Diagnosis and Treatment Insomnia for primary care physician
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This curriculum vitae outlines the education and experience of Dr. Andri, including obtaining a medical degree from the University of Indonesia in 2003 and specializing in psychiatry there in 2008. He has additional training in psychosomatic medicine from American and European institutions between 2010-2014. He currently works as a psychiatrist lecturer and head of the psychosomatic clinic at Omni Hospital. The document provides details on his competencies, sample cases, and a presentation on insomnia and related disorders.
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Diagnosis and Treatment Insomnia for primary care physician
- 1. Curriculum Vitae Nama : Dr.Andri,SpKJ,FAPM Pendidikan : Dokter : Fakultas Kedokteran Universitas Indonesia (Lulus 2003) Psikiater : Fakultas Kedokteran Universitas Indonesia (Lulus 2008) Pendidikan tambahan di bidang psikosomatik medis dari American Psychosomatic Society di Portland, Oregon, USA tahun 2010 dan Academy of Psychosomatic Medicine di Atlanta, USA 2012, di Tucson 2013 dan di Fort- LeDaurdale 2014 Pengakuan sebagai Fellow of The Academy of Psychosomatic Medicine (FAPM) November 2013 Organisasi : IDI PDSKJI American Psychosomatic Society Academy of Psychosomatic Medicine Jabatan : Dosen Psikiatri di FK UKRIDA, Jakarta Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera
- 2. 4th Update inPsychosomatic Medicine “Insomnia andItsRelated Disorder” A N D R I Klinik Psikosomatik RS OMNI Alam Sutera, Tangerang Selatan
- 3. Kompetensi 4A Insomnia Gangguan Somatoform Kompetensi 3A Gangguan Campuran Cemas dan Depresi Gangguan Psikotik 144 Diagnosis 155 Diagnosis Masalah Keswa di Fasyankes Primer Di Indonesia
- 4. Ilustrasi Kasus 1 Wanita 32 tahun, kesulitan memulai tidur. Dia mengatakan memang sering sulit tidur sejak usia 20an. Setiap minggu ada sekali sulit tidur. 3 bulan terakhir pasien merasa tidurnya makin sulit Tidak ada riwayat gangguan jiwa sebelumnya Pasien telah ke dokter umum dan diberikan alprazolam 0.25mg untuk membantu tidurnya. Seminggu pakai, pasien merasa khawatir akan ketergantungan walaupun tidurnya membaik. Belakangan setiap menjelang sore, pasien menjadi cemas khawatir tidak bisa tidur. Kualitas hidup terganggu terutama dalam bekerja karena ngantuk di siang hari walaupun tidak bisa tidur dan sulit konsentrasi
- 5. Introduction 30-50% of American adults experience insomnia during a 1 year period Prevalence of chronic/severe insomnia is 10% 49% of adults surveyed were dissatified with their sleep > 5 nights per month 50% of patients presenting to primary care physicians experience insomnia NHLBI working group on Insomnia. Bethesda, Md: NHLBI; 1998. NIH Publication 98-4088 Smith MT, et al. Am J psychiatry. 2002; 159:5-11 Hajak G et al. Eur Psychiatry. 2003; 18:201-8 Ringdahl EN et al. J Am Board Fam Pract. 2004; 17:212-219
- 6. Normal Aging Changes In general, with advancing age, sleep becomes more fragmented, More time is required to fall asleep More awakenings occur Relatively less deep sleep is experienced, People tend to spend more time in bed. It is common for elderly hospitalized patients to report not sleeping at all, despite nursing observations of 6–8 hours of apparent sleep, complete with snoring
- 7. SLEEPPATTERNSININSOMNIA Sleep onset insomnia Difficulty falling asleep Longer time to sleep onset Sleep maintenance insomnia Difficulty staying asleep Frequent nocturnal awakenings Sleep offset insomnia Waking too early in the morning Nonrestorative sleep Fatigue despite adequate sleep duration DSM-IV-TR. 4th ed. 2000:597-661 Czeisler CA et al. Harrison’s Principles of Internal Medicine” 15th ed. 2001: 155-163
- 8. Ilustrasi Kasus 2 Pasien wanita 45 tahun,tidak bersemangat hidup sejak 4 bln belakangan ini sjk kasus hukum yg menimpa perusahaannya. Pasien menjadi lebih mengurung diri di kamar, tdk mau melakukan apa-apa. Setiap hari aktifitas hanya tidur-2an di kamar. Kualitas tidur jauh memburuk apalagi, setiap malam pasien terbangun setiap satu jam dan kadang terjaga selama 1-2 jam. Mood depresif, psikomotor menurun, putus asa, tidak ada harapan hidup Tidak ada riwayat gangguan jiwa sebelumnya Fungsi sebelum sakit baik
