SLEEP DISORDERS
Two Major Categories*
◦ Dyssomnias
◦ Parasomnias
*This classification system is similar to that used by the American Sleep Disorders
Association.
Dyssomnias
◦The sleep itself is pretty normal.
◦But the client sleeps too little, too
much, or at the wrong time.
◦So, the problem is with the amount
(quantity), or with its timing, and
sometimes with the quality of sleep.
Parasomnias
◦Something abnormal occurs
during sleep itself, or during the
times when the client is falling
asleep or waking up (e.g., bad
dreams.
◦The quality, quantity, and
timing of the sleep are
essentially normal.
The Sleep Disorders chapter has four
major sections:
I.
Primary Sleep Disorders include all
sleep disorders, except:
II.
Sleep Disorder Related to Another Mental Disorder
III. Sleep Disorder Due to a General
Medical Condition (GMC)
IV. Substance-Induced Sleep Disorder
I. Primary Sleep Disorders
◦ Dyssomnias
A. Primary Insomnia - too little sleep (criteria listed on p. 604)
◦ Characteristics
◦ Difficulty initiating or maintaining sleep
◦ Persists for 1 month or longer
◦ This diagnosis is rarely independent of an Axis I or II disorder or a GMC or substance use.
I. Primary Sleep Disorders (cont.)
A. Primary Insomnia (too little sleep)
Often due to:
◦ Major Depressive Episode, Manic Episode, or anxiety disorder
◦ Commonly misused substances, as well as some prescription medicines.
◦ Breathing-related problems
◦ The cause sometimes can not be identified.
I. Primary Sleep Disorders (cont.)
A.
Primary Insomnia (too little sleep)
Treatment
◦
Vigorous daytime exercise, not exercising before sleep
◦
Sexual intercourse, if pleasurable
◦
Metronome or ticking clock- slow, 60 beats per minute or slower, beat
of human heart
◦
Relaxation exercises, practice regularly but condensed to 5 minutes
◦
Decrease stimulation and increase soothing environments, such as ear
plugs or calm reading
◦
Practice good sleep habits
◦
Read “How to Become an Insomniac”
I. Primary Sleep Disorders
◦ Dyssomnias
B. Primary Hypersomnia (sleeping too much, as well as being drowsy at
times when client should be alert) (criteria listed on p. 609)
◦ Characteristics
◦ Excessive sleepiness
◦ Persists for 1 month or longer
◦ Rarely a diagnosis independent of an Axis I or II disorder or a GMC or substance use.
◦ Specify if: Recurrent.
I. Primary Sleep Disorders (cont.)
B. Primary Hypersomnia (too much sleep) (cont.)
◦ Often due to:
◦ Major Depressive Episode, Dysthymic Disorder with atypical features
◦ Use of substances is less likely to produce hyersomnia than insomnia, but it can
happen (e.g., sleeping pills overdose)
◦ The cause sometimes can not be identified.
Treatment: Exercise when becoming sleepy
I. Primary Sleep Disorders
Dyssomnias
◦
C. Narcolepsy (Sleeping at the wrong time)
(criteria listed on pg. 615)
◦
Characteristics
◦
Sleep intrudes into wakefulness, causing clients to fall asleep almost instantly
◦
Sleep is brief but refreshing
◦
May also have sleep paralysis, sudden loss of strength, and hallucinations as
fall asleep or awaken.
Treatment: Stimulants, sometimes antidepressants, with less success.
I. Primary Sleep Disorders
Dyssomnias
◦
D. Breathing-Related Sleep Disorder
(criteria listed on p. 622)
Characteristics
Sleep disruption (excessive sleepiness or insomnia)
◦
◦
Due to sleep-related breathing condition (e.g., Obstructive Sleep Apnea
Syndrome)
I. Primary Sleep Disorders
◦
Dyssomnias
D.
Breathing-Related Sleep Disorder
Treatment (Criteria on p. 622)

In mild cases: weight loss, sleeping on one’s side, and avoiding
hypnotics and alcohol
(To sleep on side, a tennis ball can be sewn into back of client’s sleep
wear)

In more serious cases: a machine that provides continuous positive
airway pressure

Surgery: Few benefits
I. Primary Sleep Disorders
◦
Dyssomnias
E.
