Download - Physiotherapy in psychiatry
A. THANGAMANI RAMALINGAM PT, MSC(PSY), MIAP
psychiatric disorder
A mental disorder or psychiatric disorder is a mental or behavioral pattern or anomaly that causes distress or disability, and which is not developmentally or socially normative.
Mental disorders are generally defined by a combination of how person feels, acts, thinks or perceives.
This may be associated with particular regions or functions of the brain or rest of the nervous system, often in a social context.
What is Abnormal Behavior?
One definition is that abnormal behavior is any that deviates from central tendencies, like the mean, for example. By this definition, abnormal behavior would be any that is statistically deviant. For example, if most of the population smoked, but you did not, then not smoking would be considered abnormal.
Another similar definition is deviation from socio-cultural norms, not statistical ones. In this definition, abnormality is when one violates behaviors that most consider proper. For example, not shaving, not going to church, and so on, would be abnormal
Other definitions are based on individuals instead of groups. For example, if a person feels uncomfortable in situations where others do not, then that person may be maladjusted
Another possible definition is simply being in trouble: trouble at home, work, school, or with the law
Word normal derived from latin word norma means rule .
Means followed the rule or pattern or standards. When the individual is able to function adquately and performs his daily living activities efficiently and feel satisfied with his life style called as normal behaviour .
NORMAL BEHAVIOUR
The word abnormal with prefix ,’ab’(away from) means away from normal. Abnormality is negative concept it means deviation from norm or standard or rules . Disturbances seen in behaviour which manifests in cognitive domain(thinking, knowing, memory)affective domain (emotion and feeling ) and conative domain (psychomotor activity) individual express his mental distress through thought, feeling and action .
ABNORMAL BEHAVIOUR
Personality types
Operational definition
Characteristics of abnormal behavior
• A perception of reality.• A positive attitude towards one’s
self, acceptance of weakness and pride in strengths.
• Capacity for withstanding anxiety and stress.
• Adequate in work, play and leisure .
• Willingness to use problem solving approches in life process.
• Capacity to adapt oneself to current situation.
• Competence in human relations.
• change in person’s thinking process, memory, perception and judgment.
• Work efficiency will be reduced • Forgetfulness • Unhappiness • Unable to cope • Worried, anxious disturbance in
daily routine activities. • No respect will be given to others or
self. • Lack of gratification. • Lack of self confidence • Feeling of stress
Characteristics of normal behavior
Models of abnormality
Mental and behavioral disorders
The International Classification of Diseases (ICD) is an international standard diagnostic classification for a wide variety of health conditions. Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups:
F0: ,Sexual including trauma, mental disorders F1: Mental and behavioural disorders due to use of psychoactive substances F2: Schizophrenia, schizotypal and delusional disorders F3: Mood [affective] disorders F4: Neurotic, stress-related and somatoform disorders F5: Behavioural syndromes associated with physiological disturbances and physical
factors F6: Disorders of personality and behaviour in adult persons F7: Mental retardation F8: Disorders of psychological development F9: Behavioural and emotional disorders with onset usually occurring in childhood and
adolescence In addition, a group of "unspecified mental disorders".
The DSM-IV-TR (Text Revision, 2000)
The DSM-IV-TR (Text Revision, 2000) consists of five axes (domains) on which disorder can be assessed. The five axes are:
Axis I: Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation)
Axis II: Personality Disorders and Mental RetardationAxis III: General Medical Conditions (must be connected to a Mental
Disorder)Axis IV: Psychosocial and Environmental Problems (for example limited
social support network)Axis V: Global Assessment of Functioning (Psychological, social and job-
related functions are evaluated on a continuum between mental health and extreme mental disorder)
Substance abuse disorders
Substance Classes
AlcoholCaffeineCannabisHallucinogens
PCP others
Inhalants
Gambling
OpioidsSedatives, hypnotics, and
anxiolyticsStimulantsTobaccoOther
Characteristics of Various Psychoactive Substances
Substance-Related Disorders
DSM-IV-TR categories of substance-related disorders:Substance-Use Disorders: Those involving
dependence and abuse.Substance-Induced Disorders: Those involving
withdrawal and substance-induced delirium.
