The metacognitive model of insomnia posits that the hyperarousal experienced during insomnia can be split into two areas. The first area is primary arousal, which includes the cognitive activities related to ones inability to fall asleep. The second area is secondary arousal, which refers to one’s relationship with their thoughts about sleep. 

Metacognitve Model of Insomnia

- Stimulants
- Antidepressants
- Corticosteroids
- Beta agonists
- Antiparkinsonian agents

Drugs that induce insomnia:

- Trouble falling asleep
- Difficulty staying asleep
- Waking up too early
- Poor quality of sleep overall

Symptoms of insomnia

- sleep-onset insomnia
- sleep-maintenance insomnia

Kinds of Insomnia

This qualitative study explores how sleep in older adults is increasingly framed as a problem requiring medical or pharmaceutical attention. Through interviews with UK health professionals, the authors find that sleep issues in older age are often normalized, yet insomnia is also increasingly viewed through a medical lens, especially in general practice. However, medicalization is uneven: doctors often express reluctance to prescribe, and some are moving toward non-drug interventions or “de-pharmaceuticalisation.”

Medicalisation, Pharmaceuticalisation, and the Sleep Problematisation of Older Age in the UK


Most general practitioners try to address sleep with non-pharmacological methods- suggesting lifestyle adjustments, sleep hygiene, or brief self-help tools- first before considering medication. When hypnotics are prescribed, it’s often seen as a reluctant compromise. General practitioners are wary of habit formation, side effects, or simply not being effective long term. In addition, growing regulatory scrutiny over hypnotics (like benzodiazepines and Z-drugs) is pushing prescribers toward shorter courses and stricter criteria. All of this suggests a potential future shift towards “de-pharmaceuticalisation”. 

Current Insomnia Treatment Patterns

Insomnia is a common health concern that causes significant distress and disruption in daily life, due to difficulty with and lack of sleep. Insomnia tends to be associated with an increased risk of developing physical health problems, anxiety, and depression.

Georgetown University

University of Georgia

- Cerebrovascular Effect
- Cognitive Impairment and Delirium
- Neuroleptic Malignant Syndrome
- Movement Disorders
- Seizure Disorders
- Serotonin Syndrome
- Insomnia

Examples of Drug-Induced Neurologic Conditions

The DSM-5-TR separates Sleep-Wake Disorders into the following specific disorders and groups:
-	Insomnia Disorder
-	Hypersomnolence Disorder
-	Narcolepsy
-	Breathing Related Sleep-Disorders*
-	Circadian Rhythm Sleep-Wake Disorders*
-	Parasomnias*
-	Restless Leg Syndrome
-	Substance / Medication-Induced Sleep Disorder
-	Other Specified Insomnia Disorder
-	Unspecified Insomnia Disorder
-	Other Specified Hypersomnolence Disorder
-	Unspecified Hypersomnolence Disorder
-	Other Specified Sleep-Wake Disorder
-	Unspecified Sleep-Wake Disorder

Note: * Groups that separate into further specific disorders

[DSM-5-TR] List of Sleep-Wake Disorders

Schisandra's seeds and fruits are prepared in a variety of ways, often consumed as a drink for its stimulant effects. One component of the plant, schisantherin A, has been demonstrated to have neuroprotective effects in mouse studies and may be promising in treating symptoms of neurodegenerative disorders like Parkinson's disease. Though generally well-tolerated, overconsumption may lead to insomnia. 

Schisandra (Schisandra chinensis)

Peters, A., Reece, J., Meaklim, H., Junge, M., Cunnington, D., Ong, J., . . . Greenwood, K. (2021). Mindfulness and Behaviour Therapy for Insomnia: An Assessment of Treatment Effect in a Sleep Disorders Clinic Population with Insomnia. Behaviour Change, 38(1), 25-39. doi:10.1017/bec.2020.18


Mindfulness and Behavior Therapy for for Insomnia: An Assessment of Treatment Effect in a Sleep Disorders Clinic Population with Insomnia

Also known as cerebellar syndrome
It is a consequence of disrupting the normal function of the brain that is responsible for coordination and balance. Many cases are reversible but the permanent cerebellar syndrome can occur.

Cerebrovascular Effect

A drug-induced neurologic disorder caused by neuroleptic and antipsychotic drugs. Thought to result from dopamine receptor D2 blockade in the corpus striatum, spinal cord, and hypothalamus. Once begun, symptoms progress rapidly and reach peak severity at 72 hours. 

Neuroleptic Malignant Syndrome

Delirium can be a side effect of drugs, especially in elderly patients. It is acute in onset and results in fluctuations in cognition, mood, attention, and arousal. Delirium can also be reversed when the underlying causative agent is removed. Prescribers can refer to the Beers Criteria to determine which drugs are linked to cognitive impairment.