Circadian Rhythm Sleep Disorder
(criteria on p. 629)
Characteristics
◦
Persistent or recurrent pattern of sleep disruption leading to excessive
sleepiness or insomnia, due to mismatch between sleep-wake schedule
required by a person’s environment and his/her circadian sleep-wake
pattern (e.g., shift work, jet lag).
I. Primary Sleep Disorders
◦
Dyssomnias
E.
Circadian Rhythm Sleep Disorder
Treatment: Difficult to treat, because it has to involve the entire
family
◦
Darken bedroom and use soundproofing
◦
Limit caffeine and hard to digest food.
◦
Ensure all family members learns shift
◦
To help jet lag, exposure to sun helps
Specify type: Delayed Sleep Phase Type, Jet Lag Type, Shift Work Type,
and Unspecified Type
I. Primary Sleep Disorders
Dyssomnias
F.
Dyssomnia NOS (listed on p. 629)
This category is for insomnias,
hypersomnias, or circadian rhythm disturbances that do not meet
criteria for any specific Dyssomnia.
I. Primary Sleep Disorders
◦
Parasomnias
A.
Nightmare Disorder (Criteria listed on p. 634)
Characteristics:
(1) Repeated awakenings from bad dreams
(2) When awakened client becomes
alert
oriented and
I. Primary Sleep Disorders
Parasomnias
◦
A. Information about Nightmare Disorder
◦
◦
◦
◦
◦
◦
◦
Usually occurs in early morning when REM sleep dominates.
The same nightmare may recur repeatedly or different ones may pop
up three times a week.
Stress may induce 60% of nightmares.
Half of the cases of nightmare disorder appear before age 10; 2/3
before age 20.
Dreams are clearly remembered
Drugs can trigger nightmares.
Suddenly withdrawing REM-suppressant medications and drugs can
cause REM rebound.
I. Primary Sleep Disorders
◦
Parasomnias
B.
Sleep Terror Disorder (criteria listed on pg. 639)
Characteristics:
(1)
Abrupt awakening from sleep, usually
beginning with a panicky scream or cry.
(2)
Intense fear and signs of autonomic
arousal
(3)
Unresponsive to efforts from other to calm
client
(4)
No detailed dream recalled
(5)
Amnesia for episode
I. Primary Sleep Disorders
◦
Parasomnias
B.
Sleep Terror Disorder
Usually only children have sleep terror disorder.
The client is not having a nightmare.
The eyes are open, screams erupt.
Usually happens in early evening.
In contrast to nightmares, sleep terrors do not respond to
psychotherapy.
Probably due to brain wave upset, fever, or medications
However, some medications may help.
I. Primary Sleep Disorders
◦
Parasomnias
C.
Sleepwalking Disorder (criteria listed on pg. 644)
Characteristics:
(1)
Rising from bed during sleep and walking about.
(2)
Usually occurs early in the night.
(3)
On awakening, the person has amnesia for
episode
I. Primary Sleep Disorders
◦
Parasomnias
C.
Sleepwalking Disorder
Most sleepwalking children are psychologically normal.
Runs in families.
Begins between ages 6 and 12 and may be stress-related.
Customarily sleepwalkers exhibit other delta-sleep
interruptions.
At some time 1-6% of children sleepwalk; of these, 15% do
so occasionally.
Adult sleepwalking is far less common, usually worse and more
chronic.
I. Primary Sleep Disorders
◦
Parasomnias
C.
Sleepwalking Disorder
Treatment:
Relaxation techniques
Biofeedback training
Hypnosis.
May need to sleep on the ground floor, have
outside doors securely locked, and have car keys
unavailable.
I. Primary Sleep Disorders
◦
Parasomnias
D. Parasomnia NOS (listed on p. 644)
Characteristics:
Abnormal behavioral or physiological events during sleep or sleepwake transitions, but that do not meet criteria for a more specific
Parasomnia
I. Primary Sleep Disorders
◦
Parasomnias
D. Parasomnia NOS (listed on p. 644)
Examples
Sleep-Talking: Often more annoying to partner than to
sleeper. Has no memory in morning. Can be during REM or
delta sleep. In REM sleep, pronunciation is clear and
understandable; in deep sleep (delta) apt to be mumbled
and unintelligible
Sleep paralysis: inability to perform voluntary movement
during the transition between waking and sleep. Usually
associated with extreme anxiety, and sometimes fear of
impending death.
