Understanding Sleep Disorders for the Clinician Part 2

1. Understanding Sleep Disorders for the Clinician Part 2 Lisa Cottrell, Ph.D., CBSM, DBSM

2. Non-Sleep Disorders in the DSM-5 that Involve Sleep • Manic/hypomanic Episodes • Major Depressive Episode • Premenstrual Dysphoric Disorder • Melancholic Features • Generalized Anxiety Disorder • Posttraumatic Stress Disorder • Alcohol Withdrawal • Caffeine Intoxication • Cannabis Withdrawal • Opioid Withdrawal • Sedative, Hypnotic, Anxiolytic Withdrawal • Stimulant Withdrawal • Tobacco Withdrawal

3. Sleep Disorders in the DSM-5 • Insomnia Disorder • Hypersomnia Disorder • Narcolepsy • Obstructive Sleep Apnea • Central Sleep Apnea • Sleep-Related Hypoventilation • Circadian Rhythm Sleep Wake Disorders • Non-REM Sleep Arousal Disorders • Nightmare Disorder • REM Sleep Behavior Disorder • Restless Legs Syndrome • Substance/Medication – Induced Sleep Disorder

5. Insomnia • DSM-5 “Insomnia Disorder” • Dissatisfaction with sleep quantity/quality • Initiation, maintenance or early morning waking • Clinically significant distress • Minimum 3 nights/week • Minimum 3 months • Adequate sleep opportunity • Not better explained or exclusively during the course of another sleep-wake disorder • Not caused by substance • Coexisting conditions don’t adequately explain • Specify: with non-sleep mental comorbidity; with other medical comorbidity; with other sleep disorder

6. ICSD-3 “Chronic Insomnia Disorder” • One or more difficulty • Initiating sleep • Maintaining sleep • Waking too early • Resistance to appropriate bedtime • Difficulty sleeping without parent or caregiver intervention • Related to sleep difficulty, one or more • Fatigue • Attention/concentration/memory impairment • Social/family/occupational/academic impairment • Mood disturbance • Daytime sleepiness • Behavioral problems • Reduced motivation • Error proneness • Dissatisfaction with/concerns about sleep • Not explained by inadequate sleep opportunity • 3 times per week • 3 months • Not better explained by another sleep disorder

8. Insomnia Diagnosis • Clinical interview, includes sleep history and rule out of other sleep disorders • Data collection – sleep diary • Actigraph • Standardized measures: e.g., Insomnia Severity Index, Dysfunctional Attitudes and Beliefs about Sleep

9. Insomnia Treatment • Cognitive-Behavioral Treatment of Insomnia (CBTI) • Medication • Cognitive-Behavioral treatment with complementary therapies • Behavior Activation • Activity-Rest-Pacing • Multiple relaxation methods • Bright light therapy/melatonin • Mindfulness • Online Cognitive-Behavioral Treament

11. Insomnia Treatment - Medication • Anecdotally, chronic patients report decreasing efficacy of most hypnotics and sedating medications and they often prefer not to take them • Psychological dependence is frequently an issue, rebound insomnia can be an issue in discontinuation • Medication issues complicated by comorbid psychiatric tx • Most commonly prescribed are benzodiazepine receptor agonists, including benzodiazepines (e.g., temazepam, lorazepam, alprazolam) and non-benzodiazepine agents that act on the same site on the GABA-A receptor complex (e.g., zolpidem, eszopiclone, zaleplon) • Sedating antidepressant drugs such as trazodone as well as sedating tricyclic antidepressants (e.g., doxepin, imipramine, nortriptyline, clomipramine, amitriptyline) are widely used • Melatonin agonist ramelteon • Melatonin • Diphenhydramine • Suvorexant (dual orexin receptor antagonist)

12. Evidence for the Efficacy of CBTI • Decades of research evidence that convincingly demonstrates the efficacy of CBTI (e.g., Edinger & Carney, 2008; Espie, 2002) as the “well established and proven” treatment approach • CBTI is just as effective as sedating hypnotics during acute treatment (4-8 weeks) (e.g., Smith et al., 2005) • CBTI is more effective than sedating hypnotics long-term (e.g., Espie et al., 2001; Morin et al., 2006) • CBTI has been established as the first line treatment approach for insomnia (Smith et al., 2002) • CBTI is more effective than zolpidem (Jacobs et al., 2004) • CBTI is more effective than zopiclone (Sivertsen et al., 2006) • When given the option, people prefer CBTI to pharmacotherapy for insomnia (Morin et al., 1992) and patients report greater satisfaction with CBTI and rate it as more effective than sleep medication (Morin et al., 1999)

