Post on 02-Aug-2020
transcript
Asst. Prof. Tantawan Awirutworakul
Department of Psychiatry
Faculty of Medicine
Ramathibodi Hospital
Non-Pharmacological Treatment of
Insomnia
DSM-IV ICSD-2 DSM-V (Proposed)
Diagnosis for primary
insomniaPrimary insomnia (307.42)
Psychophysiological insomnia
(307.42)Insomnia disorder
Paradoxical insomnia (307.42)
idiopathic insomnia (307.42)
Comorbid insomnia disorder
Sleep disorder due to general
medical condition, insomnia type
(327.01)
Insomnia due to medical condition
(327.01)
No separate category; includes
specifier to clarify comorbid
physical or mental illness
Insomnia related to another
mental disorder (327.02)
Insomnia due to mental disorder
(327.02)
Duration
Difficulty initiating or maintaining
sleep, or nonrestorative sleep for
at least 1 month
Not specified
Sleep difficulty occurs at least 3
nights per week, for at least
3 months
Other subtypes of insomnia Substance-induced insomnia
Adjustment insomnia, inadequate
sleep hygiene, insomnia due to
drug or substance, insomnia
unspecified and physiological
insomnia
Not yet specified
Summary of insomnia diagnoses across classification systems
Precipitating and Perpetuating Factors Contribute to Insomnia Over
TimeIN
SOM
NIA
SEV
ERIT
Y
TIME
THRESHOLD
Spielman AJ et al. Assessment techniques in Insomnia. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia, PA: Elsevier Saunders, 2005: Ch 119.
Precipitating Factors
Perpetuating Factors
Predisposing Factors
Insomnia
Hyper-arousal disorder not
related to another condition
Due to any of the following
• Psychiatric illness
• Medical illness/ medications
• Other sleep disorders
– Obstructive Sleep Apnea– Circadian rhythm disorders– Narcolepsy– Restless Leg Syndrome
Primary
Co-morbid (secondary)Insomnia
Determinants of SleepTwo-process Model of Sleep Regulation
Sleep propensity increases as waking accumulates and dissipates with sleep (Process S)
Sleep propensity oscillates with a daily (circadian) variation (Process C)
Social/External Factors
Intrinsic Illness
Borbély AA, Achermann P. 2000
Arousal Systems in Insomnia Subjects That
Do Not Deactivate From Waking to Sleep
ARASARAS
Thalamus
Mesial
temporal
cortex
Hypothalamus
Cingulate
Mesial
temporal
cortex
Hypothalamus
ARAS
Insular
cortex
ARAS, ascending reticular system.Nofzinger EA et al. Am J Psychiatry. 2004;161(11):2126-2128.
Core Temperature
Heart Rate
Plasma Melatonin
Plasma Cortisol
Happiness
N=11 insomniacs and N=13 controls
BMI (25) and age (29 yrs) matched
24-hour blood sampling every 30 min.
Significant 24-hour increase; significant daytime (730-2230); significant sleep (2300-630) increase
HPA Hyperactivity in Insomnia: Cortisol
BMI = Body Mass Index.
Vgontzas AN et al. J Clin Endocrinol Metab. 2001;86:3787-3794.
0
50
100
150
200
250
300
350
400
450
500
550
08:0
0
10:0
0
12:0
0
14:0
0
16:0
0
18:0
0
20:0
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22:0
0
00:0
0
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0
Cor
tiso
l (n
mol
/L
)
Time (Clock Hours)
Insomniacs Normals
Catecholamines in
Primary Insomnia
NE (µg/24 h) Epi (µg/24 h)
0
10
20
30
40
50
60
70
80
Uri
nar
y E
xc
reti
on
(µ
g/
24 h
)
Normal (n=7)
Insomnia (n=10)
1. Richardson GS, Poe GR, Seymore A, Roth T: Objective and subjective sleep disruptionfollowing dietary salt restriction in normal subjects. Sleep. 2001;24(abstract suppl):A114.
