일차진료에서불면증치료 김종우. Primary Insomnia : DSM-IV criteria 경희대학교의과대학정신과학교실 MEMO. Diagnostic Criteria for Insomnia (ICSD-2) 개원의와함께하는임상강좌

Transcription

1 개원의와함께하는임상강좌 2011 일차진료에서불면증치료 경희대학교의과대학정신과학교실 김종우 Diagnostic Criteria for Insomnia (ICSD-2) International Classification of Sleep Disorders, 2nd Edition (ICSD-2) Primary Insomnia : DSM-IV criteria A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, a circadian rhythm sleep disorder, or a parasomnia. D. The disturbance does not occur exclusively during the course of another mental disorder (eg, major depressive disorder, generalized anxiety disorder, a delirium). E. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition. 개원의와함께하는임상강좌

2 맞춤진료 불면증이란? 불면증에해당하는증상 잠들기가어렵다. 자주깨고다시잠들기힘들다. 새벽에일찍깬다. 자도피곤이풀리지않는다. 불면증이란다음날활동을하는데지장을줄정도로양적, 질적으로충분한잠을못자는상태 ICSD-2 Insomnia Diagnoses Sleep disorsers : DSM-IV Classification 1. Primary Sleep Disorders Dyssomnias 수면이상 Primary insomnia Primary hypersomnia Narcolepsy Breathing-related sleep disorder Circadian rhythm sleep disorder Dyssomnia NOS Parasomnias 사건수면 Nightmare disorder Sleep terror disorder Sleepwalking disorder Parasomnia NOS 2. Sleep Disorders Related to Another Mental Disorder Insomnia related to another mental disorder Hypersomnia related to another mental disorder 3. Other Sleep Disorders Sleep disorder due to a general medical condition Substance-induced sleep disorder 80 개원의와함께하는임상강좌 2011

3 김종우 : 일차진료에서불면증치료 ICD-10 Classification F51.0 F51.1 F51.2 F51.3 F51.4 F51.5 F51.8 F51.9 Nonorganic insomnia Nonorganic hypersomnia Nonorganic disorder of the sleep-wake schedule Sleepwalking (somnambulism) 몽유병 Sleep terrors (night terrors) 야경증 Nightmares 악몽 Other nonorganic sleep disorders Nonorganic sleep disorders, unspecified Epidemiology Insomnia Prevalence in general adult population According to the DSM-IV Insomnia Criteria, including 1) primary insomnia; 2) insomnia disorder related to another mental disorder; 3) substance-induced sleep disorder, insomnia type; 4) sleep disorder due to a medical condition, insomnia type Ohayon, Sleep Med Reviews 2002 Persons who report having difficulty sleeping - Do you discuss that with your physician? 24% never discussed scheduled appointment 6% mentioned 70% National Sleep Foundation, 1995 개원의와함께하는임상강좌

4 맞춤진료 NIH State-of-the-Science Meeting, June 2005 In most cases, chronic insomnia exists in the context of other medical or psychiatric conditions Clinically, it is best to consider insomnia to be comorbid with, not seconday to, another condition. Insomnia often predates the coexisting condition and/or is refractory to the successful treatment of that condition Clinically, this suggests that insomnia needs to be treated directly to maximize patient outcomes. Soldatos & Dikeos, 2003 NIH State-of-the-Science Meeting, June 2005 Non-pharmacological treatment should be considered in the first step. Pharmacological treatment should be combined with nonpharmacological modalities. Aim of hypnotics administration is to enhance patient s sense of mastery in the initial phase of treatment. Both cognitive behavioral therapy and BZD receptor agonists are effective in treating insomnia But long-term effectiveness of the BZD receptor agonists requires further study Soldatos & Dikeos, 2003 Comorbid insomnia 82 개원의와함께하는임상강좌 2011

5 김종우 : 일차진료에서불면증치료 Common Comorbid Medical Disorders, Conditions, and Symptoms 개원의와함께하는임상강좌

6 맞춤진료 Common Contributing Medications and Substances 84 개원의와함께하는임상강좌 2011

7 김종우 : 일차진료에서불면증치료 MULTIFACETED ETIOLOGY PREDISPOSING FACTORS OLDER AGE GENDER (FEMALE) SOCIOECONOMIC STATUS (UNDERPRIVILEDGED) FAMILY OR PERSONAL HISTORY OF INSOMNIA VARIOUS MEDICAL OR PSYCHIATRIC ILLNESSES CERTAIN PERSONALITY CHARACTERISTICS GENETIC PRECIPITATING FACTORS ACUTE OR CHRONIC MAJOR STRESSORS PERPETUATING FACTORS POOR SLEEP HABITS IRREGULAR SLEEP SCHEDULING FEAR OF SLEEPLESSNESS 신체질환 관절염, 심장병, 고혈압, 폐경, 임신, 위식도역류, 만성신부전, 천식, 감염, 뇌졸중... 심리적사회적스트레스 불면증 행동적원인정신생리적불면증불량한수면위생불규칙한수면-각성주기과도한낮잠... 정신과질환우울병, 불안장애, 치매, 정신분열병, 약물남용... 약물 알코올, 부신피질호르몬제, 기관지확장제, 진통제, 자극성우울제, 혈압강하제, 니코틴, 갑상선호르몬제... 특정수면질환 주기적사지운동증하지불안증후군수면무호흡증코골이... Sleep History Primary insomnia complaint: Characterization of Complaint(s): Difficulty falling asleep Awakenings Poor or unrefreshing sleep Onset Duration Frequency Severity Course Perpetuating factors Past and current treatments and responses Pre-Sleep Conditions: Pre-bedtime activities Bedroom environment Evening physical and mental status 개원의와함께하는임상강좌

