Insomnia in bipolar

In this study, scientists found that viewing images that evoke negative emotions activates the amygdala, which is responsible for the formation of memory associated with emotional experiences. When non-emotional images were shown, the responses of the two groups were approximately the same, however, the amygdala response to negative emotional images was 60% greater in people with sleep deprivation. nine0003

“When we take a healthy brain and deprive it of sleep, we can see altered brain activity similar to that seen in some mental disorders,” Walker says. Similar hyperactivity in the amygdala has also been seen in mood disorders, and unpublished data from Walker's lab suggests that sleep deprivation may mimic some of the brain processes found in anxiety disorder.

Paradoxical as it may sound, some depressed patients who were deprived of sleep for one night had symptoms of the disease subside the next day. Sleep deprivation is thought to suppress the overactivity of the anterior cingulate cortex, an overactivity that is typical of depression. However, after patients are able to sleep again, the symptoms return, so sleep deprivation is not an effective treatment for depression. This discovery contributed to the emergence of studies looking for the types of sleep involved in this effect. Some facts point to REM sleep (REM). For example, tricyclic antidepressants are thought to work by disrupting PBS. “In some cases, the effectiveness of an antidepressant is related to how well it suppresses FBS,” says Benka. But this is hardly the full picture of what is happening. Benki's group demonstrated that disruption of slow wave production during deep sleep has an antidepressant effect, suggesting that some manipulation of slow wave activity may be effective. Researchers in the Walker lab have suggested a possible mechanism for this effect. They found that when healthy but sleep-deprived people view a series of neutral or positive images, they categorize most of the images as positive, in contrast to sleepy people. They also have increased neuronal activity in the mesolimbic system, which is thought to be responsible for "reward", suggesting that sleep deprivation increases pleasure center activity. These results are a kind of reference to the violent reaction previously discovered by Walker to images that cause negative emotions in very tired volunteers - sleep deprivation, according to the researchers, increases emotional reactivity in general. nine0003

Night improvement

The causal relationship between sleep and affectivity is not yet clear, but the value of treatment is to get people to sleep better. “Such sleep disturbances are quite manageable,” says Alison Harvey, a clinical psychologist at the University of California, Berkeley. “Simple but powerful behavioral changes can lead to marked improvements in sleep and anxiety.”

For example, Frank and her colleagues have developed an approach to treating bipolar disorder that encourages patients to adhere to a daily schedule of waking up, eating, socializing, and sleeping. This method, according to Frank, prevents the occurrence of new attacks in bipolar disorder, and also helps people get rid of depression much faster. This is especially important, because although drugs can control mania, a depressive episode of bipolar disorder is not so well controlled. nine0003

Harvey and her colleagues began to apply similar principles to unipolar depression. She has unpublished data suggesting that if patients manage their sleep disturbances, they are less likely to relapse into depression. Another group found that treatment with cognitive-behavioral therapy, which is used for insomnia, helps to improve the condition of a patient with depression.

Walker refers to sleep as a therapy that lasts throughout the night. During PBS, the phase during which we dream, the brain's production of norepinephrine (also known as norepinephrine) is reduced. Norepinephrine is the brain's form of the stress hormone adrenaline, so its absence during FBS creates a calming neurochemical environment in which the brain can process turbulent events. “It essentially smooths out the sharp edges of the emotional experience,” Walker says. nine0003

This process is disrupted in PTSD because too much norepinephrine is present in patients with this disorder, coupled with insufficient duration of FBS. It is interesting to note that Raskind has discovered that it is possible to treat traumatic nightmares with the blood pressure drug prazosin, which also blocks norepinephrine receptors in the brain.

A week after using prazosin, Hall told Raskind that for the first time since his military service in Vietnam, he slept through the night without waking. “I didn't know I was such a good psychotherapist,” Raskind recalls, “I was sure it was a placebo effect.” But after Raskind gave the medication to another Vietnam War veteran suffering from PTSD, he noticed that his condition also improved. Randomized trials have shown that prazosin improves sleep, reduces nightmares and other symptoms of combat-induced PTSD. Today, about 70,000 US Army veterans take this drug. Raskind reports that during the entire time of taking prazosin, Hall "keeps at bay" his nightmares. And it's noticeable. nine0003

Raskind keeps another photograph in his office, from Hall's recent wedding, of an older-looking but more peaceful man: a portrait that reflects the role of a good night's sleep in healing the mind. “He looks a lot better here than in the photo with his wrinkled forehead,” Raskind says. “Notice the difference in his facial expression - it's the prazosin effect.”

