EU_Psychiatry_Mignot_Capasso_quark6.qxp 30/6/08 02:20 Page 47
Diagnosis and Management of Common Sleep Disorders – An Overview for the Psychiatrist
medication use.
19
The major property to consider for prescription is half-life dopamine agonists (talipexole, cabergoline, piribidel and alpha-
and duration of action. Zaleplon, for example, acts for only two to three dihydroergocryptine) and the dopaminergic agents amantadine and
hours, and may be useful for sleep-initiating difficulties or early-morning selegiline may be effective in the treatment of RLS and PLMD, but the
insomnia in jet-lag. Zolpidem and zolpidem CR or eszopiclone are effective level of effectiveness of these medications is not currently established.
for five to six hours and six to seven hours, respectively.
19,20
Lastly, no specific recommendations can be made regarding
dopaminergic treatment of children or pregnant women with RLS or
Ramelteon, a selective melatonin receptor agonist, was recently approved PLMD.” The use of dopamine agonists is generally thought to be
for the treatment of insomnia. This compound has more of an effect on preferable to that of L-DOPA on a chronic basis. Opioids and
sleep onset than sleep maintenance
22
and thus may be less effective in benzodiazepines are commonly used for the treatment of these
the overall treatment of insomnia, but also has less potential for conditions as a second intention; however, the risk of drug dependence
dependence and thus may be more appropriate for patients with a must be considered.
history of substance abuse. Antihistaminics and sedating antidepressants
(mirtazapine, trazodone) lack objective evidence for their use as Importantly, RLS can be secondary to medical disorders, including
hypnotics, but are commonly used.
8
The mode of action of these drugs is iron deficiency, neuropathies and renal disease. Ferritin levels should
the blocking of the H
1
receptors or of the 5-HT
2
receptor. A problem with be investigated in these patients: if below 45–60mg/ml, iron
supplementation should be considered.
Insomnia may be treated with cognitive
Hypersomnia/Excessive Daytime Sleepiness –
Disease and Symptoms
behavioural therapy and instruction in
The International Classification of Sleep Disorders (ICSD) defines excessive
sleep hygiene, either alone or in
daytime sleepiness (EDS) as “the inability to stay awake and alert during the
major waking episodes of the day, resulting in unintended lapses into
association with hypnotic medications.
drowsiness or sleep”.
25
Several factors may cause hypersomnia,
including medical and neurological conditions (e.g. rheumatological
disorders, congestive heart failure, cancer, hypothyroidism, anaemia,
these compounds is that they have not been designed for hypnotic use, neurodegenerative disorders such as Parkinson’s and Alzheimer’s disease,
and often have a long duration of action, leading to daytime sleepiness head trauma and encephalitis), primary sleep disorders (sleep-disordered
and morning grogginess. breathing [SDB], PLMs, idiopathic hypersomnia, narcolepsy) and medication
use or withdrawal (opioids, anticonvulsants, antidepressants, illicit drugs). In
Restless Legs Syndrome and Periodic a population-based study, hypersomnia was associated with psychiatric
Limb Movements of Sleep disorders in 46.5% of cases.
26
It is important to bear in mind that although
Despite being different clinical entities, RLS and periodic limb medical, neurological or psychiatric illness or medication side effects can be
movements of sleep (PLMs) are usually discussed together due to the a cause of sleepiness, insufficient sleep is the most common cause of EDS in
high chance of co-existence, a similar genetic predisposition and the general population.
the use of similar treatments. They generally present with insomnia,
restless sleep and/or excessive daytime sleepiness, and they may be
present in as many as 25% of patients who have sleep disorders. RLS
Despite being different clinical
is common and is severe in 3–4% of the population.
23,24
It is more
entities, restless legs syndrome and
common in females (especially during pregnancy), is often familial and
is exacerbated by neuroleptics. All patients with a sleep problem should
periodic limb movements of sleep are
be evaluated for RLS.
usually discussed together due to the
RLS is a sensorimotor disorder characterised by a nearly irresistible urge
high chance of co-existence, a similar
to move the legs. It is often accompanied by other dysesthesias or
genetic predisposition and the use
paresthesias occurring primarily at rest and at night, and is alleviated
of similar treatments.
by movement. RLS is frequently associated with PLMs,
25
which are
repetitive movements that affect one or both legs and usually occur
during NREM sleep. PLMs is sometimes associated with awakening. The The atypical features specific to a mood disorder episode include
typical movement found in PLMs is a flexing of the ankle, knee and hip hypersomnia as a diagnostic feature in the diagnostic criteria from the
with an extension of the toes. PLMs is found in 80% of RLS patients Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
undergoing polysomnogram.
23
Revision (DSM-IV-TR).
27
An association between hypersomnia and a mood
episode is reported in 16–20% of patients;
28
however, there is a paucity
According to the Standards of Practice Committee of the American of objective findings documented. Nofzinger et al.
29
performed a multiple
Academy of Sleep Medicine (AASM), The Practice Parameters for the sleep latency test (MSLT) to objectively evaluate daytime sleep latency in
Dopaminergic Treatment of Restless Legs Syndrome and Periodic Limb depressed patients, and the results did not show abnormalities, suggesting
Movement Disorder
24
states that: “levodopa with decarboxylase that the hypersomnia in such patients is a subjective complaint. As a result,
inhibitor, and the dopaminergic agonists pergolide, pramipexole and hypersomnia in a psychiatric context is difficult to evaluate and treat. A
ropinirole are effective in the treatment of RLS and PLMs. Other misdiagnosis may result in gross mismanagement (e.g. the use of
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