Week 12 Basic Psychopharmacology For Counselors And Psychotherapists

WEEK 12- Basic Psychopharmacology for Counselors and Psychotherapists - Chapter 11 CHAPTER ELEVEN: TREATMENT OF SLEEP DISORDERS
Instructor: Jeff Garrett Ph.D.

Objective: To explore sleep disturbances, primary sleep disorders and parasomnias. Various treatment issues and options will be presented and discussed.

Topics to be addressed:· Stages of sleep.· Sleep disorders and conditions.· Behavioral techniques for treating sleep disorders.· Pharmacology for sleep disorders.· Holistic treatments.

Sleep DisturbancesInitial insomnia - difficulty falling asleep.Middle insomnia - intermittent awakening throughout the night.Terminal insomnia - awaken early morning with difficulty falling back to sleep.

STAGES OF SLEEPFive Stages of Sleep
Stages 1 and 2- The theta stages, are rather light stages of sleep.- If patients' names are called out during these stages they would probably awaken without feeling groggy.- People spend about 50 percent of sleep time in stages 1 and 2.

Stages 3 and 4- The delta stages of sleep, are characterized by slow-wave patterns and very deep, restorative sleep.- Shaking the patient is necessary to awaken him or her, and the patient would be groggy.- People spend about 20 percent of their sleep time in these stages.

Stage 5- The rapid-eye-movement or REM stage.- It occupies about 25 percent of the night and is characterized by both theta- and beta-type activity that resembles the wave patterns seen while awake.Most dreams occur during this stage.- If patients are sleep deprived, they will demonstrate additional time spent in stages 3, 4, and REM during their next sleep period, which is called the rebound phenomenon.

Neurotransmitters During Sleep
- Serotonin is necessary to maintain adequate sleep, especially in stages 1-4.- Norepinephrine is necessary for stage 5, REM sleep.- Depressed patients with lower levels of serotonin and norepinephrine experience problems with the quality of their sleep.

SLEEP DISORDERS AND CONDITIONS
- Co-occurring mental illness and sleep disturbances will report either initial and/or terminal insomnia.- Initial insomnia is usually indicative of an anxiety disorder such as generalized anxiety disorder, or an adjustment disorder with anxious mood.- Middle insomnia (intermittent awakening) is usually indicative of an affective component, such as major depression, schizoaffective disorder, dysthymia, or an adjustment disorder with depressed or mixed features.- A primary care physician or neurologist should evaluate the patient for the presence of other dyssommas or primary sleep disorders.- The following list describes a few that may affect the patient:

Primary Sleep Disorders
1. Obstructive Sleep Apnea (OSA). - A milder form is called upper airway resistance syndrome.- Common in overweight, middle-aged men.- Medications are usually not used.

1. Obstructive Sleep Apnea (OSA). - A milder form is called upper airway resistance syndrome.- Common in overweight, middle-aged men.- Medications are usually not used.2. Sleep Bruxism.- Sleep-related teeth grinding is a parasomnia much more common among children, but it can be seen in adults during times of stress.- Psychotherapy and/or anxiety-reducing medications may improve this condition.3. Sleepwalking and Night Terrors.- Typically seen in about 10 percent of children.- Since they are usually outgrown, the use of medications such as benzodiazepines is not recommended for children or those patients with a history of substance dependence.4. Narcolepsy.- Uncontrolled attacks of short-duration, restful sleep.- The attacks are usually triggered by strong emotions such as laughter or anger.- Narcolepsy is typically treated with various psychostimulants e.g., methylphenidate (Ritalin).5. Restless Legs Syndrome (RLS) and Periodic Leg Movement Disorder (PLMD).- Often occur together, but they are distinct entities.- Patients feel restless or jittery and may not be able to relax.- Treatment for both disorders involves either the use of benzodiazepines such as clonazepam (Klonopin) or the use of dopaminergic agents such as levodopa/carbidopa (Sinemet) or pramipexole (Mirapex).- In severe cases, opioids may be considered.

2. Sleep Bruxism.- Sleep-related teeth grinding is a parasomnia much more common among children, but it can be seen in adults during times of stress.- Psychotherapy and/or anxiety-reducing medications may improve this condition.

3. Sleepwalking and Night Terrors.- Typically seen in about 10 percent of children.- Since they are usually outgrown, the use of medications such as benzodiazepines is not recommended for children or those patients with a history of substance dependence.

4. Narcolepsy.- Uncontrolled attacks of short-duration, restful sleep.- The attacks are usually triggered by strong emotions such as laughter or anger.- Narcolepsy is typically treated with various psychostimulants e.g., methylphenidate (Ritalin).

5. Restless Legs Syndrome (RLS) and Periodic Leg Movement Disorder (PLMD).- Often occur together, but they are distinct entities.- Patients feel restless or jittery and may not be able to relax.- Treatment for both disorders involves either the use of benzodiazepines such as clonazepam (Klonopin) or the use of dopaminergic agents such as levodopa/carbidopa (Sinemet) or pramipexole (Mirapex).- In severe cases, opioids may be considered.

