14 – Sleep Disorders




Abstract




Sleep disorders are prevalent, disabling, and deleterious to an array of physiologic systems. Given the intricate relationship between sleep, cognition, and emotional regulation, it is not surprising that complaints about sleep are especially frequent in the psychiatry clinic. It is incumbent on the clinician to identify potential sleep disorders, as treatment can have substantial benefits for both physical and mental health.





14 Sleep Disorders


Susan Chang and John Winkelman



Introduction to Sleep Disorders


Sleep disorders are prevalent, disabling, and deleterious to an array of physiologic systems. Given the intricate relationship between sleep, cognition, and emotional regulation, it is not surprising that complaints about sleep are especially frequent in the psychiatry clinic. It is incumbent on the clinician to identify potential sleep disorders, as treatment can have substantial benefits for both physical and mental health.


When approaching the patient with a sleep disorder, it is often helpful to categorize the problem: insomnia (difficulty sleeping), parasomnia (abnormal behaviors during sleep), or hypersomnia (excessive sleep or sleepiness). The last of these is often the most challenging to correctly identify, since it may easily be confused with common medical and psychiatric symptoms such as fatigue (lack of energy) or apathy (lack of interest or concern). This distinction can be made by careful history. One may ask, “If you sit down to read a book, do you begin to nod off?” or “Do you have difficulty staying awake on a long drive?” An affirmative answer suggests true sleepiness.


Several tools can be helpful additions to clinical history in the evaluation of the patient with a sleep disorder. The Epworth Sleepiness Scale (ESS) is a commonly used instrument for patients with hypersomnia. The ESS poses a series of scenarios and asks patients to rate their likelihood of dozing in each case. Scores can be used to quantify the degree of sleepiness and to track changes during treatment of the sleep disorder. On the other hand, progress during treatment of insomnia or a parasomnia is best monitored using sleep diaries. Patients are asked to document on a daily basis their sleep times and/or nocturnal behaviors. These “real-time” records often provide a more accurate picture of the sleep problem compared to the patient’s recollection at the time of the visit. This may allow the identification of important patterns and external influences that may assist in treatment.



Insomnia


Difficulty sleeping is one of the most common concerns among psychiatric patients. According to the DSM-V, insomnia disorder encompasses difficulty initiating sleep, difficulty maintaining sleep, and/or chronically nonrestorative sleep that are present at least three times per week for a minimum of three months. Among US adults, the prevalence of insomnia disorder is approximately 10–20 percent, and roughly half of those follow a chronic course. Insomnia is more common in women, the elderly, and those who are widowed, divorced, or of lower socioeconomic status. Insomnia is also overrepresented in psychiatry clinics due to very high rates of comorbidity with mood, psychotic, substance abuse, and anxiety disorders.


Insomnia is often triggered by a stressful life event – the precipitant. This could be a social, medical, or psychological stressor that temporarily disrupts the normal sleep pattern. Acute insomnia is common in this setting and frequently resolves without treatment, though a short course of hypnotic medication may be warranted if the sleeplessness is severe or distressing. However, a subset of patients will go on to develop chronic insomnia disorder. In these individuals, a variety of unfavorable predisposing and perpetuating factors maintain the unsatisfactory sleep pattern despite the resolution of the precipitating circumstances. Predisposing conditions may include an anxious diathesis, older age, or medical illness. Perpetuating factors are often compensatory responses to the insomnia that eventually become counterproductive and/or inadvertent conditioned negative responses to the sleeping environment. For instance, she may go to bed earlier, nap during the daytime, worry excessively about sleep, and focus unduly on the effort to initiate sleep despite heightened alertness.


Evaluation of the patient with insomnia should focus on a careful understanding of sleep patterns (including any daytime napping), precipitating and perpetuating factors, and daytime consequences of the sleep disturbance. Every patient, whether in the psychiatry clinic or elsewhere, should be queried about symptoms of mood and anxiety disorders, since these are common causes of insomnia that often warrant independent treatment. It is also important to ask about symptoms of restless legs syndrome, circadian rhythm disorders, and obstructive sleep apnea, as well as symptoms such as pain, nocturnal dyspnea, and frequent urination that can interfere with sleep, and whose treatment can improve sleep (Table 14.1).




Table 14.1 Differential diagnosis of insomnia











Differential diagnosis of insomnia



  • Psychiatric illness (e.g., depression, anxiety)



  • Stress



  • Irregular sleep schedule



  • Disruptive sleeping environment (e.g., noise, light)



  • Excess caffeine



  • Substance abuse (e.g., alcohol, cocaine)



  • Symptoms of medical problems, e.g.:




    • Pain



    • Nocturia



    • Shortness of breath



    • Cough



    • Palpitations



    • Tinnitus




  • Neurodegenerative disorders



  • Menopause



  • Medications



  • Circadian rhythm disorders



  • Restless legs syndrome



  • Obstructive sleep apnea


Treatment of insomnia incorporates two strategies: cognitive-behavioral therapy (CBT) and pharmacologic therapy. The selection of a treatment approach should be made in collaboration with the patient and in response to his or her needs. Some patients have a preference to avoid medications, while others are unable to make the time commitment required for CBT. In those who are willing and able, a combination of the two approaches is probably the most effective for long-term management.


