Current p SYCHIATRY When patients can’t sleep Practical guide to using Karl Doghramji, MD areful investigation can often Professor of psychiatry and human behavior reveal insomnia’s cause1—whether Director, Sleep Disorders Center a psychiatric or medical condition Thomas Jefferson University or poor sleep habits. Understanding why patients Philadelphia C can’t sleep is key to effective therapy. Acute and chronic sleep deprivation is associ- ated with measurable declines in daytime perfor- Tips to effective workup mance (Box). Some data even suggest that long- term sleeplessness increases the risk of new psychi- and treatment of insomnia— atric disorders—most notably major depression.3 whether acute or chronic PSYCHIATRIC DISORDERS AND INSOMNIA and associated with almost any Depression. Many depressed persons—up to 80%—experience insomnia, although no one psychiatric or medical disorder. sleep pattern seems typical.2 Depression may be associated with: • difficulties in falling asleep • interrupted nocturnal sleep • and early morning awakening. Anxiety disorders. Generalized anxiety disorder (GAD), social phobia, panic attacks, and post- traumatic stress disorder (PTSD) are all associat- ed with disrupted sleep. Patients with GAD 40 VOL. 2, NO. 5 / MAY 2003 and choosing hypnotic therapy VOL. 2, NO. 5 / MAY 2003 Current 41 p SYCHIATRY Insomnia Box have disrupted sleep patterns. These include The sleepless society: prolonged sleep latency, fragmented sleep with Chronic insomnia’s impact frequent arousals, decreased slow-wave sleep, variable REM latency, and decreased REM ne-half of adult Americans experience insomnia rebound after sleep deprivation. Despite Oduring their lives, and 10% report persistent sleep investigations going back to the 1950s, no spe- difficulties (longer than 2 weeks). Individuals who cific link between REM sleep and psychosis complain of insomnia report: has been found.6 Interestingly, increases in • daytime drowsiness REM sleep time and REM activity have been • diminished memory and concentration associated with an increased risk of suicide in • depression patients with schizophrenia.7 • strained relationships Adjustment sleep disorder. Acute emotional • increased risk of accidents stressors—such as bereavement, job loss, or • impaired job performance. hospitalization—often cause adjustment sleep disorder. Symptoms typically remit Despite these complaints, a surprising 70% of those with insomnia never seek medical help. Only 6% soon after the stressors abate, so this tran- visit their physicians specifically for insomnia, and sient insomnia usually lasts a few days to a 24% address sleep difficulty as a secondary complaint. few weeks. Treatment with behavioral ther- Many (40%) self-medicate with over-the-counter sleep apies and hypnotics8 is warranted if: aids or alcohol.2 • sleepiness and fatigue interfere with Insomnia becomes more frequent with aging, daytime functioning associated with increased rates of medical and • a pattern of recurring episodes psychiatric illness and an age-related deterioration develops.9 in the brain’s sleep-generating processes.3 Psychophysiologic insomnia. Once initiat- ed—regardless of cause—insomnia may persist well after its precipitating factors experience prolonged sleep latency (time needed resolve. Thus, short-term insomnia may develop to fall asleep after lights out) and fragmented into long-term, chronic difficulty with recurring sleep, similar to those with primary insomnia. episodes or a constant, daily pattern of insomnia. Subjective sleep quality may be impaired in Sufferers often spend hours in bed awake focused patients with social phobia. Some patients expe- upon—and brooding over—their sleeplessness. rience panic symptoms while sleeping, possibly in which in turn further aggravates their insomnia. association with mild hypercapnia. Patients with Adjustment sleep disorder and psychophysio- sleep panic attacks tend to have earlier onset of logic insomnia are included within DSM-IV’s panic disorder and a higher likelihood of comor- term “primary insomnia.” bid mood and other anxiety disorders.4 In patients with PTSD, disturbed sleep con- OTHER CAUSES OF INSOMNIA tinuity and increased REM phasic activity—such Medications that may affect sleep quality include as eye movements—are directly correlated with antidepressants (Table 1),10,11 antihypertensives, severity of PTSD symptoms. Nightmares and antineoplastic agents, bronchodilators, stimulants, disturbed REM sleep are hypothesized hallmarks corticosteroids, decongestants, diuretics, hista- of PTSD.5 mine-2 receptor blockers, and smoking cessation Schizophrenia. Patients with schizophrenia often aids. 42 Current VOL. 2, NO. 5 / MAY 2003 p SYCHIATRY Current p SYCHIATRY Recreational drugs, such as Table 