Substance-Related Disorders
Substance AbuseExtends over a period of 12 months.Leads to notable impairment or distress.Continues despite social, occupational,
psychological, physical or safety problems.
Substance-Related Disorders
Substance Dependence: Maladaptive pattern of use over 12-month period, characterized by:
Unsuccessful efforts to control use, despite knowledge of harmful effects.
Takes more of substance than intended. Tolerance: Increasing doses are necessary to
achieve desired effect.
Devotes considerable time to activities necessary to obtain the substance.
Substance-Related Disorders
Withdrawal: Distress/impairment in social, occupational, other areas of functioning or physical or emotional symptoms (e.g., shaking, irritability, inability to concentrate) after reducing or ceasing intake.
Intoxication: A substance affecting CNS is ingested and causes maladaptive behaviors or psychological changes.
Substance-Use Disorders
Physical Dependence: State of body such that bodily processes become modified & produce physical withdrawal symptoms when drug is removed.
Psychological Dependence: A compulsion which requires continued use of a drug for some pleasurable effect.
Substance-Induced
IntoxicationWithdrawalPsychotic DisorderBipolar DisorderDepressive Disorder
Anxiety DisorderSleep DisorderDeliriumNeurocognitiveSexual Dysfunction
ALCOHOL- CNS depressantIntoxication
Blood Alcohol Level - 0.08g/dl
Progress from mood lability, impaired judgment, and poor coordination to increasing level of neurologic impairment (severe dysarthria, amnesia, ataxia)
Can be fatal (loss of airway protective reflexes, pulmonary aspiration, profound CNS depression)
Alcohol Withdrawal
Early anxiety, irritability, tremor, HA, insomnia, nausea,
tachycardia, HTN, hyperthermia, hyperactive reflexes Seizures
generally seen 24-48 hours most often Grand mal
Withdrawal Delirium (DTs) generally between 48-72 hours altered mental status, hallucinations, marked autonomic
instability life-threatening
scale
CIWA (Clinical Institute Withdrawal Assessment for Alcohol)
Assigns numerical values to orientation, Nausea/Vomiting, tremor, sweating, anxiety, agitation, tactile/ auditory/ visual disturbances and Headache. Vital Signs checked but not recorded.
Total score of > 10 indicates more severe withdrawal
Alcohol Withdrawal (cont.)
Benzodiazepines GABA agonist - cross-tolerant with alcohol reduce risk of SZ; provide comfort/sedation
Anticonvulsants reduce risk of SZ and may reduce kindling helpful for protracted withdrawal Carbamazepine or Valproic acid
Thiamine supplementation Risk thiamine deficiency (Wernicke/Korsakoff)
Alcohol treatment
Support education skills training psychiatric and psychological treatment
Medications:Disulfiram NaltrexoneAcamprosate
Benzodiazepine( BZD)/ Barbiturates
Benzodiazepine( BZD)/ Barbiturates
Intoxication similar to alcohol but less cognitive/motor impairment variable rate of absorption (lipophilia) and onset of
action and duration in CNS the more lipophilic and shorter the duration of action,
the more "addicting" they can be
Benzodiazepine
Withdrawal Similar to alcohol with anxiety, irritability, insomnia, fatigue, HA, tremor,
sweating, poor concentration - time frame depends on half life Common detox mistake is tapering too fast; symptoms worse at end of
taper Convert short elimination BZD to longer elimination half life drug and then
slowly taper Outpatient taper- decrease dose every 1-2 weeks and not more than 5 mg
Diazepam dose equivalent 5 diazepam = 0.5 alprazolam = 25 chlordiazepoxide = 0.25 clonazepam = 1 lorazepam
May consider carbamazepine or valproic acid especially if doing rapid taper
Benzodiazapines
Alprazolam (Xanax) t 1/2 6-20 hrs*Oxazepam (Serax) t 1/2 8-12 hrs*Temazepam (Restoril) t 1/2 8-20 hrsClonazepam (Klonopin) t 1/2 18-50 hrs*Lorazepam (Ativan) t1/2 10-20 hrsChlordiazepoxide (Librium) t1/2 30-100 hrs (less lipophilic)Diazepam (Valium) t ½ 30-100 hrs (more lipophilic)
*Oxazepam, Temazepam & Lorazepam- metabolized through only glucuronidation in liver and not affected by age/ hepatic insufficiency.
