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Block 8 week 1 > Sleep disorders and psychiatric disorders - Gentry > Flashcards

Sleep disorders and psychiatric disorders - Gentry Flashcards

1
Q

What is the diagnostic criteria (DSMV) for an insomnia disorder?

A
  1. a predominate complaint of dissatisfaction with sleep quantity or quality, associated with one or more of following symptoms - difficulty falling asleep, staying asleep or early morning awakening with inability to return to sleep
  2. the sleep disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
  3. Sleep difficulty occurs at least 3 nights per week and is present for at least 3 months
  4. sleep difficulty occurs despite adequate opportunity
  5. insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder
  6. insomnia is not attributable to the physiological effects of substance use
  7. co-existing mental and medical disorders do not adequately explain the predominant complaint
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2
Q

How prevalent is insomnia?

A
  1. up to 50% of primary care patients - 1/3 mention the problem and 5% seek treatment
  2. approx. 1/3 of US adults obtain insufficient sleep
  3. up to 12% of adults are impacted by insomnia on a chronic basis
  4. persistent and severe sleep disturbance affects at least 1 in 10 adults and 1in 5 older adults
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3
Q

In what groups/situations is prevalence of insomnia increased?

A
  1. women
  2. older adults - especially those with depression
  3. patients with chronic medical or psychiatric problems
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4
Q

What chronic medical or psychiatric problems are associated with insomnia?

A
  1. depression
  2. PTSD
  3. substance use
  4. chronic pain/ medical disorders - insomnia can also increase pain sensitivity
  5. other sleep disorders - often comorbid with sleep apnea
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5
Q

In what ways can insomnia be disabling?

A
  1. causes more difficulty with intellectual, social and or vocational functioning
  2. associated with less job satisfaction, lower performance scores, less productivity and higher rates of absenteeism
  3. increases risk for development of widespread pain - increases risk 3 fold over 15 months
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6
Q

What are the costs of insomnia?

A

Direct and indirect costs exceed 100 billion annually.

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7
Q

What is involved with the direct costs of insomnia?

A
  1. physician visits
  2. prescriptions
  3. procedures
    Direct costs exceed 13 billion annually, with over 800 million in prescription meds
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8
Q

What is involved with the indirect costs of insomnia?

A
  1. motor vehicle accidents
  2. workplace accidents
    These account for 77-92 billion annually
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9
Q

Chronic insomnia is a risk factor for what?

A

Both new onset and recurrent medical and psychiatric illness.

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10
Q

Patients with insomnia are more likely to suffer from what?

A
  1. pain conditions
  2. GI distress
  3. hypertension
  4. heart disease
  5. possibly diabetes
  6. depression - insomnia can actually cause or start a depressive episode
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11
Q

Up to 90% of patients with major depressive disorder complain of what?

A

Sleep problems

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12
Q

Disturbed sleep during depression is associated with what?

A
  1. increased symptom severity
  2. slower and lower rates of remission
  3. higher treatment dropout rates
  4. less stable response to treatment
  5. increased risk of suicide - insomnia alone is actually a risk factor for increased suicide
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13
Q

The group most represented at sleep clinics with insomnia is what?

A

Those with depression.

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14
Q

Depressed patients with insomnia are more likely to have what?

A

They are 2-6 times more likely to have new onset or recurrent episodes of depression compared to depressed patients without insomnia. Even after remission of depression 50% had residual sleep problems.

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15
Q

What types of drugs are available to treat insomnia?

A
  1. nonbenzodiazepines
  2. benzodiazepines
  3. anti depressants
  4. Melatonin receptor agonist - Remaelteon (Rozerem), is selective agonist at MT1 and MT2 receptors
  5. Antihistamine - Diphenhydramine (benadryl), Hydroxine (Vistaril)
  6. Antipsychotics
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16
Q

What are the nonbenzodiazepines used to treat insomnia?

A
  1. Zolpidem - ambien
  2. Zolpidem ER - ambien CR
  3. Zaleplon - sonata
  4. Eszopiclone - lunesta
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17
Q

What are the advantages of nonbenzodiazepines?

A

Bind to sub-types of GABA receptors that specifically modulate sleep and therefore are thought to have less unwanted side effects.

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18
Q

What are the adverse effects of the nonbenzodiazepines?