Delirium and Cognitive Impairment 

Serotonin Syndrome (SS) include predictable symptoms resulting from excess serotonin  and overstimulation of 5-HT receptors. SS can range from mild to severe and is potentially fatal, although its incidence is low.  SS rarely occurs with use of a single agent; it is more commonly the result of a drug-drug interaction. 

Serotonin Syndrome

- Symptoms associated with drug-induced seizures are similar to those of non-drug related seizures.
- Majority of seizures induced by drugs present as generalized tonic-clonic seizures
- The withdrawal of drugs such as benzodiazepines may provoke seizures
- It is important to consider whether the suspected drug has seizure potential at normal doses or at higher serum concentrations (as is the case with tricyclic antidepressants, theophylline, and clozapine)
- Many substances can lower the seizure threshold and cause seizures




Seizure Disorders

Drug-induced movement disorders (DIMDs) can reduce the quality of life, decrease drug adherence, and cause compromised performance of motor skills. 
Parkinsonism, akathisia, tardive syndrome, and acute dystonia are associated with DIMDs. 

Movement Disorders

Insomnia 

A sleep disorder that consists of not getting enough sleep.

Insomnia

Insomnia, the most prevalent sleep disorder, is characterized by a persistent difficulty in initiating or maintaining sleep. Individuals with this condition often experience significant delays before falling asleep and may wake up frequently during the night, struggling to resume sleep. According to diagnostic criteria, these sleep disturbances must occur at least three nights a week for a minimum of one month.

Non-Rapid Eye Movement Sleep Arousal (NREM) Disorders are characterized by repeated episodes incomplete awakenings during sleep that usually last about 1-10 minutes but can also last as long as 1 hour without any recollection. Little to no dream imagery is recalled. 

NREM Sleep Arousal Disorders


Narcolepsy is a sleep disorder characterized by an uncontrollable urge to fall asleep at inopportune times. These sleep episodes are frequently accompanied by cataplexy, a sudden loss of muscle tone. Narcoleptic attacks often exhibit features characteristic of REM sleep; for instance, about a third of those with the disorder report experiencing vivid, dream-like hallucinations during an episode.

Narcolepsy

Sleep apnea is a disorder characterized by episodes in which a person's breathing stops during sleep. These cessations can last for 10-20 seconds or longer and often result in brief arousals. Although individuals with sleep apnea may be unaware of these repeated sleep disruptions, they frequently experience significant daytime fatigue. The condition is commonly associated with loud snoring and is more prevalent in overweight people.

Sleep Apnea

A sleep disorder in which someone physically acts out their dream. This disorder typically presents after age 50, is more common in men than women, and usually followed by Parkinson’s and/or dementia symptoms, suggesting it’s the start of widespread neurodegeneration. Usually controlled by anti-anxiety drugs like benzodiazepines at night. 

REM Behavior Disorder

Somnambulism, or sleepwalking, is a condition more common in childhood that can persist into adulthood. It involves episodes of complex behaviors, lasting from seconds to minutes, which are often not remembered. While these episodes most frequently occur during stage 3 slow-wave sleep (SWS), they can happen at any time during a sleep period. Sleepwalkers are not acting out their dreams.

Somnambulism

Substance/medication-induced sleep disorders are characterized by a severe sleep disturbance that occurs during or soon after substance intoxication, medication exposure, or substance/medicine withdrawal.

Substance/Medication-Induced Sleep Disorder

* Obstructive Sleep Apnea Separate Specific Disorder
* Central Sleep Apnea
* Sleep-Related Hypoventilation


Specific Breathing Sleep-Related Disorders

Circadian rhythm sleep-wake disorders happen when constant patterns of sleep disturbances occur. These disturbances can be caused by a new circadian rhythm or discrepancies between the person’s circadian rhythm and the sleep-wake schedule that is demanded by the person’s social life, occupation, or environment.

Circadian Rhythm Sleep-Wake Disorders

Hypersomnolence disorder consists of sleeping for too many hours at night, trouble staying completely awake after being woken up, or frequent episodes of sleep throughout the day. 

Hypersomnolence Disorder

Reference for Sleep-Wake Disorders

REM behavior disorder (RBD), sleepwalking, restless leg syndrome, and night terrors are examples of parasomnias, which involve unwanted motor behaviors or experiences during the sleep cycle.

Examples of Parasomnias

- Caused by degradation of cells containing dopamine that project on basal ganglia cells 
- Symptoms include tremors during periods of stagnation, loss of facial muscle tone, rigid muscles, and decreased voluntary movement
- Disease usually not inherited, but there are some defective genes that can be inherited, including a-synuclein (protein normally found in basal ganglia cells) and parkin

Parkinson's Disease

Neurodegenerative diseases refers to neurological diseases caused by neuronal death or deterioration due to many factors, including protein aggregation/misfolding, apoptosis, and mitochondrial dysfunction. 

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