Sleep Initiation and Maintenance Disorders: Tufik S

Passos GS, Tufik S, Santana MG, Poyares D, Mello MT. · Universidade Federal de São Paulo, São Paulo, SP, Brazil. · Rev Bras Psiquiatr. · Pubmed #17713700 links to  free full text

Abstract: The purpose of this manuscript is to briefly describe the main modalities of non-pharmacological therapy and its utilization on the chronic insomnia treatment. Insomnia is the most frequent sleep disorder and that is more associated with psychiatry disorders. The pharmacotherapy is the most frequent treatment, but the nonpharmacologic therapy has been studied. The most common therapy modalities include behavioral approaches, stimulus control, sleep restriction, paradoxical intention, sleep hygiene, progressive muscle relaxation and biofeedback and, more recently, physical exercise practices. At first behavioral therapy aimed to improve sleep quality, however, recent studies have been emphasizing the effect of behavioral and cognitive approaches on quality of life, on decrease of dosage and frequency of drugs intake. Since insomnia is a chronic condition, long-term and safe treatments are warranted.

Poyares D, Guilleminault C, Ohayon MM, Tufik S. · Disciplina de Medicina e Biologia do Sono, Departamento de Psicobiologia da Universidade Federal de São Paulo, Brazil. · J Psychiatr Res. · Pubmed #15003439 No free full text.

Abstract: We studied the sleep of patients with insomnia during continuous and very long-term use of benzodiazepines (BZDs), and after withdrawal. A group of 25 patients (mean age 44.3+/-11.8 years) with persistent insomnia, who had been taking BZDs nightly for 6.8+/-5.4 years was selected. The control group was comprised of 18 age-matched healthy individuals. Sleep stage parameters were analyzed during Night 1 (while taking BZDs), Night 2 (first night after completing BZD withdrawal), and Night 3 (15 days after gradual BZD withdrawal). Sleep data for control subjects was monitored in parallel. Sleep EEGs of the patients were analyzed using Period Amplitude Analysis (PAA), during Nights 1 and 3 only. During BZD use, a significant reduction of Total Sleep Time (TST) and increased sleep latency were found in the insomniac group when compared to controls. We found an increase in stage 2 non-REM (NREM) sleep, and a reduction in Slow Wave Sleep (SWS) when comparing to night 3 (after withdrawal). Sleep EEGs analysis showed an increase in sigma band and decrease in delta count in stages 2, 3, 4 NREM and REM sleep in the BZD group when comparing to night 3 (after withdrawal). During the BZD withdrawal period, six out of nine subjects taking lorazepam failed withdrawal. In the remaining 19 subjects, gradual withdrawal of BZDs was associated with immediate worsening of nocturnal sleep, as indicated by sleep parameters. However, 15 days after withdrawal (Night 3), some of the sleep structure parameters of patients were not significantly different from baseline (while taking BZDs), except for a significant increase in SWS and in delta count throughout most sleep stages, and a decrease in stage 2 NREM sleep. These values were not different from those shown by control subjects. REM sleep parameters showed no significant variation across the experimental conditions. Subjective sleep quality was significantly improved on Night 3 compared with Night 1. Conclusions: Chronic intake of BZDs may be associated with poor sleep in this population. A progressive 15-day withdrawal did not avoid an immediate worsening of sleep parameters. But at the end of the protocol, SWS, delta count, and sleep quality were improved compared to those recorded during the chronic BZD intake, despite the lack of change in sleep efficiency.

Poyares DR, Guilleminault C, Ohayon MM, Tufik S. · Sleep Laboratory of the Department of Psychobiology, Universidade Federal de São Paulo, São Paulo, Brazil. · Prog Neuropsychopharmacol Biol Psychiatry. · Pubmed #11999905 No free full text.

