Cant sleep Is this PD or am I anxious or depressed

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Anxiety and depression are common in PD and can interfere with sleep; however, insomnia (difficulty falling asleep or difficulty staying asleep or both) is part of PD.

It is normal during sleep for people to awaken during the night—to roll over, to change positions, and then to fall back to sleep without any problem. People with PD may awaken and find themselves so stiff that they are unable to make such adjustments and then can't go back to sleep. The problem may be that your last dose of Sinemet wasn't enough to give you the mobility that you need in bed to sleep through the night. This problem can be helped by adding Comtan or a dopamine agonist. Insomnia consists of one or more of the following: difficulty falling asleep, difficulty remaining asleep, frequent nighttime awakenings, early-morning awakening, and unrefreshing sleep.

Temporary insomnia lasting less than 4 weeks is self-limited and has no serious repercussions. It occurs in up to 50% of all people and is more frequent in older people, shift workers, international travelers, and peo ple who are under stress. Chronic insomnia, such as occurs in PD, lasts longer than 4 weeks, is not self-limited, and may have repercussions. Such insomnia usually results in daytime fatigue, grogginess, irritability, mood swings, and difficulty paying attention or concentrating. People with chronic insomnia are more likely to suffer from anxiety, depression, mood swings, or paranoia. Whether these disorders came first and insomnia is part of them or whether the insomnia came first and unmasked them is a source of debate. In discussing insomnia with your doctor, you should be prepared to answer questions such as these:

• What time do you go to bed? Before midnight? After midnight?

• How long does it take for you to fall asleep? Less than an hour? More than an hour?

• While trying to fall asleep, what do you do? Read? Listen to the radio? Watch TV? Worry? Stare into space?

• Do you wake up during the night? For what reason? Bad dream? Going to the bathroom? Worry? Restless legs? No reason?

• How many times do you wake up? Once? More than once?

• How many hours do you sleep? Four hours? Two hours?

• When do usually wake up? Before 4:00 a.m.? After 4:00 a.m.?

• After you wake up, do you get out of or stay in bed? How long? Less than an hour? More than an hour?

• When you wake up, are you refreshed? Or groggy?

• Do you nap during the day? Once? More than once?

If you have a bed partner, he or she can be a valuable source of information because most people are unaware of their behavior while sleeping. Your bed partner is probably the only one who can comment on specific behaviors: talking in your sleep, crying out or shouting during sleep, snoring (which may indicate sleep apnea), thrashing or kicking while asleep, or walking in your sleep.

Such preparation will help you and your doctor to identify the cause (or causes) of your insomnia. Just telling your doctor that you can't sleep without first analyzing your sleep habits is not helpful.

Temporary insomnia may be caused by anxiety (worry over family, friends, business), situational adjustments (new bed, strange bed, new house, new job, new bed partner), sleep-wake disruptions (change in schedule, international jet travel), or a new drug. Once the cause of insomnia is identified, corrective measures can be taken, and the insomnia will disappear.

Chronic insomnia has many causes, which may include the following:

• Heart and lung disease.

• Kidney, prostate, and bladder disease.

• Endocrine disorders such as an overactive thyroid gland or diabetes.

• Sleep apnea (this results from decreased tone of the muscles of the roof of your mouth, which in turn, results in your uvula falling back into your throat and partially blocking your airway when you lay down).

• PD drugs such as deprenyl and amantadine.

• Drugs for other conditions such as sleeping pills, which may, paradoxically, worsen insomnia if used improperly or withdrawn inappropriately.

Many people with PD have insomnia. This may be related to a primary sleep disorder that arises from an as yet unknown disturbance in sleep rhythm. The centers regulating sleep are in the brainstem, a region uniquely positioned to regulate sleep as it regulates eye opening and closing, posture, and tone. The centers regulating sleep are located near the substantia nigra, the region most affected in PD. Thus, it's not surprising that there is an association between PD and difficulty sleeping. The diagnosis of a primary sleep disorder is made in the absence of other causes of insomnia. Sometimes the diagnosis of a primary sleep disorder requires evaluation in a sleep laboratory. If such a disorder causes insomnia, initial treatment is to provide you with information about sleep and to instruct you in such simple and effective measures as to go to bed only when you're sleepy; to leave your bedroom if you're unable to fall asleep within 30 minutes or if you wake up and can't get back to sleep within 30 minutes and to return only when you're sleepy; to wake up at the same time every morning, including weekends; and to avoid daytime naps.

Relaxation techniques are helpful. Examples include neck muscle relaxation and diaphragmatic breathing. Some people with insomnia without realizing it engage in activities that aggravate the problem: excessive use of stimulants such as coffee or caffeine-containing soft drinks, sleeping excessively on weekends, or daytime napping.

Many people with insomnia become anxious and preoccupied with their difficulty sleeping, and because worry and concern tend to peak around bedtime, this worsens the insomnia. If education and instructions in proper sleep hygiene are insufficient, the next approach is short-term use of a prescription or nonprescription drug. Your doctor must decide on the proper drugs or combination of drugs. Commonly used nonprescription, over-the-counter drugs include the following: kava root, usually up to 500 mg per night; melatonin, a hormone secreted by the pineal gland and thought to regulate cir-cadian rhythms, usually 1 to 3 mg per night; and valerian root, usually 500 mg per night. These drugs, although not requiring a prescription, may like other drugs have side effects and interact with prescription drugs. You must tell your doctor about all of the drugs that you are taking.

Commonly used prescription drugs include benzodiazepines, a class of drugs that bind to a special receptor in the brain, called the benzodiazepine receptor; nonbenzo-diazepine sleep medications, a class of drugs that are not benzodiazepines but that bind to the benzodiazepine receptors; and antidepressants with sleep-inducing properties. Some drugs have a long half-life, reflecting delayed metabolism by the body. Such drugs are likely to cause daytime grogginess or drowsiness. Examples include Elavil, Norpramin, and Sinequan.

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