Insomnia – Evaluation and management

Insomnia – Evaluation and management Pradeep Sahota MD, FAAN, FAASM Professor & Chairman, Dept. of Neurology Director, Sleep Disorders Center University of Missouri Health Care

NOTE • This is a lengthy topic • Difficult to cover in 1 session • The handout is longer than actual presentation • This is to cover the topic in somewhat more detail than can be done in the limited time of presentation • The presentation will cover only selected slides

Insomnia –format - new • Handout format • A. Definition - Normal sleep & insomnia • B. Epidemiology • C. Classification of insomnia • D. ICSD classification • E. Development of insomnia • F. Course and Consequences of Insomnia • G. Diagnosis • H. Management - Medical & Behavioral & Other • Z. Common pitfalls, summary, references

Normal Sleep • Sleep that is long enough and good enough for feeling rested and restored the next day • Absolute duration is not a criteria • Typically 7-8 hours long • Long sleepers and short sleepers • Age dependant expression • Polysomnographic criteria • Norms of Sleep onset, REM onset, sleep stages • Restful and refreshing

A. Insomnia – DefinitionIn lay terms • Inability to obtain sleep • That is long enough or good enough (quality and quantity) • For feeling rested or restored the next day • Not defined by total sleep time as a group

Insomnia – DSM IV • Difficulty initiating sleep or maintaining sleep or non-restorative sleep of >1 month, with daytime fatigue or impaired daytime functioning causing significant distress or impairment in social, occupational or other areas of functioning • Primary • Not exclusively Related to another axis I/II disorder • Not exclusively Related to physiological effects of a substance • Not exclusively related to another sleep disorder • Now the prevalence drops to ~6%

A. Insomnia – ICSD definition • Repeated difficulty with Sleep initiation Sleep consolidation or maintenance Sleep duration Sleep quality (non restorative or poor quality sleep) • Occurs despite adequate time & opportunity for sleep • Results in some form of daytime impairment

A. Insomnia – ICSD definition • KEYS are: • Persistent sleep difficulty despite Adequate sleep opportunity • And Associated daytime dysfuntion At least 1 of following EDF, EDS, malaise, decreased energy, motivation or initiative, mood disturbance or irritability, concerns / worries about sleep, Prone to accidents at work or while driving, & cognitive impairment (attention, memory, concentration), Tension, Headaches, or GI symptoms in response to sleep loss • Adults – impaired social & vocational functioning • Children – poor school performance

B. Insomnia - epidemiology • In surveys, it is the commonest sleep related complaint • Incidence depends on definition • Survey • 1 or more symptoms of insomnia in past 30 days-1 year-32-40% • Duration of 2 weeks to longer with exclusion of illness, medication or substance abuse as sole causes – 10-17% • Breslau et al 1007 young adults (1996), 21-30% had at least 1 episode of DIS, DMS or EMA over 2 weeks or longer, with daytime consequences Annualized incidence rate of 38/1000 • Ohayon et al (2002), used DSM IV criteria – past 30 day prevalence of 4.4-6.0% in 5 different countries • Non restorative but normal duration sleep usually not included in most epidemiological studies

B. Insomnia – epidemiology • Overall incidence 6 - 40% • Elderly>young, 5% at age 20, 25-35% in elderly(>60) • females>males (3:2); • No difference just by race or ethnicity • Unemployed, divorced,widowed, separated,low educational level • Estimated annual cost 100 billion dollars- lost productivity, Rx & insomnia related accidents - Eddy et al 1999 • Underrepresented, underdiagnosed & poorly understood • 2/3 patients do not discuss insomnia with their docs • 5% make physician visit focused mainly on insomnia

B. Insomnia - epidemiology • Epidemiological gaps • Difference in definitions • No longitudinal studies • Limited knowledge of incidence, associated risk factors chronicity, natural disease course • Insomnia in children & adolescents • References: Ohayon et al 2002 • Roth & Drake 2004 • Roth 2005 • NIH conference statement 2006

C. Insomnia - types • Symptom not a disease • Many different causes • Therefore, organization into a single topic arbitrary • Divided into several types - By time of onset by duration by etiologyby severity by age • Effective treatment depends on Etiologic Diagnosis and • Early detection and early treatment

C. Insomnia- based on timing • Classification based on time of onset of symptoms • Sleep onset insomnia - anxiety, tension • Sleep maintenance insomnia Medical/neurological diseases Parasomnias - RLS/PLMS etc Alcohol, stimulants, hypnotic/drug withdrawal • Early morning insomnia – depression • CRSD - Phase-shift disorder- depending on shift • Cyclical insomnia - drug/alcohol abuse, psych/medical disorders- bipolar disorder, bulimia, anorexia • ICSD Classification – diagnosis, code