13. Some techniques used in CBTI • Sleep education • Motivational interviewing • Sleep scheduling • Sleep restriction • Cognitive therapy • Relaxation training • Mindfulness • Self monitoring • Activity scheduling

15. Components of CBTI • Behavioral • Stimulus control • Sleep restriction therapy • Both must be used cautiously and with appropriate understanding of factors that impact patient safety as well as full sleep assessment • Cognitive • Thoughts and beliefs about sleep • Address dysfunctional thoughts and educate patient

17. Obstructive Sleep Apnea • DSM-5 “ Obstructive Sleep Apnea Hypopnea” • Either 1 or 2 • (1)Evidence by polysomnography of at least 5 obstructive sleep apneas &/or hypopneas AND • snoring, snorting, breathing pauses OR • daytime sleepiness not attributable to inadequate sleep opportunity or another medical/mental condition • (2)Evidence by polysomnography of 15 or more apneas &/or hypopneas Rated by events per hour: mild (<15), moderate (15-30) or severe (>30)

18. ICSD-3 “Obstructive Sleep Apnea, Adult” • (A and B) or C • (A) One or more of the following: • Sleepiness/nonrestorative sleep/fatigue/insomnia • Observer reports snoring/breathing interruptions • Patient wakes breath holding, gasping, choking • Diagnosis of mood disorder, hypertension, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, T2 diabetes • (B) PSG demonstrates 5 or more predominantly obstructive respiratory events • (C) PSG or OCST demonstrates 15 or more predominantly obstructive respiratory events per hour

19. ICSD-3 “Obstructive Sleep Apnea, Pediatric” • Presence of one or more of the following: • Snoring • Labored or obstructed breathing during sleep • Sleepiness/hyperactivity/behavioral problems/learning problems • AND PSG demonstrates • One or more apneas/hypopneas per hour of sleep OR • A pattern of obstructive hypoventilation

20. Obstructive Sleep Apnea Treatment • Estimated 60% of moderate to severe OSA is attributable to obesity; in those cases, weight loss may reduce or eliminate the OSA • Positive airway pressure still most common treatment (CPAP, BiPAP, AutoPAP) • Dental device (OPT, oral pressure treatment) • UPPP (surgery) Patient compliance is a key factor. Anxiety and claustrophobic reactions can reduce PAP therapy compliance. Appropriate gradual desensitization treatment can be effective to address those concerns.

21. Latest treatments for OSA • HypoglossusNerve Stimulation • A relatively new advancement (approved by the FDA in 2014), a small device is surgically implanted in the chest, and can be turned on and off by the patient. While you sleep, the device monitors your breathing and stimulates a nerve that keeps the upper airway open. Initial research has shown that HGS improved patients’ symptoms, and had few side effects and good compliance. Doctors may recommend this therapy for patients with moderate to severe obstructive sleep apnea who are not helped by PAP therapy.  • Expiratory Positive Airway Pressure (EPAP) • The EPAP system uses disposable adhesive valves that are placed over the nose when you sleep. When you inhale, the valve opens and helps the airway remain unobstructed. When you exhale, the airflow is directed into small channels, which creates pressure and, again, keeps the airways open. Open airways mean fewer incidences of obstructed breathing and interruptions in sleep. Initial research has shown EPAP therapy has a high level of adherence—a good sign for successful OSA treatment. Source: National Sleep Foundation

23. Circadian Rhythm Sleep Wake Disorders • DSM-5 subtypes: • Delayed sleep phase • Advanced sleep phase • Irregular sleep wake type • Non 24 hour type • Shift work type • Unspecified type

24. ICSD-3 Circadian Rhythm Sleep-Wake Disorders • Delayed Sleep-Wake Phase Disorder • Advanced Sleep-Wake Phase Disorder • Irregular Sleep-Wake Rhythm Disorder • Non-24 –Hour Sleep Wake Rhythm Disorder • Shift Work Disorder • Jet Lag Disorder • Circadian Sleep-Wake Disorder Not Otherwise Specified

25. Treatment of Circadian Rhythm Sleep Wake Disorders • Light • Activity scheduling • Nap scheduling • Melatonin • Ramelteon • Stimulant medications (???) • Sedating/hypnotic medications (???)

