iNSOMNIA

1. El-SayedSaleh, M.D. Ass. Prof. of Psychiatry iNSOMNIA

2. سورة الأنفال جزء (9) – آية 11 إِذْ يُغَشِّيكُمُ النُّعَاسَ أَمَنَةً مِّنْهُ وَيُنَزِّلُ عَلَيْكُم مِّن السَّمَاء مَاء لِّيُطَهِّرَكُم بِهِ وَيُذْهِبَ عَنكُمْ رِجْزَ الشَّيْطَانِ وَلِيَرْبِطَ عَلَى قُلُوبِكُمْ وَيُثَبِّتَ بِهِ الأَقْدَامَ صدق الله العظيم

3. مراحل نوم الإنسان عند العرب يقول العرب في ترتيب النوم • أول النوم النعاس: وهو أن يحتاج الإنسان إلى النوم • ثم الوسن: وهو ثقل النعاس • ثم الترنيق: وهو مخالطة النعاس العين • ثم الكرى والغمض: وهو أن يكون الإنسان بين النائمواليقظان • ثم التغفيق: وهو النوم وأنت تسمع كلام القوم • ثم الإغفاء: وهو النوم الخفيف • ثم التهويم والغرار والتهجاع: وهو النوم القليل • ثم الرقاء: وهو النوم الطويل • ثم الهجود والهجوع والهيوع: وهو النوم الغرق • ثم التسبيخ: وهو أشد النوم

4. Definitions • Sleep is a state of unconsciousness in which the brain is relatively more responsive to internal than to external stimuli • Mechanisms within the brainstem and hypo-thalamus regulate sleep through GABA and acetylcholine

5. Wake 2/3 of life REM Sleep ~20% of night NREM Sleep ~80% of night Sleep Stages ___________________________

6. Stages of sleep___________________________ 1. NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep

7. Sleep Requirements • Average - 7 1/2 to 8 1/2hrs/night • Range (for adults) - 5-9 hrs/night • Steadily decreases from birth to old age • newborns sleep 14-16 hours/24 hours • Elderly spend less time sleeping per night, but increase in sleep latency and more frequent arousals make their requirement in bed longer.

8. Initiation of Sleep = Time to fall asleep • Standard - less than 30 minutes • Sleep Efficiency = Time sleeping/ Time in bed • Standard - Greater than 85% • May be caused by awakening frequently during the night with subsequent difficulty in re-initiating sleep, or awakening too early without being able to go back to sleep at all

9. Philagrypnia • Ability to stay alert with very little sleep

10. Sleep disorders (ICSD 2) • Insomnia. • Sleep Related Breathing Disorders. • Hypersomnia. • Cicadian Rhythm Sleep Disorder. • Parasomnia. • Sleep related Movement Disorder.

11. Important facts • Sleep disorders arecommon • Sleep disorders are serious • Sleep disorders are treatable • Sleep disorders areunder diagnosed

12. iNSOMNIA

13. Insomnia – definition • Insomnia is defined as difficulty with the initiation, maintenance of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep. • Patient’s subjective dissatisfaction with the sleep quality and quantity • The normal requirement for sleep ranges between 4 and 10 hours • Insomnia is a symptom, not a disorder by itself

14. Poor Sleep Maintenance • Waking after sleep has been initiated, but before desired waking time

15. Types of insomnia • Transient insomnia • < 4 weeks triggered by excitement or stress, occurs when away from home • Short-term • 4 wks to 6 months , ongoing stress at home or work, medical problems, psychiatric illness • Chronic • Poor sleep every night or most nights for > 6 months, psychological factors (prevalence 9%)

16. Some patients may not meet any of the above conditions, but awake feeling poorly rested.

17. Scope of the Problem • 1997 survey of almost 2000 ‘health maintenance organization (HMO)’ patients showed that 10% had current major insomnia as defined as taking more than 2 hours to fall asleep each night. • Only 5% spoke to their physician about it • Over 38 million prescriptions per year for sleeping pills