Opioids
OPIOIDSBind to the mu receptors in the CNS to modulate
pain
Intoxication- pinpoint pupils, sedation, constipation, bradycardia, hypotension and decreased respiratory rate
Withdrawal- not life threatening unless severe medical illness but extremely uncomfortable. s/s dilated pupils lacrimation, goosebumps, n/v, diarrhea, myalgias, arthralgias, dysphoria or agitation
Rx- symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant (methocarbamol), NSAIDS, clonidine and maybe BZD
Neuroadaptation: increased DA and decreased NE
Treatment - Opiate Use Disorder
CD treatment support, education, skills building, psychiatric and psychological
treatment,
Medications Methadone (opioid substitution) Naltrexone Buprenorphine (opioid substitution)
Treatment - Opiate Use Disorder
Naltrexone Opioid blocker, mu antagonist 50mg po daily
Methadone Mu agonist Start at 20-40mg and titrate up until not craving or using illicit opioids Average dose 80-100mg daily Needs to be enrolled in a certified opiate substitution program
Buprenorphine Partial mu partial agonist with a ceiling effect Any physician can Rx after taking certified ASAM course Helpful for highly motivated people who do not need high doses
Stimulants
STIMULANTS
Intoxication (acute) psychological and physical signs
euphoria, enhanced vigor, gregariousness, hyperactivity, restlessness, interpersonal sensitivity, anxiety, tension, anger, impaired judgment, paranoia
tachycardia, papillary dilation, HTN, N/V, diaphoresis, chills, weight loss, chest pain, cardiac arrhythmias, confusion, seizures, coma
Chronic intoxication affective blunting, fatigue, sadness, social withdrawal, hypotension,
bradycardia, muscle weaknessWithdrawal
not severe but have exhaustion with sleep (crash) treat with rest and support
Cocaine
Route: nasal, IV or smoked Has vasoconstrictive effects that may
outlast use and increase risk for CVA and MI (obtain EKG)
Can get rhabdomyolsis with compartment syndrome from hypermetabolic state
Can see psychosis associated with intoxication that resolves
Neuroadaptation: cocaine mainly prevents reuptake of DA
Treatment - Stimulant Use Disorder (cocaine)
CD treatment including support, education, skills, CA
Pharmacotherapy No medications FDA-approved for treatment If medication used, also need a psychosocial treatment component
AmphetaminesSimilar intoxication syndrome to cocaine
but usually longerRoute - oral, IV, nasally, smoked No vasoconstrictive effectChronic use results in neurotoxicity
possibly from glutamate and axonal degeneration
Can see permanent amphetamine psychosis with continued use
Treatment similar as for cocaine but no known substances to reduce cravings
Neuroadaptation inhibit reuptake of DA, NE, SE - greatest effect on DA
Treatment – Stimulant Use Disorder (amphetamine)
CD treatment: including support, education, skills, CA
No specific medications have been found helpful in treatment although some early promising research using atypical antipsychotics (methamphetamine)
Tobacco
Drug Interactions induces CYP1A2 - watch for interactions when start or stop
(ex. Olanzapine)No intoxication diagnosis
initial use associated with dizziness, HA, nauseaNeuroadaptation
nicotine acetylcholine receptors on DA neurons in ventral tegmental area release DA in nucleus accumbens
Tolerance rapid
Withdrawal dysphoria, irritability, anxiety, decreased concentration,
insomnia, increased appetite
Treatment – Tobacco Use Disorder
Cognitive Behavioral TherapyAgonist substitution therapy
nicotine gum or lozenge, transdermal patch, nasal spray Medication
bupropion (Zyban) 150mg po bid, varenicline (Chantix) 1mg po bid
Hallucinogens
Hallucinogens
Naturally occurring - Peyote cactus (mescaline); magic mushroom(Psilocybin) - oral
Synthetic agents – LSD (lysergic acid diethyamide) - oral
DMT (dimethyltryptamine) - smoked, snuffed, IV
STP (2,5-dimethoxy-4-methylamphetamine) –oral
MDMA (3,4-methyl-enedioxymethamphetamine) ecstasy – oral
MDMA (XTC or Ecstacy)
Designer club drugEnhanced empathy, personal insight,
euphoria, increased energy 3-6 hour durationIntoxication- illusions, hyperacusis,
sensitivity of touch, taste/ smell altered, "oneness with the world", tearfulness, euphoria, panic, paranoia, impairment judgment
Tolerance develops quickly and unpleasant side effects with continued use (teeth grinding) so dependence less likely
MDMA (XTC or Ecstacy)Neuroadaptation- affects serotonin (5HT), DA, NE but