1 cocaine, often cause insomnia. Antidepressants’ effects on sleep and wakefulness Hypnotics and anxiolytics can cause insomnia following long- Activating Bupropion, protriptyline, most selective serotonin term use and during withdrawal. agents reuptake inhibitors, venlafaxine, monoamine Other disorders known to dis- oxidase inhibitors turb sleep include periodic limb Sedating Amitriptyline, doxepin, trimipramine, nefazodone, movement disorder (PLMD), agents trazodone, mirtazapine restless legs syndrome (RLS), Neutral Citalopram, escitalopram sleep apnea syndrome, disrupted agents circadian rhythms (as with travel or shift work), cardiopulmonary disorders, chronic pain, diabetes, hyperthyroidism, hot flashes associated with Carefully review sleep patterns on weekdays and menopause, seizures, dementia, and Parkinson’s weekends, bedtime habits, sleep hygiene habits, disease, to name a few. and substance and medication use. Sleep clinic referrals. Consider an evaluation by a WORKUP OF SLEEP COMPLAINTS sleep disorders center when: Acute. Most short-term insomnias—lasting a few • the diagnosis remains unclear weeks or less—are caused by situational stressors, • or treatment of the presumed conditions circadian rhythm alterations, and sleep hygiene fails after a reasonable time violations. A logical initial approach, therefore, is to combine sleep hygiene measures with support- BEHAVIORAL TREATMENTS ive psychotherapy. Hypnotic agents may be con- Behavioral treatments—with or without hyp- sidered for apparent daytime consequences—such notics—are appropriate for a wide variety of as sleepiness and occupational impair- insomnia complaints, includ- ment—or if the insomnia seems ing adjustment sleep disorder, to be escalating. psychophysiologic insomnia, and Chronic. For longer-term insom- Behavioral measures depression. Behavioral measures may nias—lasting more than a few take longer to take longer to implement than drug ther- weeks—consider a more thor- implement but last apy, but their effects have been shown to ough evaluation, including longer than drug last longer in patients with primary insom- medical and psychiatric history, therapy nia. In many cases, it may be useful to start physical examination, and men- with both hypnotic and behavioral treat- tal status examination. Inquire ments and withdraw the hypnotic after about cardinal symptoms of disorders associated behavioral measures take effect. with insomnia, including: Sleep hygiene. Many individuals unknowingly • snoring or breathing pauses during sleep engage in habitual behaviors that impair sleep. (sleep apnea syndrome) Those with insomnia, for example, often try to • restlessness or twitching in the lower compensate for lost sleep by staying in bed later extremities (PLMS/RLS). in the morning or by napping, which further Question the bed partner, who may be more fragment nocturnal sleep. Advise these patients to aware of such symptoms than the patient. adhere to a regular awakening time—regardless continued on page 47 VOL. 2, NO. 5 / MAY 2003 43 Current p SYCHIATRY continued from page 43 of how long they slept the night before— Table 2 and to avoid naps. Other tips for getting a How to get a good night’s sleep good night’s sleep are outlined in Table 2.12 Caffeine has a plasma half-life of 3 to • Maintain a regular waking time, regardless of 7 hours, although individual sensitivity amount of sleep the night before varies widely and caffeine’s erratic • Avoid excessive time in bed absorption can prolong its effects. Advise • Avoid naps, except if a shift worker or elderly patients with insomnia to avoid caffeine- • Spend time in bright light while awake containing beverages—including coffee, tea, and soft drinks—after noon. • Use the bed only for sleeping and sex Relaxation training. Muscle tension can be • Avoid nicotine, caffeine, and alcohol reduced through electromyography • Exercise regularly early in the day (EMG) biofeedback, abdominal breath- • Do something relaxing before bedtime ing exercises, or progressive muscle relax- • Don’t watch the clock ation techniques, among others. • Eat a light snack before bedtime if hungry Relaxation training is usually effective within a few weeks. Psychotherapy. Cognitive-behavioral therapy can help identify and dispel tension-pro- dard textbooks but is clearly needed by a small ducing thoughts that are disrupting sleep, such as number of patients with chronic insomnia. In preoccupation with unpleasant work experiences these cases, carefully monitor for tolerance, as or school examinations. Reassurance may help manifested by dosage patients overcome fears about escalation. Long-term hyp- sleeplessness; suggest that patients notic treatment is not suitable deal with anxiety-producing Prolonged hypnotic for patients