Insomnia in Chronic Pulmonary Diseases - Understanding and Management

1. الله الذي جعل لكم الليل لتسكنوا فيه والنهار مبصرا إن الله لذو فضل على الناس ولكن أكثر الناس لا يشكرون) غافر 61صدق الله العظيم

2. Insomnia In Chronic Pulmonary Diseases BYAHMAD YOUNESPROFESSOR OF THORACIC MEDICINE Mansoura faculty of medicine

3. Insomnia - What is it? • A broad term denoting unsatisfactory sleep. • Trouble falling asleep, staying asleep, or waking too early. • Perception that sleep is inadequate or abnormal • Common problem • A symptom, not a disease or sign, therefore difficult to measure

4. 3 P’s of Short term Insomnia • Predisposition • Anxiety, depression, etc. • Precipitation • Sudden change in life • Perpetuation • Poor sleep hygiene • Precipitating causes lower the threshold for short term insomniain people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia • Start aggressive treatment in the short term insomnia phase, before the patient goes into CHRONIC insomnia

5. Diagnostic criteria for insomnia • Complaints not explained by inadequate opportunity or circumstances • Sleep disturbance and associated daytime symptoms occur at least 3 times/week • Sleep/wake difficulty not better explained by another sleep disorder • Short-term • Present for ≤ 3 months • Chronic • Present for ≥ 3 months • One or more of : • Difficulty initiating sleep • Difficulty maintaining sleep • Waking up earlier than desired • One or more of : • Fatigue/malaise • Attention, concentration, or memory impairment • Impaired social, family, occupational, or academic performance • Mood disturbance/irritability • Daytime sleepiness • Reduced motivation/energy/ initiative • Proneness for errors/accidents • Concerns about or dissatisfaction with sleep

6. Diagnostic Criteria for Insomnia • The International Classification of Sleep Disorders, second edition (ICSD-3) lists diagnostic criteria for insomnia that include requirements for an insomnia sleep complaint , adequate opportunity and circumstances for sleep, and some form of daytime impairment related to the sleep difficulty. • The sleep complaints associated with insomnia include difficulty initiating sleep (sleep-onset insomnia), difficulty maintaining sleep (sleep-maintenance insomnia), or (waking up too early). • A diagnosis of insomnia requires that patients must report at least one of these insomnia complaints. However, it is not uncommon for individual patients to report all of them.

9. INSOMNIA SUBTYPES The three most common insomnia disorders include adjustment insomnia, psychophysiologic insomnia, and insomnia due to a mental disorder. A number of other sleep disorders not included in this group can also present with complaints of insomnia. The sleep apnea syndromes can be associated with repetitive arousal and sleep-maintenance problems. In patients with sleep apnea, insomnia symptoms are more likely to be present in women than in men. The circadian rhythm sleep disorders (CRSDs) can also be associated with insomnia complaints including the delayed sleep phase syndrome (sleep-onset insomnia) and the advanced sleep phase syndrome (early morning awakening).

10. INSOMNIA SUBTYPES • In CRSD free-running type, patients may report periods of insomnia alternating with hypersomnia. • The restless legs syndrome/periodic limb movement disorder can also be associated with symptoms of insomnia. • Other classifications of insomnia divide disorders into primary and secondary (co-morbid) insomnia. The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), lists diagnostic criteria for primary insomnia . This type of insomnia would include adjustment insomnia, psychophysiologic insomnia, paradoxical insomnia, idiopathic insomnia, and inadequate sleep hygiene. • Insomnia associated with a mental disorder is termed secondary or co-morbid insomnia.

11. Diagnostic Criteria for Primary Insomnia A. The predominant complaint is difficulty initiating or maintaining sleep for at least 1 month. B. The sleep disorder causes clinically significant distress or impairment of social, occupation, or other important areas of functioning. C. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia. D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a delirium). E. The disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medication condition.

