Zhang Xinjun: Interrupting the vicious circle between insomnia and anxiety| Interview with Big Coffee, No. 8

introduction

Insomnia and anxiety are common in psychiatry, and they often coexist and exacerbate each other, significantly impairing the patient's functional level and quality of life, and even increasing the patient's risk of suicide. Effectively dealing with insomnia and anxiety symptoms and blocking the vicious cycle between the two is of great significance to improve the patient's treatment outcome.

In this context, the 8th issue of "Interview with Big Coffee" specially invited Zhang Xinjun, director of the Department of Sleep Medicine of Tianjin Anding Hospital, to share wonderful views on insomnia and anxiety-related issues.

Experts in this issue

Zhang Xinjun Chief Physician

Director of the Department of Sleep Medicine, Tianjin Anding Hospital

Member of the Sleep Disorders Collaborative Group of the Chinese Medical Association

He is a standing committee member of the Sleep Medicine Committee of the Chinese Association of Research Hospitals

Member of the Sleep Medicine Professional Committee of the Chinese Geriatrics Association

Member of the Sleep Medicine Education Professional Committee of the Chinese Sleep Research Association

Member of the Northern Psychiatric Forum Committee

Chairman of sleep medicine professional committee of Tianjin Association of Integrative Traditional and Western Medicine

Vice Chairman of the Psychosomatic Professional Committee of Tianjin Association of Integrative Traditional chinese and Western Medicine

The following is the transcript of the interview -

Based on your clinical observations, what is the correlation between insomnia and anxiety in psychiatric patients?

Insomnia and anxiety are closely related, causal and mutually affected. Anxiety can cause insomnia, and insomnia can also cause anxiety. Insomnia is often a precipitating factor for anxiety and depression, and insomnia symptoms are also one of the important indicators to measure the effectiveness of anxiety and depression treatment.

The insomnia caused by anxiety is not only reflected in the difficulty of falling asleep, but also in the quality of sleep. For example, people with insomnia problems will frequently dream about bad things during sleep, worry too much about the future, worry too much about physical health, etc., and most insomnia patients have problems such as excessive awakening.

What principles should be followed in the treatment of patients with chronic insomnia with significant anxiety symptoms or anxiety disorders?

For patients with chronic insomnia disorder with mild anxiety symptoms, insomnia disorder should be treated first. According to the guidelines for the treatment of chronic insomnia disorders, it is necessary to avoid directly and blindly using drugs such as benzodiazepines to treat insomnia disorders during initial treatment, and cognitive behavioral therapy for insomnia is usually recommended.

For patients with chronic insomnia disorders with more severe anxiety symptoms, anxiety symptoms should be treated first. Commonly used anxiolytic drugs include benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and 5-HT1A receptor partial agonists. When the patient's anxiety symptoms are well controlled, the next step is for the doctor to evaluate the patient's control of chronic insomnia disorder:

In the first case, the patient's chronic insomnia disorder is well controlled. On this basis, the doctor's general treatment policy for insomnia problems is still cognitive behavioral treatment of insomnia.

In the second case, the patient's chronic insomnia disorder is poorly controlled. Doctors should re-evaluate the patient's sleep, consider whether there are some underlying factors affecting sleep, analyze the causes of insomnia disorders, dig into the related diseases behind insomnia, and also consider whether these diseases are also the underlying causes of severe anxiety in patients.

What are the advantages of clinical use or combination of benzodiazepines in the treatment of insomnia with anxiety? What are the disadvantages and precautions?

Benzodiazepines can alleviate anxiety symptoms and sleep problems at the same time when used in the short term, but the benefits and efficacy of long-term application are far less than the risks themselves, which are mainly reflected in the following four aspects:

First, damage the sleep structure and sleep rhythm. Benzodiazepines can only increase the light sleep of patients with chronic insomnia disorders, which not only has no significant improvement effect on the patient's deep sleep, but may also exacerbate the reduction of deep sleep. Benzodiazepines have a long half-life, taking alprazolam and clonazepam as an example, patients may have daytime drowsiness problems after taking the drug, further impairing the sleep rhythm, and the damage of this sleep rhythm in turn will have a negative effect on nighttime sleep, gradually forming a vicious circle.

