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Insomnia in Psychiatric Disorders 137 Table 5 Sleep Abnormalities in Psychiatric Disorders Disorder Symptoms Objective findings Major depression Insomnia, vivid dreams, ↓total sleep ↑sleep latency nightmares, and fatigue ↓sleep efficiency ↑wake time ↑REM Seasonal affective disorder/ bipolar depression Hypersomnia ↑total sleep time Mania Insomnia ↓total sleep ↑sleep latency ↓sleep efficiency ↑wake time ↑REM Anxiety disorders Insomnia ↓ sleep continuity Posttraumatic stress disorder Insomnia, flashback dreams Normal or ↑REM Schizophrenia Insomnia, reversal of sleep ↓ sleep continuity, normal or wake cycles ↓SWS, normal or ↓REM sleep Eating disorders Insomnia, sleep-related Normal or ↓ sleep continuity, eating spells normal or ↓REM sleep Alcoholism Insomnia ↓ sleep continuity, ↓SWS, normal or ↓REM sleep, normal or ↑REM % Dementia Alzheimer’s Insomnia, reversal of sleep– ↓total sleep ↑sleep latency type wake cycles ↑wake time, ↓SWS. Adapted from ref. 15. REM, rapid eye movement; SWS, slow-wave sleep Insomnia and Substance Abuse Alcoholism Special attention needs to be given to alcoholism, as it is often associated with anxiety disorders, depression, and insomnia. Acute alcohol use reduces the amount of wakefulness for the first 3 to 4 hours of sleep. The amount of wakefulness increases during the second half of the night and sometimes the number of dreams, particularly anxiety dreams, increase. Chronic, excessive alcohol use eventually results in fragmented and restless sleep (5). Sleep problems due to alcohol abuse could be confused with insomnia due to psychiatric disorders or primary insomnia if the problem with alcoholism is overlooked or not addressed. It is advisable to avoid prescribing benzodiazepines if alcohol use is a problem. Benzodiazepine-prescribing decisions vary widely among physicians. Although some agreed with prescribing for patients with high probability of alcohol abuse,
138 Karaz other physicians avoided benzodiazepines unnecessarily, depriving certain insomnia patients from a viable treatment option (21). Caffeine Caffeine is a stimulant that is consumed in coffee (85 mg–150 mg per cup), tea (60–75 mg per cup), cocoa (50 mg per cup), chocolate, over-the-counter (OTC) cold preparations (15 mg–60 mg per tablet), and OTC stimulants (100–200 mg). Caffeine effects may last for 8 to 14 hours. Caffeine consumption might induce or worsen insomnia, even if it is consumed as early as the late afternoon. For most people, 1 g of caffeine may induce insomnia. Other more sensitive individuals may become overstimulated on as little as 250 mg (16). The polysomnography changes with caffeine shows increased SL, decreased TST, increased wake after sleep onset (WASO), decreased REM sleep, and decreased delta sleep (22). Nicotine Nicotine can be consumed by smoking, chewing tobacco, snuff, nicotine patches, and nicotine gum. Nicotine is addictive. Withdrawal from nicotine starts 1 to 2 hours after the last smoke (16). Abrupt cessation or decrease of the nicotine consumption can result in insomnia in the following 24 hours (4). Cigarette smoking accelerates the metabolism of certain medications including Diazepam, Lorazepam, Oxazepam, and Imipramine. This could result in a decrease of the sedative effect of these medications among smokers. Nicotine polysomnography changes include increased SL, decreased TST, and decreased REM sleep (22). Stimulants Amphetamines such as methamphetamine “speed” are taken intravenously, by snorting, or by smoking “ice.” PSG changes on amphetamines are decreased TST, increased WASO, increased movement during sleep, decreased REM sleep, and decreased delta sleep (22). Cocaine is also taken intravenously, by snorting, or smoking (as free base “crack”). PSG changes on cocaine are increased SL, decreased TST, and decreased REM sleep (22). Serious medical and psychiatric complications result from stimulant abuse and among these complications are a disruption of the sleep–wake pattern and insomnia. Stimulants (e.g., amphetamines and methylphenidate) are used therapeutically in the treatment of narcolepsy, attention deficit hyperactivity disorder, some causes of depression, and other related disorders. The availability of objective diagnostic tools and careful clinical monitoring helps decrease the risk of stimulant abuse among these patients population. Anxiolytics and Sedative Hypnotics The present major anxiolytics and sedative hypnotics include benzodiazepine and other miscellaneous drugs (Zolpidem, Chloral Hydrate, and Zalpelon) (16).
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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
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76 Fig. 2. Sleep log after treatmen
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78 Attarian 18. Bonnet, M. H. and A
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80 Attarian 65. Perlis, M., Aloia,
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82 Attarian was confirmed by resear
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84 Attarian times worrying about th
Page 103 and 104: 86 Attarian insomnia or for other s
Page 105 and 106: 88 Attarian
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 145 and 146: 128 Karaz Table 1 DSM-IV Diagnoses
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: 136 Karaz complained of feeling anx
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
Page 195 and 196: 178 Attarian Antidepressants Becaus
Page 197 and 198: 180 Attarian The use of benzodiazep
Page 199 and 200: 182 Attarian to placebo. Zaleplon a
Page 201 and 202: 184 Attarian 3. Wyatt, R. J., Engel
Page 203 and 204: 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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