tara leigh taylor, md, fccp intensivist, wyoming medical ...secondary insomnia (standard)...

Tara Leigh Taylor, MD, FCCP

Intensivist, Wyoming Medical Center

Objectives� Define the magnitude of the problem

� Define diagnostic criteria of insomnia

� Understand the risk factors and consequences of insomnia

� Outline and understand the evaluation of insomnia

� Discuss the non-pharmacologic management of insomnia

Insomnia - Prevalence� 50 to 80% adult patients experience significant

problems with falling or staying asleep during any year (typical psychiatric practice)1

� General Population – 10 to 18% of adults consider sleep to be a serious chronic problem2

� Women and the elderly (fall in the lower quartile of socioeconomic status)

Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002; 150: 5-111

Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:97-1112

Chronic Insomnia� 10 to 15% primary origin

� Insomnia comorbid with psychiatric disorders, medical disorders, circadian rhythm disorders, or substances/medications accounts for nearly 85 to 90%

Smith MT, Perlis ML, Park A et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry 2002; 150: 5-111

Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 2002; 6:97-1112

Primary Insomnia� Subsumes a number of insomnia diagnoses in the

ICSD-2

� Psychophysiologic insomnia

� Sleep-state misperception

� Idiopathic insomnia

� Inadequate Sleep Hygiene

ICSD-2, International Classification of Sleep Disorders

Primary Insomnia� A. Complaint of difficulty initiating or maintaining sleep or

of nonrestorative sleep that lasts for at least 1 month

� B. Causes clinically significant distress or impairment in social, occupational, or other important areas of function

� C. The disturbance in sleep does not occur exclusively during the course of another sleep disorder

� D. The disturbance in sleep does not occur exclusively during the course of a mental disorder

� E. The disturbance is not caused by the direct physiologic effects of a substance or a general medical condition.

DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Rev

Diagnostic Criteria Insomnia

Syndrome� Difficulty sleeping, characterized by either (or both) of

the following

� Difficulty initiating sleep (>/= 30 minutes to fall asleep

� Difficulty maintaining sleep (> 30 min of nocturnal awakenings) with corresponding sleep efficiency (the ratio of total sleep time to time spent in bed) <85%

� Sleep disturbance occurs >/= 3 nights per week

� Sleep disturbance causes significant impairment of daytime functioning

DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Rev. ICSD-2, International Classification of Sleep Disorders

Diagnosis� Patient must experience daytime consequences from

the disturbed sleep� Reduced attention and concentration

� Memory lapses

� Slowed reaction time

� Poor coordination

� Dysphoria

� Increased anxiety/worry about sleep

� Fatigue

� Tiredness, lethargy and occasionally sleepiness

Becker PM. Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis and Evaluation. ACCP Sleep Medicine Board Review: 4th Edition

RISK FACTORS� FEMALE

� AGE > 60

� MENTAL HEALTH DISORDER

� STRESS

� WORK NIGHTS OR CHANGING SHIFTS

� LONG DISTANCE TRAVEL

http://www.mayoclinic.com/health/insomnia/DS00187

COMPLICATIONS� LOWER PERFORMANCE on the job or at school

� Slowed reaction time while driving and higher risk of accidents

� Psychiatric problems such as depression or an anxiety disorder

� Overweight or obesity

� Poor immune system function

� Increased risk and severity of long-term diseases such as high blood pressure, heart disease and diabetes

http://www.mayoclinic.com/health/insomnia/DS00187

Causes of Chronic Insomnia Based on Time

of Presentation during the Night� Insomnia Type� Sleep Onset

� Causes� Learned or conditioned activation (primary insomnia)� Anxiety, including situational, panic disorder, generalized

anxiety disorder, and obsessive compulsive disorder� Mood disorders, including major depression, bipolar

disorder I or II, dysthymia� Psychotic disorders during acute exacerbation� Delayed sleep phase syndrome� Restless Legs Syndrome� UARS (and less commonly sleep apnea, either obstructive

or central)� Substances such as caffeine and decongestants� Chronic Pain, any type� Cardiopulmonary disorders, particularly those

exacerbated by the recumbent position� Neuropathy



of Presentation during the Night� Insomnia Type� Sleep Maintenance

� Causes� Excessive time in bed� Major depression, or dysthymia or bipolar disorder in

association with anxiety� Sleep-disordered breathing: sleep apnea, UARS� Periodic limb movements of sleep� Chronic pain, particularly arthritis of hips, shoulders,

and neck, as well as disc disease of the lumbosacralspine

� Respiratory disorders, particularly those exacerbated by the recumbent position

� Cardiovascular disease: heart failure, angina, atrialfibrillation, others

� Neurologic disease: fatal familial insomnia, dementia, Parkinson and other movement disorders, seizures, degenerative CNS disorders, peripheral nerve disease, toxic exposure



of Presentation during the Night� Insomnia Type

� Early Awakening

� Causes

� Major depression

� Advance Sleep Phase Syndrome

� Learned or conditioned activation (primary insomnia)

� Forced awakening for work or family responsibility


www.modernhomesteaders.net

Plumpetals-workinitout.blogspot.com

Ionmyhealth.com

Patient Evaluation� Self report – sleep questionnaires

� Psychological Testing

� Sleep Log/Diary

� Polysomnography- not routinely

� Except in pathologic sleepiness where pt reports symptoms of other sleep pathologies such as SDB, PLM, parasomnias, narcolepsy

� Actigraphy - not routinely

� When combined with information from a clinical interview and sleep log actigraphy contributes additional objective data regarding sleep phase changes and variability of sleep patterns over time.

