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

1. Insomnia: Physiological And Medical Findings And Implications For Diagnosis And Care* George G Burton MD Medical Director, Sleep Disorders Center Kettering Health Network, Dayton, Ohio * With appreciation to M Bonnet and D Arand

2. Goals Of This Presentation: • Understand Insomnia’s 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

3. 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

4. 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

5. 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

6. AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder) • Adjustment Insomnia • Psychophysiological Insomnia • Paradoxical Insomnia • Idiopathic Insomnia • Insomnia Due To Mental Disorder • Inadequate Sleep Hygiene • Behavioral Insomnia Of Childhood (more)

7. AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder) (Continued…) 8. Insomnia Due To A Drug Or Substance • Insomnia Due To Medical Condition • Insomnia – Unspecified (non-organic) • Insomnia – Unspecified (organic)

8. 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

9. Consequences of Insomnia: Cost(2012)

10. 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

12. There Is A Big Difference In These Two Concepts: • Insomnia is a risk factor for… (Causality) • Insomnia is comorbid with… (Association) • Role of Bayesian Statistics being explored

13. 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”

14. 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

15. 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

16. 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)

17. 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

18. 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?

19. Insomnia is 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?

20. 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

21. Neurotransmitters Involved In Sleep And Arousal* • Facilitate sleepiness: Adenosine, GABA, Galanin, Glycine, Melatonin • Facilitate arousal: Acetylcholine, Dopamine, Glutamate, Histamine, Norepinephrine, Orexin, Serotonin *Gulyani S et al Sleep Medicine Pharmocotherapies Overview. Chest 142:1659-1668(2012)

22. 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

23. Hyperarousal And Insomnia

24. 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)

25. 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)

26. 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

27. An Insomnia Work-Up Paradigm Based On Costs

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

29. 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 - In-lab PSG normal except for “long sleep latency and decreased sleep efficiency”

30. 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 psychophysiologicalinsomnia

31. A Typical Insomnia Case (continued…) • Told to: “Lighten Up!” by his family PCP and Psychiatrist without improvement • Referred for CBTI for eight sessions • Additional history obtained • Dramatic improvement