REM sleep behavior disorder: characterized by agitated
and violent behavior.
Parasomnia is present but unable to determine whether it is
primary, due to GMC, or substance induced.
The Sleep Disorders chapter has four
major sections:
I.
Primary Sleep Disorders include all
sleep disorders, except:
II.
Sleep Disorder Related to Another Mental Disorder
III. Sleep Disorder Due to a General
Medical Condition (GMC)
IV. Substance-Induced Sleep Disorder
II.
Sleep Disorder Related to
Another Mental Disorder
◦ Two Diagnoses
1.
Insomnia Related to Another Mental
Disorder (criteria listed on p. 650)
2. Hypersomnia Related to Another
Mental Disorder (criteria listed on p.
650)
II.
Sleep Disorder Related to
Another
Mental
1.
Insomnia Related
to Another Disorder
Mental
Disorder
Characteristics
◦ Difficulty in initiating or maintaining sleep
◦ Persists for at least 1 month
2. Hypersomnia Related to Another
Mental Disorder
Characteristics:
◦ Excessive sleepiness
◦ Persists for at least 1 month
II.
Sleep Disorder Related to
Another Mental Disorder
◦ Two Diagnoses
1.
Insomnia Related to… another mental
disorder – indicate the Axis I or II disorder
(criteria listed on p. 650)
2. Hypersomnia Related to…another
mental disorder – indicate the Axis I or II
disorder (criteria listed on p.
650)
III. 327.xx Sleep Disorder Due to … a
General Medical Condition
(list the GMC) (criteria on p. 654)
Also GMC on Axis III
Prominent disturbance in sleep that is sufficiently
severe to warrant independent clinical attention.
◦ Evidence has to be present that the sleep disturbance is a direct
physiological consequence of a general medical condition.
◦ Specify Type:
(1)
.52
Insomnia Type
(2)
.54
Hypersomnia Type
(3)
.59
Parasomnia Type
(4)
.59
Mixed Type
IV. Substance-Induced Sleep Disorder
(Indicate Substance) (criteria is on p. 660)
Characteristics
◦ Evidence must be present that the sleep disturbance is a direct physiological
consequence of substance use.
◦ Substance use that produces a sleep disorder severe enough to warrant
independent clinical attention
Code:
291.8 Alcohol; 292.89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine;
292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other (or
unknown) Substance
IV. Substance-Induced Sleep Disorder
(Indicate Substance) (criteria is on p. 660)
Types:
Insomnia Type
Hypersomnia Type
Parasomnia Type
Mixed Type
Specify if:
With Onset During Intoxication
With Onset During Withdrawal
INSOMNIA
Insomnia
◦ A broad term denoting unsatisfactory sleep
◦ Perception that sleep is inadequate or abnormal
◦ Common problem
◦ A symptom, not a disease or sign, therefore difficult to measure
Diagnosis
◦ Complaint that the sleep is:
◦ Brief or inadequate
◦ Light or easily disrupted
◦ Non-refreshing or non-restorative
International Congress of Sleep
Disorders Classification
◦ Based on the duration of symptoms
◦ Transient or acute
◦ Few days to 2-4 weeks
◦ Chronic
◦ Persisting for more than 1-3 months
Definitions
◦ Mild
◦ Almost nightly complaint of non-restorative sleep
◦ Associated with little or no impairment of social or occupational functioning
◦ Moderate
◦ Nightly complaints of disturbed sleep
◦ Mild to moderate impairment of social or occupational function
◦ Severe
◦ Nightly complaints of disturbed sleep
◦ Severe daytime dysfunction
Classification
◦ Sleep initiating insomnia
◦ Sleep maintaining insomnia
◦ Early morning insomnia
◦ Short period of sleep
◦ Non-restorative sleep
◦ Multiple awakenings
◦ Combination of above patterns
Presentation Goals
◦ Review of normal sleep cycle
◦ Causes of insomnia
◦ Diagnosis and assessment of insomnia
◦ Treatment modalities
Stages of Sleep
◦ Non-Rapid Eye Movement (NREM) sleep
◦ Stage I
◦ Stage II
◦ Stages I & II are light sleep
◦ Stage III
◦ Stage IV
◦ Stages III & IV are deep sleep
◦ Rapid Eye Movement (REM) sleep
Normal Sleep Pattern
◦ Sleep is an integral portion of human existence which is sensitive to most
physiological or pathological changes (aging, stress, illness, etc.)