18. Possible causes of insomnia

19. سورة ال عمران جزء (4) – آية 154 ثُمَّ أَنزَلَ عَلَيْكُم مِّن بَعْدِ الْغَمِّ أَمَنَةً نُّعَاسًا يَغْشَى طَآئِفَةً مِّنكُمْ وَطَآئِفَةٌ قَدْ أَهَمَّتْهُمْ أَنفُسُهُمْ يَظُنُّونَ بِاللّهِ غَيْرَ الْحَقِّ ظَنَّ الْجَاهِلِيَّةِ يَقُولُونَ هَل لَّنَا مِنَ الأَمْرِ مِن شَيْءٍ قُلْ إِنَّ الأَمْرَ كُلَّهُ لِلَّهِ يُخْفُونَ فِي أَنفُسِهِم مَّا لاَ يُبْدُونَ لَكَ يَقُولُونَ لَوْ كَانَ لَنَا مِنَ الأَمْرِ شَيْءٌ مَّا قُتِلْنَا هَاهُنَا قُل لَّوْ كُنتُمْ فِي بُيُوتِكُمْ لَبَرَزَ الَّذِينَ كُتِبَ عَلَيْهِمُ الْقَتْلُ إِلَى مَضَاجِعِهِمْ وَلِيَبْتَلِيَ اللّهُ مَا فِي صُدُورِكُمْ وَلِيُمَحَّصَ مَا فِي قُلُوبِكُمْ وَاللّهُ عَلِيمٌ بِذَاتِ الصُّدُورِ صدق الله العظيم

20. Medications and insomnia

21. Insomnia – associated features At least one (or more) of the following • Fatigue or malaise • Attention, concentration impairment • Social/ vocational dysfunction/ poor work • Mood disturbance or irritability • Daytime sleepiness

22. Insomnia – resultant problems • Reduction in motivation, energy or initiative • Proneness for errors or accidents at work or while driving • Tension, headaches or gastrointestinal symptoms in response to sleep loss • Concerns or worries about sleep • Secondary psychiatric problems

23. Consequences • Mood Disturbance • Depression and/or Anxiety • Poor memory • Difficulty concentrating • Motor vehicle and other accidents

24. Insomnia – assessment • Determine the pattern of sleep problem (frequency, associated events, how long it takes to go to sleep, and how long the patient can stay asleep) • Include a full history of alcohol and caffeine intake and other factors that might affect sleep • Review current medications that patient is taking to eliminate these as possible causes • Take a history to rule out physical cause and/or psychosocial cause

25. Sleep History • Timing of insomnia • Sleep schedule • Sleep environment • Sleep habits • Symptoms of other sleep disorders • Daytime effects • Medications, caffeine • Life stressors and worry over insomnia

26. Physical Exam • Anatomic features of obstructive sleep apnea • Neurologic exam in case of restless leg or other neurologic syndrome

27. Sleep Log • Maintain for 2-4 weeks • Sleep and wake times • Awakenings • Daytime naps and activities • Correlation with bed partner

28. Management of insomnia____________________________ • Good Sleep History • Rule out primary psychiatric disorders • Rule out adverse effects of medications • Sleep Diary • Good Sleep Hygiene Measures • Interventions – CB therapy, medications

29. Management of insomnia___________________________ • Treat underlying Medical Condition • Treat underlying Psychiatric Condition • Improve sleep hygiene • Change environment • CBT: ‘primary insomnias’, transient insomnia • Pharmacological • Light, melatonin, or ‘chronotherapy’ for circadian disorders

30. Nonpharmacalogic Therapy • Cognitive Behavioral Therapy • Individual counseling- 6 sessions • Effective in 50% of patients

31. Non pharmacological treatments

32. Cognitive Behaviour Therapy (CBT)____________________________

33. Bed room__________________________ • Temperature • Fresh air • S&S • Comfortable bed

34. Stimulus control__________________________ • Go to bed when sleepy • Only S & S in bedroom • Get up the same time every morning • Get up when sleep onset does not occur in 20 min, and go to another room • No daytime napping

35. Sleep hygiene__________________________ • Behaviours that interfere with sleep • Caffeine • Alcohol • Nicotine • Daytime napping • Exercise < 4hrs before bed

36. Relaxation training__________________________ • Progressive muscle relaxation • Diaphragmatic breathing • Biofeedback • Meditation, Yoga • Hypnosis to ↓ anxiety & tension at bedtime

