Tara Leigh Taylor, MD, FCCP Intensivist, Wyoming Medical Center

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1 Tara Leigh Taylor, MD, FCCP Intensivist, Wyoming Medical Center

2 Objectives Define the magnitude of the problem Define diagnostic criteria of insomnia Understand the risk factors and consequences of insomnia Outline and understand the evaluation of insomnia Discuss the non-pharmacologic management of insomnia

3 Insomnia -Prevalence 50 to 80% adult patients experience significant problems with falling or staying asleep during any year (typical psychiatric practice) 1 General Population 10 to 18% of adults consider sleep to be a serious chronic problem 2 Women and the elderly (fall in the lower quartile of socioeconomic status) Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002; 150: OhayonMM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:

4 Chronic Insomnia 10 to 15% primary origin Insomnia comorbid with psychiatric disorders, medical disorders, circadian rhythm disorders, or substances/medications accounts for nearly 85 to 90% Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002; 150: OhayonMM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:

5 Primary Insomnia Subsumes a number of insomnia diagnoses in the ICSD-2 Psychophysiologic insomnia Sleep-state misperception Idiopathic insomnia Inadequate Sleep Hygiene ICSD-2, International Classification of Sleep Disorders

6 Primary Insomnia A. Complaint of difficulty initiating or maintaining sleep or of nonrestorative sleep that lasts for at least 1 month B. Causes clinically significant distress or impairment in social, occupational, or other important areas of function C. The disturbance in sleep does not occur exclusively during the course of another sleep disorder D. The disturbance in sleep does not occur exclusively during the course of a mental disorder E. The disturbance is not caused by the direct physiologic effects of a substance or a general medical condition. DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Rev

7 Diagnostic Criteria Insomnia Syndrome Difficulty sleeping, characterized by either (or both) of the following Difficulty initiating sleep (>/= 30 minutes to fall asleep Difficulty maintaining sleep (> 30 min of nocturnal awakenings) with corresponding sleep efficiency (the ratio of total sleep time to time spent in bed) <85% Sleep disturbance occurs >/= 3 nights per week Sleep disturbance causes significant impairment of daytime functioning DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Rev. ICSD-2, International Classification of Sleep Disorders

8 Diagnosis Patient must experience daytime consequences from the disturbed sleep Reduced attention and concentration Memory lapses Slowed reaction time Poor coordination Dysphoria Increased anxiety/worry about sleep Fatigue Tiredness, lethargy and occasionally sleepiness Becker PM. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. ACCP Sleep Medicine Board Review: 4 th Edition

9 RISK FACTORS FEMALE AGE > 60 MENTAL HEALTH DISORDER STRESS WORK NIGHTS OR CHANGING SHIFTS LONG DISTANCE TRAVEL

10 COMPLICATIONS LOWER PERFORMANCE on the job or at school Slowed reaction time while driving and higher risk of accidents Psychiatric problems such as depression or an anxiety disorder Overweight or obesity Poor immune system function Increased risk and severity of long-term diseases such as high blood pressure, heart disease and diabetes

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12 Causes of Chronic Insomnia Based on Time of Presentation during the Night Insomnia Type Sleep Onset Causes Learned or conditioned activation (primary insomnia) Anxiety, including situational, panic disorder, generalized anxiety disorder, and obsessive compulsive disorder Mood disorders, including major depression, bipolar disorder I or II, dysthymia Psychotic disorders during acute exacerbation Delayed sleep phase syndrome Restless Legs Syndrome UARS (and less commonly sleep apnea, either obstructive or central) Substances such as caffeine and decongestants Chronic Pain, any type Cardiopulmonary disorders, particularly those exacerbated by the recumbent position Neuropathy Becker PM. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. ACCP Sleep Medicine Board Review: 4 th Edition

13 Causes of Chronic Insomnia Based on Time of Presentation during the Night Insomnia Type Sleep Maintenance Causes Excessive time in bed Major depression, or dysthymiaor bipolar disorder in association with anxiety Sleep-disordered breathing: sleep apnea, UARS Periodic limb movements of sleep Chronic pain, particularly arthritis of hips, shoulders, and neck, as well as disc disease of the lumbosacral spine Respiratory disorders, particularly those exacerbated by the recumbent position Cardiovascular disease: heart failure, angina, atrial fibrillation, others Neurologic disease: fatal familial insomnia, dementia, Parkinson and other movement disorders, seizures, degenerative CNS disorders, peripheral nerve disease, toxic exposure Becker PM. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. ACCP Sleep Medicine Board Review: 4 th Edition

14 Causes of Chronic Insomnia Based on Time of Presentation during the Night Insomnia Type Early Awakening Causes Major depression Advance Sleep Phase Syndrome Learned or conditioned activation (primary insomnia) Forced awakening for work or family responsibility Becker PM. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. ACCP Sleep Medicine Board Review: 4 th Edition

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17 Patient Evaluation Self report sleep questionnaires Psychological Testing Sleep Log/Diary Polysomnography- not routinely Except in pathologic sleepiness where pt reports symptoms of other sleep pathologies such as SDB, PLM, parasomnias, narcolepsy Actigraphy- not routinely When combined with information from a clinical interview and sleep log actigraphycontributes additional objective data regarding sleep phase changes and variability of sleep patterns over time.

