Innovations In Clinical Neuroscience

MAR-APR 2018

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

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31 ICNS INNOVATIONS IN CLINICAL NEUROSCIENCE March-April 2018 • Volume 15 • Number 3–4 R E V I E W Patients with social phobia also tend to have poorer sleep quality, increased sleep latency, more sleep disturbances, and altered daytime functioning than healthy controls. 34,35 Sleep difficulties also predict the severity of the social anxiety disorder. 36 Agoraphobia. Agoraphobia is marked fear or anxiety about real or anticipated exposure to situations, such as use of public transportations, being in open or enclosed spaces, being in a crowd, or being outside the home alone. The sleep profile in agoraphobia mirrors what is seen in patients with panic disorder. Generalized anxiety disorder (GAD) . GAD is characterized by excessive anxiety and worry (apprehensive expectation) about a number of events or activities. Sleep disturbance is one of the DSM-5 diagnostic criteria for GAD. Symptoms include sleep disturbance, difficulty falling asleep or staying asleep, and restless, unsatisfying sleep. 31 Ohayon et al 39 conducted an epidemiological study on insomnia complaints in 5,622 subjects and found that insomnia symptoms were reported by 18.6 percent of the sample. An anxiety disorder diagnosis was given to 33.1 percent of those who reported insomnia. GAD was seen in about half the cases who were diagnosed with an anxiety disorder. In an earlier study by Ohayon et al of the French population, 40 researchers found that GAD was the most prevalent psychiatric diagnosis among subjects reporting insomnia. Alfano et al, 41 in a study of 30 nonmedicated, pre-pubescent children (ages 7–11 years), of which 15 had GAD and 15 were healthy controls, researchers used polysomnography (PSG) and found that children with GAD showed significantly increased sleep onset latency. Monti and Monti, 42 in a review of polysomnographic studies involving patients with GAD, found that sleep disturbance associated with mild- to-moderate GAD was sleep-maintenance insomnia and, to a lesser extent, sleep-onset insomnia. Most of the studies reported a decrease in total sleep time (TST). Four out of six studies reported an increase in waking after sleep onset (WASO). 43 Clinical Implications . Insomnia is common in patients with various anxiety disorders. Insomnia can be a presenting complaint is patients with GAD. Insomnia is seen in studies using both subjective and objective testing, such as polysomnography. INSOMNIA AND ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) Some children with ADHD might have sleep- onset insomnia; others might have a predilection for delayed sleep onset but otherwise sleep well. Medications used to treat ADHD can contribute to sleep disturbances. Sleep disorders, such as obstructive sleep apnea (OSA) and restless legs syndrome, lead to sleep disruption and thereby can contribute to the symptoms of ADHD. These disorders might also present with ADHD-like symptoms. These sleep problems and disorders affect the quality of life of children and adolescents with ADHD, with potential adverse effects on learning and memory processing. It is recommended that all children with ADHD be evaluated for sleep problems and primary sleep disorders. These children should also be treated for comorbid sleep problems and disorders, preferably with nonpharmacological behavioral interventions before or concurrent with treatment of ADHD. Long-acting stimulants might also be more beneficial than short-acting stimulants to prevent sleep disturbances. 43 INSOMNIA AND SUBSTANCE ABUSE A complex bidirectional relationship exists between insomnia and substances of abuse. Substances of abuse produce their effects by acting on various receptors and neurotransmitter systems, some of which are involved in normal sleep regulation. Prevalence of insomnia is higher in patients with substance use disorders. 44 Mahfoud et al 45 found the prevalence of insomnia to be three times higher in individuals with substance abuse disorder. Insomnia has also been shown to predispose to individuals to substance use disorder. Alcohol is the most commonly used sleep aid. People with insomnia are twice as likely to develop alcohol-related problems than those without insomnia. Patients with substance use disorder are more susceptible to effects of sleep deprivation. Rates of insomnia range from 36 to 91 percent in patients admitted for treatment of alcoholism. Insomnia can persist for many weeks or months after abstinence from alcohol. Persistent insomnia can lead to relapse. This is often not recognized by substance abuse treatment programs. Incorporating strategies to help with insomnia can lead to relapse prevention. Cognitive behavior therapy for insomnia (CBTi) can help patients with substance use disorders but might need to be modified to achieve desired effects. Patients with substance use might respond differentially to CBTi. Pharmacological strategies include trazodone, gabapentin, and melatonin. Gabapentin has also shown to decrease risk of relapse in patients with alcohol use disorder. 46 SUMMARY Clinicians should evaluate their psychiatric patients for sleep problems. They should also evaluate their patients who present with complaints of insomnia for comorbid psychiatric problems. Clinicians should query their patients about the quantity and quality of sleep and, daytime somnolence/ hypersomnia, as well as screen for initial, middle, and terminal insomnia. Circadian rhythm disruptions might also be present and should be assessed. Insomnia presentation is of particular clinical importance among patients with comorbid psychiatric disorders. A comprehensive history should include caffeine and alcohol/drug use; level of physical activity; presence comorbid psychiatric symptoms, psychosocial stressors, medical conditions, and medications; and overall sleep hygiene. A physical examination that includes height, weight, and description of body habitus is also recommended. Screening questionnaires, such as the Epworth Sleepiness Scale (ESS) (eight questions), 47 the Insomnia Severity Index (ISI) (seven questions), 48 and the Berlin Questionnaire (10 questions), 49 might aid in the detection of sleep problems, and multiple such instruments are available, Polysomnography and other more intensive and costly examinations are useful in making definitive diagnoses of various primary sleep disorders, such as OSA, and should be reserved for patients who are suspected of having such disorders. As an initial step in treatment, medical conditions that might contribute to the sleep dysfunction should be assessed. Multiple medical conditions can cause sleep and circadian disturbances, including nasal and sinus allergies, hypothyroidism and hyperthyroidism, coronary artery disease, congestive heart failure, diabetes, arthritis, asthma, gastroesophageal reflux disease, and chronic pain. CBTi is the preferred treatment for insomnia. 51 Internet-based CBTi is also an option because in-person CBTi might not be readily available. 50 Sleep promoting medications can be used alone or concomitantly with CBTi, usually for short- term treatment of few weeks.

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