Sleep disorders in anxiety and anxiety-depressive disorders | Kovrov G.V., Lebedev M.A., Palatov S.Yu., Merkulova T.B., Posokhov S.I. nine0001

In clinical practice, sleep disorders are usually associated with anxiety and depression. Existing studies show a close relationship between sleep disorders and anxiety and depressive disorders [1, 2]. A clear dependence of the severity of the course of both groups of diseases on concomitant sleep disorders was shown [1]. In general somatic practice, the prevalence of insomnia reaches 73% [3], in borderline psychiatry, clinically defined insomnia occurs in 65%, and changes in nocturnal sleep according to polysomnography are noted in 100% of cases [4]. nine0003

Combination of sleep disorders and anxiety disorders

It is known that the relationship between sleep disorders and anxiety disorders is noted, on the one hand, when sleep disorders can provoke the development of anxiety disorders [5], and on the other hand, when the onset of an anxiety disorder precedes the onset of sleep disorders. Complaints about problems associated with sleep are typical for patients with all diseases included in the group of anxiety disorders. In the case of major generalized disorder and post-traumatic stress disorder (PTSD), sleep disturbances are one of the criteria required for a diagnosis. There are objective reasons for the development of sleep disorders within anxiety disorders, namely: anxiety is manifested by increased cortical activation, which entails the difficulty of falling asleep and maintaining sleep. nine0003

In the clinic, anxiety is manifested by anxiety, irritability, motor excitation, decreased concentration of attention, increased fatigue [6].

The most striking manifestation of anxiety disorders is generalized anxiety disorder (GAD), which is diagnosed on the basis of the presence of at least 3 of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances. The duration of the disease should be at least 6 months, the symptoms should cause psychosomatic discomfort and / or social disadaptation. nine0003

Sleep disorders in this situation are one of the 6 diagnostic criteria for GAD. The main symptom of GAD, excessive, persistent anxiety, is a major predisposing factor in the development of insomnia. Insomnia and GAD are closely related, usually comorbid disorders. The difference between insomnia in anxiety disorder and primary insomnia, not associated with other diseases, is the nature of the experiences in the process of falling asleep. In the case of GAD, the patient is concerned about current problems [7] (work, study, relationships), which hinders the process of falling asleep. In the case of primary insomnia, the anxiety itself is caused by the disease itself. nine0003

A polysomnographic study can reveal changes characteristic of insomnia: increased time to fall asleep, frequent awakenings, reduced sleep efficiency, and a decrease in its total duration.

Another striking example of anxiety disorders is panic disorder, which is manifested by recurrent states of severe anxiety (panic). Attacks are accompanied by phenomena of depersonalization and derealization, as well as severe autonomic disorders. In the behavior of the patient, avoidance of situations in which the attack occurred for the first time is noted. There may be a fear of loneliness, a repetition of the attack. A panic attack occurs spontaneously, outside of formal situations of danger or threat. nine0003

Panic disorder is more common in women and typically begins around the age of 20. A hallmark of panic disorder are spontaneous episodes of panic attacks, characterized by bouts of fear, anxiety, and other autonomic manifestations. About 2/3 of patients with this disorder experience some form of sleep disturbance. Patients complain of difficulty falling asleep, non-restorative sleep, and characteristic nocturnal panic attacks. It should be noted that the presence of certain problems associated with sleep can lead to aggravation of anxiety disorders, including panic disorder. nine0003

Polysomnographic examination can detect frequent awakenings, reduced sleep efficiency and a reduction in its total duration [8]. It is not uncommon to see depression coexisting with anxiety disorders, and it is possible that the presence of other changes in sleep patterns in patients with panic disorder is associated with comorbid depression, and therefore the diagnosis of depression should be ruled out in patients with similar sleep disorders.

The sleep paralysis characteristic of narcolepsy can also occur with panic disorder. It is a movement paralysis that occurs during falling asleep or waking up, during which patients experience fear, a feeling of pressure in the chest, and other somatic manifestations of anxiety. This symptom also occurs in patients with post-traumatic stress disorder.