12. PHYSIOLOGIC FINDINGS IN PRIMARY INSOMNIA • Increased high frequency EEG activity, increased whole body and brain metabolic activity, elevated heart rate, and sympathetic nervous system activation(decreased heart rate variability) during both day and night in patients with insomnia. • These findings suggest that patients with insomnia are in a state of hyper-arousal. • Functional neuro-imaging has found greater global cerebral glucose metabolism during sleep and while awake and a smaller decline in relative metabolism from waking to sleep in wake-promoting regionsin patients with insomnia compared with normal controls .Reduced metabolism was found in the pre-frontal cortex of patients with primary insomnia while awake.

13. PHYSIOLOGIC FINDINGS IN PRIMARY INSOMNIA • It is not clear whether these findings represent cause or effect. • A recent study of magnetic resonance spectroscopy found a global reduction in gamma-aminobutyric acid (GABA) in non medicated patients with primary insomnia compared with normal controls. This neurotransmitter is generally inhibitory and higher levels would be expected to promote sleep.

14. Adjustment Insomnia • Adjustment insomnia, at least in milder forms, is experienced by a large percentage of otherwise normal sleepers at some time in their lives. • The 1-year prevalence of adjustment insomnia in adults is 15% to 20%. • The problem resolves with time in most cases. If the insomnia persists beyond 3 months, it is considered a chronic insomnia. • Some cases of psycho-physiologic insomnia may have started as adjustment insomnia. • Most patients with adjustment insomnia are not evaluated by a sleep specialist. However, they may request hypnotic medication from their primary care physician or self-medicate with over-the-counter sleep aids.

15. Adjustment Insomnia Key Features Adjustment insomnia is a disorder of less than 3 months ’ duration that is in response to a definitely identifiable event . It is expected to resolve but may require treatment if a significant impact on sleep and daytime functioning is noted. Patients with adjustment insomnia can develop a chronic insomnia disorder. Differential Diagnosis Psycho-physiologic and paradoxical insomnia typically last longer than 3 months. Some patients with psycho-physiologic insomnia report the onset of their problem after an acute stress. Insomnia due to medical disorder or medication is temporally associated with starting a medication or the onset of the medical disorder. Insomnia due to mental disorder typically lasts longer than 3 months and waxes and wanes with the mental disorder. Also may develop if the patient with adjustment insomnia develops depression as a result of the acute stressor.

17. Treatment • Benzodiazepine receptor agonists (BZRAs), ramelteon, anxiolytics, or counseling are used to treat adjustment insomnia (if necessary).

18. Psycho-physiologic Insomnia Psycho-physiologic insomnia is the most common primary insomnia type seen in sleep clinics and it is often called “conditioned or learned insomnia.” Key Features Conditioned sleep difficulty, heightened arousal in bed, and learned sleep-preventing associations are the essential characteristics of this disorder. Mental arousal (“racing mind/ thoughts”) occurring when trying to go to sleep is a common complaint. The patient becomes conditioned so that the bedroom is a “cue” to develop tension, anxiety, and inability to fall asleep. Some patients sleep better away from home. Patients typically can fall asleep during monotonous activities but not after getting into bed and trying to sleep. For example, a patient may fall asleep while watching television in the living room but become wide awake after entering the bedroom and attempting to sleep.

19. Psycho-physiologic Insomnia This disorder may start after a precipitating event (death in family, job stress) but then persists owing to perpetuating behaviors even after the precipitating event has resolved. Patients may report a lifelong pattern of being “light sleepers” or episodically poor sleep . Psycho-physiologic insomnia is present in 1% to 2% of the general population and 12% to 15% of patients seen in sleep centers. This disorder is more common in women than in men. If left untreated, the disorder may persist for decades with periodic worsening.

20. Diagnostic Criteria of Psycho-physiologic Insomnia Patient’s symptoms meet the criteria for insomnia. Evidence of conditioned sleep difficulty and/or heightened arousal in bed as indicated by one or more of the following: i. Excessive focus on sleep, anxiety about sleep. ii. Difficulty falling asleep in bed at desired bedtime or during planned naps BUT no difficulty falling asleep during other monotonous activities when not intending to sleep. iii. Ability to sleep better away from home. iv. Mental arousal in bed characterized by either intrusive thoughts or a perceived inability to volitionally cease sleep-preventing mental activity. v. Heightened somatic tension in bed reflected by a perceived inability to relax the body sufficiently to allow the onset of sleep. C. The sleep disturbance is not better explained by another sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance abuse.

