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Insomnia in Psychiatric Disorders 127 From: Current Clinical Neurology: Clinical Handbook of Insomnia Edited by: H. P. Attarian © Humana Press Inc., Totowa, NJ 127 11 Insomnia in Psychiatric Disorders The best bridge between despair and hope is a good night’s sleep —E. Joseph Cossman Samy S. Karaz INTRODUCTION Management of insomnia without a basic understanding of the possible underlying psychiatric disorders might result in an inadequate, if not hazardous outcome. Insomnia is listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as a symptom of several psychiatric disorders (see Table 1) (1). Insomnia related to other DSM-IV mental disorders was found to be as high as 77%. In more than 50% of the cases, the diagnosis was a depressive disorder (2). In general, 57% of individuals reporting insomnia have a psychiatric disorder or will develop one within a year (3). Second to depression, anxiety disorders are strongly associated with insomnia. SLEEP AND DEPRESSIVE DISORDERS Patients with major depressive disorders present with depressed mood or loss of interest or pleasure. The full DSM-IV criteria of major depression are listed in Table 2 (4). The most characteristic feature of insomnia seen in major depression is repeated awakenings leading to early morning or “premature” insomnia. Waking up early and not being able to return to sleep is a cardinal complaint (5). Younger depressed patients might present with initial insomnia. The most characteristic sleep-tracing (polysomnographic) features of major depression is earlier onset of the first rapid eye movement (REM) period. Other abnormalities include reduced delta sleep and increased REM sleep (5). The severity of insomnia correlates with the severity of depression. Despite the overwhelming evidence of insomnia and sleep architecture abnormalities, patients with major depression do not usually present with symp-
128 Karaz Table 1 DSM–IV Diagnoses with Insomnia as a Symptom Diagnosis DSM-IV Criteria Separation anxiety disorder Reluctance or refusal to go to sleep without being near a major attachment figure and repeated nightmares involving the theme of separation. Alcohol withdrawal Insomnia Stimulant withdrawal (including cocaine, Insomnia or hypersomnia amphetamines, nicotine or caffeine) Sedative withdrawal (including opiates, Insomnia hypnotics, anxiolytics, and antidepressants) Major depression Insomnia or hypersomnia every day Dysthymia Insomnia or hypersomnia Posttraumatic stress disorder Recurrent distressing dreams of the traumatic event leading to difficulty falling or staying asleep. Acute stress disorder Reexperiencing the trauma in recurrent nightmares Generalized anxiety disorder Insomnia Primary insomnia The predominant complaint is difficulty initiating or maintaining sleep or nonrestorative sleep, for at least 1 month. Nightmares Repeated awakening from any sleep period due to frightening and vivid dreams Sleep terrors Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode. Sleep disorder due to another psychiatric Insomnia due to the other psychiatric disorder disorder Sleep disorder due to another medical Insomnia due to other medical disorder condition Postconcussional disorder Insomnia or hypersomnia Premenstrual dysphoric disorder Insomnia or hypersomnia Adapted from ref. 1. toms of excessive daytime sleepiness. Patients with major depression frequently present with symptoms of tiredness and lack of energy. Accordingly, it is of clinical importance to try to differentiate between tiredness with a lack of energy and excessive daytime sleepiness in patients with insomnia. On the other hand, as a part of bipolar disorder and seasonal affective disorder, depression is usually accompanied by increased sleep efficiency, frequent napping, and daytime sleepiness (5). In hypomanic or manic phase of bipolar disorder, patients usually sleep as little as 2 to 4 hours each night, yet they wake up feeling subjectively refreshed. The
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Clinical Handbook of Insomnia Edite
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C URRENT CLINICAL NEUROLOGY Daniel
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© 2004 Humana Press Inc. 999 River
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Series Editor’s Introduction The
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x Foreword nervous system hypersomn
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Contents Series Editor’s Introduc
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Contributors HRAYR P. ATTARIAN, MD
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2 Attarian et al.
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4 Attarian et al. until the 1970s t
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6 Attarian et al. Table 2 Diagnosti
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8 Attarian et al. Duration of Illne
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10 Attarian et al. REFERENCES 1. Ma
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12 Attarian Another study in Austri
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14 Attarian even less well studied.
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16 Attarian communities. A structur
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18 Attarian 5. Sutton, D. A., Moldo
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20 Attarian 53. Kageyama, T., Kabut
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22 Attarian
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24 Bonnet and Arand Table 1 Reporte
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26 Bonnet and Arand On the day spen
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28 Bonnet and Arand SUMMARY These m
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30 Bonnet and Arand chronic caffein
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32 Bonnet and Arand response that a
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34 Bonnet and Arand The Development
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36 Bonnet and Arand ACKNOWLEDGMENT
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38 Bonnet and Arand 45. Bonnet, M.