37. Thought stopping__________________________ • Interrupt unwanted pre-sleep cognitive activity by instructing patient to repeat sub-vocally ‘the’ every 3 sec (articulatory suppression) • To yell sub-vocally “stop” (thought stopping)

38. Behavioural therapies__________________________ • Explicit instruction to stay awake when they go to bed; Aim is to reduce anxiety associated with trying to fall asleep – Paradoxical intention • Alter irrational beliefs about sleep, provide accurate information that counteracts false beliefs – Cognitive restructuring • Patient imagines 6 common objects (candle, kite, fruit, hourglass, blackboard, light bulb) emphasis on imagining shape, colour, texture – Imagery training

39. Benzodiazepine receptor agonists__________________________ • Non Benzodiazepines • Zolpidem • Zolpidem CR • Zeleplon • Eszopiclone • Both these classes act on the GABAA receptors (BzRA) in PCN • Benzodiazepines • Lorazepam • Clonezepam • Temazepam • Flurazepam • Quazepam • Alprazolam • Triazolam • Estazolam

40. Other classes of medications__________________________ • Melatonin Receptor Agonists • Melatonin • Ramelteon • Miscellaneous • Valerian • Diphenhydramine • Cyclobenzaprine • Hydroxyzine • Alcohol • Antidepressants • Trazadone • Mirtazapine • Doxepin • Amitryptyline • Antipsychotics • Olanzapine • Quitiepine

41. BzRAs – side effects and safety__________________________ • Anterograde amnesia • Residual sedation – longer acting BzRAs • Rebound Insomnia? • Abuse and dependence? • Mostly used short term (2 weeks) • When used as a sleeping aid dose escalation rare • No physical dependence with night time use • Low psychological dependence with night time use • Increased fall risk, cognitive effects in the elderly

42. Benzodiazepines____________________________ • Benzodiazepines (GABA receptor agonist) • Transient insomnia, (max 2 wks, ideally 2-3/wk) • Long ½ life - nitrazepam • Medium ½ life - temazepam • Short ½ life - diazepam • Poor functional day time status, cognitive impairment, daytime sleepiness, falls and accidents, depression • Acute withdrawal, confusion, psychosis, fits - may occur up to 3/52 from stopping

43. Benzodiazepine use____________________________ • Benzodiazepines are the drugs of choice for the treatment of insomnia. • Flurazepam can be used for up to one month with little tolerance. • Temazepam can be used for up to three months with little tolerance. • Intermittent use recommended (every three days). Use for no longer than 3 – 6 months.

44. Benzodiazepine use____________________________ • Half-life is an important factor • Benzodiazepines with long half lives (e.g., flurazepam) produce sustained sleep, but increased risk of daytime somnolence • Benzodiazepines with short half lives may be best for patients with difficulty falling asleep, but can produce rebound insomnia • Development of tolerance can produce rebound insomnia in compounds with short half lives

45. Benzodiazepine abuse____________________________ • Benzodiazepines have relatively low abuse potential. • Prolonged use can lead to withdrawal symptoms: headache, irritability, dizziness, abnormal sleep • Rebound insomnia - triazolam

46. Benzodiazepine toxicity____________________________ • Low toxicity when taken alone • In combination can be fatal • Flumanzenil is a benzodiazepine antagonist that can be used to block adverse effects of benzodiazepines • Stomach pump, charcoal, hemodialysis

47. Non benzodiazepines____________________________ • Act at the benzodiazepine receptor • Less risk of dependence • Zaleplon short ½ life • Zolipidem, Zopiclone slightly longer ½ life • No difference in effectiveness & safety • More expensive • Only to be used if adverse effects to BZP

48. Zolpidem____________________________ • Short half life • Does not produce rebound insomnia • Low abuse potential • Less likely to produce withdrawal symptoms • Rebound insomnia after first night of withdrawal, but soon resolves

49. Barbiturates____________________________

50. Other drugs____________________________ • TCA - Amitriptyline, if depression also an issue • Antihistamines – Promethazine • Melatonin • Hormone secreted by pineal gland, effects circadian rhythm, synthesised at night • Use to counteract jet lag (2-5mg @ bedtime for Four nights after arrival); • Synthetic analogue of malatonin - Remelteon • Used in paediatric sleep disorders