C. Insomnia – based on duration • Transient or Chronic • Transient<4weeks long and/or intermittent-COMMON • Stress related – hyper arousal - happy or sad • Environment induced- noise/travel, hospital • Shift work • Jet lag-easier with westward travel • Altitude-(12,000 feet) - Acute mountain Sickness sleep disturbance usually in the setting of high altitude Nausea, vomiting, headache, decreased mental acuity & insomnia, poor appetite Periodic breathing, CA-arousals, Alveolar hypoxia, art.hypoxemia Later polycythemia, decreased stage 3 & 4 Rx-descent,Acetazolamide 250mg Bid 3-4 days before ascent • May not see many of these patients

C. Insomnia –based on duration • Chronic insomnia – daily symptoms for > a month – sub-acute or for >6 months - chronic • In reality, chronic insomniacs have variable sleep • Symptoms may not be present every night • Vary night to night • Some nights better than others • So - Chronic intermittent insomniamore pertinent description for many patients • Most insomnia patients in the clinic have chronic insomnia

D. Insomnia– based on cause, age perpetuating factor & presentingsymptoms (ICSD – international classification of Sleep Disorders) • Adjustment insomnia • Psychophysiological insomnia • Paradoxical insomnia • Idiopathic insomnia • Insomnia due to mental disorder • Inadequate sleep hygiene • Behavioral insomnia of childhood • Insomnia due to drug or substance • Insomnia due to medical condition • Physiological (organic insomnia), unspecified • Insomnia not due to substance or known physiological condition (Non- organic insomnia, NOS) • Basically – ICSD classification separates out insomnia due to drugs/substance use/medical/psych disorders

D. Insomnia – type 1- Acute insomnia or Adjustment insomnia • Insomnia in association with an identifiable stressor • Insomnia temporally associated with identifiable stressor that is psychological, psychosocial, or interpersonal, environmental, or physical in nature • The sleep disturbance is expected to resolve when the acute stressor resolves or when the individual adapts to the stressor. • Sleep disturbance lasts for < 3 months(usuallydays to weeks)

D. Insomnia – type 1 • IDENTIFIABLE STRESSORS • Dispute in interpersonal relationships • Occupational stress • Personal loss, Bereavement • Diagnosis of a new medical condition • Visiting or moving to a new location • Changes or stresses with positive emotional tone • Physical changes to the usual sleep environment • Associated daytime features • Fatigue, anxiety, worry, ruminative thoughts, irritability, impaired concentration, may result in alcohol/substance use

D. Insomnia Type 2 – conditioned or Psychophysiological insomnia • Insomnia due to heightened arousal & learned sleep preventing associations • Evidence of conditioned sleep difficulty and/or heightened arousal in bed is present • Present for >1 month • Learned insomnia

D. Type 2 - Psychophysiological insomnia or LEARNED or conditioned insomnia 1. Excessive focus on & heightened anxiety about sleep Anxiety or tension around getting to bed 2. Difficulty falling asleep in bed at the desired bedtime or naptime BUT no difficulty falling asleep during monotonous activities when not intending to sleep 3. Ability to sleep better away from home than at home - sleep better in a strange environment-couch, hotel room, Relates to place & situation 4. Mental arousal in bed characterized by intrusive thoughts or perceived inability to volitionally stop sleep preventing mental activity- Cant stop thinking, Try hard, gets harder to sleep 5. Heightened somatic tension in bed reflected by a perceived inability to relax the body sufficiently to allow the onset of sleep - Conditioned arousal in response to efforts to sleep

D. Insomnia – type 3 Paradoxical insomnia • Severe insomnia without objective sleep disturbance • Was called Sleep Misperception syndrome • One or more of the following criteria apply 1. Pt. reports chronic pattern of little or no sleep most nights with rare nights of relatively normal amounts of sleep 2. Sleep-log data during one or more weeks of monitoring show average sleep time<published age-adjusted normative values, often with no sleep at all indicated for several nights/week typically with absence of daytime naps 3. Consistent mismatch between objective & subjective findings (Objective from PSG or Actigraphy and subjective sleep estimates derived either from self report or a sleep diary)

D. Paradoxical insomnia –type 3 • And at least 1 of the following is observed: 1. patient reports constant or near constant awareness of environmental stimuli throughout most nights 2. Patient reports pattern of conscious thoughts or ruminations throughout most nights while maintaining a recumbent posture • Daytime impairment similar to reports by other insomnia types But less than expected given extreme level of sleep deprivation • No intrusive daytime sleep episodes, disorientation, serious mishaps due to marked loss of alertness or vigilance, Even following reportedly sleepless nights • Symptoms for at least 1 month