21. Psychophysiologic Insomnia Polysomnography Although sleep studies are not indicated for evaluation of most patients with insomnia, typical findings include a prolonged sleep latency (>30 min), increased WASO, and decreased sleep efficiency. Sometimes, the reverse first-night effect is noted with better sleep in the sleep center than at home. Patients may underestimate their sleep duration but not the “gross underestimation” seen in paradoxical insomnia. Sleep Logstypically show a long sleep latency, reduced TST, increased WASO, and a large number of nocturnal awakenings. Typically, there is considerable night-to-night variability in sleep quality.

22. Psychophysiologic Insomnia • There may also be evidence of poor sleep hygiene with prolonged time in bed, napping, and variability in wake times. • Actigraphy Findings may overestimate or underestimate TST when compared with PSG. Actigraphy typically provides a better estimate of TST than of wake time. Typical actigraphic findings would substantiate patient reports and findings from sleep logs. • Treatment CBT for insomnia and pharmaco-therapy are treatment options.

23. Paradoxical Insomnia (Sleep State Misperception) Key Features The severe degree of sleep disturbance reported in patients with paradoxical insomnia is out of proportion to the relatively mild daytime impairment and the severity of sleep disturbance documented on PSG. • Patients often report little or no sleep on many nights followed by days with relatively minimal dysfunction and no napping. • Patients with paradoxical insomnia often report hearing every noise in the house while in the bedroom and/or actively thinking for the entire night.

24. Paradoxical Insomnia (Sleep State Misperception) • Daytime impairment reported is consistent with other types of insomnia but is much less severe than expected, given the severe level of sleep deprivation reported. • There are no intrusive sleep episodes or serious mishaps due to loss of alertness, even following nights reportedly without sleep . • Paradoxical insomnia is found in less than 5% of insomnia patients evaluated in sleep clinics. • Sleep Log Data information is usually consistent with the patient’s complaints, but NOT consistent with objective evidence (from PSG or actigraphic data). There may be nights with little or no sleep reported followed by days with no napping.

25. Diagnostic Criteria of Paradoxical Insomnia (Sleep State Misperception) A. Symptoms meet criteria for insomnia. B. One or more of the following criteria apply: i. Chronic pattern of little or no sleep most nights with rare nights during which relatively normal amount of sleep is obtained. ii. Sleep log data during 1 or more weeks of monitoring show an average sleep time well below published age-adjusted normative values, often with no sleep at all indicated for several nights per week: typically there is an absence of naps following such nights. iii. The patient shows a consistent mismatch between objective findings from PSG or actigraphy and subjective sleep estimates derived from either sleep report or sleep diary.

26. Diagnostic Criteria of Paradoxical Insomnia (Sleep State Misperception) C. At least one of the following is observed: i. Constant or near-constant awareness of environmental stimuli throughout most nights. ii. The patient reports a pattern of conscious thoughts or rumination throughout most nights while maintaining a recumbent posture. D. Daytime impairment reported is consistent with other types of insomnia subtypes but is much less severe than expected, given the extreme level of sleep deprivation reported; there is no report of intrusive daytime sleep episodes, disorientation, or serious mishaps due to marked loss of alertness or vigilance, even following reportedly sleepless nights. F. The sleep disturbance is not better explained by another sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance abuse.

27. Paradoxical Insomnia (Sleep State Misperception) • PSG Findingsindicated lack of significant deficits in TST or an excessively prolonged sleep latency. If abnormalities are noted on the PSG, they are less severe than reported by the patient. Reported sleep latency and WASO at least 1.5 times the PSG values. • Multiple Sleep Latency Test The sleep latency in patients with paradoxical insomnia is typically normal or slightly decreased.