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19 Psychological and Behavioral Treatments for Primary Insomnias Stimulus Control Therapy Sleep Restriction Therapy Relaxation Training Cognitive Therapy Sleep Hygiene Education Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA,

20 Stimulus Control Therapy A set of instructions designed to reassociatethe bed/bedroom with sleep, and to reestablish a consistent sleep-wake schedule: Go to bed only when sleepy Get out of bed when unable to sleep Use the bedroom for sleep only (e.g., no reading, watching TV) Arise at the same time every morning No napping Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p

21 Sleep Restriction Therapy A method to curtail time in bed to actual sleep time, thereby creating mild sleep deprivation, which results in more consolidated and more efficient sleep Based on sleep diary Actigraphy Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p

22 Relaxation Training Clinical procedures aimed at reducing: Somatic tension Progressive muscle relaxation, autogenic training Intrusive thoughts Imagery training, meditation Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p

23 Cognitive Therapy Psychotherapeutic method aimed at changing faulty beliefs and attitudes about sleep, insomnia, and the next-day consequences. Other cognitive strategies are used to control intrusive thoughts at bedtime and prevent excessive monitoring of the daytime consequences of insomnia Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA,

24 Cognitive Therapy The main therapeutic message to communicate to patients is as follows: Keep realistic expectations Do not blame insomnia for all daytime impairments Never try to sleep Do not give too much importance to sleep Do not catastrophize after a poor night s sleep Develop some tolerance to the effects of insomnia Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p. 728.

25 Sleep Hygiene Education General Guidelines about: Health Practices Diet Exercise Substance Use Environmental Factors that may promote or interfere with sleep Light Noise Temperature Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA

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27 Insomnia (difficulty initiating and/or maintaining sleep associated with daytime consequences) 1 Acute Insomnia </= 4 weeks Identify trigger Recent death Loss of job Marital breakup yes Address trigger and consider short term sedative no 2 Chronic Insomnia (> 4 weeks) Daytime Impairment yes Insomnia Screening Questionnaire No PRIMARY SLEEP DISORDERS C: Circadian rhythm: night owl/shift work A: Sleep Apnea: snoring, gasping L: Restless, abnormal movement and/or behavior in sleep Monitor/ reassure

28 yes PRIMARY SLEEP DISORDERS C: Circadian rhythm: night owl/shift work A: Sleep Apnea: snoring, gasping L: Restless legs, abnormal movement and/or behavior in sleep yes SECONDARY CAUSES OF INSOMNIA M: Mood Disorders (MDD/GAD) M: Medical Disorders M: Medications. Consider timing and dosing S: Substance abuse No 3 Primary sleep disorder Treat or refer 4 Secondary insomnia Optimize treatment of primary disease Address sleep hygiene Prevent Comorbid primary insomnia 5 Primary Insomnia Refer to: Primary Insomnia Evaluation

29 RECOMMENDATIONS ACCORDING TO TYPE OF INSOMNIA Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary insomnia (Standard) Psychological and behavioral interventions are effective and recommended in the treatment of secondary insomnia (Standard) Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006.

30 Recommendations for Specific Therapies Stimulus control therapy is effective and recommended therapy in the treatment of chronic insomnia (Standard) Relaxation training is effective and recommended therapy in the treatment of chronic insomnia (Standard) Sleep restriction is effective and recommended therapy in the treatment of chronic insomnia (Guideline) Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006.

31 Recommendations for Specific Therapies Cognitive behavior therapy, with or without relaxation therapy is effective and recommended therapy in the treatment of chronic insomnia (Standard) Multicomponenttherapy (without cognitive therapy) is effective and recommended therapy in the treatment of chronic insomnia (Guideline) Paradoxical Intention is effective and recommended therapy in the treatment of chronic insomnia (Guideline) Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006

32 Recommendations for Specific Therapies Biofeedback is effective and recommended therapy in the treatment of chronic insomnia (Guideline) Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006

33 Recommendations Relevant to Specific Patient Groups Psychological and behavioral interventions are effective and recommended in the treatment of insomnia in older adults (Standard) Psychological and behavioral interventions are effective and recommended in the treatment of insomnia among chronic hypnotic users (Standard) Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006

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