tara leigh taylor, md, fccp intensivist, wyoming medical ...secondary insomnia (standard)...
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Tara Leigh Taylor, MD, FCCP
Intensivist, Wyoming Medical Center
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
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 problem2
� 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: 5-111
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:97-1112
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: 5-111
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:97-1112
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
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
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
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: 4th Edition
RISK FACTORS� FEMALE
� AGE > 60
� MENTAL HEALTH DISORDER
� STRESS
� WORK NIGHTS OR CHANGING SHIFTS
� LONG DISTANCE TRAVEL
http://www.mayoclinic.com/health/insomnia/DS00187
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
http://www.mayoclinic.com/health/insomnia/DS00187
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: 4th Edition
Causes of Chronic Insomnia Based on Time
of Presentation during the Night� Insomnia Type� Sleep Maintenance
� Causes� Excessive time in bed� Major depression, or dysthymia or 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 lumbosacralspine
� Respiratory disorders, particularly those exacerbated by the recumbent position
� Cardiovascular disease: heart failure, angina, atrialfibrillation, 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: 4th Edition
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: 4th Edition
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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 actigraphy contributes additional objective data regarding sleep phase changes and variability of sleep patterns over time.
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, 2005. http://www.mayoclinic.com/health/insomnia/DS00187
Stimulus Control Therapy� A set of instructions designed to reassociate the
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. 727. http://www.mayoclinic.com/health/insomnia/DS00187
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. 727. http://www.mayoclinic.com/health/insomnia/DS00187
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. 728. http://www.mayoclinic.com/health/insomnia/DS00187
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, 2005. http://www.mayoclinic.com/health/insomnia/DS00187
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.
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 2005. http://www.mayoclinic.com/health/insomnia/DS00187
Insomnia(difficulty initiating and/or maintaining sleep associated with daytime
consequences)
1Acute
Insomnia </= 4 weeks
2Chronic Insomnia
(> 4 weeks)
Identify triggerRecent deathLoss of job
Marital breakup
yes no
Address trigger and consider short term
sedative
Daytime Impairment
Insomnia Screening Questionnaire
yes
No Monitor/reassure
PRIMARY SLEEP DISORDERSC: Circadian rhythm: night owl/shift work
A: Sleep Apnea: snoring, gasping L: Restless, abnormal movement and/or
behavior in sleep
PRIMARY SLEEP DISORDERSC: Circadian rhythm: night owl/shift work
A: Sleep Apnea: snoring, gaspingL: Restless legs, abnormal movement and/or
behavior in sleep
yes
3Primary sleep
disorderTreat or refer
SECONDARY CAUSES OF INSOMNIAM: Mood Disorders (MDD/GAD)
M: Medical DisordersM: Medications. Consider timing and dosing
S: Substance abuse
yes
4Secondary insomnia
Optimize treatment of primary disease
Address sleep hygienePrevent Comorbidprimary insomnia
No
5Primary InsomniaRefer to: Primary
Insomnia Evaluation
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.
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.
Recommendations for Specific
Therapies
� Cognitive behavior therapy, with or without relaxation therapy is effective and recommended therapy in the treatment of chronic insomnia (Standard)
� Multicomponent therapy (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
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
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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