predominantly 5HT2 receptor agonistsPsychosis
Hallucinations generally mild Paranoid psychosis associated with chronic use Serotonin neural injury associated with panic, anxiety,
depression, flashbacks, psychosis, cognitive changes.Withdrawal – unclear syndrome (maybe similar to
mild stimulants-sleepiness and depression due to 5HT depletion)
Cannabis
Cannabis
Most commonly used illicit drug in America THC levels reach peak 10-30 min, lipid soluble; long half life
of 50 hours Intoxication-
Appetite and thirst increase Colors/ sounds/ tastes are clearer
Increased confidence and euphoriaRelaxationIncreased libidoTransient depression, anxiety, paranoiaTachycardia, dry mouth, conjunctival injectionSlowed reaction time/ motor speedImpaired cognitionPsychosis
Neuroadaptation CB1, CB2 cannabinoid receptors in brain/ body Coupled with G proteins and adenylate cyclase to CA channel
inhibiting calcium influx Neuromodulator effect; decrease uptake of GABA and DA
Withdrawal - insomnia, irritability, anxiety, poor appetite, depression, physical discomfort
Treatment-Detox and rehab
- Behavioral model-No pharmacological treatment but may treat other psychiatric symptoms
PCP
PHENACYCLIDINE ( PCP)"Angel Dust"
Dissociative anestheticSimilar to Ketamine used in anesthesiaIntoxication: severe dissociative reactions –
paranoid delusions, hallucinations, can become very agitated/ violent with decreased awareness of pain.
Cerebellar symptoms - ataxia, dysarthria, nystagmus (vertical and horizontal)
With severe OD - mute, catatonic, muscle rigidity, HTN, hyperthermia, rhabdomyolsis, seizures, coma and death
Treatment antipsychotic drugs or BZD if required Low stimulation environment acidify urine if severe toxicity/coma
Neuroadaptation opiate receptor effects allosteric modulator of glutamate NMDA
receptor
No tolerance or withdrawal
ANXIETY DISORDERS
ANXIETY DISORDERS
Etiology – Biopsychosocial perspective
• emotion
• biology
• environment
• behaviour
• cognition
ANXIETY DISORDERS
Types – Specific phobia
• animal
• environmental
• blood, injury, injection
• specific situation – elevators, flying
• other
ANXIETY DISORDERS
Types – Specific phobia – Diagnostic features
• marked and persistent fear and avoidance of specific stimulus or situation
• must interfere significantly with person’s life
• must be considered excessive or unrealistic
• ANS arousal
ANXIETY DISORDERS
Types – Specific phobia
• prevalence rates from 7-11%
• often emerge during adolescence, usually earlier than age 25
• tend to be chronic, but may fluctuate over life course
• usually assessed with self-report
• conditioning theories systematic desensitization
ANXIETY DISORDERS
Systematic desensitization (SD) for specific phobia
Wolpe (1958) – reciprocal inhibition and SD
3 components of SD
• construction of stimulus hierarchy
• progressive (deep muscle) relaxation training
• progress through the hierarchy while practicing relaxation response
ANXIETY DISORDERS
Panic disorder
• recurrent, unexpected panic attacks
• persistent concern, preoccupation with having another attack
• worry about consequences of attack
• significant behaviour change in response to attacks
ANXIETY DISORDERS
Panic disorder – Other clinical features
• often accompanied by avoidance behaviours (agoraphobia)
• possible to have agoraphobia without panic attacks
• onset around late adolescence, early adulthood
• more women than men
• high rates of service utilization, poor quality of life
ANXIETY DISORDERS
Clark’s cognitive model of panic disorder)
• catastrophic misinterpretation of arousal-related bodily sensations
• agoraphobia (avoidance) as way of coping
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD)
• recurrent obsessions, compulsion, or both
• obsessesions – thoughts, images, impulses, that are persistent, markedly distressing
• compulsion – repetitive behaviours performed in response to an obsession
• common obsessions – violence, sex, contamination, order
• common compulsions – washing, cleaning, checking, seeking reassurance, ordering or arranging objects
• cleaners vs. checkers – focus on harm vs. order
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) - Background
• very rare – 2.5% lifetime prevalence rate
• little gender difference
• high overlap with depression and Tourette’s syndrome
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) – Psychodynamic perspective
• anal fixation – “Does anal-retentive have a hyphen?”
