Conference Coverage

Treat insomnia as a full-fledged disorder



CRYSTAL CITY, VA. – Insomnia is a neuropsychiatric disorder of hyperarousal that should be evaluated as a disorder and treated with any associated comorbid conditions, Karl Doghramji, MD, said at Focus on Neuropsychiatry presented by Current Psychiatry and the American Academy of Clinical Psychiatrists.

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“When I was a resident, I used to say insomnia is never a disorder. It’s always a symptom; you’ve got to find the primary disorder to know what the insomnia is caused by,” said Dr. Doghramji, medical director of the Jefferson Sleep Disorders Center at Jefferson Medical College, Philadelphia. “We no longer believe that. Throw that out the window.”

According to the new definition under the DSM-5, insomnia is characterized by dissatisfaction with sleep quality or quantity in the presence of adequate opportunity for sleep that causes significant distress or impairment for more than 3 nights per week over a period of 3 months. A survey of almost 7,500 U.S. health plan subscribers conducted a few years ago found that the prevalence of insomnia was estimated at 23.2% (Sleep. 2011 Sep 1;34[9]:1161-71).

Insomnia is also not well identified in clinical practice: In results published from his own group, Dr. Doghramji and colleagues evaluated 97 patients who were administered the Insomnia Severity Index; of those patients, 79.4% met the criteria for insomnia, but there was no mention of insomnia in the discharge notes for those patients (J Nerv Ment Dis. 2018 Oct;206[10]:765-9).

Many cognitive impairments can occur as a result of insomnia, which affects performance at work; decreases enjoyment of social activities; can lead to motor vehicle accidents or falls; and can affect health in the form of diabetes, hypertension, and increased mortality. Insomnia also can predict the risk of future depression and is a risk factor for suicide, Dr. Doghramji said at the meeting presented by Global Academy for Medical Education.

Adults can have insomnia for many reasons, including genetics, stress, negative conditioning, intrapsychic conflict, and bad habits, as well as medical and psychiatric conditions. While knowledge surrounding insomnia has advanced under a hyperarousal model, “It is really a hyperarousal disturbance which defies psychological understanding,” said Dr. Doghramji, who is also professor of psychiatry, neurology, and medicine at the university.

Evaluating the type of insomnia a patient is experiencing should be the first step in managing the disorder, followed by determining whether the insomnia is contributing to daytime impairment or decreased quality of life for the patient. From there, the insomnia can be treated with behavioral or pharmacotherapy. However, if insomnia is associated with another comorbid condition, the condition should be treated alongside the insomnia.

Sleep is highly comorbid with psychiatric and medical conditions (Sleep Med Clin. 2019 Jun;14[2]:167-75). Initial insomnia is more likely to be associated with delayed sleep phase disorder and restless legs syndrome, while middle insomnia is associated with sleep apnea and depression. Patients who wake early and are unable to go back to sleep (terminal insomnia) are likely to have depression, shift work disorder, or advanced sleep phase disorder.

“Once you identify [insomnia], there are all sorts of wonderful ways to manage it, including behavioral and pharmacological therapy,” said Dr. Doghramji. The comorbid condition also should be considered when deciding how to treat insomnia. For example, a patient with gastroesophageal reflux disease and insomnia would be more suited to cognitive-behavioral therapy than pharmacologic agents to help with sleep, because being able to wake up during the night from acid building in the esophagus is the body’s defense mechanism for the disease, Dr. Doghramji said.

Dr. Doghramji reported serving as a consultant for Eisai, Merck, and Pfizer. He also receives research funding from and owns stock in Merck.

Global Academy for Medical Education, Current Psychiatry, and this news organization are owned by the same company.

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