Download Insomnia

El-Sayed Saleh, M.D.
Ass. Prof. of Psychiatry
‫سورة األنفال‬
‫جزء (‪ – )9‬آية ‪11‬‬
‫م ُّ‬
‫ش ُ‬
‫َّ‬
‫ماء مَاء‬
‫الس َْ‬
‫ل َعلَي ُكم ِمن‬
‫ه َْو ُين َِز ُْ‬
‫الن َعاسَْ أَ َمنَةْ ِمن ُْ‬
‫يك ُْ‬
‫إِذْ ُي َغ ِ‬
‫هبَْ َع ُ‬
‫نكمْ ِرج َْز ال َّ‬
‫طَ َع ْلَى ُق ُلوبِ ُكمْ‬
‫ن َولِيَربِ ْ‬
‫شيطَا ِْ‬
‫لِ ُيطَ ِه َر ُكم بِ ِْ‬
‫ه َو ُيذ ِ‬
‫ه األَقدَا َْ‬
‫م‬
‫ت بِ ِْ‬
‫َو ُي َث ِب َْ‬
‫صدق هللا العظيم‬
‫مراحل نوم اإلنسان عند العرب‬
‫يقول العرب في ترتيب النوم‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫أولْالنومْالنعاس‪ :‬وهوْأنْيحتاجْاإلنسانْإلىْالنوم‬
‫ثمْالوسن‪ :‬وهوْثقلْالنعاس‬
‫ثمْالترنيق‪ :‬وهوْمخالطةْالنعاسْالعين‬
‫ثمْالكرىْوالغمض‪ :‬وهوْأنْيكونْاإلنسانْبينْالنائم واليقظان‬
‫ثمْالتغفيق‪ :‬وهوْالنومْوأنتْتسمعْكالمْالقوم‬
‫ثمْاإلغفاء‪ :‬وهوْالنومْالخفيف‬
‫ثمْالتهويمْوالغرارْوالتهجاع‪ :‬وهوْالنومْالقليل‬
‫ثمْالرقاء‪ :‬وهوْالنومْالطويل‬
‫ثمْالهجودْوالهجوعْوالهيوع‪ :‬وهوْالنومْالغرق‬
‫ثمْالتسبيخ‪ :‬وهوْأشدْالنوم‬

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 hypothalamus regulate sleep through GABA and
acetylcholine
Wake
2/3 of life
NREM Sleep
REM Sleep
~80% of night
~20% of night
5
1. NREM Sleep
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
2. REM Sleep
6

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.

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

Ability to stay alert with very little sleep
1.
2.
3.
4.
5.
6.
Insomnia.
Sleep Related Breathing Disorders.
Hypersomnia.
Cicadian Rhythm Sleep Disorder.
Parasomnia.
Sleep related Movement Disorder.
10
Important facts

Sleep disorders are common

Sleep disorders are serious

Sleep disorders are treatable

Sleep disorders are under diagnosed
11

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

Waking after sleep has been initiated, but before
desired waking time

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%)

Some patients may not meet any of the above
conditions, but awake feeling poorly rested.
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

