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Insomnia: Physiological And Medical Findings And Implications For Diagnosis And Care*. George G Burton MD Medical Director, Sleep Disorders Center Kettering Health Network, Dayton, Ohio. * With appreciation to M Bonnet and D Arand. Goals Of This Presentation:.

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insomnia physiological and medical findings and implications for diagnosis and care

Insomnia: Physiological And Medical Findings And Implications For Diagnosis And Care*

George G Burton MD

Medical Director, Sleep Disorders Center

Kettering Health Network, Dayton, Ohio

* With appreciation to M Bonnet and D Arand

goals of this presentation
Goals Of This Presentation:
  • Understand Insomnia’s objective diagnostic and treatment outcome criteria
  • Recognize insomnia as a true medical problem (not secondary)
  • Recognize utility of a new diagnostic paradigm in insomnia care
definition o f insomnia icsd 2
Definition Of Insomnia – ICSD-2
  • Complaint of difficulty initiating sleep, difficulty maintaining sleep, waking up too early, or non-restorative sleep
  • Occurs despite adequate sleep environment and opportunity
  • Includes reported daytime impairment, such as fatigue, impaired attention, irritability, sleepiness, or poor motivation related to the poor sleep
classifications of insomnia
Classifications Of Insomnia
  • Simple: Sleep Initiation or Sleep Maintenance

OR

Objective or Subjective

  • Complex: ICD-10 or DSM-V or AASM Nosology (ICSD-2)

Unfortunately, complexity clouds our understanding but is a necessary evil

insomnia a symptom and a diagnosis
Insomnia A Symptom AND A Diagnosis
  • Like CFS/FM
  • Leads to professional skepticism and hostility
  • Frustrates research enthusiasm and financing
  • Encourages therapeutic nihilism

NOT: Insufficient sleep syndrome

aasm insomnia nosology icsd 2 associates subjective complaint with possible contributing disorder
AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder)
  • Adjustment Insomnia
  • Psychophysiological Insomnia
  • Paradoxical Insomnia
  • Idiopathic Insomnia
  • Insomnia Due To Mental Disorder
  • Inadequate Sleep Hygiene
  • Behavioral Insomnia Of Childhood

(more)

slide7
AASM Insomnia Nosology ICSD-2 (Associates Subjective Complaint With Possible Contributing Disorder) (Continued…)

8. Insomnia Due To A Drug Or Substance

  • Insomnia Due To Medical Condition
  • Insomnia – Unspecified (non-organic)
  • Insomnia – Unspecified (organic)
prevalence of insomnia
Prevalence Of Insomnia
  • Lifetime prevalence 4-24%. Most common sleep disorder. Incidence varies with patient age and sex.
  • Women have a lifetime risk 1.5 - 2.5 times men.
  • Additional factors:

Employment Status

Obesity

Rotating Shifts

  • Chronic prevalence (2-3 months is 6-10%)
  • Subtypes of prevalence vary widely
consequences of insomnia quality of life
Consequences Of Insomnia: Quality Of Life
  • Medical Outcomes Study Short Form (SF-36)

- Insomnia patients have significant decreases

on all dimensions

- Level of decrease is comparable to patients with

depression or congestive heart failure

  • Poor sleepers have fewer promotions and increased health care needs
  • Recent data found increased risk for all cause mortality in patients with “nearly everyday” insomnia
there is a big difference in these two concepts
There Is A Big Difference In These Two Concepts:
  • Insomnia is a risk factor for… (Causality)
  • Insomnia is comorbid with… (Association)
  • Role of Bayesian Statistics being explored
insomnia is a risk factor for
Insomnia Is A Risk Factor For:
  • Depression/Anxiety/Substance Abuse
  • Anxiety and mood disorder relapse
  • ? Pain
  • Diabetes and hypertension
  • Infectious disease conditions/immune status
  • Suicide

“Sleepy patients are like deaf children with respect to short-term memory and task organization”

insomnia is often a comorbid condition with
Insomnia Is Often A Comorbid Condition With:
  • Depression/Anxiety states
  • Pain
  • Respiratory, GI, Neurologic, Musculoskeletal, Endocrinologic and Cardiovascular Disorders
  • Drug use such as anti-hypertensives and anti-depressants, bronchodilators, nasal decongestants
treatment studies do not separate comorbility from risk issue 100 of the time
Treatment Studies Do Not Separate Comorbility From Risk Issue 100% Of The Time

Examples:

