_disorders medicine in psychiatry在精神病学睡眠障碍的药物课件

1 Sleep Disorders Medicine In Psychiatry Alan B. Douglass MD, FRCPC, Dip. ABPN, Dip. Amer. Board of Sleep Medicine Asst. Professor, Dept of Psychiatry, University of Ottawa Medical Director, Sleep Disorders Service, Royal Ottawa Hospital 2 Introduction nFinancial Disclosure: Nothing to declare nToday we will cover: nBasic sleep physiology nNarcolepsy a disorder of the REM control system nPeriodic Limb Movement Disorder nObstructive Sleep Apnea nInsomnia diagnosis eyes and diaphragm OK; pt. remains awake but paralyzed. nHypnagogic / Hypnopompic hallucinations n“Multimodal” visual, tactile, auditory, smell. Often highly emotional, sexual, frightening nSleep Paralysis nAwakes unable to move anything but eyes. Cant breathe voluntarily or talk. HH often occur here too. Narcolepsy: age of onset Silber 2004, p.97. Narcolepsy Biology HUMANDOG Orexin / Hypo- cretin cells Destroyed by immune system Normal Orexin receptors NormalGenetic abnormality, inactive REM intrusion: (SP, Cataplexy) + Narcolepsy Treatments: nSLEEPINESS: Stimulants (noradrenalin receptor agonists): amphetamine, methylphenidate, modafinil. nCATPLEXY: Antidepressants that increase serotonin and or noradrenaline and block ACh, i.e. clomipramine, venlafaxine. 31 Narcolepsy versus Schizophrenia Narcolepsy Actually Daytime REM sleep intrusion Apparent “Schizophrenic” Hallucinations n90% aassociation of narcolepsy with an HLA antigen DNA fragment (DQB1*0602) allows “inverse” screening of schizophrenics for narcolepsy nNarcolepsy is detectable in sleep lab (MSLT) but pt. must be medication-free for at least 3 weeks. Worm in lateral hypothalamus causing narcolepsy. (neurocysticercosis) J. Clin. Sleep Med. 1(1) 2005, p. 41. 33 Obstructive Sleep Apnea Normal Sleep Apnea 37 OSA Clinical Symptoms 38 Clinical Applicability Apnea nSleep apnea and depression share clinical features; apnea can produce secondary depression. nSerious sleep apnea can cause sufficient impairment to suggest dementia; severe snoring in a “demented” patient could be a treatable illness. nApnea or PLMD can cause sleep deprivation which can cause relapse of mania or depression. 39 Restless Legs Syndrome / Periodic Limb Movement Disorder (RLS-PLMD) Periodic Limb Movement Disorder 41 RLS PLMD: neurochemistry nLikely due to iron deficiency in basal ganglia (Fe+ is co-factor for enzymes that synthesize DA). nMay predict onset of “syn-nuclein- opathies” (REM behaviour disorder, PSP, Parkinsons, Lewy Body dementia). 42 RLS PLMD: Sx and Tx nSYMPTOMS nLate evening / night nLegs cramp, squirm, move by themselves nMultiple awakenings n“Charley Horses” nCant tolerate legs being immobilized nWorse in elderly nTREATMENT nCheck Fe, ferritin, B12, folate nDopamine agonists (L-DOPA, ropinirole, pramipexole) nBenzodiazepines or opiates now 2nd line nQuinine obsolete 43 Polysomnographic Abnormalities In Psychiatric Patients 44 Sleep Abnormalities in Psychiatry Benca, 1992 nMeta-analysis of sleep in all major psychiatric disorders showed affective disorders had the largest and most consistent differences from controls. Kaneko, 1981 nExtremely short nocturnal REM latency is common to both psychiatric disorders and narcolepsy 45 Psychiatric Sleep Measurements nSleep Latency (SL) sleep onset defined as first 3 contiguous 30-sec. pages of Stage 1 sleep nREM Latency (RL) time from sleep onset to first epoch of REM sleep nREM Latency Minus Awake (RLMA) subtract any interposed pages of waking from the RL nEye Movement Density in REM Sleep (REM Density, RD) the actual number of eye movements divided by minutes spent in REM 46 REM Latency (RL normalized by SSRI (antidepressants are REM suppressants because they increase neurotransmission in serotonergic and adrenergic pathways). nHigh REM density (also a good predictor of eventual depression in a never-ill person) 48 MDD (cont.) nSome powerful sleep mechanism underlies the expression of depression nTotal sleep deprivation or selective REM deprivation dramatically improves mood of severely depressed patients (benefit is lost after one nights sleep or even short nap) nAmount of Non-REM sleep in nap predicts worsening of mood 49 Bipolar Disorder vs. MDD nMDD patients typically have reduced total night sleep, but normal day alertness nDepressed bipolar patients in often have excess sleep (up to 18 hours/day), crushing fatigue when awake, ravenous appetite, when does alarm ring in AM? nIs there napping in the daytime (causes insomnia at night). nIs there Shiftwork? How long on one shift before rotation? nIn what part of night does insomnia occur? nIs it associated with physical or environmental causes? nIs there alcohol consumption after 19:00h? nIs there caffeine consumption after 14:00h? nIs there stimulant drug use or abuse? nIf indicated, do a full psychiatric diagnostic screening. nConsider pain and physical illnesses that could cause it. Treatment Plan for Insomnia Is it ACUTE? Y N Does reassurance & support help? Y N end Rx benzos short-term Identify & treat medical, surgical, or environmental causes No better? Go to next page Is the insomnia acute? Ask psychiatric questions: substance abuse, depression, anxiety + Treat psychiatric illness or refer to psychiatrist. - Ask: sleep hygiene, naps, caffeine, shifts Counsel pt. yourself Refer to sleep psychologist, esp. if “primary insomnia” - + Physical sleep disorders? Refer to sleep lab if (+). + When to refer to sleep clinic nSymptoms of sleep apnea (obese, snores, HTN, weight gain, awakens choking, morning headache). nSymptoms