Second, benzodiazepines can damage daytime executive function and cognitive function while improving nighttime sleep, and patients with frequent daytime attention disorders.

Third, benzodiazepines will have a relaxing effect on elderly patients and increase the risk of falls and fractures.

Fourth, long-term use of benzodiazepines is easy to form drug dependence and tolerance.

Based on your observations, what effects do commonly used antidepressants in the clinic have on sleep?

Certain SSRIs may relieve depressive symptoms but may induce or worsen sleep disturbances. For example, paroxetine can cause patients to have excessive nighttime awakenings and a decrease in sleep quality, while a decrease in sleep quality makes it more difficult to eliminate the patient's remaining depressive symptoms. Norepinephrine and the specific serotonergic antidepressant (NaSSA) mirtazapine may induce sleep disorders such as nightmare disorder, night terrors, sleep paralysis, and restless legs syndrome.

Compared with benzodiazepines, what are the advantages of 5-HT1A receptor partial agonists represented by tanduspirone?

The 5-HT1A receptor partial agonist tanduspirone can increase deep sleep while improving anxiety symptoms, less likely to induce or aggravate sleep disorders, and less affect cognitive function and memory, and can also avoid the risk of benzodiazepines. For patients with chronic insomnia disorders accompanied by anxiety, it is clinically recommended to use tanduspirone combined with insomnia cognitive behavioral therapy, which will not affect the sleep structure while alleviating anxiety, nor induce other sleep diseases, and the long-term benefits are better.

Based on the current clinical situation in China, what are your experiences or suggestions for front-line psychiatrists to carry out cognitive behavioral treatment for insomnia, and can you briefly share them with your colleagues?

Cognitive behavioral therapy for insomnia is a first-line treatment for insomnia recommended by the current mainstream guidelines and has been widely used clinically by psychiatrists. However, in general hospitals and non-psychiatry, although some physicians have a deep theoretical foundation in cognitive behavioral treatment for insomnia, there may be the following three problems in the specific practice process:

First, doctors lack understanding of the causes of insomnia disorders. The same insomnia patients, using the same insomnia cognitive behavioral treatment method, why is the treatment effect different? This may be due to different causes behind insomnia disorders. When treating insomnia, physicians should not only focus on the insomnia itself, but also pay attention to the deep-seated etiology problems.

Second, the doctor's assessment of insomnia is not comprehensive enough. The premise of implementing cognitive behavioral therapy for insomnia is to accurately assess sleep problems, and some physicians may blindly implement cognitive behavioral therapy for insomnia without comprehensive evaluation, resulting in unsatisfactory treatment results. Therefore, in some cases, the poor treatment effect of patients is not necessarily a problem of treatment methods, but may be that the work of the preliminary evaluation link is not in place.

Third, doctors lack understanding of the effects of drugs on sleep. Many patients with chronic insomnia disorders with anxiety may require a combination of multiple medications. If drugs with a greater impact on sleep, such as benzodiazepines, are selected in the initial treatment, it is easy to cause repeated anxiety symptoms when gradually replacing or reducing certain drugs after the implementation of cognitive behavioral therapy for insomnia in the later stage. In this case, physicians can appropriately increase the use of anxiolytic drugs, such as tandospirone, in order to achieve a smooth transition and successfully complete cognitive behavioral therapy for insomnia.

If the doctor takes into account the effect of drugs on sleep at the beginning of treatment, and actively chooses some drugs that have less impact on sleep, it is not easy to fluctuate symptoms when changing or reducing drugs in the later stage. Therefore, the smooth implementation of cognitive behavioral therapy for insomnia is inseparable from the rational use and reasonable substitution of drugs. (Final)

Approval code: DSPC-NP-SED-21-12-0002

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