  • Sleep on the efficiently of anti-depressant drugs
  • Sleep on the treatment of pain
  • Sleep on insulin resistance in diabetes
conditioned stress is comorbid with insomnia
Conditioned Stress Is Comorbid With Insomnia
  • Inability to relax in bed
  • Mental arousal In bed (intrusive thoughts)
  • Sleeps better away from home
  • Difficulty in falling asleep in bed but not at
  • other times (i.e. watching tv)
aging and poor sleep
Aging And Poor Sleep
  • Normal aging is associated with:
  • - Increased incidence of pain and other
  • medical problems
  • - Increased sympathetic nervous system activity
  • - Decreased activity (decreasing amplitude of
  • circadian rhythms)
  • - Decreased sleep (SWS) sleep
  • - Increased awakenings and wake
  • time during sleep
aging and poor sleep continued
Aging And Poor Sleep (continued…)
  • Is poor sleep with aging a normal change or a sign
  • of slowly evolving pathology? If it were
  • hypertension, we would treat.
  • What is the specificity/sensitivity relationship
  • between the ESS, sleep latency, sleep efficiency,
  • and WASO?
insomnia is comorbid with other sleep disorders
Insomnia is Comorbid With Other Sleep Disorders
  • Sleep Apnea – refer patients with insomnia

and significant snoring

  • Periodic Limb Movements – refer patients with

nocturnal restlessness

  • Restless Legs
  • Dream Anxiety Attacks
  • REM Behavior Disorder
  • Should we base some of our treatment decisions

on ESS, etc?

interests and concerns in insomnia
Interests And Concerns In Insomnia
  • Attendance at insomnia sessions at AASM extremely

high

  • AASM subspecialty examination in Behavioral Sleep

Medicine and cognitive behavioral therapy growing

  • As for OSA in 2002, cost is a big concern
  • Potential solutions:

- Judicious use of expensive tests and therapies (e.g.

PSG and Cognitive Behavioral Therapy)

- Emergent consensus that success of these tools are

based in the neurobiology of insomnia

neurotransmitters involved in sleep and arousal
Neurotransmitters Involved In Sleep And Arousal*
  • Facilitate sleepiness: Adenosine, GABA, Galanin, Glycine, Melatonin
  • Facilitate arousal: Acetylcholine, Dopamine, Glutamate, Histamine, Norepinephrine, Orexin, Serotonin

*Gulyani S et al Sleep Medicine Pharmocotherapies Overview. Chest 142:1659-1668(2012)

physiologic findings more pronounced in persons with objective and primary insomnia
Physiologic Findings More Pronounced In Persons With Objective And Primary Insomnia
  • Numerous studies have shown that patients

with primary insomnia suffer from CNS

hyperarousal, usually linked to the

sympathetic nervous system as indicated by:

    • Increased heart rate
    • Decreased heart rate variability
    • Increased whole body and brain metabolic rate
    • Increased high frequency EEG
    • Increased secretion of cortisol, ACTH
hyperarousal state in insomnia
Hyperarousal State In Insomnia*

*Bonnet M, Burton G and Arand D, Physiologic and Medical Findings In

Insomnia: Implications For Diagnosis And Care. Sleep Rev 2013(In Press)

insomnia workup and therapy paradigm
Insomnia Workup And Therapy Paradigm*

*Bonnet M, Burton G and Arand D, Physiologic and Medical Findings In

Insomnia: Implications For Diagnosis And Care. Sleep Rev 2013(In Press)

the psg modified for insomnia psg i
The PSG Modified For Insomnia(PSG-I)
  • The standard PSG Plus:

- Nocturnal blood pressure recording

- Heart rate variability

- Beta-power analysis on EEG

  • Patients identified as having objective/primary

insomnia should be directed to CBT-I

therapy
THERAPY
  • Treat comorbid conditions first
  • CBTI: Best results in paradoxical/objective insomnia. Example Follows
  • Self-directed therapy

- Environmental management

- Sleep scheduling

  • Pharmacological

- 15 new drugs under clinical study

- Anti-depressants and anxiolytics very popular

- Sedatives

a typical insomnia case
A Typical Insomnia Case
  • 47 Year old male bank executive in good health

- 15 Year history of SII, SMI, worry about work

and family would keep him from sleeping

- No known comorbitities

- Good sleep hygiene by history

- Sleep log, FSS, screening laboratory all normal

- In-lab PSG normal except for “long sleep

latency and decreased sleep efficiency”

a typical insomnia case continued
A Typical Insomnia Case (continued…)

- ESS 15/24

- Neuropsychiatric assessment: moderate

anxiety depression

- Anxiolytics and various anti-depressants no

help over the past 5 years

- PSG-I: Long sleep latency, elevated arousal

index; otherwise normal

  • Diagnosis: paradoxical insomnia versus

psychophysiologicalinsomnia

a typical insomnia case continued1
A Typical Insomnia Case (continued…)
  • Told to: “Lighten Up!” by his family PCP and Psychiatrist without improvement
  • Referred for CBTI for eight sessions
  • Additional history obtained
  • Dramatic improvement