How to Evaluate and Treat SLEEP PROBLEMS and INSOMNIA? - A Quick Guide | Psychiatrist Explains
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- เผยแพร่เมื่อ 1 ส.ค. 2024
- In this video, Dr Sanil Rege, Consultant Psychiatrist, explains the evaluation of sleep difficulties using a practical algorithm.
#sleep #sleepdisorder #insomnia #obstructivesleepapnea #restlesslegs #remsleep
Insomnia is defined as an ongoing subjective dissatisfaction with the duration or quality of sleep.
Sleep difficulties do not always equate to insomnia. In order for insomnia to be diagnosed - other causes should be ruled out.
0:00 - Introduction
0:25 - Definition of insomnia
1:24 - Nature of insomnia
2:12 - Sleep habits
3:00 - Stimuli affecting sleep
3:39 - Sleep restriction
4:19 - Types of Insomnia
4:39 - Principles in the management of Insomnia - Pharmacological and Non-Pharmacological
7:26 - Specific Types of medications for Insomnia
According to the DSM-V, the following are the key criteria for insomnia:
Predominant complaints of dissatisfaction with sleep quantity or quality associated with difficulty initiating sleep, difficulty maintaining sleep and early morning awakening with an inability to return to sleep.
The sleep difficulty occurs at least three nights per week, and the difficulty is present for at least three months.
Sleep difficulties may be due to :
1. Stress
2. Travel
3. Poor sleep hygiene
4. Medications or use of substances
5. Psychiatric disorders - ADHD, PTSD, depression, agitation etc
5. Sleep disorders - Obstructive sleep apnoea, Restless Legs Syndrome (RLS), REM sleep behaviour disorder
5. Narcolepsy
Thus it is important to evaluate the causes and the associated factors in order to devise an appropriate treatment plan.
Treatment consists of treating the causes
e.g. OSA - CPAP
RLS - treating iron deficiency, MG supplement, Dopamine agonists
PTSD nightmares - clonidine or prazosin
Psychophysiological insomnia - Sleep hygiene, sleep restriction, stimulus control
CBT-insomnia
Medications
Benzodiazepines
Z drugs - Zopiclone, zolpidem
Orexin antagonists - Lemborexant or suvorexant
Treating psychiatric disorders
Reading material - psychscenehub.com/psychinsigh...
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Thank you
I love fluvoxamine because it works great for anxiety, however, my sleep has been affected in a negative light. Does insomnia or sleep disturbance from SSRI’s go away with time? I plan on using fluvoxamine for life because I can’t go back to the hell that is anxiety and OCD. Thank you for all the videos you put out ❤️
It may in some, may not in others. Was insomnia a pre-existing issue? Has it been exacerbated by fluvoxamine or is this new onset post fluvoxamine. Usually SSRIs suppress REM sleep but aren't helpful for overall sleep architecture. In such cases since the primary medication helps one can consider augmentation strategy to exploit synergy. The choice of medication depends on the nature of insomnia. As outlined in this video there are a number of options.
Thanks. So informative I wish you could help me and my son. Love from Scotland 🏴 x
Thank you 🙏🏼. I wish you and your son well.
Great video. I have been learning a lot from Dr. Rege
Thank you for your feedback 🙏🏼
I love your videos a lot, I'm so glad I found your channel. I have several disorders where I can't sleep at night. I have zolpidem and xanax and my doctor encourages me to take them so I can sleep, but I hate taking them because they take hours to take effect and I don't want to sleep deeply and have nightmares. Also I feel I have to be hypervigilant at night in case someone tries to break into my house. I can sleep only when the sun is coming up and only sleep 4-5 hours a day. I tried melatonin several times but it gives me a headache. I can't seem to relax at night but someone told me to try ashwagonda root supplement? I don't know the correct spelling. Do you have any thoughts on this supplement?
