Insomnia: Physiological And Medical Findings And Implications For Diagnosis And Care*

George G Burton MDMedical Director, Sleep Disorders CenterKettering Health Network, Dayton, Ohio

* With appreciation to M Bonnet and D Arand

Goals Of This Presentation:

• Understand objective diagnostic and treatment outcome criteria

• Recognize insomnia as a true medical problem (not secondary)

• Recognize utility of a new diagnostic paradigm in insomnia care

Definition Of Insomnia – ICSD-2

• Complaint of difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or non-restorative sleep

• Occurs despite adequate sleep environment and opportunity

• Includes reported daytime impairment, such as fatigue, impaired attention, irritability, sleepiness, or poor motivation related to the poor sleep

Classifications Of Insomnia

• Simple: Sleep Initiation or Sleep Maintenance OR Objective or Subjective

• Complex: ICD-10 or DSM-V or AASM Nosology (ICSD-2)

Unfortunately complexity clouds our understanding but is a necessary evil

Insomnia A Symptom AND A Diagnosis

• Like CFS/FM• Leads to professional skepticism and hostility• Frustrates research enthusiasm and financing• Encourages therapeutic nihilism

NOT: Insufficient sleep syndrome

AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder)

1. Adjustment Insomnia2. Psychophysiological Insomnia3. Paradoxical Insomnia4. Idiopathic Insomnia5. Insomnia Due To Mental Disorder6. Inadequate Sleep Hygiene7. Behavioral Insomnia Of Childhood

(more)

AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder) (Continued…)

8. Insomnia Due To A Drug Or Substance9. Insomnia Due To Medical Condition10. Insomnia – Unspecified (non-organic)11. Insomnia – Unspecified (organic)

Prevalence Of Insomnia

• Lifetime prevalence 4-24%. Most common sleep disorder. Incidence varies with patient age and sex.

• Women have a lifetime risk 1.5 - 2.5 times men.• Additional factors: Employment Status Obesity Rotating Shifts• Chronic prevalence (2-3 months is 6-10%)• Subtypes of prevalence vary widely

Consequences of Insomnia: Cost

Home and Public Accidents $3.7 Billion

Work-Related Accidents $10.3 Billion

Motor Vehicle Accidents $29.2 Billion

Work Place Productivity Loss $150.0 Billion

Consequences Of Insomnia: Quality Of Life

• Medical Outcomes Study Short Form (SF-36) - Insomnia patients have significant decreases on all dimensions - Level of decrease is comparable to patients with depression or congestive heart failure• Poor sleepers have fewer promotions and increased

health care needs• Recent data found increased risk for all cause

mortality in patients with “nearly everyday” insomnia

There Is A Big Difference In These Two Concepts:

• Insomnia is a risk factor for…

• Insomnia is comorbid with…

Insomnia Is A Risk Factor For:

• Depression/Anxiety/Substance Abuse• Anxiety and mood disorder relapse• ? Pain• Diabetes and hypertension• Infectious disease conditions/immune status• Suicide

“Sleepy patients are like deaf children with respect to short-term memory and task organization”

Insomnia Is Often A Comorbid Condition With:

• Depression/Anxiety states• Pain • Respiratory, GI, Neurologic, Musculoskeletal,

Endocrinologic and Cardiovascular Disorders• Drug use such as anti-hypertensives and anti-

depressants, bronchodilators, nasal decongestants

Treatment Studies Do Not Separate Comorbility From Risk Issue 100% Of The Time

Examples:• Sleep on the efficiently of anti-depressant

drugs• Sleep on the treatment of pain• Sleep on insulin resistance in diabetes

Conditioned Stress Is Comorbid With Insomnia

• Inability to relax in bed• Mental arousal In Bed (intrusive thoughts)• Sleeps better away from home• Difficulty in falling asleep in bed but not at other times (i.e. watching tv)

Aging And Poor Sleep

• Normal aging is associated with: - Increased incidence of pain and other medical problems - Increased sympathetic nervous system activity - Decreased activity (decreasing amplitude of circadian rhythms) - Decreased sleep (SWS) sleep - Increased awakenings and wake time during sleep

Aging And Poor Sleep (continued…)

• Is poor sleep with aging a normal change or a sign of slowly evolving pathology? If it were Hypertension, we would treat.• What is the specificity/sensitivity relationship between the ESS, sleep latency sleep efficiency, and WASO?

