Diagnosis and Management of Insomnia GP CME 2015
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1 Diagnosis and Management of Insomnia GP CME 2015 Dr Tony Fernando Psychiatrist and Sleep Specialist Department of Psychological Medicine University of Auckland
2 When a patient presents with a sleep symptom Don t just whip out your prescription pad and prescribe a hypnotic/ sleep med What is causing the symptom? Treat accordingly psychiatric disorder medication/ substances/ medical sleep disorder Lifestyle/ body clock Sleep Diary Sleep Questionnaire ( try the Auckland Sleep Questionnaire Sleep Specialist Referral if needed Polysomnography ( Overnight Sleep Study) if needed
3 3 major groups of sleep symptoms Sleep Symptoms Insomnia? Excessive Daytime Sleepiness? Parasomnias?
4 Insomnias Report of poor, unrefreshing sleep Initial, middle, late insomnia (delay, fragmentation of sleep) Daytime consequences More than a month (chronic)
5 Conditions presenting as insomnia Psychiatric disorders- mainly mood disorders and anxiety disorders (50%) Primary insomnia (30%) Medical problems (i.e. chronic pain, GE reflux, CFS/ME, hyperthyroidism, fibromyalgia) Substances ( Recreational and Prescribed) Poor sleep hygiene Circadian Rhythm disorders (i.e. DSPD, jet lag, shift work) Other sleep disorders (i.e. sleep apnoea, RLS, parasomnias, nocturnal panic, nightmares)
6 Evaluation of Insomnia Clinical Interview Sleep Questionnaires Auckland Sleep Questionnaire (forms) Sleep Diary Diagnostic Tests? Polysomnogram (Overnight Sleep Study)? WHEN?
7 Evaluation of Insomnia Clinical Interview Initial, middle, late? Effects during the day? Safety? Onset, course, duration? Triggers? Sleep schedule- usual bed time, preferred bed time if on holiday, awakenings, time feel really sleepy, final waking time, preferred waking time if on holiday Daytime routines- meals, exercises, relaxation times, computer use, NAPS! Sleep conditions Substances ( caffeine, nicotine, recreational, prescribed, OTC) Current and past sleep treatments Other sleep symptoms Psychiatric/ Medical/ Family history of sleep symptoms
8 Auckland Sleep Questionnaire Screening tool Gold Standard Questionnaire Prof Bruce Arroll, Tony Fernando, Karen Falloon, Guy Warman validated tool for diagnosing sleep disorders. (forms)
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11 Sleep Diary
12 Primary Insomnia DSM diagnosis About 30% of chronic insomniacs Diagnosis of exclusion; must have ruled out psychiatric, medical, neurologic, substances Marker for future depression?
13 Primary Insomnia Clinical features Initial/ middle or late insomnia Not attributable to other sleep/ psychiatric/ medical disorders Poor functioning the following day hyperarousal
14 Primary Insomnia Treatments CBT for Insomnia Addressing distorted cognitions about sleep/ insomnia Sleep hygiene Stimulus control Sleep Restriction/ Sleep Rescheduling***
15 Primary Insomnia Treatments Medications Benzo and analogues Sedating antidepressants; antihistamines; antipsychotics Melatonin? Valerian? Non medications Relaxation techniques- PMR Mindfulness Meditation*** Cardiovascular exercise Light treatment
16 Optimizing body clocks Examining their circadian patterns. Look at sleep diary. Consider increased activities and stimulation during the early part of the day and winding down/relaxing activities at night. Avoiding gadgets from 3 hours before target bed time
17 Calm and focused mind Learning mindfulness Focusing on the present moment usually by focusing on the breathing sensation Not judging, just observing
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20 When a patient presents with a sleep symptom Don t just prescribe a sleep medication What is causing the symptom? Treat accordingly. psychiatric disorder medication/ substances/ medical sleep disorder lifestyle Sleep Diary Sleep Questionnaire ( try the Auckland Sleep Questionnaire Sleep Specialist Referral if needed Polysomnography ( Overnight Sleep Study) if needed
21 Helpful Websites ( sleep questionnaire and sleep diary) ( downloadable mp3 s on meditation, relaxation, self hypnosis, positive psychology) (general information, patient resources on sleep and sleep disorders)
22 You can wake up now. Talk over
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