@@Stopnormalizingviolence thank you for your feedback. While I haven’t specifically covered this aspect - for nightmares one has to look at noradrenaline and the amygdala - nightmares occur due to an unsilenced rem sleep which requires Noradrenergic silencing. For this clonidine and prazosin are very very useful. Often not included under the banner of insomnia medications but very useful for insomnia which is disturbed by nightmares. You can discuss this with your doctor . Ps mot medical advice. Here is a video on this th-cam.com/video/TioM9NymZXc/w-d-xo.html
@@PsychiatrySimplified Thank you so much! I watched this and I'm definitely going to ask my doctor about those 2, though I know the last time I brought up trying something different, he felt I was already on enough. Bupropion, Tramadol, Adderall, Meloxicam Levothyroxine, Zyrtec, then my occasionals, Zolpidem, and Xanax but I can't go on barely sleeping. I appreciate this advice, thank you.🙏
Excellent vid.,thx
Thanks for the feedback 🙏
Sir, Can I take advice from you of my case in detail,thc
For me it’s waking up around 3 times a night every night. It’s to the point now where I don’t even bother trying to sleep at night. And when I was younger I’d wake up at 3 o clock on the dot every single night. No idea why but it’s always happened
Allow me to clarify 1 thing. 14 is when I remember is starting it could of started even sooner.
Was a sleep study ever done? And is it vivid dreams or nightmares that head to the waking up? These are treatable if they significantly affect once functioning. Lack of sleep can significantly affect health over the long term. Please see a doctor who could assist you with this. Wish you well
Great Video. After getting off Cymbalta have insomnia. SO bad that I have to now be on Klonopin. Why did Cymbalta create insomnia. Was on lowest 20mg dose.
Cymbalta or any Serotonergic agent after cessation can result in REM rebound - Increasing noradrenaline NA ( especially as one of the mechanisms of Serotonergic potentiation is to reduce amygdala NA activity. So removal results in a rebound) . This is not uncommon.
My sleep was fine up until around 2 months ago. I had a prescription for Remeron that was supposed to be for sleep. I had rarely used it every few months and when I did it was no more than 7.5mg. In October I started taking it consecutively for around 10 days and my life completely turned around for the worst. Severe agitation, insomnia, heart always racing etc. The psychiatrist said that's not possible, probably to cover for herself when it comes to liability. I had the same experience when I took prednisone for 5 days back in 2014, it took 6 months to recover. Psychiatrists may offer a lot of help to people, but these drugs can also wreck your life as well.
Sorry to hear. Mirtazapine can lead to this side effect in some individuals . 28 percent of individuals can also have restless legs syndrome activated . Activation is uncommon hence in general psychiatrists may not pick it up . When this happens it can indicate clues to the nature of insomnia and the need to evaluate further or consider medication hypotheses differently. Prednisone is known to lead to activation . This can indicate the presence of an underlying mixed state as a possibility. Ps not medical advice . We have covered this in another video . I’ve covered the range of medications here psychscenehub.com/psychinsights/neurobiology-sleep/
@@PsychiatrySimplified the issue with psychiatry is that it’s subjective. You don’t go to an appointment and get an injection in your brain to figure out what’s going on, it’s really just a best guess. All these symptoms on the DSM could be a multitude of other things. In the medical world, there’s so much ego that doctors can’t admit that they’re wrong or don’t know something.
So many terrible stories resulting from medication. Did you manage to get back to some kind of normal sleeping? Did your heart settle down?
This may sound stupid but it has worked for me on several occasions, but may not work for others. If you have a dream, it doesn’t matter how weird it is, try to remember it, or write it down. When you go to bed the next night, and when it’s quiet, close your eyes and think of the dream you had the night before. I don’t know what happens, but maybe the brain thinks “let’s continue on with the dream” and after a while, off you go to sleep and dream part of the same dream you had the night before and continue on sleeping. Just a suggestion you might try.
I work as a psych provider in the US and after being diagnosed with fluoroquinolone poisoning from ciprofloxacin I barely sleep even with heavy doses of eszopiclone going on for 4 months like 2-3 hours a night. It’s a nightmare. I never used to have a problem with sleep. I’ve never encountered it in practice, but it’s unreal. I’ve talked to the FDA about updating the black box warning in the US and adding to REMS. I later found out they’re NMDA agonists and GABA antagonists. Basically ruined my life and can barely practice medicine anymore. Hoping I can recover at some point.
So sorry to hear. If insomnia is triggered as a result - as you say, the mechanism involves GABA antagonism and NMDA activation - agitation may be a possibility hence benzodiazepines may not provide the full benefit. PS, not medical advice. Wish you well.
Did you get better?
@@tonberrykinged Fully recovered other than some annoying dark floaters in my eyes and sometimes mild palinopsia. Took 10 months or so.
@@seasidepatio832 Well that's good to hear. Good effort. I once struggled with palpitations and insomnia after I combined energy drinks with antibiotics. Took me 6 months to get rid of the palpitations but the insomnia was tough to shake. To this day I can't have a single cup of coffee unless I want to stay up until 4am!
