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

3. 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

4. Wake System ___________________________

5. Sleep System ___________________________

6. Sleep Wake Cycle ___________________________

7. Changes in sleep with age ___________________________

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

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

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

11. 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

12. 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

13. 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

14. Cognitive Model of Insomnia

15. Evolution of Insomnia

16. 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

17. 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

18. 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

19. 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

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

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

22. 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%)

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

24. Other problems __________________________
Caffeine
Nicotine
Alcohol
Exercise
Noise
Light
Hunger

25. 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

26. 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

27. 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

28. 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

29. Cognitive Behaviour Therapy (CBT) ____________________________

30. Non pharmacological treatments

31. Bed room __________________________
Temperature
Fresh air
S&S
Comfortable bed

32. 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

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

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

35. 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)

36. 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

37. 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

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

39. 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

40. 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

41. 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.

42. 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

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

44. 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

45. 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

46. 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

47. 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.

48. 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

49. 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.

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 bedtime for Four nights after arrival);
Synthetic analogue of malatonin - Remelteon
Used in paediatric sleep disorders

51. 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.

52. 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

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

54. Thank you all Have good sleep