Nighttime panic attacks are a common occurrence in this disease [9]. They are manifested by a sudden awakening and all the symptoms characteristic of panic attacks. Awakening occurs during the phase of non-REM sleep, which most likely excludes their connection with dreams. It was also found that nocturnal attacks are an indicator of a more severe course of the disease. It must be remembered that patients, fearing the recurrence of such episodes, deprive themselves of sleep, which leads to more serious disorders and, in general, reduces the quality of life of these patients.

PTSD is a disease from the group of anxiety disorders, in which sleep disturbances are a diagnostic criterion. Sleep disorders in this disease include 2 main symptoms: nightmares and insomnia. Other phenomena inherent in PTSD and associated with sleep are: somnambulism, sleep-talking, hypnagogic and hypnopompic hallucinations. The changes detected by polysomnography are not specific and in some cases may be absent. Possible changes include: an increase in the representation of the 1st stage of sleep, a decrease in the representation of the 4th stage of sleep. Also, with PTSD, breathing disorders during sleep are often found. nine0003

Agoraphobia can also be a manifestation of anxiety disorders, which is defined as anxiety that occurs in response to situations, the way out of which, according to the patient, is difficult. In the clinical picture, as a rule, there is a persistent fear of the patient to be in a crowded place, public places (shops, open squares and streets, theaters, cinemas, concert halls, workplaces), fear of independent long trips (by various modes of transport). The situational component of the agoraphobia syndrome is expressed in the confinement of phobic experiences to certain situations and in the fear of getting into situations in which, according to patients, a repetition of painful sensations is likely. Often, agoraphobic symptoms cover many fears of various situations, forming panagoraphobia - the fear of leaving the house with the development of deep social maladaptation. There are attempts by the patient to overcome their own experiences, in adverse cases, there is a restriction of social activity. nine0003

Specific phobias are characterized by an association of anxiety with certain situations (air travel, contact with animals, the sight of blood, etc.), also accompanied by an avoidance reaction. Patients are critical of their experiences, however, phobias have a significant impact on various areas of activity of patients. There are the following forms: cardiophobia, cancerophobia, claustrophobia, etc. Sleep disturbances in these patients are non-specific, and from the point of view of the patient, they are a minor manifestation of the disease. nine0003

In general, the most common manifestations of sleep disturbances in anxiety states are presomnic disorders. The initial phase of sleep consists of 2 components: drowsiness, a kind of craving for sleep, and actually falling asleep. Often, patients have no desire to sleep, no desire to sleep, muscle relaxation does not occur, they have to perform various actions aimed at falling asleep. In other cases, there is an inclination to sleep, but its intensity is reduced, drowsiness becomes intermittent, undulating. Drowsiness occurs, the muscles relax, the perception of the environment decreases, the patient takes a comfortable position for falling asleep, and a slight drowsiness appears, but soon it is interrupted, disturbing thoughts and ideas arise in the mind. In the future, the state of wakefulness is again replaced by mild drowsiness and superficial drowsiness. Such changes in states can be repeated several times, leading to emotional discomfort that prevents the onset of sleep. nine0003

In a number of patients, experiences about disturbed sleep can acquire an overvalued hypochondriacal coloration and come to the fore according to the mechanisms of actualization, often there is an obsessive fear of insomnia - agripnophobia. It is usually combined with an anxious and painful expectation of sleep, certain requirements for others and the creation of the above-mentioned special conditions for sleep.

Anxiety depression is characterized by the patient's constant experience of anxiety, a sense of impending danger and insecurity. Anxious experiences change: anxiety about their loved ones, fears about their condition, their actions. The structure of anxious depression, as a rule, includes anxiety, feelings of guilt, motor restlessness, fussiness, fluctuations in affect with worsening in the evening, and somatovegetative symptoms. Anxious and melancholy affects often occur simultaneously, in many cases it is impossible to determine which of them is leading in the patient. Anxiety depression is most often found in people of involutionary age and proceeds according to the type of protracted phases. In addition, it is actually the leading type of neurotic depression [10]. nine0003

The patient exhibits a variety of symptoms of anxiety and depression. Initially, one or more physical symptoms (eg, fatigue, pain, sleep disturbances) may be present. Further questioning allows us to state a depressive mood and/or anxiety.

Signs of anxiety depression:

• depressed mood;
• loss of interest;
• severe anxiety.

