Curriculum Vitae

Nama : Dr.Andri,SpKJ,FAPM

Pendidikan : Dokter : Fakultas Kedokteran Universitas Indonesia (Lulus 2003)

Psikiater : Fakultas Kedokteran Universitas Indonesia (Lulus 2008)

Pendidikan tambahan di bidang psikosomatik medis dari American Psychosomatic Society di Portland, Oregon, USA tahun 2010 dan Academy of Psychosomatic Medicine di Atlanta, USA 2012, di Tucson 2013 dan di Fort- LeDaurdale 2014

Pengakuan sebagai Fellow of The Academy of Psychosomatic Medicine (FAPM) November 2013

Organisasi : IDI

PDSKJI

American Psychosomatic Society

Academy of Psychosomatic Medicine

Jabatan : Dosen Psikiatri di FK UKRIDA, Jakarta

Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera

Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera

4th Update in Psychosomatic Medicine “Insomnia and Its Related Disorder”

A N D R I Klinik Psikosomatik RS OMNI Alam Sutera,

Tangerang Selatan

Kompetensi 4A

Insomnia

Gangguan

Somatoform

Kompetensi 3A

Gangguan Campuran Cemas

dan Depresi

Gangguan Psikotik

144 Diagnosis 155 Diagnosis

Masalah Keswa di Fasyankes Primer Di Indonesia

Ilustrasi Kasus 1 Wanita 32 tahun, kesulitan memulai tidur. Dia mengatakan memang sering sulit tidur sejak usia 20an. Setiap minggu ada sekali sulit tidur. 3 bulan terakhir pasien merasa tidurnya makin sulit Tidak ada riwayat gangguan jiwa sebelumnya Pasien telah ke dokter umum dan diberikan alprazolam 0.25mg untuk membantu tidurnya. Seminggu pakai, pasien merasa khawatir akan ketergantungan walaupun tidurnya membaik. Belakangan setiap menjelang sore, pasien menjadi cemas khawatir tidak bisa tidur. Kualitas hidup terganggu terutama dalam bekerja karena ngantuk di siang hari walaupun tidak bisa tidur dan sulit konsentrasi

Introduction

30-50% of American adults experience insomnia during a 1 year period

Prevalence of chronic/severe insomnia is 10%

49% of adults surveyed were dissatified with their sleep > 5 nights per month

50% of patients presenting to primary care physicians experience insomnia

NHLBI working group on Insomnia. Bethesda, Md: NHLBI; 1998. NIH Publication 98-4088 Smith MT, et al. Am J psychiatry. 2002; 159:5-11

Hajak G et al. Eur Psychiatry. 2003; 18:201-8 Ringdahl EN et al. J Am Board Fam Pract. 2004; 17:212-219

Normal Aging Changes

In general, with advancing age, sleep becomes more fragmented,

More time is required to fall asleep

More awakenings occur

Relatively less deep sleep is experienced,

People tend to spend more time in bed.

It is common for elderly hospitalized patients to report not sleeping at all, despite nursing observations of 6–8 hours of apparent sleep, complete with snoring

SLEEP PATTERNS IN INSOMNIA

Sleep onset insomnia Difficulty falling asleep

Longer time to sleep onset

Sleep maintenance insomnia Difficulty staying asleep

Frequent nocturnal awakenings

Sleep offset insomnia Waking too early in the morning

Nonrestorative sleep Fatigue despite adequate sleep duration

DSM-IV-TR. 4th ed. 2000:597-661 Czeisler CA et al. Harrison’s Principles of Internal Medicine” 15th ed. 2001: 155-163

Ilustrasi Kasus 2

Pasien wanita 45 tahun,tidak bersemangat hidup sejak 4 bln belakangan ini sjk kasus hukum yg menimpa perusahaannya. Pasien menjadi lebih mengurung diri di kamar, tdk mau melakukan apa-apa. Setiap hari aktifitas hanya tidur-2an di kamar. Kualitas tidur jauh memburuk apalagi, setiap malam pasien terbangun setiap satu jam dan kadang terjaga selama 1-2 jam.