2. Vgontzas AN, et al. J Psychosom Res. 1998; 45 (1 Spec No): 21-31).
rxy=.49 (P=.07)
Norepinephrine (µg/24 hr)W
ake
Tim
e A
fte
r Sl
ee
p O
nse
t (m
ins)
Sleep-Wake History
Daytime activities
& symptoms
Pre-sleep activities
&symptoms Events during sleep
Events on awakening
Sleep
12:00 Midday 0:00 midnight
Sleep-Wake History
Daytime activities
& symptoms
Pre-sleep activities
&symptoms Events during sleep
Events on awakening
Sleep
12:00 Midday 0:00 midnight
Relaxation therapy
Process or activity
: Helps a person to relax
: Increased calmness
: Reduce levels
- Anxiety
- Stress
- Anger
Relaxation
Stress management
program
Decrease muscle tension
Lower the blood pressure
Slow heart & breath rates
Other health benefits
Relaxation technique
Progressive Muscle Relaxation
Deep breathing
Meditation
Yoga
Deep breathing
- Expansion : Abdomen > Chest
“หายใจเข้าท้องป่อง หายใจออกท้องแฟบ”
Meditation
-Promote relaxation
-Build internal energy or life force
Example
- Breathing
- Wisdom words
- Movement
Usefulness:
Relaxation
Calm
Compassion
Love
Care
Clip : ))
Yoga
Progressive Muscle
Relaxation
- Learning
: Specific muscle group
Tense
- By Tensing
Letting it go
- Clip : )))
- Exercise
Recording and display
- Small changes in the physiological level
Visual
Auditory
Awareness of many physiological functions
Provide information on the activity
Biofeedback
Goal : manipulate them at will
Usefulness :
- Improve health, performance, and the physiological changes
- Changes to thoughts, emotions, and behavior
Feedback instrument
Electroencephalograph (EMG)
Electroencephalograph (EEG)
Electrocardiograph (ECG)
heart rate variability (HRV)
VDO
Biofeedback 1
Biofeedback 2
VDO
- Stress 1
- Stress 2
- Relax 1
- Relax 2
Bruxism
- EMG –masseter muscle
- High tone - muscle contract
- Low tone –muscle relax
Patients- learn to alter the tone
Relaxation
Sleep Feedback
: Sound Alarms
Not appear to be effective in reducing
nocturnal bruxing
"subjects learned to ignore the tone
and to maintain sleep."
Cognitive Behavioral Therapy vs Relaxation
Therapy for Primary Sleep-maintenance Insomnia
CBT = Cognitive Behavioral Therapy.
PMR = Progressive Muscle Relaxation.
PT = Placebo Therapy.
TST = Total Sleep Time.
MWASO = Middle Wake Time After Sleep Onset.
Edinger JD et al. JAMA. 2001;285:1856-1864.
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74
76
78
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84
86
CBT PMR PT
P<.002; CBT>PMR and PT
Mean Sleep Efficiency
(%)
0
10
20
30
40
50
CBT PMR PT
P=.004; CBT<PMR and PT
Mean MWASO
Min
utes
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6.0
6.1
6.2
6.3
CBT PMR PT
P=.02; CBT>PT
Mean TST
Hou
rs
Mindfulness Training Results from the University of
Pennsylvania
MALADAPTIVE HABITS•Excessive time in bed
•Irregular sleep schedule
•Daytime napping
•Sleep- incompatible activities
AROUSAL•Emotional
•Cognitive
•Physiologic
DYSFUNCTIONAL COGNITIONS•Worrying over sleep loss
•Ruminating over consequences
•Unrealistic Expectations
CONSEQUENCES•Mood Disturbances
•Fatigue
•Performance impairments
•Social Discomfort
Cycle of Persistent Insomnia
Hope you all sleep well.