D. Insomnia – Type 4Idiopathic insomnia • A. Symptoms meet criteria for insomnia, • B. Chronic course as indicated by each of the following: 1. Onset in infancy or childhood 2. No identifiable precipitant or cause 3. Persistent course with no periods of sustained remission • C. Sleep disturbance not better explained by other causes • life-long difficulty, Symptoms unrelenting over decades • Limited data-?males = females, 0.7% of adults, 1% adolescents • No other characteristic features • Daytime sequelae • Some may have minimal brain dysfunction, ADD or LD • No consistent genetic markers or neural pathology • Etiology unknown - Abnormal Sleep-wake control systems? • Difficult to treat - Long-term therapy needed

D. Insomnia – Type 5 – due to mental disorders • Symptoms meet criteria for insomnia, present for I month or > • A mental disorder has been diagnosed by DSM IV criteria • Insomnia is temporally associated with the mental disorder; however, in some cases insomnia may appear a few days or weeks before the emergence of the underlying mental disorder • Insomnia is more prominent than that typically associated with the mental disorder, as indicated by causing marked distress or constituting an independent focus of treatment • F. Sleep disturbance is not better explained by another sleep, medical, neurological, mental disorder -------

D. Insomnia – Type 5 – due to mental disorders • Hippocrates- “insomnolencyassociated with sorrow and pains” • 30% of chronic insomniacs have psychiatric disorders • 40% of patients with sleep complaints have psychiatric disorder (JAMA 1989, 262, 1479-84. NIMH study) • Increased risk of development of psychiatric disorders in patients with insomnia – 1 year follow-up(Ford 1989) • And, sleep disorders can worsen psych.condition • Anxiety, phobias, Panic disorder • Post-traumatic Stress disorder • Mood disorder – depression, manic depressive disorder • Thought disorder – schizophrenia • Situational - approaching Tenure - anxiety

D. Insomnia – type 5 • Bixler et al. Insomnia in central Pennsylvania. Psychosomatic Research 53, 589-92, 2002 • Study of association between physical and mental health symptoms and objective measures of sleep disturbance while controlling for age, gender and BMI • 1741 patients -age 20-100 years • Had a single night sleep evaluation • Concluded - Mental health variables have primary independent association with complaint of insomnia • Other factors associated to a lesser degree were hypertension, minorities • Sleep apnea, age did not play a major role

D. Insomnia –Depression –Type 5 • 50-80% or more of patients with bipolar disorder have insomnia during depressive episode • Early morning insomnia or terminal insomnia vs. initial/middle • Presence of suicidal thinking during major depression more common in patients with insomnia – as compared with depressed patients without insomnia (Agargun et al 1997) • Resolution of insomnia during Rx of elderly depressed patient is associated with reduced risk of relapse of depression (Reynolds et al 1997)

D. Insomnia & anti-depressant treatment (type 9) • Manber et al. The effects of psychotherapy, nefazodone, and their contribution on subjective assessment of disturbed sleep in chronic depression. Sleep 26, 130-36, 2003 • Multicenter study- 484 patients with chronic depression • 24 item HRS for depression & 30 item inventory of depressive symptamotology-self rating • Nefazodone 300-600 in 2 dosages vs CBT • Nefaz.alone and CBT alone had comparative effects on global measures of depression outcome- only nefaz.Rx improved early am awakening and TST • Nefazodone may have direct impact on disturbed sleep associated with depression – beyond expected from improved depression

D. Insomnia-Psych. Disease – type 5 • Finally treatment of depression can also lead to insomnia e.g MAO inhibitors- phenelzine, tranylcypromine, effexor • PSG - shortened REM onset latency Not as short as in patients with narcolepsy Antidepressant treatment prolongs that May correlate with clinical improvement • Increased risk of development of psychiatric disease in patients with insomnia (Ford 1989) – 4 fold increase in developing psych.disorder if insomnia lasts >12 months (depression, anxiety, alcohol abuse disorder)

D. Insomnia – type 5 • Schizophrenia • day night reversal- specially in paranoid schizophrenia • Heightened threat perception at night • Similar findings also in Alzheimer's disease - but those are - Due to degeneration of suprachiasmatic nucleus • Anxiety, phobias, panic disorders • Difficulty initiating sleep • Difficulty maintaining sleep