◦ Why do we sleep?
◦ Not clear, but has to do with regeneration (NREM) and brain
development/memory (REM) – REM sleep is essential for the development of the
mammalian brain
◦ Stages III & IV are involved in synaptic “pruning and tuning”
◦ Why do we get sleepy?
◦
◦
◦
◦
Circadian factors
Process S: linear increase in sleepiness
Process C: rhythmic fluctuations of the circadian alert system
Other factors: sleep duration, quality, time awake, etc.
Causes
◦ Insomnia is a downstream symptom of an upstream problem, for example:
◦
◦
◦
◦
◦
◦
Medical
Psychological/ Psychiatric
Behavioral
Parasomnias
Drug-induced
Combination of factors in chronic insomnia
Normal Sleep Values
◦ Normal sleep per day is between 6-8 hours, although some people can
maintain a 4-6 hour cycle
◦ 4-6 NREM/REM cycles per night
◦ Sleep structure changes throughout life
◦ Wakefulness after sleep
◦ Less than 30 minutes
◦ Sleep Onset Latency (SOL)
◦ Less than 30 minutes
◦ REM Sleep Latency
◦ 70-120 minutes
Epidemiology
◦ Studies throughout the world show that it occurs everywhere
◦ Depending on the area, study, etc., between 10-50% of the population are affected
◦ Increases with age
◦ Twice as common in females
◦ Up to the age of 30, there is little difference between sexes
◦ Beyond 30 years, it is more common in females
◦ Beyond 70 years, females are affected twice as much as males
Etiology
◦ Symptom of numerous diverse etiologies
◦ Usually due to more than one factor and each needs a separate evaluation
◦ In all cases, one should strive to find the cause as it will dictate the proper treatment
3 P’s of Acute Insomnia
◦ Predisposition
◦ Anxiety, depression, etc.
◦ Precipitation
◦ Sudden change in life
◦ Perpetuation
◦ Poor sleep hygiene
◦ Precipitating causes lower the threshold for acute
insomnia in people with predisposing and
perpetuating causes as well as further lowers the
threshold for chronic insomnia
◦ Start aggressive treatment in the ACUTE phase,
before the patient goes into CHRONIC insomnia
Acute Insomnia
◦ Resolves with the management of inciting factors
◦ Adjustment sleep disorder
◦ Acute stress such as momentous life events or unfamiliar sleep environments
◦ PSG: increased SOL, increased awakenings and sleep fragmentation with
poor sleep efficiency
◦ More common in women and those with anxiety
◦ Jet Lag
◦ Symptoms last longer with eastbound travel
◦ Remits spontaneously in 2-3 days
◦ More common in the elderly
Chronic Insomnia
◦ Primary or Intrinsic
◦ Secondary or Extrinsic
◦ Causes
◦
◦
◦
◦
Changes in circadian rhythm, behavior, environment
Body movements in sleep
Medical, neurological, psychiatric disorders
Drugs
Primary/Intrinsic Insomnia
◦ Idiopathic
◦ Starts early in childhood, rare but relentless course
◦ Rare disorders affect both genders
◦ CNS abnormalities, unknown etiology, etc.
◦ Sleep State Misinterpretation (5%)
◦ Underestimate of the sleep obtained
◦ Females affected more than males
◦ Psychophysiological insomnia (30%)
◦ Maladaptive sleep-preventing behaviors develop and progress to become
dominant factors
◦ Females more than males
Secondary/Extrinsic Insomnia
1.
Circadian rhythm sleep disorder: sleep attempted at a time when the circadian
clock is promoting wakefulness
◦
Advanced sleep phase syndrome
◦
Delayed sleep phase syndrome
◦
Irregular sleep/wake patterns
◦
Non-24 hour sleep/wake syndrome
◦
Shift work sleep disorder
◦
Short sleeper
2.
Behavioral disorders: rooted behaviors that are arousing and
not conductive to sleep
◦
Inadequate sleep
◦
Limit setting sleep disorder
◦
Nocturnal eating/drinking syndrome
◦
Sleep onset association disorder
3.