A
  1. drowsiness
  2. dizziness
  3. unsteadiness of gait
  4. rebound insomnia and memory impairment have been reported
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19
Q

What drugs are specifically FDA approved to treat insomnia?

A
  1. the nonbenzodiazepines
  2. Temazepam
  3. Doxepin
  4. Rozerem
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20
Q

What are the Benzodiazepines used to treat insomnia?

A
  1. Alprazolam - Xanax
  2. Lorazepam - Ativan
  3. Clonazepam - Klonopin
  4. Temazepam - Restoril
  5. Diazpepam - Valium
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21
Q

What are the advantages of Benzodiazepines in treating insomnia?

A

They enhance sleep and decrease anxiety.

22
Q

What are the adverse side effects associated with Benzodiazepines?

A
  1. daytime sedation
  2. unsteadiness of gait - increased fall risk in elderly
  3. higher risk of tolerance
  4. higher risk of dependence, withdrawal and risk of abuse
23
Q

What antidepressants are used to treat insomnia?

A
  1. TCA’s such as Doxepin (sinequan), Amitriptyline (Elavil)

2. Second generation antidepressants such as Trazadone (desyrel), and Mirtazapine (remeron)

24
Q

What are the advantages of antidepressant treatment for insomnia?

A

They can be used to treat both insomnia and depression and these conditions are commonly co-morbid. The side effects of the antidepressants are still a consideration.

25
Q

List the antipsychotics that are used to treat insomnia?

A
  1. Quetiapine - seroquel
  2. Chlorpromazine - thorazine
  3. Risperidone - risperdal
  4. Olanzapine - zyprexa
  5. Ziprasidone - geodon
26
Q

What is the first line treatment for insomnia?

A

Cognitive behavior therapy for insomnia or CBTI.

27
Q

What are the goals of CBTI?

A
  1. improved sleep quality
  2. decreased daytime impairment
  3. decreased insomnia symptoms
  4. form a positive and clear association between bed and sleeping
  5. decreased psychological distress related to sleep deprivation
28
Q

Is CBTI the same as sleep hygiene?

A

No. Sleep hygiene is not effective for treating insomnia.

29
Q

Describe CBTI as a treatment model.

A
  1. inexpensive and effective - even after treatment ends
  2. a thorough sleep assessment is done to rule out medical contributors
  3. generally consists of 4-6 sessions of around 30 minutes or longer
  4. conceptualizes model of chronic insomnia and addresses behavioral and cognitive components while trying to reduce physical and cognitive hyperarousal
  5. patient completes weekly sleep diary and evaluates improvements in sleep efficiency over time
30
Q

Describe Spielman’s 3 ‘P’ model.

A

This a model for chronic insomnia.

  1. Predisposing factors - includes biologic, psychological traits and social factors
  2. Precipitating factors - includes medical or psychiatric illness and stressful life events
  3. Perpetuating Factors - includes excessive time in bed, napping and conditioning
31
Q

What is sleep efficiency?

A

Describes how much of the time in bed is actually spent sleeping.

32
Q

Behavioral components of insomnia do what?

A

These are the behaviors specific to a person that maintain insomnia and cause it to become chronic.

33
Q

Predisposing factors do what?

A

These are the factors that increase risk of insomnia but do not necessarily cause insomnia.

34
Q

Precipitating factors do what?

A

These are the factors that add to preclinical insomnia caused by predisposing factors - leads to insomnia.

35
Q

What are the behavioral components of insomnia addressed in CBTI?

A
  1. Stimulus control - works through extinction of a conditioned arousal - repeated experiences of anxiety, frustration and tension when unable to sleep
  2. sleep restriction therapy - goals are to reduce time in bed to how much the patient is actually sleeping then gradually increase time in bed as unwanted wakefulness and sleep quality improves
36
Q

What does sleep restriction therapy do?

A

It matches up how much time a patient spends in bed with how much time they are actually sleeping.

37
Q

Is the overall goal of CBTI to increase sleep quantity?

A

No, the goal is to first increase sleep quality and hopefully sleep quantity increases too.

38
Q

What is cognitive arousal?

A
  1. hyper-attention to threats to sleep such as clock monitoring
  2. pre-sleep anticipatory anxiety, arousal producing cognitions - attributing poor daytime function, negative mmpd and ill-being to poor sleep
  3. avoidance behaviors, rigid sleep related rules in the effort to prevent poor sleep or following poor sleep
39
Q

How does CBTI address cognitive arousal?