Headache
Abdominal pains
Bad or vivid dreams
Fever/night sweats
Problems of breathing
Leg cramps
Chest pain/heartburn
Fear/anxiety
Need to pass urine or
move bowels
Depression
‫سورة ال عمران‬
‫جزء (‪ – )4‬آية ‪154‬‬
‫فةْ ِم ُ‬
‫م أَ َم َْنةْ ن ُّ َعاسا يَغ َ‬
‫نك ْ‬
‫م‬
‫شى طَآئِ َْ‬
‫د ال َغ ِْ‬
‫ل َعلَي ُكم ِمن بَع ِْ‬
‫م أَن َز َْ‬
‫ُث َّْ‬
‫ه َّ‬
‫مت ُهمْ أَن ُف ُ‬
‫وَطَآئِ َفةْ َقدْ أَ َ‬
‫ظَ َّْ‬
‫ن‬
‫َق ْ‬
‫الل َغي َْر الح ِْ‬
‫ون بِ ِْ‬
‫َظ ُّن َْ‬
‫س ُهمْ ي ُْ‬
‫ة ي َُق ُ‬
‫ون َ‬
‫هل لَّنَا ِمنَْ األَم ِْر ِمن َ‬
‫ن األَم َْر ُْكل َّ ُْ‬
‫ه‬
‫شيءْ ُقلْ إِ َّْ‬
‫ول َْ‬
‫هلِيَّ ِْ‬
‫الجَا ِ‬
‫ك ي َُق ُ‬
‫ان ْلَنَا ِمنَْ‬
‫ون لَوْ َك َْ‬
‫ول َْ‬
‫ون لَ َْ‬
‫د َْ‬
‫ل َ ُيب ُْ‬
‫س ِهم َّما ْ‬
‫لل ُيخ ُف َْ‬
‫ِ َّ ِْ‬
‫ون فِي أَن ُف ِ‬
‫ه ُ‬
‫شيءْ َّما ُقتِلنَا َ‬
‫األَم ِْر َ‬
‫اهنَا ُقل لَّوْ ُْكن ُتمْ فِي ُب ُيوتِ ُكمْ لَْبَ َر َْز ال َّ ِذينَْ‬
‫ل إِلَى َم َ‬
‫الل مَا ْفِي‬
‫ُْ‬
‫ج ِع ِهمْ َولِيَب َت ِل َْ‬
‫ي‬
‫م ال َقت ُْ‬
‫ُك ِتبَْ َعلَي ِه ُْ‬
‫ضا ِ‬
‫ُّ‬
‫م َّ‬
‫ُ‬
‫ور ُكمْ َولِ ُي َ‬
‫د ِْ‬
‫ور‬
‫الص ُْ‬
‫الل َعلِيمْ بِ َذاتِْ‬
‫حصَْ مَا فِي ُق ُلوبِ ُكمْ َْو ُْ‬
‫ص ُد ِ‬
‫صدق هللا العظيم‬
Type of medication
Example
CNS stimulants
D-amphetamine
Blood pressure drugs
 - blockers,  - blockers
Respiratory medicines
Albuterol, Theophylline
Decongestants
Phenylephrine, Pseudoephedrine
Hormones
Thyroxin, Corticosteroids
Other substances
Alcohol, Nocotine, Caffeine
20
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
21





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
22





Mood Disturbance
Depression and/or Anxiety
Poor memory
Difficulty concentrating
Motor vehicle and other accidents

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








Timing of insomnia
Sleep schedule
Sleep environment
Sleep habits
Symptoms of other sleep disorders
Daytime effects
Medications, caffeine
Life stressors and worry over insomnia


Anatomic features of obstructive sleep apnea
Neurologic exam in case of restless leg or
other neurologic syndrome

Maintain for 2-4 weeks
 Sleep and wake times
 Awakenings
 Daytime naps and activities
 Correlation with bed partner






Good Sleep History
Rule out primary psychiatric disorders
Rule out adverse effects of medications
Sleep Diary
Good Sleep Hygiene Measures
Interventions – CB therapy, medications
28

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

Cognitive Behavioral Therapy
 Individual counseling- 6 sessions
 Effective in 50% of patients
31
Cognitive Behaviour Therapy (CBT)
____________________________
32




Temperature
Fresh air
S&S
Comfortable bed
33





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
34






Behaviours that interfere with sleep
Caffeine
Alcohol
Nicotine
Daytime napping
Exercise < 4hrs before bed
35
Progressive muscle relaxation
Diaphragmatic breathing
Biofeedback
Meditation, Yoga
 Hypnosis to ↓ anxiety & tension at bedtime




36

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)
37

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
38

Benzodiazepines

Non Benzodiazepines
 Lorazepam
 Zolpidem
 Clonezepam
 Zolpidem CR
 Temazepam
 Zeleplon
 Flurazepam
 Eszopiclone
 Quazepam
 Alprazolam
 Triazolam
 Estazolam
39

Both these classes act on
the GABAA receptors
(BzRA) in PCN

Antidepressants
Melatonin Receptor Agonists
 Trazadone
 Melatonin
 Mirtazapine
 Ramelteon
 Doxepin



Miscellaneous
 Amitryptyline
 Valerian
Antipsychotics
 Diphenhydramine
 Olanzapine
 Cyclobenzaprine
 Quitiepine
 Hydroxyzine
 Alcohol
40




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

Benzodiazepines (GABA receptor agonist)

Transient insomnia, (max 2 wks, ideally 2-3/wk)

Long ½ life -

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
42
nitrazepam

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.

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

Benzodiazepines have relatively low abuse
potential.

Prolonged use can lead to withdrawal
symptoms: headache, irritability, dizziness,
abnormal sleep

Rebound insomnia - triazolam

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


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
47

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
Drug
Duration of action
Half-life
Phenobarbital
Long
24 – 140 hrs.
Butabarbital
Intermediate
34 – 42 hrs.
Amobarbital
Short-intermediate
8 – 42 hrs.
Pentobarbital
Short-intermediate
15 – 48 hrs.
Secobarbital
Short-intermediate
19 – 34 hrs.



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
52