Environmental factors
◦
Environmental sleep disorder
◦
Food allergy insomnia
◦
Toxin-induced sleep disorder
4.
Movement disorders
◦
PLMS disorder (5%)
◦
RLS syndrome (12%)
◦
REM behavior disorder
5.
Medical Disorders: Respiratory
◦
Altitude insomnia
◦
Central alveolar hypoventilation syndrome
◦
Central apnea syndrome
◦
COPD
◦
OSAS (4-6%)
◦
Sleep-related asthma
6.
Medical: Cardiac
◦
7.
Nocturnal myocardial ischemia
Medical: GI
◦
Peptic ulcer disease
◦
GERD
8.
Medical: Musculoskeletal
◦
Fibromyalgia
◦
Arthritis
9.
Medical: Endocrine
◦
Hyperthyroidism
◦
Cushing’s disease
◦
Menstrual cycle association
◦
Pregnancy
10. Medical: Neurological
◦
Cerebral degeneration disorder
◦
Dementia
◦
Fatal familial insomnia
◦
Parkinson’s disease
◦
Sleep related epilepsy
◦
Sleep related headaches
11. Medical: Psychiatric
◦
Alcoholism
◦
Anxiety disorders
◦
Mood disorders
◦
Panic disorders
◦
Psychosis
◦
Drug dependency
12.
Pharmacological causes
◦
Alcohol dependent sleep disorder
◦
Hypnotic dependent sleep disorder
◦
Stimulus dependent sleep disorder
◦
Medications
◦
B-blockers
◦
Theophylline
◦
L-dopa
Parasomnia Events
◦ Physical phenomena occurring in sleep
◦ Rhythmic movement disorder
◦ Confusional arousals
◦ Painful erections
◦ Nightmares
◦ Sleep starts
◦ Nocturnal leg cramps
◦ Sleep terrors
◦ Nocturnal paroxysmal dystonia
◦ Sleep walking
◦ REM sleep behavior disorder
◦ Abnormal swallowing
◦ Hyperhidrosis
◦ Laryngospasms
Physical, Emotional, and Cognitive
Effects of Insomnia
◦ Mood changes, irritability, poor concentration, memory defects,
etc.
◦ Impairs creative thinking, verbal processing, problem solving
◦ Risk of errors, accidents due to excessive daytime sleepiness
◦ Markedly increases if awake more than 16-18 hours (micro-sleep attacks)
◦ Increased appetite, decreased body temperature
◦ Physiologic effects
◦ Rats die after 11-12 days of sleep deprivation
◦ Hippocampal atrophy in chronic jet lag or shift work
Evaluation
◦ HISTORY!
◦
◦
◦
◦
◦
◦
Precipitating factors
Psychiatric and medical disturbances
Medications
Sleep hygiene
Circadian tendencies
Cognitive distortions and conditional arousals
◦ Sleep diary
Evaluation
◦ PSG
◦ if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological
interventions fail as recommended by the AASM
◦ Not routinely employed in the evaluation of transient or chronic insomnia
◦ Should not be substituted for a careful clinical history
Epworth Sleepiness Scale
A good measure of excessive daytime sleepiness. How likely are you to doze off or
fall asleep in the following situations, in contrast to feeling just tired? This refers to
your usual way of life in recent times. Even if you have not done some of these
things recently, try to work out how they would affect you. Use the following scale
to choose the most appropriate number for each situation:
0=no chance of dozing
chance
1=slight chance
2=moderate chance
Sitting and reading
____
Watching TV
____
Sitting inactive in a public place (ex. theater, meeting)
As a passenger in a car for an hour without a break
____
____
Lying down to rest in the afternoon
____
Sitting and talking to someone
____
In a car, while stopped for a few minutes in traffic
____
____ Total Score
Normal < 10
Severe > 15
3=high
Insomnia questionnaire
I have real difficulty falling asleep.
Thoughts race through my mind and this prevents me from sleeping.
I wake during the night and can’t go back to sleep.
I wake up earlier in the morning than I would like to.
I’ll lie awake for half an hour or more before I fall asleep.
I anticipate a problem with sleep almost every night
If you checked three or more boxes, you show symptoms of insomnia, a
persistent inability to fall asleep or stay asleep.
Treatment Selection
1.
Meet and educate about disease, goals, options, side effects, and document
safety.
