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Advances in Sleep Disorders: What’s New Under the Moon? More than half of all psychiatric patients complain of disturbances of sleep and wakefulness. Sleep disorders are associated with impaired daytime function and predict a heightened future vulnerability to psychiatric illness. They are also associated with physiological impairments and diminish lifespan. Their comorbid presence complicates psychiatric disorders, and their management may offer the potential for greater efficacy in the alleviation of emotional symptoms. These were some of the key points made by Karl Doghramji, M.D., a professor of psychiatry, neurology, and medicine at Thomas Jefferson University, in an “Advances in Medicine” seminar at APA’s 2012 annual meeting. He updated attendees on new developments in understanding and managing a variety of sleep disorders, including insomnia, narcolepsy, sleep apnea syndrome, circadian rhythm disorders, and the parasomnias. Doghramji noted that recent research has raised the possibility of a shared genetic bases for certain sleep disorders, notably circadian sleep disorders, such as delayed sleep phase syndrome, with mood disorders. These data raise the possibility that circadian misalignment may underlie certain mood disorders and that the correction of this misalignment may offer additional benefit in the management of refractory depression, especially in the context of bipolar disorder. Doghramji clarified changes in nosology in sleep disorders that are likely to be incorporated into the DSM-5 sleep disorders section and reviewed the rationale for these changes. He noted that DSM-5 will likely “lump” primary and secondary insomnia categories into one category of “insomnia disorder.” He also noted that the rationale for this is derived from emerging data suggesting that insomnia appears to follow a relatively independent course in the context of psychiatric disease, blurring potential lines of etiology and raising the possibility that, at least in certain settings, insomnia may represent an independent clinical condition that requires focused and specific management. DSM-5 will, however, likely allow for the specification of comorbid conditions that accompany insomnia disorder. Other potential changes include the provision of greater detail regarding impairments associated with insomnia, which are now known to be extensive, and the addition of criteria for duration and frequency. From a clinical perspective, Doghramji emphasized the following take-home messages: • Insomnia and daytime sleepiness can no longer be viewed as sole manifestations of psychiatric disease, even in the psychiatric context, raising the importance of a thorough differential diagnostic evaluation that includes nonpsychiatric comorbidities and primary sleep disorders. • The independent management of underlying sleep disorders may therefore be a necessary factor for the management not only of sleep complaints, but also of emotional and cognitive symptoms. • Regarding insomnia, consideration should be given to the use of cognitive-behavioral therapy, whose efficacy in achieving remission is superior to that of pharmacotherapy alone. • The armamentarium of pharmacological agents available for insomnia has increased substantially over the last few years and has seen the emergence of agents with novel mechanisms. This trend will likely continue. It is now more possible, therefore, to tailor agents to specific sleep/wake complaints. • Societal demands for greater productivity at the expense of sleep seem threaten to impact the health and welfare of many individuals; thus, psychiatrists are well served to carefully examine the possibility of sleep deprivation, that is, self-imposed sleep curtailment, in their patients. |
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Copyright © 2012 American Psychiatric Association. All rights reserved.