1. El-Sayed Saleh, M.D. Ass. Prof. of Psychiatry

2. إِذْ يُغَشِّيكُمُ النُّعَاسَ أَمَنَةً مِّنْهُ وَيُنَزِّلُ عَلَيْكُم مِّن السَّمَاء مَاء لِّيُطَهِّرَكُم بِهِ وَيُذْهِبَ عَنكُمْ رِجْزَ الشَّيْطَانِ وَلِيَرْبِطَ عَلَى قُلُوبِكُمْ وَيُثَبِّتَ بِهِ الأَقْدَامَ صدق الله العظيم سورة الأنفال جزء (9) – آية 11

3.  أول النوم النعاس : وهو أن يحتاج الإنسان إلى النوم  ثم الوسن : وهو ثقل النعاس  ثم الترنيق : وهو مخالطة النعاس العين  ثم الكرى والغمض : وهو أن يكون الإنسان بين النائم واليقظان  ثم التغفيق : وهو النوم وأنت تسمع كلام القوم  ثم الإغفاء : وهو النوم الخفيف  ثم التهويم والغرار والتهجاع : وهو النوم القليل  ثم الرقاء : وهو النوم الطويل  ثم الهجود والهجوع والهيوع : وهو النوم الغرق  ثم التسبيخ : وهو أشد النوم مراحل نوم الإنسان عند العرب يقول العرب في ترتيب النوم

4.  Sleep is a state of unconsciousness in which the brain is relatively more responsive to internal than to external stimuli  Mechanisms within the brainstem and hypo- thalamus regulate sleep through GABA and acetylcholine

5. 5 REM Sleep ~20% of night NREM Sleep ~80% of night Wake 2/3 of life

6. 6 1. NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep

7.  Average - 7 1/2 to 8 1/2hrs/night  Range (for adults) - 5-9 hrs/night  Steadily decreases from birth to old age  newborns sleep 14-16 hours/24 hours  Elderly spend less time sleeping per night, but increase in sleep latency and more frequent arousals make their requirement in bed longer.

8.  Initiation of Sleep = Time to fall asleep  Standard - less than 30 minutes  Sleep Efficiency = Time sleeping/ Time in bed  Standard - Greater than 85%  May be caused by awakening frequently during the night with subsequent difficulty in re-initiating sleep, or awakening too early without being able to go back to sleep at all

9.  Ability to stay alert with very little sleep

10. 10 1. Insomnia. 2. Sleep Related Breathing Disorders. 3. Hypersomnia. 4. Cicadian Rhythm Sleep Disorder. 5. Parasomnia. 6. Sleep related Movement Disorder.

11. 11  Sleep disorders are common  Sleep disorders are serious  Sleep disorders are treatable  Sleep disorders are under diagnosed Important facts

13.  Insomnia is defined as difficulty with the initiation, maintenance of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep.  Patient’s subjective dissatisfaction with the sleep quality and quantity  The normal requirement for sleep ranges between 4 and 10 hours  Insomnia is a symptom, not a disorder by itself

14.  Waking after sleep has been initiated, but before desired waking time

15.  Transient insomnia  < 4 weeks triggered by excitement or stress, occurs when away from home  Short-term  4 wks to 6 months, ongoing stress at home or work, medical problems, psychiatric illness  Chronic  Poor sleep every night or most nights for > 6 months, psychological factors (prevalence 9%)

16.  Some patients may not meet any of the above conditions, but awake feeling poorly rested.

17.  1997 survey of almost 2000 ‘health maintenance organization (HMO)’ patients showed that 10% had current major insomnia as defined as taking more than 2 hours to fall asleep each night.  Only 5% spoke to their physician about it  Over 38 million prescriptions per year for sleeping pills

18. Headache Bad or vivid dreams Problems of breathing Chest pain/heartburn Need to pass urine or move bowels Abdominal pains Fever/night sweats Leg cramps Fear/anxiety Depression