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40 Attarian Table 1 Types of Insomn
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42 Attarian 15 to 40 seconds. PLMs
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44 Fig. 1. Example of a 1-week slee
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46 Fig. 3. One-week printout of an
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48 Attarian Fig. 4. Algorithm. (Use
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50 Attarian 27. Polo-Kantola, P., E
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52 Garcia
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54 Garcia association is known as s
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56 Fig. 1. A sleep log used in chil
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58 Garcia the reality that the tend
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60 Fig. 2. Actigraph recording in a
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62 Garcia neurodevelopmental disabi
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64 Garcia 35. Czeisler, C., kronaue
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66 Garcia
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68 Attarian showed similar degrees
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70 Attarian agitation and hence the
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72 Attarian Affective disorder is s
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74 Attarian and Drug Administration
Page 93 and 94: 76 Fig. 2. Sleep log after treatmen
Page 95 and 96: 78 Attarian 18. Bonnet, M. H. and A
Page 97 and 98: 80 Attarian 65. Perlis, M., Aloia,
Page 99 and 100: 82 Attarian was confirmed by resear
Page 101 and 102: 84 Attarian times worrying about th
Page 103 and 104: 86 Attarian insomnia or for other s
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Page 107 and 108: 90 Duntley tion systems found that
Page 109 and 110: 92 Duntley Case 1 A 36-year-old fem
Page 111 and 112: 94 Fig. 2. The objective amount of
Page 113 and 114: 96 Duntley PROGNOSIS AND COMPLICATI
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Page 117 and 118: 100 Attarian EPIDEMIOLOGY There are
Page 119 and 120: 102 Attarian CLINICAL MANIFESTATION
Page 121 and 122: 104 Attarian DIAGNOSTIC WORKUP The
Page 123 and 124: 106 Attarian 13. Hauri, P. J. (1998
Page 125 and 126: 108 Plotkin
Page 127 and 128: 110 Plotkin quality of sleep. Ultim
Page 129 and 130: 112 Plotkin of the therapeutic effi
Page 131 and 132: 114 Plotkin months or years. The ef
Page 133 and 134: 116 Plotkin associated somatic disc
Page 135 and 136: 118 Plotkin Table 1 Causes of Secon
Page 137 and 138: 120 Plotkin Table 1 (continued) Lew
Page 139 and 140: 122 Plotkin REFERENCES 1. Foley, D.
Page 141 and 142: 124 Plotkin 48. Marchetti, F., Rome
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Page 147 and 148: 130 Karaz poor. Focusing only on th
Page 149 and 150: 132 Karaz He felt hopeless that his
Page 151 and 152: 134 Karaz Table 4 Diagnostic Criter
Page 153 and 154: 136 Karaz complained of feeling anx
Page 155 and 156: 138 Karaz other physicians avoided
Page 157 and 158: 140 Karaz 17. Attarian, H. P. (2000
Page 159 and 160: 142 Duntley disorders has been conf
Page 161 and 162: 144 Duntley itance. A recent study
Page 163 and 164: 146 Duntley The patient’s primary
Page 165 and 166: 148 Duntley return to sleep. He tos
Page 167 and 168: 150 Duntley Treatment of RLS should
Page 169 and 170: 152 Duntley 34. Cartwright, R. (197
Page 171 and 172: 154 Perlis et al.
Page 173 and 174: 156 Perlis et al. Fig. 1. A schemat
Page 175 and 176: 158 Perlis et al. ditioned arousal
Page 177 and 178: 160 Perlis et al. subjected to empi
Page 179 and 180: 162 Perlis et al. effect), (3) may
Page 181 and 182: 164 Perlis et al. Cognitive Therapy
Page 183 and 184: 166 Perlis et al. Table 2 Cognitive
Page 185 and 186: 168 Perlis et al. Perhaps more impo
Page 187 and 188: 170 Perlis et al. 28. Carskadon, M.
Page 189 and 190: 172 Perlis et al.
Page 191 and 192: 174 Attarian Secondary Insomnias Re
Page 193 and 194: 176 Attarian 50 years of age who sl
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178 Attarian Antidepressants Becaus
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180 Attarian The use of benzodiazep
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182 Attarian to placebo. Zaleplon a
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184 Attarian 3. Wyatt, R. J., Engel
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186 Attarian residual sedation foll
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188 Index Clonidine, 183 CNS arousa
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190 Index Proton pump inhibitors, 1
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Current Clinical Neurology CLINICAL
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