2.
Identify the 3 P’s.
3.
Intrinsic v. Extrinsic
4.
Treat perpetuating causes
◦
Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep
restriction, cognitive behavior therapy (CBT), combination of medications and CBT
CBT
◦ Longest lasting improvements, assuming the precipitating cause is dealt with
◦ “counseling” or “talk through” therapy for thoughts and attitudes that may be leading
to the sleep disturbances
◦ Identifying distorted attitudes or thinking that makes the patient anxious or stressed and
replacing with more realistic or rational ones
CBT Examples
◦ “I need more hours of sleep or I will not function”
◦ “I can never die”
◦ Uses restructuring techniques
◦ Short circuit cycle of insomnia, cognitive distortions, distress
◦ Sleep hygiene, relaxation, stimulus control, sleep restrictions
Sleep Hygiene
◦ Exercise earlier during the day, and no more than 4-6 hours
before sleep
◦ Keep bedroom dark and quiet, to be used only for sex or sleep
◦ Curtail time in bed to only when sleepy
◦ Fixed sleep/wake times for 365 days
◦ Avoid naps
◦ Avoid stimulus or stimulating activities before sleep or in bed
◦ No alcohol at least 4 hours before sleep, no caffeine after noon,
and quit smoking!!
◦ Light snack before bedtime
Stimulus Control
◦ Use bedroom for sleep or sex only
◦ Go to bed only when tired and sleepy
◦ Remove clock from the bedroom to avoid constantly watching it
◦ Regular sleep/wake times
◦ Light therapy if required
◦ No bright lights when you wake up at night
Sleep Restriction
◦ An effective form of treatment
◦ Estimate the time actually asleep then limit bedtime to that amount, but no less than 5
hours
◦ Add time in bed gradually once the patient sleeps more than 85% of that time
Pharmacotherapy
◦ Nationally, there has been a decline in hypnotic usage with an increase in usage of
non-hypnotics
◦ Trazadone
◦ Seroquel
◦ Self-medication with alcohol and over-the-counter medications
◦ Benadryl
◦ Nyquil
Hypnotics
◦
5 questions to ask when choosing a hypnotic:
1.
Are you looking for sleep initiation or maintenance?
2.
What are the daytime residual effects of the drug?
3.
Does tolerance develop to this drug?
4.
Will rebound withdrawal insomnia occur when discontinued?
5.
What is the half-life of the medication?
Benzodiazepines
Dose
Half-life
Comments
Flurazepam(Dalmane)
15,30 mg
Long
Daytime drowsiness
common; rarely used
Clonazepam(Klonopin)
0.5-2 mg
Long
Temazepam (Restoril)
15,30 mg
Intermediate
Used for PLM, REM
behavior disorder; can
cause morning
drowsiness
Estazolam (ProSom)
1-2 mg
Intermediate
Can cause
agranulocytosis
Triazolam (Halcion)
0.125,0.25 mg
Short
Rebound insomnia may
occur
Zolpidem (Ambien)
5,10 mg
Short
A nonbenzodiazepam
Zopliclone (Sonata)
5,10 mg
Short , 1-1.5 hours
A nonbenzodiazepam
Recent Medication Additions
◦ Eszopiclone
1,2,3 mg
Intermediate
◦ Approved for chronic insomnia
◦ (Lunesta)
◦ Zolpidem
◦ (Amvien CR)
◦ Rozerem
◦ (Ramelton)
Action 6-8 hrs.
10 mg
Action same as above
Alternative Medications
◦ Antidepressants
◦ Not much research
◦ Some, including SSRIs, can cause daytime drowsiness
◦ Melatonin
◦ Good for jet leg, especially in elderly, but not much information on long-term
use
◦ Reported to cause depression, vasoconstriction
◦ Benadryl
◦ Rarely indicated, can cause a hangover
◦ Herbal supplements
◦ Use in conjunction with a sleep log
Conclusion
◦ Insomnia is a complex symptom with many causes and perpetuating
influences
◦ It is nerve-racking for patients and physicians yet it is very remediable,
if properly diagnosed and treated
◦ It should be aggressively treated as emerging evidence is that chronic
insomnia can precipitate major depressive disorder
◦ Depression in turn confers an increased risk of suicide, cardiovascular
disease, death, etc.