The following symptoms are also often seen: nine0003

• sleep disorders;
• physical weakness and loss of energy;
• fatigue or decreased activity;
• difficulty concentrating, fidgeting;
• impaired concentration;
• excitation or retardation of movements or speech;
• appetite disorders;
• dry mouth;
• tension and anxiety;
• irritability; nine0114
• tremor;
• heartbeat;
• dizziness;
• suicidal thoughts.

Often with anxiety depression, variants of presomnic disorders are observed, in which the desire to sleep is pronounced, drowsiness increases rapidly, and the patient falls asleep relatively easily, but wakes up suddenly after 5-10 minutes, drowsiness completely disappears, and then within 1-2 hours he does not can fall asleep. This period without sleep is characterized by unpleasant ideas, thoughts, fears, reflecting to a greater or lesser extent the experienced conflict situation and the reaction to the inability to sleep. There is also hyperesthesia to sensory stimuli. Those suffering from this form of sleep disorder react extremely painfully to the slightest sensory stimuli, up to flashes of affect. nine0003

For disturbed falling asleep, lengthening of the drowsy period is characteristic. This drowsy state is often accompanied by motor, sensory and visceral automatisms, sharp shudders, vivid perceptions of sounds and visual images, palpitations, sensations of muscle spasms. Often these phenomena, awakening the patient, cause various painful ideas and fears, sometimes acquiring an obsessive character.

Sleep disorders and their polysomnographic manifestations among mental illnesses are the most studied for depressive disorder. Among the sleep disorders in depressive disorder, insomnia is the most common. The severity and duration of insomnia are manifestations of a more severe depressive disorder, and the appearance of insomnia during remission indicates the imminent occurrence of a recurrent depressive episode [1]. In addition, sleep disorders in this disease are the most persistent symptom. The close relationship of this disorder with sleep disorders is explained by the biochemical processes characteristic of depression. In particular, in depressive disorder, there is a decrease in the level of serotonin, which plays a role in the initiation of REM sleep and the organization of delta sleep [11]. Depressive disorder is characterized by the following manifestations of sleep disturbances: difficulty falling asleep [10], non-restorative sleep, as a rule, reduced total sleep time. The most specific symptoms for depression are frequent nocturnal awakenings and early terminal awakenings. Complaints about difficulty falling asleep are more often observed in young patients, and frequent awakenings are more characteristic of the elderly [12]. nine0003

With masked depression, complaints of sleep disturbances may be the only manifestation of the disease. In depression, in contrast to primary insomnia, there are complaints of sleep disturbances typical of this disease: frequent awakenings, early morning awakening, etc. [12].

In polysomnographic study, the following changes are observed: an increase in the time to fall asleep, a decrease in sleep efficiency. The most common and depressive disorder-specific symptoms are shortened REM sleep latency and reduced delta sleep. It has been found that patients with a higher proportion of delta sleep stay in remission longer than those with a decrease in the proportion of delta sleep [13]. nine0003

Attempts have been made to explore the possibility of using depression-specific sleep disturbances as markers of depressive disorder. Due to the heterogeneity of the manifestations of sleep disorders, this issue remains not fully resolved.

The features of sleep disorders in various types of depression were also highlighted. For patients with a predominance of the anxious component, difficulty falling asleep and early awakenings are more characteristic. With this type of depression, dream plots are associated with persecution, threats, etc. In addition, in these patients, in general, there was a high level of wakefulness before falling asleep. For depressions with the leading affect of melancholy, early morning awakenings and dreams of static types of gloomy content are most characteristic. Depression with the affect of apathy is characterized by early awakenings and rare, unsaturated dreams. Also typical of depression with apathetic affect is the loss of a sense of boundaries between sleep and wakefulness. Patients with bipolar disorder have a similar polysomnographic pattern [14]. nine0003

Features of sleep disturbance in bipolar disorder are a significant decrease in the duration of sleep during a manic episode and a greater tendency of patients to hypersomnia during depressive episodes compared with the unipolar course of the disorder. Complaints of sleep disturbances during manic episodes are usually absent.