• reaction formation, undoing, displacement
ANXIETY DISORDERS
Obsessive-compulsive disorder (OCD) –Treatments
• Prozac - SSRIs
• Exposure and response prevention
ANXIETY DISORDERS
Post-traumatic stress disorder (PTSD)
Person has been exposed to traumatic event
3 symptom clusters
• recurrent re-experiencing of event
• avoidance of trauma-related stimuli and numbing
• increased arousal
Persists for at least 1 month after trauma
ANXIETY DISORDERS
Post-traumatic stress disorder (PTSD) –Etiology
Cognitive theories
• expectations and appraisals
• fear structure in long-term memory
• fear conditioning
ANXIETY DISORDERS
Generalized anxiety disorder (GAD) • Core feature is worrying – worries are unrealistic, difficult to control, excessive
• “Free floating” anxiety
• Verbal thoughts rather than images as in OCD
• Motor tension, vigilance, scanning
• “What if?” – background of intolerance of uncertainty
ANXIETY DISORDERS
Generalized anxiety disorder (GAD) –Description3 key features
• uncontrollability
• intolerance of uncertainty
• ineffective problem-solving skills
ANXIETY DISORDERS
Treatments - Pharmacotherapy
3 main drugs
• Xanax
• Paxil
• Zoloft
SSRIs, bezodiazepines, tricyclic anti-depressants, MAOs
ANXIETY DISORDERS
Treatments - Exposure
• flooding, response prevention
• confrontation with anxiety-producing stimulus
• developing more adaptive internal representations of the stimuli and their non-threatening consequences
ANXIETY DISORDERS
Treatments – Cognitive restructuring
• identify maladaptive cognitions
• challenge maladaptive cognitions
• develop more adaptive cognitions
ANXIETY DISORDERS
Treatments – Relaxation training
• Decreases physiological arousal through
• Deep muscle relaxation
• Positive imagery
• Meditation
• Deep breathing
Sleep disorders
ICSD summary
1990, 1997
(WHM p. 202)
Dyssomnias
A broad category of sleep disorders characterized by either hypersomnia or insomnia.
The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm.
Insomnia is often a symptom of a mood disorder (i.e., emotional stress, anxiety, depression) or underlying health condition (i.e., asthma, diabetes, heart disease, pregnancy or neurological conditions).[7]
Primary hypersomnia. Idiopathic hypersomnia: a chronic neurological disease similar to narcolepsy in which there
is an increased amount of fatigue and sleep during the day. Recurrent hypersomnia - including Kleine–Levin syndromePosttraumatic hypersomniaMenstrual-related hypersomniaSleep disordered breathing (SDB), including (non exhaustive):Several types of Sleep apneaSnoringUpper airway resistance syndromeRestless leg syndromePeriodic limb movement disorderCircadian rhythm sleep disordersDelayed sleep phase disorderAdvanced sleep phase disorderNon-24-hour sleep–wake disorder
Parasomnia
REM sleep behaviour disorder Sleep terror . Sleepwalking (or somnambulism) Bruxism (Tooth-grinding) Bedwetting or sleep enuresis. Sleep talking (or somniloquy) Sleep sex (or sexsomnia) Exploding head syndrome - Waking up in the night hearing
loud noises
Medical or psychiatric conditions that may produce sleep disorders
Psychosis (such as Schizophrenia)Mood disordersDepressionAnxietyPanicAlcoholismSleeping sickness - a parasitic disease
which can be transmitted by the Tsetse fly
“Bad Dreams”PTSD: Traumatic experience that is re-experienced in
the dream. Any sleep stage. Very terrifying, worse than nightmares. Daytime symptoms also.