Sleep Study
- For serious sleep disturbances, the clinician should order a complete sleep study or nocturnal polysomnogram (NPSG).- Data are recorded from electroencephalogram (EEG) or brain-wave activity electrocardiogram (EKG) and pulse facial muscle movement leg muscle movement respiratory effort (chest and abdominal wall excursion) oxygen saturation and carbon dioxide output.- If the patient is concerned about taking a prescription sleep medication, the clinician can suggest over-the-counter sleep aids such as Nidol, Sominex, Tylenol PM, or even Benadryl (brand of diphenhydramine).

BEHAVIORAL TECHNIQUES FOR TREATING SLEEP DISORDERS
- Behavioral approaches such as relaxation training and biofeedback may be helpful.- Many professionals use these behavioral techniques along with various medications for both immediate and lasting relief. A- All patients with sleep disturbances should consider these sleep-hygiene tips:

Sleep-hygiene Tips
1. Reduce or eliminate the use of nicotine, alcohol, caffeine, or other stimulating substances, except those suggested by a health-care provider.2. Try to maintain a regular sleep-wake cycle, that is, sleep and rise at the same time each day.3. Avoid napping during the day unless advised to do so.4. Use the bed only for sleeping and sex, not for thinking, working, reading, or watching TV.

Sleep-hygiene Tips
5. Try to relax and unwind an hour before going to bed.6. Try not to go to bed hungry; a light snack is permissible an hour before bed.7. If you cannot sleep, don't lie there staring at the clock. Get up, read, watch TV, or engage in a nonstimulating activity in another room until you are tired.8. Often moderate exercise during the day, or light exercise, such as walking an hour or so before bed, helps you to feel tired and sleep better.

Sleep-hygiene Tips
9. A warm bath before bed helps to relax sore muscles and induce sleep.10. Make a fist two hours before bed of all activities you need to accomplish the next day. This will reduce the need to dwell on them while you are trying to relax and sleep.11. Counseling or psychotherapy helps identify issues and reduce stress associated with sleep disturbances. Professionals can assist patients with coping skills and relaxation training.12. Adjust temperature and noise and light levels in the room before you retire.

PHARMACOLOGY FOR SLEEP DISORDERS
- Sedative-hypnotics are indicated for most sleep disturbances.- Diphenhydramine (Benadryl) or other antihistamine hypnotics are used for intermittent insomnia.- Should not use these medications, especially the benzodiazepines, for more than two to three weeks.- Barbiturates such as amobarbital (Amytal), phenobarbital (Nembutal), and secobarbital (Seconal) are not used much today because they have a narrow therapeutic index, a high potential for abuse, and may interfere with normal sleep cycles.

PHARMACOLOGY FOR SLEEP DISORDERS
- Sedating antidepressants may be helpful assuming a mood disorder.- Eszopiclone (a nonbenzodiazepine) was approved by the FDA early in 2005 for both short- and long-term treatment of insomnia, because it may pose less of an abuse and tolerance risk.- Melatonin is an endogenous chemical produced in the pineal glad that depletes w/ age and the use of aspirin and ibuprofen. Studies suggest that 0.5-3 mg/day of melatonin may reduce the effects of insomnia.- For chronic sleep problems a sleep study, physical examination, and psychotherapy.

Medications Used in Treating Sleep Disturbances
TRADE / GENERIC / TYPICAL DOSE MG-DAY / ONSET OF ACTION.BenzodiazepinesDalmane / flurazepam / 15-30 / rapid.Doral / quazepam / 7.5-15 / rapid.Halcion / triazolam / 0.125-0.25 / rapid.Prosom / estazolam / 2-4 / rapid.Restroil / temazepam / 15-30 / intermediate.ImidazopyridineAmbien / zolpidem / 5-10 / rapid.PyrazolopyrimidineSonata / zaleplon / 10-20 / rapid.OtherLunesta / eszopiclone / 2-3 / rapid.

HOLISTIC TREATMENTS
KavaKava has been used in the South Pacific for thousands of years.Its action is similar to a sedative-hypnotic, because it appears to bind at the GABA receptors.It acts much like a benzodiazepineIt may increase the risk of liver damage with prolonged use.
ValerianValerian (or valerian root) has been used as a mild sedative, anxiolytic, and antidepressant.Since GABA itself is a component of valerian, scientist and holistic advocates believe that valerian is a source of naturally occurring GAGA.However, since GABA crosses the blood-brain barrier poorly, valerian is an unlikely source of GABA that would affect the central nervous system.

Week 12 Basic Psychopharmacology For Counselors And Psychotherapists

by Jeff Garret on Jul 07, 2009

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Week 12 Basic Psychopharmacology For Counselors And Psychotherapists — Presentation Transcript