Insomnia Dr Terri Henderson MBChB FCPsych
Plan Basics of insomnia Pharmacology Medication CBT
Details of insomnia Unsatisfactory sleep that impairs daytime well-being Starts with specific problem or change in sleep patterns Co-morbid with psychiatric disturbance Age, female gender and chronicity Prevalence 15% Long-term disorder Factors causing persistence Making a diagnosis
Detrimental effects of insomnia Q of L depression absenteeism hypertension overaroused but tired Activation of the HPA axis Road traffic accidents
Other sleep disorders Circadian rhythm disorder Parasomnias: Non-REM disorders; Night terrors & Sleepwalking REM disorders; Nightmares & RBD
Questions to eliminate other sleep disorders Are you a heavy snorer and/or does your partner say you stop breathing at night?(osas) Do your legs often twitch and can t keep still in bed? (RLS) Do you sometimes fall asleep in the day without warning? (narcolepsy) Do you tend to sleep well but just at the wrong times? (CRSD) Do you have unusual behaviours associated with your sleep? (Parasomnias)
Drugs that cause insomnia Alcohol Anticonvulsants Bronchodilators Caffeine Cocaine Estrogen Levodopa MAO inhibitors Ritalin SSRI Steroids Sympathomimetics Thyroid hormone Theophylline Z-drugs
Sleep-wake function Arousal and wakefulness: brainstem thalamus/forebrain (NA, 5HT, Ach, DA, histamines) Promotion of sleep: GABA Adenosine Melatonin Circadian pacemaker
Drug Rx : Z-drugs and Benzo s Zopiclone Longer half life > 6 hrs, some hangover effect Useful with awakenings through the night Zolpidem Sleep onset difficulties Not good at maintaining sleep CR prolongs actions but poorly Benzodiazepines Memory and motor effects
Long-term use, tolerance and dependence Controversial Original consensus 2-3 wks Tolerance not a frequent problem Withdrawal symptoms Psychological dependence Early intervention, non-nightly dosing concomitant CBT
Antidepressants SSRI s trazodone Mirtazepine, mianserin, TCA Prescribe at therapeutic doses where co-existent mood disorder
Other drugs melatonin antipsychotics antihistamines Special considerations Pregnancy zolpidem Elderly melatonin, zolpidem
Cognitive-Behavioural Therapy Good efficacy 6 sessions Therapy focuses on maladaptive thoughts and coping mechanisms that maintain insomnia Principles: o Operant and classical conditioning o Focus on sleep-interfering behaviour/hygiene o Reduction of hyperarousal features o Improvement of circadian rythym with sleep scheduling and partial sleep deprivation.
Assessment for CBT Detailed history of sleep, medical and mental health history Emphasis on factors contribute to initiation and maintenance of insomnia Sleep diary o Time to bed o Time out of bed o Minutes to fall asleep (latency) o Minutes awake during time to bed
Order of treatment interventions 1. Sleep education (regular sleep-wake times, no tobacco, alcohol, large meals, vigorous exercise before sleep) 2. Stimulus control therapy 3. Sleep restriction 4. Relaxation training
Stimulus control therapy Staying in bed when awake Extending sleep opportunity awakenings Alarm for a fixed daily wake time No nap during the day Keep bed/bedroom for sleep/sexual activity Lie down to sleep only when sleepy Leave bedroom when awake > 15 min Return to bed only when sleepy No clock-watching Increase bed/bedroom as strong cues for sleep conditioned arousal frequent/longer
Sleep restriction therapy Determine sleep average over 2 weeks Establish fixed wake time Sleep window + 30 minutes Sleep diary Adjust sleep window with increased sleep efficiency
summary Insomnia is common and often chronic Treatment should consider each individual case CBT ST hypnotics CBT & ST hypnotics AD Intermittent dosing hypnotics & CBT Ensure other disorders are adequately treated Refer: failure of CBT and Hypnotic drug RX
CBT Psychologists Zareena Parker 082 686412755 Cleo Kolbe 082 4361242 Irieza Fortune 082 5532477