Anxiety Dreams: REM, “bad regular dream”Nightmares: REM, intense emotion, awaken with
full alertness / terrified / emotional++ / SNS active. Night Terrors: NREM early in night, mainly kids.
Scream++, inconsolable, thrashing, dazed, SNS+++, no recall in morning. Benign.
Sleepwalking vs. RBDSleepwalking:
NREM sleep, first 1/3 of night, children and teens; may persist to adulthood. Not a dream. Confused if awoken. Simple to very complex behaviour. Rarely violent.
Sleep Talking: Children; NREM; rarely intelligible; often sleepwalk too. Can
persist to adulthood.REM Behaviour Disorder:
Old men; brainstem stroke or degeneration; loss of normal REM paralysis nuclei; frequently severe injuries; mostly last 1/3 of night.
NARCOLEPSY
A chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. People with narcolepsy often experience disturbed nocturnal sleep and an abnormal daytime sleep pattern, which often is confused with insomnia. Narcoleptics, when falling asleep, generally experience the REM stage of sleep within 5 minutes, while most people do not experience REM sleep until an hour or so later.
Periodic Limb Movement Dis.
Due to low brain iron stores, esp. in basal ganglia. Low ferritin, B12, folate -- these are needed to make dopamine.
Electrodes on anterior tibialis musc. (shins)RLS = leg cramps / movements in evening,
before bed. PLMD = same, but in sleep. Day symptoms similar to UARS – result of
sleep fragmentation, loss of stages 3 & 4.
PLMD, cont’d
Worsened by: caffeine, red wine, spices, SSRI antidepressants
Helped by: exercise, warm baths, opiates, stretching, massage, some sleeping pills
Medical Treatment: dopamine agonists (ropinirole, pramipexole), or dopamine “feedstock” L-DOPA.
REM Behaviour Disorder
Older men, esp. those with Parkinson’s, or Lewy Body dementia
Brainstem damage: n. magnocellularis, n. paramedianus (REM paralytic pathways)
Severe brain injuriesUsually no daytime psychopathologyThis is how the general public conceives of
“sleepwalking” (incorrect: it’s in NREM).
RBD, Treatment
Antidepressants are almost all REM suppressants, but they worsen RBD (not known why).
Clonazepam (anti-epileptic BZD) is the treatment of choice.
RBD can be seen in alcohol withdrawal and various drug abuse withdrawal.
Insomnia
A broad term denoting unsatisfactory sleepPerception that sleep is inadequate or
abnormalCommon problemA symptom, not a disease or sign, therefore
difficult to measure
Diagnosis
Complaint if sleep is: Brief or inadequate Light or easily disrupted Non-refreshing or non-restorative
International Congress of Sleep Disorders Classification
Transient or acute Few days to 2-4 weeks
Chronic Persisting for more than 1-3 months
Definitions
Mild Almost nightly complaint of non-restorative sleep Associated with little or no impairment of social or
occupational functioningModerate
Nightly complaints of disturbed sleep Mild to moderate impairment of social or occupational
functionSevere
Nightly complaints of disturbed sleep Severe daytime dysfunction
Classification
Sleep initiating insomniaSleep maintaining insomniaEarly morning insomnia
Short period of sleepNon-restorative sleep
Multiple awakenings Combination of above patterns
Presentation Goals
Review of normal sleep cycleCauses of insomniaDiagnosis and assessment of insomniaTreatment modalities
Stages of Sleep
Non-Rapid Eye Movement (NREM) sleep Stage I Stage II
Stages I & II are light sleep Stage III Stage IV
Stages III & IV are deep sleep
Rapid Eye Movement (REM) sleep
Normal Sleep Pattern
Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.)
