Sleep, Sex, drugs Flashcards
What is insomnia?
Trouble with quality of sleep
Part of a psychiatric d/o or stand alone
Types of insomnia?
Can be trouble:
- getting to sleep
- staying asleep
- early awakening
Severity levels for insomnia?
Episodic: 1-3 months
Persistent: 3+ months
Recurrent: 2+ episodes in 1 yr
Situational insomnia?
Insomnia for a few days/weeks
Treatment for insomnia?
Psych:
- sleep hygiene education
Pharm:
- lorazepam, temazepam
- non benzo hypnotics (zolpidem, zaleplon)
- antihistamines
- trazadone (low dose)
Problems with giving antihistamines to the elderly?
They may cause
- confusion
- urinary problems
How should nonbenzo hypnotics be given for sleep aid?
Short course 1-2 weeks only
What is hypersomnolence d/o?
Excessive daytime sleepiness despite getting >7hrs plus 1 of:
- recurrent sleep lapses during day
- sleeping > 9hrs (nonrestorative)
- difficulty being fully awake after abrupt awakening (groggy)
Timeline for hypersomnolence?
Must be 3x per week x 3 months
- acute - 1 month
- subacute - 1-3 months
- persistent >3 months
Severity for hypersomnolence?
Mild: 1-2 days/week
Moderate: 3-4 days/week
Severe: 5-7 days/week
Narcolepsy is?
Recurrent periods of:
- an irrepressible need to sleep
- lapsing into sleep
- napping
Occurring w/in the same day 3x/week x 3 mohths
Tetrad of symptoms for narcolepsy?
- Sudden brief sleep attacks (during any type of activity)
- Cataplexy: sudden loss of muscle tone in specific or gen muscle groups
(Slump to floor, cant move) - Sleep paralysis: gen flacidity of muscles w full consciousness
- Hypnagogoc hallucinations: visual/auditory
Txt for narcolepsy?
Daily stimulant:
- dextroamphetamine sulfate
- modafinil
What is needed for a diagnosis of “breathing related sleep disorder”?
Either (by polysomnography)
- min 5 OSA or hypopneas per hr w symptoms
- 15+ OSA or hypopneas/hr w/o symptoms
Symptoms that are seen with OSA or hypopneas?
Nocturnal breathing disturbances
Daytime sleepiness, fatigue, or other un-refreshing sleep
MC breathing related sleep d/o?
OSA - obstructive sleep apnea hypopnea
Describe OSA
Can be:
- Snoring
- Gasping
- Breathing pauses
And 5+ apnease or hypoapneas per hr
What is central sleep apnea?
Evidence of 5 or more sleep apneas cause by centrally (brain not airway)
What is sleep related hypoventilation?
Polysomnography shows episodes of decreased respiration and high Co2
What is a circadian rhythm sleep-wake d/o?
Sleep disruption due to alteration of circadian system or misalignment between endogenous circadian rhythm and sleep-wake schedule
Your job and your sleep cycle dont match
What are parasomnias?
Sleep terror
Nightmares
Sleepwalking
Enuresis
Common in kids not so much in adults
Payor nocturnus?
Sleep terror - abrupt terrifying arousal from sleep.
- fear,
- sweating,
- tachy,
- confusion
X several minutes with AMNESIA
When do nightmares occur?
During REM sleep
What is somnabulism?
Sleep walking
- ambulation
- other intricate behaviors
With amnesia, while sleeping
Patient population for sleep walking?
Kids - normal
Elderly - dementia
What is enuresis
Wetting the bed
- confusion and amnesia are common
Sleep terror tx?
Benzo’s to suppress stage 3 and 4 of sleep
Somnambulism tx?
Benzo’s to suppress stage 3 and 4 of sleep
Enuresis tx?
Imipramine or desmopressin nasal spray
Also sleep alarms
Stages of sexual stuff?