Insomnia Comorbid With Other Sleep Disorders

• Sleep Apnea – refer patients with insomnia and significant snoring• Periodic Limb Movements – refer patients with

nocturnal restlessness• Restless Legs• Dream Anxiety Attacks• REM Behavior Disorder• Should we base some of our treatment decisions

on ESS, etc?

Interests And Concerns In Insomnia

• Attendance at insomnia sessions at AASM extremely high

• AASM subspecialty examination in Behavioral Sleep Medicine and cognitive behavioral therapy growing

• As for OSA in 2002, cost is a big concern• Potential solutions: - Judicious use of expensive tests and therapies e.g.

PSG and Cognitive Behavioral Therapy - Emergent consensus that success of these tools are

based in the neurobiology of insomnia

Neurotransmitters Involved In Sleep And Arousal*

• Facilitates sleepiness: Adenosine, GABA, Galanin, Glycine, Melatonin

• Facilitates arousal: Acetylcholine, Dopamine, Glutamate, Histamine, Norepinephrine, Orexin, Serotonin

*Gulyani S et al Sleep Medicine Pharmocotherapies Overview. Chest 142:1659-1668(2012)

Physiologic Findings More Pronounced In Persons With Objective And Primary Insomnia

• Numerous studies have shown that patients with primary insomnia suffer from CNS

hyperarousal, usually linked to the sympathetic nervous system as indicated by:– Increased heart rate– Decreased heart rate variability– Increased whole body and brain metabolic rate– Increased high frequency EEG– Increased secretion of cortisol, ACTH

Hyperarousal And Insomnia

Hyperarousal State In Insomnia*

*Bonnet M, Burton G and Arand D, Physiologic and Medical Findings In Insomnia: Implications For Diagnosis And Care. Sleep Rev 2013(In Press)

Insomnia Workup And Therapy Paradigm*

*Bonnet M, Burton G and Arand D, Physiologic and Medical Findings In Insomnia: Implications For Diagnosis And Care. Sleep Rev 2013(In Press)

The PSG Modified For Insomnia(PSG-I)

• The standard PSG Plus: - Nocturnal blood pressure recording - Heart rate variability - Beta-power analysis on EEG• Patients identified as having objective/primary insomnia should be directed to CBT-I

An Insomnia Work-Up Paradigm Draft Based On Costs

INEXPENSIVE MORE EXPENSIVE VERY EXPENSIVE/RESEARCH

H&P PSG-I Cortisol Panel

Sleep Log Beta-Power Analysis TNF-α

ESS/FSS/Beck Depression Inventory

Nocturnal Blood Pressure Recording

Leptin

Pain Scale Rating Collagen-Vascular Panel Ghrelin

CBC, ESR, hs-CRP Immune Globulins Interleukins

HgB-A-1-C CD-4/CD-8 Assay

Thyroid Function PFT/Echocardiogram

Recording Oximetry Formal Neuropsychiatric Testing

BP Log

THERAPY

• Treat comorbid conditions first• CBTI: Best results in paradoxical/objective insomnia• Self-directed therapy - Environmental management - Sleep scheduling• Pharmacological - 15 new drugs under clinical study - Anti-depressants and anxiolytics very popular - Sedatives

A Typical Insomnia Case

• 47 Year old male bank executive in good health - 15 Year history of SII, SMI, worry about work and family would keep him from sleeping - No known comorbitities - Good sleep hygiene by history - Sleep log, FSS, screening laboratory all normal - Home sleep study normal except for “long sleep latency and decreased sleep efficiency”

A Typical Insomnia Case (continued…)

- ESS 15/24 - Neuropsychiatric assessment moderate anxiety depression - Anxiolytics and various anti-depressants no help over the past 5 years - PSG-I: Long sleep latency, elevated arousal index; otherwise normal• Diagnosis: paradoxical insomnia versus psychophysiological insomnia

A Typical Insomnia Case (continued…)

• Told to: “Lighten Up!” by his family PCP and Psychiatrist without improvement

• Referred for CBTI for eight sessions• Dramatic improvement