Why do we sleep? Not clear, but has to do with regeneration (NREM) and brain
development/memory (REM) – REM sleep is essential for the development of the mammalian brain
Stages III & IV are involved in synaptic “pruning and tuning”
Normal Sleep Values
Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle
4-6 NREM/REM cycles per nightSleep structure changes throughout lifeWakefulness after sleep
Less than 30 minutesSleep Onset Latency (SOL)
Less than 30 minutesREM Sleep Latency
70-120 minutes
Epidemiology
Studies throughout the world show that it occurs everywhere
Depending on the area, study, etc., between 10-50% of the population are affected
Increases with ageTwice as common in females
Up to the age of 30, there is little difference between sexes Beyond 30 years, it is more common in females Beyond 70 years, females are affected twice as much as males
3 P’s of Acute Insomnia
Predisposition Anxiety, depression, etc.
Precipitation Sudden change in life
Perpetuation Poor sleep hygiene
Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia
Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia
Acute Insomnia
Adjustment sleep disorder Acute stress such as momentous life events or unfamiliar
sleep environments PSG: increased SOL(sleep onset latency“)increased
awakenings and sleep fragmentation with poor sleep efficiency
More common in women and those with anxietyJet Lag-desynchronosis-chronobiological
Symptoms last longer with eastbound travel Remits spontaneously in 2-3 days More common in the elderly
Chronic Insomnia
Primary or Intrinsic Secondary or ExtrinsicCauses
Changes in circadian rhythm, behavior, environment Body movements in sleep Medical, neurological, psychiatric disorders Drugs
Primary/Intrinsic Insomnia
Idiopathic Starts early in childhood, rare but relentless course Rare disorders affect both genders CNS abnormalities, unknown etiology, etc.
Sleep State Misinterpretation (5%) Underestimate of the sleep obtained Females affected more than males
Psycho physiological insomnia (30%) Maladaptive sleep-preventing behaviors develop and progress
to become dominant factors Females more than males
Secondary/Extrinsic Insomnia
1. Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness Advanced sleep phase syndrome Delayed sleep phase syndrome Irregular sleep/wake patterns Non-24 hour sleep/wake syndrome Shift work sleep disorder Short sleeper
2. Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep
Inadequate sleep Limit setting sleep disorder Nocturnal eating/drinking syndrome Sleep onset association disorder
3. Environmental factors Environmental sleep disorder Food allergy insomnia Toxin-induced sleep disorder
4. Movement disorders PLMS disorder (5%) RLS syndrome (12%) REM behavior disorder
5. Medical Disorders: Respiratory Altitude insomnia Central alveolar hypoventilation syndrome Central apnea syndrome COPD OSAS (4-6%) obstructive sleep apnea Sleep-related asthma
6. Medical: Cardiac Nocturnal myocardial ischemia
7. Medical: GI Peptic ulcer disease GERD
8. Medical: Musculoskeletal Fibromyalgia Arthritis
9. Medical: Endocrine Hyperthyroidism Cushing’s disease Menstrual cycle association Pregnancy
10. Medical: Neurological Cerebral degeneration disorder Dementia Fatal familial insomnia Parkinson’s disease Sleep related epilepsy Sleep related headaches
11. Medical: Psychiatric Alcoholism Anxiety disorders Mood disorders Panic disorders Psychosis Drug dependency
12. Pharmacological causes Alcohol dependent sleep disorder Hypnotic dependent sleep disorder Stimulus dependent sleep disorder Medications
B-blockers Theophylline L-dopa
Parasomnia Events
Physical phenomena occurring in sleep Confusional arousals Nightmares Nocturnal leg cramps Nocturnal paroxysmal
dystonia REM sleep behavior disorder
Rhythmic movement disorder
Painful erections Sleep starts Sleep terrors Sleep walking Abnormal swallowing Hyperhidrosis Laryngospasms
Physical, Emotional, and Cognitive Effects of Insomnia
Mood changes, irritability, poor concentration, memory defects, etc.