28. Paradoxical Insomnia (Sleep State Misperception) • Differential Diagnosis Unlike idiopathic insomnia, paradoxical insomnia does not begin in childhood. In contrast to psycho-physiologic insomnia, patients with paradoxical insomnia are more prone to report little or NO sleep on many nights. However, some patients with psycho-physiologic insomnia also underestimate their nocturnal sleep. Whereas patients with paradoxical insomnia often report being aware of the environment for the entire night or ruminating on problems, they tend to have less prominent sleep-preventing associations compared with patients with psycho-physiologic insomnia. • Treatment CBT of insomnia (CBTI), pharmaco-therapy, or both are recommended.

29. Idiopathic Insomnia • Idiopathic insomnia is also called childhood-onset insomnia.The patient usually recalls the insidious onset of the insomnia problems in childhood. • The history is one of lifelong insomnia problems . • Key Features Patients with idiopathic insomnia report this problem since childhood with no periods of significant remission.There is no identifiable cause or precipitating factor. The onset is often insidious. • Idiopathic insomnia occurs in less than 10% of patients with insomnia.

31. Idiopathic Insomnia Polysomnography findings include a long sleep latency, increased WASO, reduced TST, and low sleep efficiency. These findings are not specific for idiopathic insomnia. Sleep LogFindings are typically consistent with the patient’s complaints. Differential DiagnosisWhereas idiopathic insomnia has an insidious onset in childhood, psycho-physiologic insomnia starts in adulthood and the time of onset can often be defined. In paradoxical insomnia, a more severe abnormality of sleep is usually reported and the disorder does not start at an early age. Treatment CBTI, pharmaco-therapy, or both are options.

32. Inadequate Sleep Hygiene Key Features • This disorder is characterized by behaviors that can potentially disrupt sleepsuch as exercise or ingestion of caffeine or alcohol near bedtime . • Patients often have irregular bedtimes and wake times and spend too much time in bed. • Napping is another behavior that makes nocturnal sleep more difficult.

33. Diagnostic Criteria of Inadequate Sleep Hygiene A. Symptoms meet criteria for insomnia. B. The insomnia is present for at least 3 months. C. Inadequate sleep hygiene practices are evident as indicated by the presence of at least one of the following: • Improper sleep scheduling consisting of frequent daytime napping, selecting highly variable bedtimes or rising times . • Routine use of products containing alcohol, nicotine, or caffeine, especially in periods preceding bedtime. iii. Engagement in mentally stimulating, physically activating, or emotionally upsetting activities too close to bedtime. iv. Frequent use of the bed for activities other than sleep (TV watching, reading, studying, snacking, thinking, planning). v. Failure to maintain a comfortable sleeping environment. D. The sleep disturbance is not better explained by another sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance abuse.

36. The importance of poor sleep hygiene in the development of insomnia is unknown. • Although sleep hygiene education is a part of most treatment programs for insomnia, there is no evidence for effectiveness of this intervention when used alone. • Insomnia due to inadequate sleep hygiene may develop in adolescence or adulthood. • Insomnia due to inadequate sleep hygiene occurs in approximately 5% to 10% of insomnias evaluated in a sleep center. • The condition is present in 1% to 2% of adolescents and young adults.

37. Objective Findings • Sleep Log Findings include variation in wake time, napping, and sleeping much longer on the weekend. Inappropriate use of caffeine and use of over the-counter medications or alcohol may also be reported on sleep logs. • Long-term Complications Patients with poor sleep hygiene may develop caffeine or alcohol dependence or eventually psycho-physiologic insomnia,

39. Treatment • Education about good sleep hygiene and CBTI, if necessary , are recommended. • As noted previously, there is no evidence that education about sleep hygiene alone is effective treatment for the insomnia syndromes. • In patients with difficulties entirely due to poor (inadequate) sleep hygiene, one might expect improvement if their sleep habits were improved.