Dear Dr. Sanil. I'm taking Effexor XR 150mg since last 8 years. It's no more available in my country, I don't want to switch to generic. Can I abruptly stop it and switch to Prozac ? Will I still have withdrawals ?
Sorry I was late to this. Switching strategy depends on half life. It’s very difficult to answer as things to take into account are - combination of two Serotonergic agents when stopped ( half life of venlafaxine is short) 2. Withdrawals - venlafaxine can have withdrawals 3. Fluoxetine may prevent these withdrawals 4. Relapse of original symptoms as fluoxetine dose may in initial stages may not suffice - so it’s a matter of adjustment and monitoring. Ps not advice
Hi Dr Sanil. Very interesting and helpful all your videos. I got got few questions to ask about one of my close friends. The person got mental breakdown in April. Doctor prescribed Mitrazapine 15mg. All symptoms disappeared and was OK for about two weeks and relapse the condition in May. Then Doctor prescribed Ariprozole 10mg and Mitrazapine 30mg. June and July this person was behaving like robot. However now I can see much improvement. Now this person going to gym and cycling 3 days per week. This person always says don't feel very natural sleep (but getting enough sleep), can't laugh or no sense to do things. Something not right. Eventually will this person be normal?
It is difficult to comment without an examination but this sounds like EPSE from aripiprazole ( dose may be too high) . Parkinsonian side effects can lead to apathy, mask like facies . It may mean a dose adjustment. This is best discussed with the doctor.
Dr Sanil, Thank you very much for the reply.
This person's Doctor prescribed Aripiprazole 5mg one day, 10mg other day.
Is there a particular reason?
@mush_touch on INSTAGRAM he sells psychedelics proven is a big statement - these are still small sample sizes. While they may be beneficial for a self selected group they are far from evidence based as a routine treatment for many psychiatric disorders.
Nice video. I took Cappuccino coffee for the first time late in the night around 12am without knowing the effects. I couldn't sleep again for days, on the 4th day I took Amitriptilin 25mg for 2 days and 10mg on 3rd day. I stopped when I discovered it was not helping me to sleep. I only have insomnia and mild tremor as symptoms. Can it wear off on its own?
This is an unusual reaction to caffeine, and it may have triggered off underlying insomnia or activation. Please see a medical doctor to rule out other causes, especially with a tremor present. Wish you well.
Sir
I have a urgent question
Sir I haven't slept from last 2 days
Sir I am suffering from OCD, Somatoform disorder, Schizotypal personality traits., hallucination, delusion
I am currently on Fluvoxamine and Aripiprajole.
Sir Can I take Plant based Gaba supplement with SSRI Fluvoxamine and Aripiprajole? Is plant based gaba safe to take?
I shall be very grateful to you
We cannot advise in situations like this. This would be irresponsible. Please see a medical professional. Wish you well
Do you know whether the DORA-orexin antagonists are very helpful for insomnia? Are they more effective than zolpidem? Mini patients of mine have developed a tolerance to the 5 mg zolpidem and are asking for the 10 mg dosing- i’ve never prescribed the DORAs nor have I met anyone that has taken them- I’d really like to hear more about efficacy in the real world
Good question - depends on the presentation.
according to the flip flop switch model in insomnia - orexin is one player in the sleep system. ( covered in video on neuro biology of sleep) - Gaba silences orexin neurons - to promote sleep. ( benzodiazepines & Z drugs)
Principle is that sleep can be ‘induced’ by silencing LC ( NA ) ( clonidine / prazosin) or histaminergic ( anti histamines / z drugs) or orexin neurons ( lemborexant / DORA). In some patients the hyper arousal - agitation ( e.g agitated depression with early morning awakening or nightmares in ptsd ) is so significant that all 3 may be required in lower doses ( as opposed to one high dose) - synergy. Individuals with adhd particularly have PFC dysregulation which means the NA and DA needed to control hyper arousal is significantly affected. This tends to be more significant in females. LC being more sensitive. So in summary - if hyperarousal is present Rx that initially : lemborexant on it's own may not help in patients with psychiatric issues and comorbid insomnia.
another example ( only one of other mechanisms) of the ‘why’from neurobiological perspective - amygdala ( part of limbic circuit) receives heavy innervation from NA neurons ( activation ). So when activated - hyper arousal. But LC neurons only have Orexin 1 receptors not OX2. OX2 is needed for NREM sleep. OX1 not much role in sleep . So agents like orexin antagonists like lemborexant ( ox1 and ox2) will not work optimally in Limbic derived hyperrousal as NA ⬆️ not addressed.