Psychological and Behavioral

Treatments for Primary Insomnias� Stimulus Control Therapy

� Sleep Restriction Therapy

� Relaxation Training

� Cognitive Therapy

� Sleep Hygiene Education

Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005. http://www.mayoclinic.com/health/insomnia/DS00187

Stimulus Control Therapy� A set of instructions designed to reassociate the

bed/bedroom with sleep, and to reestablish a consistent sleep-wake schedule:

� Go to bed only when sleepy

� Get out of bed when unable to sleep

� Use the bedroom for sleep only (e.g., no reading, watching TV)

� Arise at the same time every morning

� No napping

Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p. 727. http://www.mayoclinic.com/health/insomnia/DS00187

Sleep Restriction Therapy� A method to curtail time in bed to actual sleep time,

thereby creating mild sleep deprivation, which results in more consolidated and more efficient sleep

� Based on sleep diary

� Actigraphy


Relaxation Training� Clinical procedures aimed at reducing:

� Somatic tension

� Progressive muscle relaxation, autogenic training

� Intrusive thoughts

� Imagery training, meditation


Cognitive Therapy� Psychotherapeutic method aimed at changing faulty

beliefs and attitudes about sleep, insomnia, and the next-day consequences.

� Other cognitive strategies are used to control intrusive thoughts at bedtime and prevent excessive monitoring of the daytime consequences of insomnia

Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005. http://www.mayoclinic.com/health/insomnia/DS00187

Cognitive Therapy� The main therapeutic message to communicate to

patients is as follows:

� Keep realistic expectations

� Do not blame insomnia for all daytime impairments

� Never try to sleep

� Do not give too much importance to sleep

� Do not catastrophize after a poor night’s sleep

� Develop some tolerance to the effects of insomnia

Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA, 2005, p. 728.

Sleep Hygiene Education� General Guidelines about:

� Health Practices

� Diet

� Exercise

� Substance Use

� Environmental Factors that may promote or interfere with sleep

� Light

� Noise

� Temperature

Meir H. Kryger, Thomas Roth, William C. Dement: Principles and Practice of Sleep Medicine; Fourth Edition, Elsevier Saunders, Philadelphia, PA 2005. http://www.mayoclinic.com/health/insomnia/DS00187

Insomnia(difficulty initiating and/or maintaining sleep associated with daytime

consequences)

1Acute

Insomnia </= 4 weeks

2Chronic Insomnia

(> 4 weeks)

Identify triggerRecent deathLoss of job

Marital breakup

yes no

Address trigger and consider short term

sedative

Daytime Impairment

Insomnia Screening Questionnaire

yes

No Monitor/reassure

PRIMARY SLEEP DISORDERSC: Circadian rhythm: night owl/shift work

A: Sleep Apnea: snoring, gasping L: Restless, abnormal movement and/or

behavior in sleep

PRIMARY SLEEP DISORDERSC: Circadian rhythm: night owl/shift work

A: Sleep Apnea: snoring, gaspingL: Restless legs, abnormal movement and/or

behavior in sleep

yes

3Primary sleep

disorderTreat or refer

SECONDARY CAUSES OF INSOMNIAM: Mood Disorders (MDD/GAD)

M: Medical DisordersM: Medications. Consider timing and dosing

S: Substance abuse

yes

4Secondary insomnia

Optimize treatment of primary disease

Address sleep hygienePrevent Comorbidprimary insomnia

No

5Primary InsomniaRefer to: Primary

Insomnia Evaluation

RECOMMENDATIONS

ACCORDING TO TYPE OF

INSOMNIA

� Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary insomnia (Standard)

� Psychological and behavioral interventions are effective and recommended in the treatment of secondary insomnia (Standard)

Morgenthaler, et al. Practice Parameters for the Psychological and

Behavioral Treatment of Insomnia: An Update. An American Academy of

Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006.

Recommendations for Specific

Therapies� Stimulus control therapy is effective and

recommended therapy in the treatment of chronic insomnia (Standard)

� Relaxation training is effective and recommended therapy in the treatment of chronic insomnia (Standard)

� Sleep restriction is effective and recommended therapy in the treatment of chronic insomnia (Guideline)

Morgenthaler, et al. Practice Parameters for the Psychological and Behavioral

Treatment of Insomnia: An Update. An American Academy of Sleep Medicine

Report. Sleep, Vol. 29, No. 11, 2006.


Therapies

� Cognitive behavior therapy, with or without relaxation therapy is effective and recommended therapy in the treatment of chronic insomnia (Standard)

� Multicomponent therapy (without cognitive therapy) is effective and recommended therapy in the treatment of chronic insomnia (Guideline)

� Paradoxical Intention is effective and recommended therapy in the treatment of chronic insomnia (Guideline)



Sleep Medicine Report. Sleep, Vol. 29, No. 11, 2006


Therapies� Biofeedback is effective and recommended therapy in

the treatment of chronic insomnia (Guideline)




Recommendations Relevant to

Specific Patient Groups� Psychological and behavioral interventions are

effective and recommended in the treatment of insomnia in older adults (Standard)

� Psychological and behavioral interventions are effective and recommended in the treatment of insomnia among chronic hypnotic users (Standard)




tara leigh taylor, md, fccp intensivist, wyoming medical ...secondary insomnia (standard)...

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