41. Insomnia Due to a Mental Disorder • Insomnia due to mental disorder (IDMD) is the most common form of insomnia seen by sleep physicians . Many times, patients have fixated on the insomnia problems while ignoring (denying) or minimizing their other symptoms of depression. •  Key FeaturesThe insomnia is viewed as a consequence of the mental disorder (e.g., depression) and shares the course of the disorder (waxing and waning together ) . Insomnia can actually precede the development of depression in some patients. • A separate diagnosis of insomnia due to mental disorder (IDMD) is made only if the insomnia is significant enough to warrant special attention.

42. Insomnia Due to a Mental Disorder • Common mental disorders associated with IDMD include major depression, bipolar disorder, and anxiety disorder. • In anxiety disorders, prominent sleep-onset insomnia is usually present. • In depressive disorders, especially in older patients, the sleep disturbance is characterized by prominent sleep maintenance insomnia and early morning awakening. • Younger patients with depression may experience more prominent sleep-onset insomnia. • IDMD is the most common cause of insomnia in patients presenting to sleep disorder centers complaining of insomnia. The disorder is more likely in women than in men. IDMD occurs in up to 3% of the population.

43. Diagnostic Criteria of Insomnia Due to Mental Disorder A. Patient’s symptoms meet criteria for insomnia. B. The insomnia is present for at least 3 month. C. A mental disorder has been diagnosed by standard criteria (Diagnostic and Statistical Manual of Mental Disorders, 5th edition). D. Insomnia is temporally associated with the mental disorder; however, in some cases, insomnia may appear a few days or weeks before the emergence of the underlying mental disorder. E. The sleep disturbance is not better explained by another sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance abuse.

45. مقياس القلق والاكتئاب: (ترجمة مصطفي عمرو – استاذ الطب النفسي و عبد الهادي الجيلاني استاذ الصحة العامة-جامعة المنصورة)( لايوجد . درجة بسيطة .درجة متوسطة .درجة كبيرة) القلق • اشعر بالتوتر (0-1-2-3) • اشعر بالرعب عند توقع حدوث مكروة(0-1-2-3) • تجول بخاطرى افكار تثير القلق(0-1-2-3) • اشعر بعدم الاستقرار (0-1-2-3) • شعور مفاجئ بالهلع (القلق الحاد)(0-1-2-3) • أجلس براحتى واشعر بالسكينة(3-2-1-0 ) • يحدث لى رعشة فى الأطراف عند الشعور بالقلق(0-1-2-3) • 0-7 = Normal • 8-10 = Borderline abnormal (borderline case) • 11-21 = Abnormal (case)

46. مقياس القلق والاكتئاب: (ترجمة مصطفي عمرو – استاذ الطب النفسي و عبد الهادي الجيلاني استاذ الصحة العامة-جامعة المنصورة)اكتئاب )درجة كبيرة- درجة متوسطة - درجة بسيطة –لايوجد( . • مازلت استمتع بالاشياء التى تعودت عليها(3-2-1-0 ) • ممكن اضحك وارى الجانب الحسن من الأشياء(3-2-1-0 ) • اتطلع الى الاستمتاع بنعم الدنيا(3-2-1-0 ) • استمتع بقراءة كتاب او مشاهدة التلفزيون(3-2-1-0 ) • اشعر بالابتهاج(3-2-1-0 ) • أشعر بالكسل(0-1-2-3) • لم اعد اهتم بمظهرى(0-1-2-3) • 0-7 = Normal • 8-10 = Borderline abnormal (borderline case) • 11-21 = Abnormal (case)

47. Insomnia Due to Mental Disorder • Polysomnography if performed shows no specific findings as far as a sleep latency, TST, or WASO. Patients with depression may have a short REM latency. • Beck Depression Inventory This inventory reveals an elevated score (BDI-I > 10, BDI-II > 14). • Sleep Logsmay show a long sleep latency, decreased TST, early morning awakening, or frequent awakenings. These findings are usually consistent with patient complaints. • Treatment of the underlying mental disorder may ultimately improve sleep.However, because the sleep complaints are so prominent, treatment with a hypnotic or the addition of a sedating antidepressant and CBT are often needed.

48. Beck Depression Inventory

49. Beck Depression Inventory

50. Beck Depression Inventory