19. ثُمَّ أَنزَلَ عَلَيْكُم مِّن بَعْدِ الْغَمِّ أَمَنَةً نُّعَاسًا يَغْشَى طَآئِفَةً مِّنكُمْ وَطَآئِفَةٌ قَدْ أَهَمَّتْهُمْ أَنفُسُهُمْ يَظُنُّونَ بِاللّهِ غَيْرَ الْحَقِّ ظَنَّ الْجَاهِلِيَّةِ يَقُولُونَ هَل لَّنَا مِنَ الأَمْرِ مِن شَيْءٍ قُلْ إِنَّ الأَمْرَ كُلَّهُ لِلَّهِ يُخْفُونَ فِي أَنفُسِهِم مَّا لاَ يُبْدُونَ لَكَ يَقُولُونَ لَوْ كَانَ لَنَا مِنَ الأَمْرِ شَيْءٌ مَّا قُتِلْنَا هَاهُنَا قُل لَّوْ كُنتُمْ فِي بُيُوتِكُمْ لَبَرَزَ الَّذِينَ كُتِبَ عَلَيْهِمُ الْقَتْلُ إِلَى مَضَاجِعِهِمْ وَلِيَبْتَلِيَ اللّهُ مَا فِي صُدُورِكُمْ وَلِيُمَحَّصَ مَا فِي قُلُوبِكُمْ وَاللّهُ عَلِيمٌ بِذَاتِ الصُّدُورِ صدق الله العظيم سورة ال عمران جزء (4) – آية 154

20. Type of medicationExample CNS stimulantsD-amphetamine Blood pressure drugs  - blockers,  - blockers Respiratory medicinesAlbuterol, Theophylline DecongestantsPhenylephrine, Pseudoephedrine HormonesThyroxin, Corticosteroids Other substancesAlcohol, Nocotine, Caffeine 20

21. 21 At least one (or more) of the following  Fatigue or malaise  Attention, concentration impairment  Social/ vocational dysfunction/ poor work  Mood disturbance or irritability  Daytime sleepiness

22. 22  Reduction in motivation, energy or initiative  Proneness for errors or accidents at work or while driving  Tension, headaches or gastrointestinal symptoms in response to sleep loss  Concerns or worries about sleep  Secondary psychiatric problems

23.  Mood Disturbance  Depression and/or Anxiety  Poor memory  Difficulty concentrating  Motor vehicle and other accidents

24.  Determine the pattern of sleep problem (frequency, associated events, how long it takes to go to sleep, and how long the patient can stay asleep)  Include a full history of alcohol and caffeine intake and other factors that might affect sleep  Review current medications that patient is taking to eliminate these as possible causes  Take a history to rule out physical cause and/or psychosocial cause

25.  Timing of insomnia  Sleep schedule  Sleep environment  Sleep habits  Symptoms of other sleep disorders  Daytime effects  Medications, caffeine  Life stressors and worry over insomnia

26.  Anatomic features of obstructive sleep apnea  Neurologic exam in case of restless leg or other neurologic syndrome

27.  Maintain for 2-4 weeks  Sleep and wake times  Awakenings  Daytime naps and activities  Correlation with bed partner

28. 28  Good Sleep History  Rule out primary psychiatric disorders  Rule out adverse effects of medications  Sleep Diary  Good Sleep Hygiene Measures  Interventions – CB therapy, medications

29.  Treat underlying Medical Condition  Treat underlying Psychiatric Condition  Improve sleep hygiene  Change environment  CBT: ‘primary insomnias’, transient insomnia  Pharmacological  Light, melatonin, or ‘chronotherapy’ for circadian disorders

30.  Cognitive Behavioral Therapy  Individual counseling- 6 sessions  Effective in 50% of patients

31. 31

32. 32 Cognitive Behaviour Therapy (CBT) ____________________________

33. 33  Temperature  Fresh air  S&S  Comfortable bed

34. 34  Go to bed when sleepy  Only S & S in bedroom  Get up the same time every morning  Get up when sleep onset does not occur in 20 min, and go to another room  No daytime napping

35. 35  Behaviours that interfere with sleep  Caffeine  Alcohol  Nicotine  Daytime napping  Exercise < 4hrs before bed

36. 36  Progressive muscle relaxation  Diaphragmatic breathing  Biofeedback  Meditation, Yoga  Hypnosis to ↓ anxiety & tension at bedtime

37. 37  Interrupt unwanted pre-sleep cognitive activity by instructing patient to repeat sub-vocally ‘the’ every 3 sec (articulatory suppression)  To yell sub-vocally “stop” (thought stopping)

