Innovations In Clinical Neuroscience

MAR-APR 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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30 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 R E V I E W Recommendations for evaluation and treatment of Insomnia in patients with psychotic disorders include the following: 1. All patients with schizophrenia should be evaluated for insomnia. 2. Medical comorbidities should be evaluated to determine their contribution to the insomnia. 3. Caffeine is well known to cause insomnia, and its use should be limited to earlier in the day. 4. Patients with schizophrenia are often prescribed statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and SSRIs. These medications can cause insomnia. In cases where a medication is the presumed cause of sleep dysfunction, alternatives should be considered. 5. Sleep apnea is common in patients with psychotic disorders. It can contribute to insomnia and poor sleep quality. It should be managed with continuous positive airway pressure (CPAP) with supportive encouragement. Lifestyle modifications, positional therapy, use of oral appliances, and consultation with an ear, nose, and throat specialist should be explored in patients who are not candidates for CPAP. 6. Pharmacotherapy for insomnia with antipsychotic medications alone might improve sleep and psychotic symptoms. Antipsychotic medications have been shown to increase total sleep time and decrease sleep latency and awakenings. Hence, olanzapine, clozapine, chlorpromazine, quetiapine, and asenapine, the more sedating atypical medications, are more frequently used when sedation is a desirable side effect. However, care should be taken to avoid other untoward effects, such as cognitive decline and increased risk of falls. 7. Melatonin has been shown to improve sleep in patients with schizophrenia. It might increase sleep efficiency, decrease awakenings, reduce sleep latency, and increase total sleep time. An added advantage of melatonin is that it might diminish antipsychotic- induced metabolic effects. 28 Tables 2 and 3 summarize the relationship between insomnia and psychotic disorders. INSOMNIA AND ANXIETY DISORDERS Insomnia is the most common sleep disturbance associated with anxiety disorders. Poor sleep quality is seen in adults with anxiety disorders. 29 Nocturnal panic occurs frequently in patients with sleep apnea and might predispose patients to developing panic disorders, 30 which can also cause insomnia. A thorough assessment of sleep difficulties should should be undertaken during clinical evaluation of patients with anxiety symptoms. Separation anxiety disorder . Separation anxiety disorder is characterized by developmentally inappropriate fear or anxiety regarding separation from home or an attachment figure. It usually occurs in childhood and is rarely seen beyond adolescence. Sleep problems form part of the criteria for the diagnosis of separation anxiety disorder in the DSM-5. 31 The individual might show a persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. The individual might also experience repeated nightmares involving the theme of separation. Sleep onset might be disturbed in these patients by unusual perceptual experiences while alone in the dark, such as seeing people peering into their room who aren't there or imagining the presence of frightening creatures reaching for them or staring at them (Table 4). 32 Panic disorder . Patients with panic disorder suffer from recurrent unexpected panic attacks. Panic attacks are abrupt surges of intense fear or discomfort that become intense within minutes. Overbeek et al 37 studied prevalence of sleep complaints in 70 patients with panic disorder (PD), comparing them with sleep complaints in 70 healthy controls. Patients with PD demonstrated a higher prevalence of insomnia than normal controls. 37 Potvin et al, in a random sample of 2,393 individuals aged 65 years or older, found that anxiety disorder, like panic disorder, was related to short sleep duration, daytime sleepiness, and sleep disturbances. 38 Phobias . Specific phobia. Specific phobia is the fear or anxiety about a specific situation or object (e.g., flying, heights, animals). It usually starts prior to the age of 10, the median age of onset being 7 to 10 years. It has a waxing and waning course, and, if it persists into adulthood, remission is rare. Patients with a specific phobia have problems with sleep latency, sleep quality, and daytime functioning, even after accounting for age, sex, marital status, education, and past-month mood or substance use disorder. 33 Social anxiety disorder (social phobia). Social anxiety disorder is a marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. The majority of children who develop the disorder do so between the ages of 8 and 15, with a median age of 13. Studies have found that insomnia occurs in up to two-thirds of patients with social anxiety. TABLE 1. Insomnia and its implications in depression RESEARCH FINDINGS RECOMMENDATIONS Depression can present as insomnia Screen patients for depression Insomnia can increase risk of suicide Screen patients with insomnia for depression and suicidal thinking Insomnia is a risk factor for subsequent development for depression Periodic follow up and screening for depression Insomnia is an indicator for relapse in patients treated for depression Evaluate patients for depression if insomnia develops TABLE 2. Sleep complaints in patients with schizophrenia Insomnia—early, middle and or late Restless sleep Nightmares Nonrestorative sleep TABLE 3. Polysomnography findings in patients with schizophrenia Increased sleep latency Decreased REM sleep latency Decreased slow wave sleep Decreased sleep efficiency Decreased spindle* activity *Spindle is a burst of 12 to 14Hz wave activity seen in Stage 2 of sleep 28 TABLE 4. Sleep problems in separation anxiety disorder Childhood insomnia- attachment type Nightmares Fearful perceptual experiences when alone in the dark Sleep terror Nocturnal enuresis

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