Mood depresif, psikomotor menurun, putus asa, tidak ada harapan hidup

Tidak ada riwayat gangguan jiwa sebelumnya

Fungsi sebelum sakit baik

Insomnia Associated With Axis I Psychiatric Illness

Anxiety disorders

Mood disorders

Dementia

Delirium

Psychosis

Adjustment disorder

Normal disruptions in mental life caused by stressful or grief-producing situations

Insomnia Associated With Physical Illness Physical conditions associated with pain (e.g.,

arthritis)

with difficulty breathing (e.g., congestive heart failure or chronic obstructive pulmonary disease)

immobility (e.g., stroke or Parkinson’s disease)

urinary obstruction secondary to prostatism or chronic urinary tract infection.

Sleep apnea (30%–40% of elderly patients) and is typically associated with obesity and snoring.

Nocturnal myoclonus

Substance-Induced Insomnia

Sympathomimetic agents (including decongestants and bronchodilators)

methylxanthine derivatives (such as theophylline and aminophylline),

Psychostimulants,

Certain antidepressants (fluoxetine, bupropion, higher doses of mirtazapine)

Medications containing caffeine

Beverages such as coffee and many cola drinks

Hypnotic medications

Inadequate Sleep Hygiene 1. Daytime napping at least two times each week

2. Having variable wake-up times or bedtimes

3. Experiencing frequent periods (two to three times per week) of extended

amounts of time spent in bed

4. Routinely using products containing alcohol, tobacco, or caffeine in the period

preceding bedtime

5. Scheduling exercise too close to bedtime

6. Engaging in exciting or emotionally upsetting activities too close to bedtime

7. Frequently using the bed for nonsleep-related activities (e.g., television watching, reading, studying, snacking)

8. Sleeping on an uncomfortable bed (e.g., poor mattress, inadequate blankets)

9. Allowing the bedroom to be too bright, too stuffy, too cluttered, too hot, too

cold, or in some way not conducive to sleep

10. Performing activities demanding high levels of concentration shortly before bed

11. Allowing mental activities, such as thinking, planning, and reminiscing, to

occur in bed

Pharmacotherapy for general

Name of Drug Reaction

onset

Half Life Dose Main

indication

Zolpidem 7-27

minutes

5-7 hours 5-10

miligram

initiation

Estazolam 120 minutes 10-24hours 0.5-2

miligram

Initiation

and

maintaining

sleep

Ramelteon 45 minutes 2-5 hours 8 miligram initiation

Approved by : Food Drug Administration (FDA) USA

Lorazepam can be used 0.5-1.0 miligrams for geriatric patients

Dietary Supplements for General Use

Not FDA regulated !!!

Valerian

Kava-Kava

Melatonin

Passion flower

Skullcap

Lavender

Hops

COGNITIVE-BEHAVIORAL TREATMENT For INSOMNIA

Indications Primary Insomnia

Psychophysiological Insomnia

Inadequate Sleep Hygiene

Comorbid Insomnia With a medical condition

With a mental disorder

Important to combine both cognitive and behavioral components

CBT for comorbid INSOMNIA

Efficacy of CBT for INSOMNIA

Efficacy of CBT for INSOMNIA

COGNITIVE THERAPY

Cognitive restructuring

Rational-Emotive therapy

Specific techniques for rumination Thought-stopping

Meditation techniques

COGNITIVE THERAPY

Five domains of cognitive activity hypothesized to contribute to insomnia

Worry and rumination

Attentional bias and monitoring for sleep-related threat

Unhelpful beliefs about sleep

Misperception of sleep and daytime deficits

The use of safety behaviors that maintain unhelpful beliefs

BEHAVIORAL TREATMENTS

Sleep hygiene education Specific behaviors will directly interfere with the ability to sleep The behaviors can be changed with education No sufficient as a ‘stand alone’ treatment

Sleep restriction therapy Increased propensity to sleep by increasing homeostatic sleep drive with partial sleep deprivation Systematic reduction of time in bed to the amount of total sleep time from sleep log data Increase time in bed by 15 minutes only when sleep efficiency exceeds 90% for 5 nights

Key Messages

Do not postpone therapy for Insomnia when diagnosis of insomnia is confirmed

When Insomnia is a part of mental health problem, treat the mental disorder as well the insomnia

Use appropriate and approved drugs for Insomnia : Zolpidem and Estazolam. Estazolam is good for maintaining sleep

When using other Bzd’s like alprazolam or lorazepam, be careful of the effect of long use

Do not forget to suggest Sleep Hygiene in the first hand

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