Impairs creative thinking, verbal processing, problem solvingRisk of errors, accidents due to excessive daytime sleepiness
Markedly increases if awake more than 16-18 hours (micro-sleep attacks)Increased appetite, decreased body temperaturePhysiologic effects
Rats die after 11-12 days of sleep deprivation Hippocampal atrophy in chronic jet lag or shift work
Evaluation
HISTORY! Precipitating factors Psychiatric and medical disturbances Medications Sleep hygiene Circadian tendencies Cognitive distortions and conditional arousals
Sleep diary
Evaluation
PSG(Polysomnography)if PLMS or sleep-related breathing disorder
or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM Not routinely employed in the evaluation of transient
or chronic insomnia Should not be substituted for a careful clinical history
Epworth Sleepiness Scale
A good measure of excessive daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation:
0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance
Sitting and reading ____ Watching TV ____ Sitting inactive in a public place (ex. theater, meeting) ____ As a passenger in a car for an hour without a break ____ Lying down to rest in the afternoon ____ Sitting and talking to someone ____ In a car, while stopped for a few minutes in traffic ____ ____ Total Score Normal < 10 Severe > 15
Insomnia questionnaire
I have real difficulty falling asleep. Thoughts race through my mind and this prevents me from
sleeping. I wake during the night and can’t go back to sleep. I wake up earlier in the morning than I would like to. I’ll lie awake for half an hour or more before I fall asleep. I anticipate a problem with sleep almost every night
If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.
Treatment Selection
1. Meet and educate about disease, goals, options, side effects, and document safety.
2. Identify the 3 P’s.3. Intrinsic v. Extrinsic4. Treat perpetuating causes
Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT
CBT
Longest lasting improvements, assuming the precipitating cause is dealt with
“counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances
Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones
CBT Examples
“I need more hours of sleep or I will not function”
“I can never die”Uses restructuring techniquesShort circuit cycle of insomnia, cognitive
distortions, distressSleep hygiene, relaxation, stimulus control,
sleep restrictions
Sleep Hygiene
Exercise earlier during the day, and no more than 4-6 hours before sleep
Keep bedroom dark and quiet, to be used only for sex or sleep
Curtail time in bed to only when sleepyFixed sleep/wake times for 365 daysAvoid napsAvoid stimulus or stimulating activities before sleep
or in bedNo alcohol at least 4 hours before sleep, no
caffeine after noon, and quit smoking!!Light snack before bedtime
Stimulus Control
Use bedroom for sleep or sex onlyGo to bed only when tired and sleepyRemove clock from the bedroom to avoid
constantly watching itRegular sleep/wake timesLight therapy if requiredNo bright lights when you wake up at night
Sleep Restriction
An effective form of treatmentEstimate the time actually asleep then limit
bedtime to that amount, but no less than 5 hours
Add time in bed gradually once the patient sleeps more than 85% of that time
Pharmacotherapy
Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics Trazadone Seroquel
Self-medication with alcohol and over-the-counter medications Benadryl Nyquil
Benzodiazepines Dose Half-life Comments
Flurazepam(Dalmane)
15,30 mg Long Daytime drowsiness common; rarely used
Clonazepam(Klonopin)
0.5-2 mg Long Used for PLM, REM behavior disorder; can cause morning drowsiness
Temazepam (Restoril)
15,30 mg Intermediate
Estazolam (ProSom)
1-2 mg Intermediate Can cause agranulocytosis
Triazolam (Halcion)
0.125,0.25 mg Short Rebound insomnia may occur
Zolpidem (Ambien)
5,10 mg Short A nonbenzodiazepamZopliclone
(Sonata)5,10 mg Short , 1-1.5 hours
A nonbenzodiazepam
Recent Medication Additions
Eszopiclone 1,2,3 mg Intermediate • Approved for chronic insomnia
(Lunesta) Action 6-8 hrs.Zolpidem 10 mg Action same as above(Amvien CR)Rozerem(Ramelton)
Alternative Medications
Antidepressants Not much research Some, including SSRIs, can cause daytime drowsiness
Melatonin Good for jet leg, especially in elderly, but not much information on
long-term use Reported to cause depression, vasoconstriction
Benadryl Rarely indicated, can cause a hangover
Herbal supplements Use in conjunction with a sleep log
Conclusion
Insomnia is a complex symptom with many causes and perpetuating influences
It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated
It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder Depression in turn confers an increased risk of suicide,
cardiovascular disease, death, etc.