- 9. Insomnia Associated With Axis I Psychiatric Illness Anxiety disorders Mood disorders Dementia Delirium Psychosis Adjustment disorder Normal disruptions in mental life caused by stressful or grief-producing situations
- 10. Insomnia Associated With Physical Illness Physical conditions associated with pain (e.g., arthritis) with difficulty breathing (e.g., congestive heart failure or chronic obstructive pulmonary disease) immobility (e.g., stroke or Parkinson’s disease) urinary obstruction secondary to prostatism or chronic urinary tract infection. Sleep apnea (30%–40% of elderly patients) and is typically associated with obesity and snoring. Nocturnal myoclonus
- 11. Substance-Induced Insomnia Sympathomimetic agents (including decongestants and bronchodilators) methylxanthine derivatives (such as theophylline and aminophylline), Psychostimulants, Certain antidepressants (fluoxetine, bupropion, higher doses of mirtazapine) Medications containing caffeine Beverages such as coffee and many cola drinks Hypnotic medications
- 12. Inadequate Sleep Hygiene 1. Daytime napping at least two times each week 2. Having variable wake-up times or bedtimes 3. Experiencing frequent periods (two to three times per week) of extended amounts of time spent in bed 4. Routinely using products containing alcohol, tobacco, or caffeine in the period preceding bedtime 5. Scheduling exercise too close to bedtime 6. Engaging in exciting or emotionally upsetting activities too close to bedtime 7. Frequently using the bed for nonsleep-related activities (e.g., television watching, reading, studying, snacking) 8. Sleeping on an uncomfortable bed (e.g., poor mattress, inadequate blankets) 9. Allowing the bedroom to be too bright, too stuffy, too cluttered, too hot, too cold, or in some way not conducive to sleep 10. Performing activities demanding high levels of concentration shortly before bed 11. Allowing mental activities, such as thinking, planning, and reminiscing, to occur in bed
- 13. Pharmacotherapy for general Name of Drug Reaction onset Half Life Dose Main indication Zolpidem 7-27 minutes 5-7 hours 5-10 miligram initiation Estazolam 120 minutes 10-24hours 0.5-2 miligram Initiation and maintaining sleep Ramelteon 45 minutes 2-5 hours 8 miligram initiation Approved by : Food Drug Administration (FDA) USA Lorazepam can be used 0.5-1.0 miligrams for geriatric patients
- 14. Dietary SupplementsforGeneralUse Not FDA regulated !!! Valerian Kava-Kava Melatonin Passion flower Skullcap Lavender Hops
- 15. COGNITIVE-BEHAVIORAL TREATMENT For INSOMNIA Indications Primary Insomnia Psychophysiological Insomnia Inadequate Sleep Hygiene Comorbid Insomnia With a medical condition With a mental disorder Important to combine both cognitive and behavioral components
- 19. COGNITIVE THERAPY Cognitive restructuring Rational-Emotive therapy Specific techniques for rumination Thought-stopping Meditation techniques
- 20. COGNITIVE THERAPY Five domains of cognitive activity hypothesized to contribute to insomnia Worry and rumination Attentional bias and monitoring for sleep-related threat Unhelpful beliefs about sleep Misperception of sleep and daytime deficits The use of safety behaviors that maintain unhelpful beliefs
- 21. BEHAVIORAL TREATMENTS Sleep hygiene education Specific behaviors will directly interfere with the ability to sleep The behaviors can be changed with education No sufficient as a ‘stand alone’ treatment Sleep restriction therapy Increased propensity to sleep by increasing homeostatic sleep drive with partial sleep deprivation Systematic reduction of time in bed to the amount of total sleep time from sleep log data Increase time in bed by 15 minutes only when sleep efficiency exceeds 90% for 5 nights
- 22. Key Messages Do not postpone therapy for Insomnia when diagnosis of insomnia is confirmed When Insomnia is a part of mental health problem, treat the mental disorder as well the insomnia Use appropriate and approved drugs for Insomnia : Zolpidem and Estazolam. Estazolam is good for maintaining sleep When using other Bzd’s like alprazolam or lorazepam, be careful of the effect of long use Do not forget to suggest Sleep Hygiene in the first hand
- 23. Facebook : Andri Andri Twitter : @mbahndi