Treatment

For the treatment of anxiety and depressive disorders, drugs of various pharmacological groups are used: tranquilizers (mainly long-acting or short-acting benzodiazepine drugs), selective serotonin reuptake inhibitors, selective serotonin reuptake stimulants, tricyclic antidepressants. All these drugs, to one degree or another, affect a person’s sleep, making it easier to fall asleep, reducing the number and duration of nocturnal awakenings, thereby affecting the recovery processes that occur during a night’s sleep. When constructing tactics for the treatment of sleep disorders associated with anxiety and depressive manifestations, it is important to remember that insomnia itself can increase anxiety, worsen well-being, mood, as a rule, in the morning hours after poor sleep [15]. In this regard, the use of hypnotics in the treatment may be promising in the presence of a predominance of insomnia symptoms in the clinical picture in order to prevent exacerbation of anxiety and depressive disorders. In this regard, the most effective helpers can be sleeping pills that affect the GABAergic (GABA - γ-aminobutyric acid) system - histamine receptor blockers (Valocordin®-Doxylamine) and melatonin preparation. The most convenient to use in the treatment of insomnia is Valocordin®-Doxylamine, which is available in drops, which allows you to select an individual dose of the drug. nine0003

Valocordin®-Doxylamine is a unique drug used as a hypnotic. Most known hypnotic drugs (benzodiazepines, cyclopyrrolones, imidazopyridines, etc.) act on the GABAergic complex, activating the activity of somnogenic systems, while histamine receptor blockers act on wakefulness systems, not sleep ones, reducing their activation. A fundamentally different mechanism of hypnotic action makes it possible to use Valocordin®-Doxylamine more widely: when changing one drug to another, reducing the dosages of "habitual hypnotics", and also, if necessary, canceling hypnotics. nine0003

A drug study conducted on healthy subjects showed that doxylamine succinate leads to a decrease in the duration of nocturnal awakenings and stage 1 sleep and an increase in stage 2 without a significant effect on the duration of stages 3 and 4 sleep and REM sleep. There was no significant subjective effect on the reports of healthy volunteers, however, compared with placebo, doxylamine increased the depth of sleep and improved its quality [16].

In Russia, one of the first studies was carried out under the supervision of A.M. Wayne [17]. It has been shown that under the influence of doxylamine such subjective characteristics of sleep as the duration of falling asleep, the duration and quality of sleep, the number of night awakenings and the quality of morning awakenings improve. An analysis of the objective characteristics of sleep showed that while taking doxylamine, there was a reduction in the time of wakefulness during sleep, a decrease in the duration of falling asleep, an increase in the duration of sleep, the time of the REM sleep phase, and the sleep quality index. It was also shown that doxylamine did not reduce the effectiveness of other drugs in patients, such as antihypertensive, vasoactive, etc. The results of a study of the effect of doxylamine on patients with insomnia indicate the effectiveness of this drug in these patients. Subjective feelings of a positive effect are confirmed by objective studies of the structure of sleep, which undergoes positive shifts, which affect such indicators as sleep duration, falling asleep duration, REM sleep phase. Of great importance is also the absence of any changes in the results of personal data regarding drowsiness and sleep apnea syndrome, which indicates the absence of an aftereffect of the drug in relation to the worsening of the course of obstructive sleep apnea syndrome. However, if obstructive sleep apnea is suspected, doxylamine should be used with caution. nine0003

Modern clinical studies do not reveal serious side effects in the treatment of therapeutic doses of the drug, but it is always necessary to remember the possible appearance of symptoms that arise due to the individual characteristics of the body, and contraindications (glaucoma; difficulty urinating due to benign prostatic hyperplasia; age up to 15 years; increased drug sensitivity).

Simultaneous administration of the drug Valocordin®-Doxylamine and sedative drugs that affect the central nervous system (CNS): neuroleptics, tranquilizers, antidepressants, hypnotics, analgesics, anesthetics, antiepileptic drugs, may enhance their effect. Procarbazines and antihistamines should be combined with caution to minimize CNS depression and potential drug potentiation. During treatment with Valocordin®-Doxylamine, alcohol should be avoided as it may unpredictably affect the effects of doxylamine succinate. nine0003

During the use of this drug, it is recommended to exclude driving a car and working with mechanisms, as well as other activities accompanied by an increased risk, at least at the first stage of treatment. The attending physician is advised to evaluate the individual reaction rate when choosing a dose. It is important to consider these features of the effect of the drug in the treatment of patients with insomnia in order to increase the effectiveness of Valocordin®-Doxylamine and exclude possible undesirable effects. nine0003

Conclusion

When diagnosing a disease, it is important to remember that, as a rule, problems falling asleep indicate the presence of severe anxiety, early awakenings are a manifestation of depression.

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