse. Hypnotics should be used cautiously, if at all, in certain medical conditions including hepatic disease and close supervision is indicated if there is a history of alcoholism or drug abuse. Some patients with psychiatric illnesses may only respond well to higher than recommended doses. Short acting BzRAs are preferable Table 5: Drugs used as hypnotics Drug Usual therapeutic Elderly Time until onset Duration of action dose (mg/day) Adult (minutes) Lormetazepam Quarter Short Oxazepam Short Nitrazepam Long Temazepam to half Short Zaleplon Short Zopiclone the adult Short Zolpidem Short Melatonin 2 dose unclear Short Promethazine (not licensed) Unclear, but may be 1-2hrs Long The Maudsley Prescribing Guidelines, 10th Edition Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1):

8 but those with longer half lives should be considered in those who are hyper aroused or have generalised anxiety disorder but they will need to be warned about daytime sedation. In a small number of cases with chronic insomnia, cotherapy (the use of multiple sleep promoting drugs) may be considered. The safety of BzRAs in pregnancy is not established and it is recommended that this should be mentioned to all women of child bearing potential, prior to prescribing hypnotics, together with a discussion about appropriate contraception methods, if appropriate. Conclusion Sleep requirements vary considerably among individuals. Rates of insomnia are high in the general population and chronic insomnia is a common complaint in the general practice setting. Certain groups, such as women, and the elderly are more at risk of insomnia and the condition can frequently be comorbid with various psychiatric and physical illnesses as well as be influenced by environmental factors. A thorough history is an essential first step in management, as a means of establishing possible aetiological factors. These can then influence and direct treatment strategies which should focus on setting clear and specific goals. Use of a sleep diary could provide further detail to assist assessment. Treatment strategies should include a range of different approaches, including lifestyle changes, behavioural interventions and psychological inputs such as CBT rather than initially (or solely), resorting to prescription of hypnotics. Finally, some individuals may have to be supported to learn to accept their insomnia and find ways in which to manage their lives around the disruption caused. References 1. American Academy of Sleep Medicine. (2005). International classification of sleep disorders (ICSD-2) (2 nd ed.). Chicago. 2. British Association of Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders, SJ Wilson et al, (2010) Journal of Psychopharmacology; 24 (11): Bootzin RR & Nicassio PM. (1978) Behavioural treatments for insomnia. In M Hersen, RM Eisler & PM Miller (Eds.), Progress in behaviour modification, New York: Academic Press, Inc. Vol 6, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). American Psychiatric Association, Espie CA. Overcoming insomnia and sleep problems- A self help guide using Cognitive Behaviour Therapy techniques. Pub Robinson, Glass J et al. sedative hypnotics in older people with insomnia: metaanalysis of risks and benefits. British medical journal 2005; 331: International Classification of Mental and Behavioural Disorders (ICD- 10). World Health Organisation, National Institute of Mental Health 2005, 9. NICE guidelines. Insomnia. Newer hypnotic drugs: Guidance 2004 (updated 2007) Further Sources of Useful Information 1. The Sleep Council. Freephone leaflet line: ; Promotes the benefits of sleeping well and provides information leaflets on sleep and beds. 2. National Sleep Foundation. American website with information on sleep and sleep disorders. 3. American Sleep Association 58 Copyright 2013 Rila Publications Ltd. Clinical Focus Primary Care 2013, 7(1): 51 58