D. Insomnia – Type 6 – inadequate sleep Hygiene • Meet criteria for insomnia, Present for 1 month or more • Inadequate sleep hygiene (1 of the following) 1. Improper sleep schedule – highly variablewake up and bedtime, too much time in bed Frequent daytimenapping (not 15-20min. nap) 2. Routine use of alcohol, nicotine, caffeine before bedtime 3. Mentally stimulating, physically activating, or emotionally upsetting activities close to bedtime 4. Frequent use of bed for non sleep activities – TV reading, studying, snacking, thinking, planning 5. Failure to maintain comfortable sleep environment factors - heat/cold, noise, light, bed, bed partner – allergies, movements/snoring, Danger, Unfamiliar surroundings – motel

D. Insomnia – type 7 – Behavioral insomnia of childhood • A. Child’s symptoms meet the criteria for insomnia based on reports of parents or adult caregivers • B. The child shows a pattern consistent with either the sleep onset association or limit setting type of insomnia • 1. Sleep onset association type includes each of the following: a. Falling asleep is extended process that requires special condition b. Sleep onset associations are highly problematic or demanding c. In the absence of associated conditions, sleep onset is significantly delayed or sleep is otherwise disrupted d. Nighttime awakenings require caregiver intervention for the child to return to sleep

D. Insomnia – type 7Behavioral insomnia of childhood • 2.Limit setting type includes each of the following: a. The individual has DIMS b. The individual stalls or refuses to go to bed at an appropriate time or refuses to return to bed following a nighttime awakening c. The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriate sleeping behavior in the child • Sleep disturbance not better explained by other sleep disorder, medical, neurological or mental disorder or medication use.

D. Insomnia – Type 8Due to drug or substance • Symptoms meet criteria for insomnia-present for at least 1 month • One of the following is present 1. There is current ongoing dependence on or abuse of a drug or substance known to have been sleep disruptive properties either during periods of use or intoxication or during periods of withdrawal 2. Patient has current ongoing use of or exposure to a medication, food, or toxin known to have sleep disruptiveproperties in susceptible individuals • D. Insomnia is temporarily associated with the substance exposure, use or abuse, or acute withdrawal • E. Sleep disturbance not better explained by another sleep, medical, neurological, mental ----- • Change in habit is as critical as use

D. Insomnia – type 8 - Secondary • Medications • Antidepressants • Bronchodilators • CNS stimulants • Corticosteroids • Decongestants • Diuretics • Thyroid medication • Other – Alcohol, Caffeine, analgesics with caffeine, Nicotine

D. Insomnia – secondary – medsLee Chiong; Sleep A comprehensive handbook,103-11

D. Insomnia – secondary Lee Chiong; Sleep A comprehensive handbook,103-11

D. Insomnia – secondaryLee Chiong; Sleep A comprehensive handbook,103-11

D. Insomnia – secondary –Lee Chiong; Sleep A comprehensive handbook,103-11

D. Insomnia – secondaryLee Chiong; Sleep A comprehensive handbook,103-11

D. Insomnia –type 8 – substance use • Alcohol- may represent self medication for insomnia or other primary conditions (anxiety) can fall asleep -Causes mid-cycle or early am insomnia, long term use can produce irreversible changes • Caffeine – excessive use or change in habit • Tobacco – nicotine is a stimulant • Drugs - Amphetamines, cocaine • Drug withdrawal- above, sedative hypnotics • Change in habit is as critical as use • Toxins – As, Cu, Pb, Hg poisoning- insomnia or hypersomnia

D. Insomnia – Type 9- Secondary • Due to Medical conditions • Meet criteria for insomnia, Present for at least 1 month • Patient has co-existing medical or physiological condition known to disrupt sleep • Insomnia is clearly associated with medical or physiological condition – began near the time of onset or with significant progression of the medical or physiological condition and waxes & wanes with fluctuation in the severity of this condition • Sleep disturbance not better explained by another sleep, mental disorder, medication or substance use disorder

D. Insomnia – type 9 • Cardiac – CHF (PND), angina • Pulmonary – COPD, asthma, nocturnal dyspnea • GI – PUD, GER • Renal failure – multi-factorial • Endocrine – Hyperthyroid, adrenal dysfuction menstrual cycle related, menopause, • Any chronic pain syndrome/Chronic medical problems- fibromyalgia, arthritis & connective tissue diseases

D. Insomnia – type 9 - Secondary • Gastro-esophageal reflux • Common • Repeated awakenings with chest discomfort • Heartburn, choking, coughing • Poor quality sleep • Experiment - acid in lower esophagus causes subject to wake up even though no other symptoms • pH measurement • Multiple arousals/ awakenings

Insomnia – Evaluation and management