8 맞춤진료 Sleep History Sleep-Wake Schedule (average, variability): Bedtime: Time to fall asleep Factors prolonging sleep onset Factors shortening sleep Awakenings number, characterization, duration; associated symptoms associated behaviors Final awakening versus Time out of bed Amount of sleep obtained Nocturnal Symptoms: Respiratory Motor Other medical Behavioral and psychological Sleep History Daytime Activities and Function: Identify sleepiness versus fatigue Napping Work Lifestyle Travel Daytime consequences (see ICSD-2 Criteria- Table 2) Quality of Life Mood disturbance Cognitive dysfunction Exacerbation of comorbid conditions Treatment of Insomnia 86 개원의와함께하는임상강좌 2011

9 김종우 : 일차진료에서불면증치료 일차성불면증의치료 원인치료 : 가장중요, 병력과수면다원검사 인지행동치료 (cognitive behavioral therapy;cbt) 수면위생 (sleep hygiene) 탈조건화 (deconditioning technique) 조건화의요소가두드러진경우유용하다. 1잠잘때외에는침대에눕지않도록한다. 2 5분이내에잠이들지않을때는일어나서뭔가다른일을한다. 3 때로침대를혹은침실을바꾸는것도도움이된다. 신체긴장, 근육긴장이두드러진경우 1이완훈련 (relaxation training) 2초월명상 (transcendental meditation) 3 바이오피이드백 (biofeedback) Cognitive-Behavioral Conceptualization of Insomnia Hyper-arousal Conditioning process Enhancement of performance anxiety Dysfunctional cognitive distortions Learned maladaptive sleep habits Psychophysiological Insomnia Learned insomnia, behavioral insomnia 잠자리에서의높은각성이조건화되었다. 잠을자려고시도하면정신이더또렷해지고못자면어쩌나걱정 낮에도잠을보충하려다보니과다각성, 수행불안, 인지왜곡, 부적응적행동양상의악순환 TV 를볼때처럼, 잠을자려고하지않을때오히려잠이잘온다. 개원의와함께하는임상강좌

10 맞춤진료 DYSFUNCTIONAL COGNITION worry over sleep loss rumination over consequences unrealistic expectation misattributions/amplification emotional cognitive physiological AROUSAL mood disturbance fatigue performance impairment social discomfort INSOMNIA CONSEQUENCES MALADAPTIVE HABITS excessive time in bed irregular sleep schedule sleep incompatible activity daytime nap 불면증의인지치료기법 불면증의원인에대한잘못된개념을교정한다 불면증의후유증이라고생각하는것을재조정한다 비현실적인수면에대한기대를바꾼다 조절과예상할수있다는지각능력을키운다 미신적사고를배제한다 Stimulus control( 자극조절요법 ) 1. 졸릴때만눕는다 2. 잘때만침대를사용한다 3. 잠이안오면거실이나다른방으로자리를옮겨 자극적이지않은반복적인일을한다. 4. 3) 의과정을되풀이한다 5. 알람을맞추고매일같은시간에일어난다 6. 낮잠을자지않는다 7. 잠자리 = 잠 88 개원의와함께하는임상강좌 2011

11 김종우 : 일차진료에서불면증치료 Restriction of time in bed; Sleep Restriction Therapy( 수면제한요법 ) 이론적배경 불면증환자들이잠자리에너무오래누워있다는사실관찰 침대에누워있는시간이길수록수면이분절되고, 적을수록수면이응축된다는관찰. 즉수면이제한될수록깊은수면증가 침대에누워있는시간을줄인다 매일의수면량을기록하여 5일간의평균수면량을기준 최소허용 total time in bed : 4.5 hr Sleep efficacy = TST/TIB X100 허용하는시간은실제취하는수면시간 +15분으로한다 수면효율이 90% 이상이면 15분씩늘려준다. Relaxation Therapy( 긴장이완요법 ) 이론 : 침대에서의생리적과각성이불면유발 목표 : 긴장감소, 각성에대한조절학습 점진적긴장이완요법 생리적인긴장을인식하고긴장을조절 근전도바이오피드백을이용 복식호흡 : 심호흡등의긴장이완을하도록지도 명상, 유도영상 (guided imagery) 매일 20 분간연습 Sleep hygiene instructions ( 수면위생 ) 기상시각을일정하게 낮잠을피하라 각성후적절한양의운동과빛의노출 자기 2시간전에뜨거운물로샤워 담배, 술, 카페인음료를줄여라. 시계를치워라 잠이안오면침실에서나와서지루한책을읽어라 저녁에격렬한운동이나수면직전까지일하는것은좋지않다 개원의와함께하는임상강좌