In summary lemborexant can act as a good augmentation agent in psychiatric practice ( as many patients have above agitation or sleep arousal) - but in primary care or insomnia without other causes- lemborexant on it's own may work. Hope this makes sense. clinically this more likely to work on milder presentations of insomnia without comorbid significant psychiatric overlay Article on dora - psychscenehub.com/psychinsights/lemborexant-mechanism-of-action-psychopharmacology-clinical-application-2/
@@PsychiatrySimplified thank you very much for the detailed response- very helpful!
My insomnia started almost 4yrs ago Unsurprisingly depression came along soon after insomnia was present. I’m a single mom of an 3,5yrs old, my psychiatrist prescribed me mirtazapin. Starting 15mg, than 7,5mg than just a Tipp of it, cause unfortunately it crashes me in such a deep sleep, that when waking up I feel like “drunk” as if my body was awake but my brain is still on sleep mode. So for me it turned out to be to strong. Especially while being responsible for a small child, work, and so on. Also tried Zolpidem same results.
could you suggest something that doesn’t effect being so druzzy ? That helps you sleep but able to wake up with energy? Any other solution I could talk about to my psychiatrist. I really want to get out of this loop 😔
Ask your doctor about low dose trazadone..12.5..
Ask your doctor about Quviviq....per clinicals trials no daytime drowsiness
While we can’t provide medical advice - agents such as Vortioxetine are helpful. But mixed features should be ruled out in which case a combination may be needed depending on the nature of insomnia. Ps not advice
Get off the meds! Please take a look at the other stories on here, there's a common thread - drugs are causing a huge problem. Even the sleep medication.
Everyone's different, but here's what helped me:
* Cutting out caffeine completely (turned out I was hyper sensitive to caffeine, even one coffee in the morning was too much. Decaff has a third of the amount of caffeine as a normal cup, so I have to be v careful with that too.
* Magnesium breakthrough supplement: contains multiple types of magensium which helps with sleep.
* Dim lights and no screens from 9pm at night - find something that chills you out!
* Getting outside for 30 mins first thing in the morning (sets your circadiam rythm)
* Learning Qi Gong - particularly those designed for sleep
* Trying meditation (I'm still not very good at it, but deep slow breathing does help - the out breath is key)
* Acupuncture (first 2 sessions worsened my sleep, but after that it started to help)
Anyways, I hope you have success.
Sir, where does the human brain store visual long term memory of shapes ?
Store likely temporal lobe but then retrieval, recognition etc involve parietal and occipital love ( visual cortex areas)
@@PsychiatrySimplified thanks a lot sir.
Hi please help
I'm 26 years old guy who gone through major depression and anxiety last year. My doctor prescribed me "Remeron 15 mg+ sertraline 50 mg+ Clopramin 25.
I'm taking these medication
Note that before take those medication also dream everynight. I have been facing this for 1.5 years everything okay except Sleep. Cause i have meaningless dream every night which made me tired and effect my temper.
And day time if i feel sleepy i go to bed but i can not sleep. I get shivering in my body and wake up.
How to solve this please help.
We cannot provide advice. But if one is experiencing vivid dreams or nightmares that interfere with sleep 1. One should ensure the medication combination is not activating 2. If dose reduction is not indicated or doesn’t help then clonidine or prazosin are effective agents ( see video) - PS not advice
I have PTSD from a serious fall and traumatic event of falling down several flights of stairs. Does CBD help 🤔
It really depends as PTSD has several domains to address . Insomnia with PTSD involves hyperarousal , rem sleep dysfunction , hypervigilance during the day - at milder levels CBD could help with insomnia potentially - but at more significant levels unlikely . It depends on the overall constellations of symptoms and the severity. Your doctor will be able to explain
What about people suffering chronic pain or any kind of pain🤫🤔 if you were any kind of a specialist in sleep issues I would think you would have at least mention it🤣😴
The aim wasn’t to provide an overview of insomnia basics not insomnia with each comorbid condition. To read about detailed principles that apply to pain conditions as well 👉psychscenehub.com/psychinsights/neurobiology-sleep/
10 years can’t fall asleep
Hopefully you can see a doctor to address it