Cognitive-behavioral therapy for insomnia (CBT-I) is a multimodal approach that teaches patients to modify unhelpful behaviors and cognitive patterns. In CBT-I, the patient keeps sleep diaries that are reviewed with the therapist. A variety of strategies are taught in CBT-I, including sleep hygiene, relaxation techniques, and cognitive restructuring, but the two components with proven efficacy are sleep restriction and stimulus control.


Stimulus control is based on the principles of classical conditioning. In this model, the bedroom and the process of attempting to sleep become stimuli that produce anxiety and physiological arousal, thereby interfering with sleep and perpetuating insomnia. Accordingly, in CBT-I the patient is directed to get out of bed when awake and unable to sleep in order to preserve the bed as a place for drowsiness/sleep. Sleep restriction, the other key intervention in CBT-I, involves limiting the total time in bed to the actual amount of time slept. Initially, total sleep time will decrease relative to baseline, but the increased sleep drive that ensues will over time facilitate faster sleep onset and better sleep maintenance, reducing anxiety regarding sleeplessness and leading to re-establishment of a pattern of regular sleep. Time in bed is then gradually increased as long as difficulties with sleep initiation or maintenance do not return.


Pharmacotherapy of insomnia is appropriate for short-term management in many patients and may be indicated for the long-term in a subset of individuals with chronic insomnia that does not resolve with behavioral techniques. The most well-studied sleeping medications bind to the benzodiazepine site on GABA(A) receptors in the CNS. These include both the benzodiazepines and the newer benzodiazepine receptor agonists. Although the newer agents are somewhat more selective for a subtype of GABA(A) receptor, practically this makes very little difference, and the choice of hypnotic should be made based on pharmacokinetic considerations and the patient’s tolerance and preference. If benzodiazepine agonists are ineffective, poorly tolerated, or contraindicated, alternative treatment options include sedating antidepressants, melatonin agonists, atypical antipsychotics, and anti-epileptics (Table 14.2).




Table 14.2 Pharmacological agents for insomnia























































Drug Half-life (hours) Dose range (mg) Side effects
Benzodiazepines


  • Lorazepam



  • Temazepam



  • Clonazepam



  • Triazolam




  • 8–12



  • 8–12



  • 20–60



  • 2–3




  • 0.5–2



  • 15–30



  • 0.25–1



  • 0.125–0.375




  • Common to all: Residual sedation, complex sleep-related behaviors, anterograde amnesia, Falls (elderly)

Benzodiazepine receptor agonists


  • Zaleplon



  • Eszopiclone



  • Zolpidem



  • Zolpidem ER



  • Zolpidem sublingual




  • 1–2



  • 5–6



  • 2–3



  • 2–3



  • 2–3




  • 5–10



  • 1–3



  • 5–10



  • 6.25–12.5



  • 1.75–3.5

Dual orexin receptor antagonists


  • Suvorexant



  • Lemborexant

12–1517–19 10–205–10 Common to both: Residual sedation
Sedating antidepressants


  • Trazodone



  • Mirtazapine



  • Amitriptyline



  • Doxepin




  • 7–15



  • 20–40



  • 10–100



  • 10–50




  • 25–150



  • 7.5–30



  • 10–100



  • 3–25




  • Dry mouth, OH, priapism



  • Weight gain, OH, dry mouth



  • Weight gain, OH, dry mouth, urinary retention



  • Weight gain, OH, dry mouth, urinary



  • retention

Antipsychotics


  • Quetiapine



  • Olanzapine




  • 7



  • 20–54




  • 25–200



  • 2.5–20

Common to both: weight gain, metabolic syndrome, OH, dry mouth, akathisia
Anticonvulsants


  • Gabapentin

100–900 5–9 Dizziness, cognitive impairment, weight gain
Melatonin agonists


  • Ramelteon

8 0.8–2 Dizziness, fatigue
Antihistamines


  • Diphenhydramine



  • Doxylamine




  • 25–50



  • 25–50




  • 5–11



  • 10–12

Common to both: dry mouth, urinary retention, constipation, OH


Medications that are FDA approved for sleep are marked in boldface. OH, orthostatic hypotension; ER, extended-release

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Jul 27, 2021 | Posted by in PSYCHIATRY | Comments Off on 14 – Sleep Disorders

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