38. 38  Explicit instruction to stay awake when they go to bed; Aim is to reduce anxiety associated with trying to fall asleep – Paradoxical intention  Alter irrational beliefs about sleep, provide accurate information that counteracts false beliefs – Cognitive restructuring  Patient imagines 6 common objects (candle, kite, fruit, hourglass, blackboard, light bulb) emphasis on imagining shape, colour, texture – Imagery training

39.  Benzodiazepines  Lorazepam  Clonezepam  Temazepam  Flurazepam  Quazepam  Alprazolam  Triazolam  Estazolam  Non Benzodiazepines  Zolpidem  Zolpidem CR  Zeleplon  Eszopiclone  Both these classes act on the GABA A receptors (BzRA) in PCN 39

40.  Antidepressants  Trazadone  Mirtazapine  Doxepin  Amitryptyline  Antipsychotics  Olanzapine  Quitiepine  Melatonin Receptor Agonists  Melatonin  Ramelteon  Miscellaneous  Valerian  Diphenhydramine  Cyclobenzaprine  Hydroxyzine  Alcohol 40

41.  Anterograde amnesia  Residual sedation – longer acting BzRAs  Rebound Insomnia?  Abuse and dependence?  Mostly used short term (2 weeks)  When used as a sleeping aid dose escalation rare  No physical dependence with night time use  Low psychological dependence with night time use  Increased fall risk, cognitive effects in the elderly

42. 42  Benzodiazepines (GABA receptor agonist)  Transient insomnia, (max 2 wks, ideally 2-3/wk)  Long ½ life -nitrazepam  Medium ½ life - temazepam  Short ½ life - diazepam  Poor functional day time status, cognitive impairment, daytime sleepiness, falls and accidents, depression  Acute withdrawal, confusion, psychosis, fits - may occur up to 3/52 from stopping

43.  Benzodiazepines are the drugs of choice for the treatment of insomnia.  Flurazepam can be used for up to one month with little tolerance.  Temazepam can be used for up to three months with little tolerance.  Intermittent use recommended (every three days). Use for no longer than 3 – 6 months.

44.  Half-life is an important factor  Benzodiazepines with long half lives (e.g., flurazepam) produce sustained sleep, but increased risk of daytime somnolence  Benzodiazepines with short half lives may be best for patients with difficulty falling asleep, but can produce rebound insomnia  Development of tolerance can produce rebound insomnia in compounds with short half lives

45.  Benzodiazepines have relatively low abuse potential.  Prolonged use can lead to withdrawal symptoms: headache, irritability, dizziness, abnormal sleep  Rebound insomnia - triazolam

46.  Low toxicity when taken alone  In combination can be fatal  Flumanzenil is a benzodiazepine antagonist that can be used to block adverse effects of benzodiazepines  Stomach pump, charcoal, hemodialysis

47. 47  Act at the benzodiazepine receptor  Less risk of dependence Zaleplon short ½ life Zolipidem, Zopiclone slightly longer ½ life No difference in effectiveness & safety More expensive Only to be used if adverse effects to BZP

48.  Short half life  Does not produce rebound insomnia  Low abuse potential  Less likely to produce withdrawal symptoms  Rebound insomnia after first night of withdrawal, but soon resolves

49. DrugDuration of actionHalf-life PhenobarbitalLong24 – 140 hrs. ButabarbitalIntermediate34 – 42 hrs. AmobarbitalShort-intermediate8 – 42 hrs. PentobarbitalShort-intermediate15 – 48 hrs. SecobarbitalShort-intermediate19 – 34 hrs.

50.  Enhance GABA A receptor activity  Increase Cl - conductance through site separate from that of benzodiazepines  Thiopental also inhibits GABA transaminase  Also block glutamate receptor-mediated excitation

51.  Progression of effects  Anxiolytic,Sedation, General anesthesia  Medullary paralysis, Death  Decrease stage III, IV, REM sleep, sleep latency  Tolerance develops to shortening REM sleep  Produce REM rebound  Anxiolytic, but with substantial drowsiness and ataxia. Anticonvulsant activity.

52. 52  TCA - Amitriptyline, if depression also an issue  Antihistamines – Promethazine  Melatonin  Hormone secreted by pineal gland, effects circadian rhythm, synthesised at night  Use to counteract jet lag (2-5mg @ bedtime for Four nights after arrival);  Synthetic analogue of malatonin - Remelteon  Used in paediatric sleep disorders