A
  1. relaxation techniques to help quiet the mind
  2. creating ‘buffer’ time before sleep
  3. cognitive therapy - helping patient to understand how thoughts can interfere with sleep and educating patients on facts and myths underlying sleep beliefs
40
Q

In the conceptualizing of insomnia how might the circadian clock and sleep drive be affected?

A
  1. circadian clock - affected when time in bed is misaligned with circadian rhythm, when napping or irregular sleep-wake schedules interfere with circadian rhythm
  2. sleep drive - affected with excess time in bed, napping and sleeping in
41
Q

In the conceptualizing of insomnia how might hyperarousal, maintaining factors and predisposing factors be involved?

A
  1. hyperarousal - contributes to insomnia via intrusive thoughts, beliefs regarding sleep and sleep effort, increased muscle tension, and conditioning to inappropriate arousal
  2. maintaining factors involve issues with the circadian clock, sleep drive, hyperarousal and beliefs and cognitions
  3. Predisposing factors - temperament, past trauma and delayed sleep phase all contribute to risk for insomnia
42
Q

What sorts of conditions must be dealt with before CBTI can be started?

A
  1. active psychotic symptoms
  2. current alcohol/drug dependence (30 days sobriety recommended prior to treatment)
  3. excessive daytime sleepiness where safety risks are present
  4. bipolar disorder

CBTI is unlikely to help with insomnia if underlying causes/associations are not addressed.

43
Q

Describe the advantages of CBTI.

A
  1. efficacy is equivalent to medications
  2. longer - lasting effects
  3. no side effects or drug-drug interactions to worry about
  4. cost effective
44
Q

What were the findings in a study that compared CBTI to the drug Zolpidem?

A
  1. The greatest effect on sleep latency involved the groups that were undergoing CBTI - rather than those just taking zolpidem
  2. in patients with persistent insomnia, the addition of zolpidem to a CBTI regimen produced added benefits during acute therapy but long term outcome was optimized when medication was discontinued but maintenance CBTI continued
45
Q

Describe some other research findings regarding CBTI.

A
  1. sustained benefits have been reported up to 24 months after treatment ended
  2. CBTI has been found to be superior to relaxation training, medication placebo and no treatment and has also been found to be superior to medications + sleep advice
  3. patients prefer CBTI over medications
  4. patients expressed expectations that CBTI would produce greater improvements in daytime functioning, better long-term effects and fewer adverse side effects
46
Q

Medications are better for treating what type of insomnia?

A

Acute insomnia - they reduce sleep related anxiety and provide relief for acute or brief forms of insomnia such as jet lag, bereavement or other unfortunate life stress.

47
Q

Are there benefits for treating chronic insomnia with medications?

A

The benefits for chronic insomnia are less clear and are affected by risk of developing tolerance and dependence. The meds are also not helpful in addressing the wide range of behaviors and cognitions associated with chronic insomnia.

48
Q

CBTI has been shown to be effective even when what types of co-morbidities are present?

A
  1. chronic pain
  2. fibromyalgia
  3. elderly patients
  4. cancers survivors
  5. PTSD and other psychiatric conditions
  6. depression
49
Q

In what ways has CBTI been shown to help depression?

A
  1. may produce remission in symptoms
  2. depression outcomes are more negative when insomnia is not addressed
  3. sleep medications and CBTI have shown to be helpful in depression therapy - there may be larger and more durable treatment effects with CBTI versus meds
50
Q

What are some alternative therapies for insomnia?

A
  1. meditation based interventions such as mindfulness based stress reduction and mindfulness based therapy for insomnia
  2. acceptance and commitment therapy - ACT
51
Q

What is one of the biggest barriers to CBTI and how can this be addressed?

A

Lack of access to therapists trained in sleep. This could be helped by adding more clinical training programs, adding online resources and by training nurses and other professionals on brief behavioral treatments for insomnia.

52
Q

What are some services related to sleep therapy?

A
  1. insomnia and OSA frequently co-occur so can have combo therapy
  2. motivational enhancent therapy for CPAP (device used to treat OSA)
  3. Exposure therapy for claustrophobic reactions to CPAP
  4. imagery rehearsal therapy for treatment of frequent nightmares

Block 8 week 1 (13 decks)

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