Abstract: PURPOSE: The authors studied the sleep of patients with insomnia who complained of poor sleep despite chronic use of benzodiazepines (BZDs). The sample consisted of 19 patients (mean age 43.3+/-10.6 years) with primary insomnia (DSM-IV), who had taken BZDs nightly, for 7.1+/-5.4 years. The control group was composed of 18 healthy individuals (mean age 37+/-8 years). Sleep electroencephalogram (EEG) of the patients was analyzed with period amplitude analysis (PAA) and associated algorithms, during chronic BZD use (Night 1), and after 15 days of a valerian placebo trial (initiated after washout of BZD, Night 2). Sleep of control subjects was monitored in parallel. RESULTS: Valerian subjects reported significantly better subjective sleep quality than placebo ones, after BZD withdrawal, despite the presence of a few side effects. However, some of the differences found in sleep structure between Night 1 and Night 2 in both the valerian and placebo groups may be due to the sleep recovery process after BZD washout. Example of this are: the decrease in Sleep Stage 2 and in sigma count; the increase in slow-wave sleep (SWS), and delta count, which were found to be altered by BZD ingestion. There was a significant decrease in wake time after sleep onset (WASO) in valerian subjects when compared to placebo subjects; results were similar to normal controls. Nonetheless, valerian-treated patients also presented longer sleep latency and increased alpha count in SWS than control subjects. CONCLUSIONS: The decrease in WASO associated with the mild anxiolytic effect of valerian appeared to be the major contributor to subjective sleep quality improvement found after 2-week of treatment in insomniacs who had withdrawn from BDZs. Despite subjective improvement, sleep data showed that valerian did not produce faster sleep onset; the increase in alpha count compared with normal controls may point to residual hyperarousabilty, which is known to play a role in insomnia. Nonetheless, we lack data on the extent to which a sedative drug can improve alpha sleep EEG. Thus, the authors suggest that valerian had a positive effect on withdrawal from BDZ use.

Hachul H, Brandão Lde C, Bittencourt LR, D'Almeida V, Andersen ML, Baracat EC, Tufik S. · Department of Psychobiology, Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Brazil. · Acta Obstet Gynecol Scand. · Pubmed #19235560 No free full text.

Abstract: OBJECTIVE: The primary purpose of this study was to assess the overall clinical profile of menopausal women complaining of insomnia who were referred to a sleep laboratory. METHODS: A total of 206 menopausal women who had complaints related to insomnia were interviewed. Each participant completed a questionnaire in order to obtain data on general health, menopausal status, medications, and sleep patterns. RESULTS: The mean age of the participants was 55.9 years. Clinical profiles revealed that the most prevalent health problems were systemic arterial hypertension (33.9%) and osteoporosis (19%), though there was no association between insomnia and incidence of chronic disease. Our data demonstrate an overall prevalence of insomnia of 4-5 times a week in 62% of the women, with 68.9% complaining of hot flashes. However, there was no association between hot flashes and frequency of insomnia across the menopausal transition period. Only 7% of women had already undergone polysomnography. Less than 5% of the participants were undergoing treatment for menopause, while 8% were taking benzodiazepines for sleep problems. CONCLUSIONS: This study provides evidence that insomnia in postmenopausal women was not associated with incidence of chronic disease. In addition, the majority of the participants were not undergoing treatment for menopause or for sleep disturbance.

Llanas AC, Hachul H, Bittencourt LR, Tufik S. · Unifesp, Rua Tirso Martins 264apto 41, Sao Paulo, Brazil. · Maturitas. · Pubmed #18819761 No free full text.

Abstract: OBJECTIVE: Regular exercise has been highly promoted and recognized as the best non-pharmacological treatment for postmenopausal problems. It may also increase total sleep time and decrease the latency of sleep onset. One study assessed the effects of exercise on sleep symptoms in postmenopausal women. Tworoger et al. [Tworoger SS, Yasui Y, Vitiello MV, et al. Effects of a Yarlong moderate-intensity exercise and stretching intervention on sleep quality in postmenopausal women. Sleep 2003;26(7):830-6] observed that increased fitness was associated with an improvement in sleep. No studies have been published describing the effects of physiotherapeutic treatments for insomnia in postmenopausal women. This study examines two cases of symptomatic postmenopausal patients with insomnia. The two patients took part in an individual physiotherapeutic treatment program that involved one and a half hour sessions twice a week for 6 consecutive months. The treatment consisted of segmental and global stretching exercises, strengthening exercises, massotherapy and relaxation techniques. Patient 1 experienced a significant increase in REM sleep and in total sleep efficiency. Patient 2 experienced a reduction in sleep latency and an increase in slow wave sleep, as shown in the polysomnograph. Both patients reported an overall improvement in their condition.

Conway SG, Roizenblatt SS, Palombini L, Castro LS, Bittencourt LR, Silva RS, Tufik S. · Instituto do Sono-Associação Fundo de Incentivo à Psicofarmacologia, São Paulo, SP, Brasil. · Braz J Med Biol Res. · Pubmed #18797708 links to  free full text