Excitement
Orgasm
Resolution
What are the 3 groups of sexual dysfunction?
- Paraphilia’s (excitement stage)
- Gender dysphoria
- Sexual dysfunctions
Name the paraphilias
Exhibitionism Transvestism Voyeurism Pedophilia Incest Sexual sadism Sexual masochism
Paraphilias txt?
Psych - generally responsive to psychotherapy
Behavioral - modeling/role playing
Social - self help groups
Pharm
- medroxyprogesterone (suppress sex drive)
- SSRI (fluoxitine) may help
Gender dysphoria txt?
Psych - safe place to “explore”
Social - peer groups
Medical - hormone/sex change
Standard of care for persistent gender dysphoria?
Hormone therapy
Sex change
Sexual dysfunction med for women?
Finasterone
Sexual dysfunction meds for men?
Afils
- Avanafil (Stendra)
- Sildenafil (Viagra)
- Tadalafil (Cialis)
- Vardenafil (Levitra, Staxyn)
Psychologic dependence
Craving and behavior involved in procurement of the drug
Physiologic dependence
Withdrawal symptoms w/o the drug
Tolerance
The need to increase dose to obtain effects
At risk drinking red flags?
At risk drinking
- men: 4 drinks/day and 14/week
- women 3 drinks/day and 7/week
Alcohol use d/o test?
AUDIT
Alcohol doses
50mg/dL - wont cause motor symptoms
80mg/dL - legal limit in most states
Syptoms of ETOH withdrawal
Anxiety Decreased cognition Tremulousness Hyperactivity Full blown DT’s
Levels of ETOH withdrawal
Mild Moderate Severe withdrawal Withdrawal seizures DT’s
What are DT’s?
Organic psychosis 48-72hrs after last drink
S/s of DT’s?
- Visual hallucinations
- Autonomic hyperactivity (tachy, HTN)
- Dehydration
- Electrolyte disturbances (hypoK, HypoMg)
- Arrhythmias/seizures
- Cardiovascular collapse
- Death
Pt comes in with unexplained delirium you should suspect?
ETOH withdrawal
How long do ETOH withdrawal symptoms last?
3-12 months
S/s of persistent long term withdrawal symptoms?
- Sleep
- Anxiety
- Depression
- Excitability
- Fatigue
- Emotional volatility
ETOH (organic) hallucinations s/s
- Paranoid psychosis w/o tremulousness
- Confusion
- Clouded sensorum
Types of alcohol use d/o?
Primary alcohol use d/o
- no other maj psych stuff
Secondary alcohol use d/o
- self medicating for underlying psych d/o
Tx for etoh use d/o?
Psych
- motivational interviewing (address pt’s ambivalence and motivational for change IOT reduce consumption)
Social
- AA
Medical
- hospitalization (only need for really bad ones)
Meds
- disulfam (toxic effects when drink)
- naltrexone (takes fun out of drinking)
- acamprosate (reduces cravings)
How are ETOH hallucinations treated?
Antipsychotics
How are withdrawal symptoms treated?
Mild
- lorazepam, chlordiazeperoxide (PO)
Moderate
- lorazepam, chlordiazeperoxide (IV q 2hrs)
Severe (ICU)
- lorazepam or chlordiazeperoxide (IV q 15 min)
Caffeine intoxication and withdrawal
Headache?
WHO CARES
Opioid withdrawal grades?
Grade 0 - craving and anxiety
Grade 1 - yawning, lacrimation, rhinorrhea and perspiration
Grade 2 - grade 1 + mydriasis, piloerection, anorexia, tremors, hot/cold flashes, gen aching
Grade 3 and 4 - grade 1 and 2 + increased temp, BP, pulse, respiratory rate/depth
- most severe cases: vomiting, diarrhea, wt loss, hemoconcentration and spontaneous ejaculation/orgasm
Treatment for opioid withdrawal?
Initial - Methadone
7-10 days later - naltrexone