26. Parasomnias • Non-REM parasomnias: • Disorders of arousal • Confusional arousals • Sleepwalking • Sleeptalking • Sleep terrors • Sleep related eating disorder • REM related parasomnias: • REM Sleep Behavior Disorder • Recurrent isolated sleep paralysis • Nightmare disorder • Other parasomnias include sleep enuresis, sleep related hallucinations and exploding head syndrome • Differential diagnosis may require overnight sleep study but can often be made based on specific symptoms

27. Narcolepsy • DSM-5 specifies with and without cataplexy, hypocretin deficiency, autosomal dominant subtypes, secondary to medical condition • ICSD-3 specifies Type 1 and Type 2 narcolepsy among other central disorders of hypersomnolence • Diagnosis requires polysomnography and/or measurement of CSF hypocretin concentration • Treatment may include antidepressant medications that suppress REM, sodium oxibate, lifestyal and behavioral changes, activity scheduling and scheduled naps

28. May require medication and/or medical management: • Hypersomnia Disorder • Central Sleep Apnea • Sleep-Related Hypoventilation • Restless Legs Syndrome • Substance/Medication – Induced Sleep Disorder

29. Thank you! • “When I woke up this morning, my girlfriend asked me, “Did you sleep good?” I said, “No, I made a few mistakes.” • Stephen Wright

30. References American Academy of Sleep Medicine (2016) AASM invites public comment on draft clinical practice guideline for pharmacological treatment of chronic insomnia. An American Academy of sleep medicine practice guideline (draft).Advance online publication. Retrieved from http://www.aasmnet.org/articles.aspx?id=6241 American Academy of Sleep Medicine (2014). The International Classification of Sleep Disorders (3rd Ed.) Westchester, IL: The American Academy of Sleep Medicine. American Academy of Sleep Medicine (2014). The International Classification of Sleep Disorders (3rd Ed.) Darien, IL: The American Academy of Sleep Medicine Carney, C., & Manber, R. (2009). Quiet Your Mind and Get To Sleep. Oakland, CA: New Harbinger Publications, Inc. Edinger, J. & Carney, C. (2008). Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach. New York: Oxford university Press, Inc. Espie, C. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology, 53, 215-243. Espie CA, Inglis SJ, Harvey L. (2001). Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: Analyses of outcome data at 12 months posttreatment. Journal of Consulting and Clinical Psychology, 69, 58–66. Jacobs, G., Pace-Schott, E., Stickgold, R., & Otto, M. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Archives of Internal Medicine, 164(17), 1888-96. Khurshid, K. (2015). A review of changes in DSM-5 sleep wake disorders. Psychiatric Times, 32(9). Kryger, M. H. (2010). Atlas of Clinical Sleep Medicine. Philadelphia, PA: Saunders Elsevier. Krystal, A. D. (2012). Psychiatric disorders and sleep.Neurologic Clinics, 30(4), 1389–1413. Morin, C., Bastien, C., Guay, B., Radouco-Thomas, M., Leblance, J., & Vallieres, A. (2004). Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. American Journal of Psychiatry, 161(2), 332-342. Morin C., Bootzin R., Buysse D., Edinger J., Espie C., & Lichstein , K. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29(11), 1398-414. Morin, C., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. Journal of the American Medical Association, 281, 991–999.

31. References (cont’d) Morin, C. & Espie, C. (2004). Insomnia: A Clinical Guide to Assessment and Treatment. New York: Springer Science + Business Media, LLC. Morin, C., Gaulier, B., Barry, T., & Kowatch, R. (1992). Patients’ acceptance of psychological and pharmacological therapies for insomnia. Sleep: Journal of Sleep Research & Sleep Medicine,15, 302-305. Perlis, M., Jungquist, C., Smith, M., & Posner, D. (2005). Cognitive Behavioral Treatment of Insomnia. New York: Springer. Qaaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, E. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-139. Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O., Kvale, G., Nielsen, G., & Nordhus, I. (2006). Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial.JAMA, 295(24), 2851-8. Smith, M., Huang, M. , & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical Psychology Review, 25(5), 559-592. Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5–11. Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. (2015). Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: Methodology and discussion. Sleep 38(8):1161-83. Wright, K. P. (Ed.) (2009). Circadian rhythm sleep disorders. Sleep Medicine Clinics, 4(2), 1-311.