12 맞춤진료 수면위생 (Homeostatic Drive for Sleep) 낮잠을피하라 수면시간을일정하게고정 규칙적인운동 Body temperture 가떨어질때졸리게된다 운동을하게되면체온이올라가나운동후약 6 시간이지나면체온이더떨어져서수면에도움이된다. 잠자기 2 시간전목욕 따뜻한물에목욕을한후에는약 2 시간이지나야체온이떨어진다 수면위생 (Circadian factors) 일주일에 7 일간규칙적인기상 수면도중밝은빛에노출금하기 잠자리에서일어난후 30 분간햇빛쬐기 수면위생 (Drug effects) 수면도중금연 오후 7 시이후흡연금지 커피제한, 오전 10 시이전에마시기 알코올제한 90 개원의와함께하는임상강좌 2011

13 김종우 : 일차진료에서불면증치료 수면위생 (Arousal in sleep setting) 시계돌려놓기또는시계치우기 오후 6 시이후심한운동삼가기 잠자기전에음식제한 가벼운스낵이도움이된다특히수면을촉진시키는 tryptophan 함유음식인우유, 치즈, 바나나, 따뜻한우유등이도움이된다. 침실은어둡고, 조용하고환기잘되고온도적당하게유지 침대는수면을위해서만사용 잠자리습관이용 Primary Insomnia 의약물치료 종류 수면제, 항불안제, 항우울제, 항정신병약물, 항히스타민제, 진통제, L- tryptophan, melatonin, 기타 일반의약품 ( 항히스타민계열 ) 선택 : 환자의특성 ( 원인, 기간, 강도 ) 과약물의특성을함께고려 종류 : benzodiazepines : 용량의존적, 주간졸리움, 반동불면, 기억력장애, 호흡억제 내성과금단 zolpidem, zopiclon ; 비습관성수면제 Trazodone 수면제는일차성불면증을근본적으로치료하지는못하므로일시적 인불면증과단기적불면증에주로사용 Anti-histamine(Diphenhydramine) Advantages: Available OTC Disadvantages: Hypnotic dose not well defined Tolerance within a week of use. Agostini et al., 2001 Diphenhydramine (25-50mg) use in hospitalized elderly. 68% were used for insomnia Common adverse events: Delirium symptoms Inattention Disorganized speech Daytime residual effects Abnormal psychomotor activity Altered sleep/wake cycle 개원의와함께하는임상강좌

14 맞춤진료 US Food and Drug Administration approved hypnotic agents Insomnia ; Pharmaceutical Therapy Options Insomnia ; Pharmaceutical Therapy Options 92 개원의와함께하는임상강좌 2011

15 김종우 : 일차진료에서불면증치료 Walsh et al Other drugs treating insomnia Trazodone 수면조절위해비교적널리사용 Starting dose : 25-50mg hs/target range : mg hs S/E : headache, orthostatic hypotension, priapism(1/6000) TCAs(tricyclic antidepressant) Amitriptyline : Dose : 5-20mg hs Cardiac S/E, anticholinergic S/E, 과량복용시치명적 Nortriptyline Dose ; 5-20mg hs Orthostatic hypotension 적어서노인에서도많이사용 Mirtazapine : 7.5mg-15mg hs, 체중증가 Quetiapine : 12.5mg Atypical antipsychotics, malignant insomnia 수면목적으로약물사용시주의점 공존신체적 - 정신과적질환고려 수면무호흡증의악화 Respiration suppression Muscle relaxation Arousal decrement 낮시간의기능고려 Performance decrements Cognitive Impairment: amnesia Incoordination: Fall and hip fx Motor vehicle accidents 의존성발생고려 개원의와함께하는임상강좌

16 맞춤진료 불면증에대한오해 잠이안올땐술한잔? 알코올은깊은잠을방해하고새벽에일찍깬다. 수면제는중독되므로먹어서는안된다. 수면제남용도문제지만, 무조건기피도좋지않다. 하루에잠은 8시간은자야한다. 다음날활동하는데지장이없을정도의잠이면충분 나이가들면잠이없어진다. 필요한수면시간은나이가들어도줄지않음 불면증은전문적인치료가필요없다. 불면증은매우다양한원인에의해발생하고적절히치료하지않으면만성화되거나우울증유발 잠못이루는사람들이흔히범하는오류잡기 Summary 비약물적치료가우선고려된다. 약물치료는비약물치료의보조적수단 수면제는단기간사용하는것을추천 약물은환자의수면에대한통제감을증대하는목적 수면무호흡증, 기타공존질환을고려 94 개원의와함께하는임상강좌 2011