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Important facts
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• Sleep disorders are common
• Sleep disorders are serious
• Sleep disorders are treatable
• Sleep disorders are under diagnosed

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Important facts
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• Sleep complaints are usually not due to
psychiatric conditions or character flaws
• Most sleep disorders are readily
diagnosable and treatable
• The studies include
– Polysomnography (PSG)
– Multiple sleep latency test (MSLT)
– Actigraphy

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Wake System
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Sleep System
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Sleep Wake Cycle
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Changes in sleep with age
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Stages of sleep
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1. NREM Sleep
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
2. REM Sleep
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Sleep Stages
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Wake
2/3 of life

NREM Sleep REM Sleep

~80% of night ~20% of night

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Sleep disorders (ICSD 2)
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1. Insomnia.
2. Sleep Related Breathing Disorders.
3. Hypersomnia.
4. Cicadian Rhythm Sleep Disorder.
5. Parasomnia.
6. Sleep related Movement Disorder.
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Insomnia - definition
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• Insomnia and excessive daytime sleepiness
are primary complaints regardless of the
stage of the disease
• Insomnia includes difficulty falling asleep,
difficulty staying asleep, and early morning
awakening
Insomnia - definition
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• Insomnia is not defined by the number of
hours of sleep, but rather, by an individual„s
ability to sleep long enough to feel healthy
and alert during the day.

• The normal requirement for sleep ranges

between 4 and 10 hours
• Insomnia is a symptom, not a disorder by
itself
Insomnia - assessment
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• 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
Cognitive Model of Insomnia

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Evolution of Insomnia

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Possible causes of insomnia
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Headache Abdominal pains
Bad or vivid dreams Fever/night sweats
Problems of breathing Leg cramps
Chest pain/heartburn Fear/anxiety
Need to pass urine or Depression
move bowels
Insomnia
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1. A complaint of difficulty in initiating,
maintaining or waking up too early or
sleep that is non-restorative or poor in
quality.
2. The above sleep difficulty occurs despite
adequate opportunity and circumstance
for sleep.
3. Insomnia is a symptom – not a disease
per se
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Insomnia – associated features
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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
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Insomnia – resultant problems
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• 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
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Insomnia - subdivisions
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• Sleep onset insomnia
• Sleep maintenance insomnia
• Sleep offset insomnia
• Non restorative sleep

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Types of insomnia
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• Transient insomnia
– < 4 weeks triggered by excitement or stress,
occurs when away from home
• Short-term
– 4 wks to 6 mons , 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%)
Medical problems
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• Depression
• Hyperthyroidism
• Arthritis, chronic pain
• Benign prostatic hypertrophy
• Headaches; Sleep apnoea
• Periodic leg movement,
• Restless leg syndrome (RLS)
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Other problems
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• Caffeine
• Nicotine
• Alcohol
• Exercise
• Noise
• Light
• Hunger
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Management of insomnia
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• Good Sleep History
• Rule out primary psychiatric disorders
• Rule out adverse effects of medications
• Sleep Diary
• Good Sleep Hygiene Measures
• Interventions – CB therapy, medications

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Management of insomnia
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• Treat underlying causes whenever possible
• Advise patient to avoid exercise, heavy
meals, alcohol, or conflict situations just
before bed
• Plain aspirin or paracetamol in low doses
may be helpful; or give short-acting
hypnotics or a sedative
• Treat underlying depression
Management of insomnia
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• 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
Medications and insomnia
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Type of medication Example

CNS stimulants D-amphetamine, Methyphenindrate

Blood pressure drugs  - blockers,  - blockers

Respiratory medicines Albuterol, Theophylline

Decongestants Phenylephine, Pseudoephedrine

Hormones Thyroxin, Corticosteroids

Other substances Alcohol, Nocotine, Caffeine

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Cognitive Behaviour Therapy (CBT)
____________________________

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Non pharmacological treatments

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Bed room
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• Temperature
• Fresh air
• S&S
• Comfortable bed

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Stimulus control
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• 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

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Sleep hygiene
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• Behaviours that interfere with sleep
• Caffeine
• Alcohol
• Nicotine
• Daytime napping
• Exercise < 4hrs before bed

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Relaxation training
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• Progressive muscle relaxation
• Diaphragmatic breathing
• Autogenic training
• Biofeedback
• Meditation, Yoga
• Hypnosis to ↓ anxiety & tension at bedtime

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Thought stopping
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• 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)

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Behavioural therapies
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• 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
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Benzodiazepine receptor agonists
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• Benzodiazepines • Non Benzodiazepines
– Lorazepam – Zolpidem
– Clonezepam – Zolpidem CR
– Temazepam – Zeleplon
– Flurazepam – Eszopiclone
– Quazepam
• Both these classes act
– Alprazolam on the GABAA receptors
– Triazolam (BzRA) in PCN
– Estazolam
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Other classes of medications
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• Antidepressants • Melatonin Receptor Agonists
– Trazadone – Melatonin
– Mirtazapine – Ramelteon
– Doxepin
• Miscellaneous
– Amitryptyline
– Valerian
• Antipsychotics – Diphenhydramine
– Olanzapine – Cyclobenzaprine
– Quitiepine – Hydroxyzine
– Alcohol
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BzRAs – side effects and safety
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• 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
Benzodiazepines
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• 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
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Benzodiazepine use
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• 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.
Benzodiazepine use
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• 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
Benzodiazepine abuse
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• Benzodiazepines have relatively low
abuse potential.
• Prolonged use can lead to withdrawal
symptoms: headache, irritability,
dizziness, abnormal sleep
• Rebound insomnia - triazolam
Benzodiazepine toxicity
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• 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
Non benzodiazepines
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• 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

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Zolpidem
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• 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
Barbiturates
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Drug Duration of action Half-life

Phenobarbital Long 24 – 140 hrs.

Butabarbital Intermediate 34 – 42 hrs.

Amobarbital Short-intermediate 8 – 42 hrs.

Pentobarbital Short-intermediate 15 – 48 hrs.

Secobarbital Short-intermediate 19 – 34 hrs.

Other drugs
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• 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
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Hypersomnia
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1. Narcolepsy with Cataplexy
2. Narcolepsy without Cataplexy
3. Narcolepsy due to Medical Condition
4. Idiopathic Hypersomnia with Long Sleep Time
5. Idiopathic Hypersomnia without Long Sl. Time
6. Behaviorally Induced Insufficient Sleep Syn
7. Hypersomnia due to Medical Condition
8. Hypersomnia due to Drug/ Substance
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Sleep related movement disorders
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1. Restless Leg Syndrome
2. Periodic Limb Movement Disorder
3. Sleep Related Leg Cramps
4. Sleep Related Bruxism

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 THANK YOU ALL

HAVE GOOD SLEEP

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