Abstract: To evaluate the effect of smoking habits on sleep, data from 1492 adults referred to the Sleep Institute were accessed and divided into 3 categories of smoking status: current, former and non-smokers. Categories of pack-years (<15 and > or =15) defined smoking severity. The association of smoking status and smoking severity with sleep was analyzed for sleep parameters, especially apnea and hypopnea index (AHI) > or =5, more than 5% of total sleep time (TST) spent with oxyhemoglobin saturation (SaO2) <90%, and arousal index. The arousal index was higher among current (21 +/- 17) and former smokers (20 +/- 17) than non-smokers (17 +/- 15; P < 0.04). Former smokers had a higher percent of TST at SaO2 <90% than non-smokers (9 +/- 18 vs 6 +/- 13; P < 0.04). Former smokers with pack-years > or =15 compared to <15 exhibited higher AHI (22 +/- 24 vs 16 +/- 21; P < 0.05) and arousal index (22 +/- 19 vs 18 +/- 15; P < 0.05). Current smokers with pack-years > or =15 compared to <15 exhibited higher arousal index (23 +/- 18 vs 18 +/- 16; P < 0.05) and percent of TST at SaO2 <90% (11 +/- 17 vs 6 +/- 13; P < 0.05). Smoking status and pack-years were not associated with AHI > or =5 on logistic regression analysis, but current smokers with pack-years > or =15 were 1.9 times more likely to spend more than 5% of TST at SaO2 <90% than non-smokers (95%CI = 1.21-2.97; P = 0.005). The variability of arousal index was influenced by gender, AHI and current smokers with pack-years > or =15 (all P < 0.01). Smoking habits seem to be associated with arousal and oxyhemoglobin desaturation during sleep, but not with AHI. The effect was more pronounced in current than former smokers.

Hachul de Campos H, Brandão LC, D'Almeida V, Grego BH, Bittencourt LR, Tufik S, Baracat EC. · Department of Psychobiology, Universidade Federal de São Paulo, Escola Paulista de Medicina, Brazil. · Climacteric. · Pubmed #16857662 No free full text.

Abstract: OBJECTIVE: The aim of this work was to investigate cardiovascular risk factors and oxidative stress parameters as well as sleep disturbances in polysomnography recordings of 38 postmenopausal women with insomnia. METHODS: Polysomnography recordings were performed on subjects for sleep analysis. Oxidative stress parameters were analyzed by measuring blood concentration of catalase, superoxide dismutase (SOD), thiobarbituric acid reactive substances (TBARS) and glutathione. For cardiovascular risk factors, we measured plasma levels of homocysteine, folic acid and vitamin B6. RESULTS: Findings of polysomnography recordings revealed: 68% experienced decreased sleep efficiency, 50% had apnea, 7.8% had periodic leg movements and 2.6% had bruxism (involuntary gnashing and grinding of the teeth during sleep). Our results showed that the majority of our subjects presented normal concentrations of the parameters studied according to standards reached in our laboratory. The only notable exception was TBARS. In this case, only 21% displayed normal values. We also found inverse correlations between SOD activity and both age and time of menopause. CONCLUSIONS: Although all women complained of insomnia, 50% of them demonstrated apnea during polysomnography recordings. Of the parameters measuring oxidative stress, only TBARS levels were increased in our sample. Some clinical data, such as time of onset of menopause, may be associated with the oxidative stress status of these women, probably due to the lack of estrogen and to sleep disturbances, such as apnea.

Peres MF, Sanchez del Rio M, Seabra ML, Tufik S, Abucham J, Cipolla-Neto J, Silberstein SD, Zukerman E. · Sao Paulo Headache Center, R Maestro Cardim, 887 01323-001, Sao Paulo SP, Brazil. · J Neurol Neurosurg Psychiatry. · Pubmed #11723194 links to  free full text

Abstract: OBJECTIVES: Chronic migraine (CM), previously called transformed migraine, is a frequent headache disorder that affects 2%-3% of the general population. Analgesic overuse, insomnia, depression, and anxiety are disorders that are often comorbid with CM. Hypothalamic dysfunction has been implicated in its pathogenesis, but it has never been studied in patients with CM. The aim was to analyze hypothalamic involvement in CM by measurement of melatonin, prolactin, growth hormone, and cortisol nocturnal secretion. METHODS: A total of 338 blood samples (13/patient) from 17 patients with CM and nine age and sex matched healthy volunteers were taken. Melatonin, prolactin, growth hormone, and cortisol concentrations were determined every hour for 12 hours. The presence of comorbid disorders was also evaluated. RESULTS: An abnormal pattern of hypothalamic hormonal secretion was found in CM. This included: (1) a decreased nocturnal prolactin peak, (2) increased cortisol concentrations, (3) a delayed nocturnal melatonin peak in patients with CM, and (4) lower melatonin concentrations in patients with CM with insomnia. Growth hormone secretion did not differ from controls. CONCLUSION: These results support hypothalamic involvement in CM, shown by a chronobiologic dysregulation, and a possible hyperdopaminergic state in patients with CM. Insomnia might be an important variable in the study findings.

Pedrazzoli M, Ling L, Young TB, Finn L, Tufik S, Mignot E. · No affiliation provided · J Sleep Res. · Pubmed #12464104 No free full text.

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