Important facts ___________________________ Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed

Important facts ___________________________ Sleep complaints are usually not due to psychiatric conditions or character flaws Most sleep disorders are readily diagnosable and treatable The studies include Polysomnography (PSG) Multiple sleep latency test (MSLT) Actigraphy

Wake System ___________________________

Sleep System ___________________________

Sleep Wake Cycle ___________________________

Changes in sleep with age ___________________________

Stages of sleep ___________________________ NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep

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

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

Insomnia - definition ___________________________ Insomnia and excessive daytime sleepiness are primary complaints regardless of the stage of the disease Insomnia includes difficulty falling asleep, difficulty staying asleep, and early morning awakening

Insomnia - definition ___________________________ Insomnia is not defined by the number of hours of sleep, but rather, by an individual‘s ability to sleep long enough to feel healthy and alert during the day. The normal requirement for sleep ranges between 4 and 10 hours Insomnia is a symptom, not a disorder by itself

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

Cognitive Model of Insomnia

Evolution of Insomnia

Possible causes of insomnia ___________________________ Headache Bad or vivid dreams Problems of breathing Chest pain/heartburn Need to pass urine or move bowels Abdominal pains Fever/night sweats Leg cramps Fear/anxiety Depression

Insomnia ___________________________ A complaint of difficulty in initiating, maintaining or waking up too early or sleep that is non-restorative or poor in quality. The above sleep difficulty occurs despite adequate opportunity and circumstance for sleep. Insomnia is a symptom – not a disease per se

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

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

Insomnia types __________________________ Psycho-physiologic Insomnia Paradoxical Insomnia Inadequate Sleep Hygiene Adjustment Insomnia Insomnia due to Medical Condition/ Mental Disorder/ Drug or Substance

Insomnia - subdivisions ___________________________ Sleep onset insomnia Sleep maintenance insomnia Sleep offset insomnia Non restorative sleep

Types of insomnia ________________________ Transient insomnia < 4 weeks triggered by excitement or stress, occurs when away from home Short-term 4 wks to 6 mons , 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%)

Medical problems __________________________ Depression Hyperthyroidism Arthritis, chronic pain Benign prostatic hypertrophy Headaches; Sleep apnoea Periodic leg movement, Restless leg syndrome (RLS)

Other problems __________________________ Caffeine Nicotine Alcohol Exercise Noise Light Hunger

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

Management of insomnia ___________________________ Treat underlying causes whenever possible Advise patient to avoid exercise, heavy meals, alcohol, or conflict situations just before bed Plain aspirin or paracetamol in low doses may be helpful; or give short-acting hypnotics or a sedative Treat underlying depression

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

Medications and insomnia ___________________________ Type of medication Example CNS stimulants D-amphetamine, Methyphenindrate Blood pressure drugs  - blockers,  - blockers Respiratory medicines Albuterol, Theophylline Decongestants Phenylephine, Pseudoephedrine Hormones Thyroxin, Corticosteroids Other substances Alcohol, Nocotine, Caffeine

Cognitive Behaviour Therapy (CBT) ____________________________

Non pharmacological treatments

Bed room __________________________ Temperature Fresh air S&S Comfortable bed

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

Sleep hygiene __________________________ Behaviours that interfere with sleep Caffeine Alcohol Nicotine Daytime napping Exercise < 4hrs before bed

Relaxation training __________________________ Progressive muscle relaxation Diaphragmatic breathing Autogenic training Biofeedback Meditation, Yoga Hypnosis to ↓ anxiety & tension at bedtime

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)

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

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

Other classes of medications __________________________ Antidepressants Trazadone Mirtazapine Doxepin Amitryptyline Antipsychotics Olanzapine Quitiepine Melatonin Receptor Agonists Melatonin Ramelteon Miscellaneous Valerian Diphenhydramine Cyclobenzaprine Hydroxyzine Alcohol

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

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

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.

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

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

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

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

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

Barbiturates ____________________________ Drug Duration of action Half-life Phenobarbital Long 24 – 140 hrs. Butabarbital Intermediate 34 – 42 hrs. Amobarbital Short-intermediate 8 – 42 hrs. Pentobarbital 15 – 48 hrs. Secobarbital 19 – 34 hrs.

Barbiturates - neurochemistry ____________________________ Enhance GABAA receptor activity Increase Cl- conductance through site separate from that of benzodiazepines Thiopental also inhibits GABA transaminase Also block glutamate receptor-mediated excitation

Barbiturates - effects ____________________________ Progression of effects Anxiolytic,Sedation, General anesthesia Medullary paralysis, Death Decrease stage III, IV, REM sleep, sleep latency Tolerance develops to shortening REM sleep Produce REM rebound Anxiolytic, but with substantial drowsiness and ataxia. Anticonvulsant activity.

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

Sleep Related Breathing Disorders ____________________________ Obstructive Sleep Apnea. Primary Central Sleep Apnea. High Altitude Periodic breathing. Cheyne Stokes Breathing Pattern. Central Sleep Apnea due to Drug or Substance.

Hypersomnia ___________________________ Narcolepsy with Cataplexy Narcolepsy without Cataplexy Narcolepsy due to Medical Condition Idiopathic Hypersomnia with Long Sleep Time Idiopathic Hypersomnia without Long Sl. Time Behaviorally Induced Insufficient Sleep Syn Hypersomnia due to Medical Condition Hypersomnia due to Drug/ Substance

Sleep related movement disorders ____________________________ Restless Leg Syndrome Periodic Limb Movement Disorder Sleep Related Leg Cramps Sleep Related Bruxism

Thank you all Have good sleep