《失眠治療趨勢》PPT课件.ppt

失眠治療趨勢,署立雙和醫院精神科 台北醫學大學附設醫院睡眠中心,Weve learned how to sleep,Weve learned how not to sleep,Sleepless in Taiwan,Lee, Yue-Joe 2001,30kg,Why Sleepless?,Why Sleepless?,貓熊怎麼睡你知道嗎？ 馬總統專程CALL動物園長詢問,2 /24/2009/台北報導,身體疾病導致失眠? Physical Illness (10%),精神疾病導致失眠? Mental Illness (40-50%),使用藥物/物質導致失眠? Substance/Drug (10%),睡醒週期障礙導致失眠? Circadian Disturbance,不寧腿症候群或週期性肢體抽動障礙? RLS/PLMD,睡眠呼吸中止症? Sleep Apnea,原發性失眠? Primary Insomnia (20-25%),猝睡症? Narcolepsy,次發性失眠,其他原發性睡眠障礙,20-25%,Why Sleepless?,Neurophysiologic Models of Insomnia,Homeostatic Regulation of Sleep,Neurochemical basis of sleep homeostasis Adenosine Genetic control of homeostatic processes Sleep duration & response to sleep loss may be affected by mutations of the murine Clock gene.,Homeostatic Regulation in Insomnia,Lowered homeostatic sleep drive Reduced EEG slow wave activity (Merica & Gaillard, 1992) Behavioral factors Increased resting in bed Sleeping outside of the nocturnal sleep period Reduced daytime activities Coffee drinking,Circadian Process of Sleep,The endogenous pacemaker regulates the sleep-wake rhythm with about 24 hour per cycle. Human circadian period is slightly longer than 24 hours. The center of circadian system: Suprachiasmatic nucleus (SCN) Dorsomedial hypothalamus (DHM),Biological Clock,Circadian Regulation in Insomnia,Extreme circadian type or less flexible circadian system as a predisposing factor for circadian rhythm sleep disorders Decreased melatonin levels? Behavioral Factors Irregular or changes of sleep-wake schedule Sleep-in during weekend to catch up lost sleep,Chronobiological Models,Normal process S & C in sleep deprivation,Riemann D, et al. Biological Psychiatry. 2001;57:67-103.,Why Sleepless?,Why Sleepless?,Why Sleepless?,Insomniacs Brain,Only Sleep,Then, to fall asleep.,NIH STATE-OF-THE-SCIENCE CONFERENCE STATEMENT on Chronic Insomnia,Historically, this has been termed “secondary insomnia.” we propose that the term “comorbid insomnia” may be more appropriate. Common comorbidities include psychiatric disorders, particularly depression and substance use disorders; cardiopulmonary disorders; and conditions resulting in chronic somatic complaints that may result in sleep disruption. Other associated sleep disorders can also contribute to insomnia, such as obstructive sleep apnea, restless legs syndrome, or periodic limb movement disorder. “Primary insomnia” implies that no other cause of sleep disturbance has been identified.,NIH, Sleep 2005; 28: 1049-1057,Insomnia is NOT ONLY a Symptom, but ALSO a Disease,Depression and Insomnia,Can insomnia instigate, perpetuate, Or exacerbate depression? This question can never be answered,Taylor DJ. Sleep. 2008;31:447-8.,Depression and Insomnia,psychiatric sleep specialists have been reluctant to use the “C” word, One can find. “MDD is associated with sleep disturbance” or “sleep is biologically linked to mood disorders” (But not) “Insomnia causes depression.”,Turek FW. Sleep. 2005;28:1362-3.,545 patients with MDD and Insomnia Morning Fluoxetine + Eszopilcone/Placebo for 8 wks Evaluate Sleep Parameters and Depressive Symptoms Plus Clinical Global Impression Improvement/Severity,Fava et al, Biological Psychiatry 2006; 59:1052-1060.,Treat Insomnia in Depression,Fava et al, Biological Psychiatry 2006; 59:1052-1060.,Treat Insomnia in Depression,Fava et al, Biological Psychiatry 2006; 59:1052-1060.,Treat Insomnia in Depression,30 patients with MDD and Insomnia Escitalopram + CBTI/Control for 7 individual sessions In Control Tx, only education about sleep and sleep hygiene HRSD-17 used for depression assessment ISI, sleep diaries, and actigraphy used for insomnia assessment,Manber R, et al. Sleep. 2008; 31:489-95.,Treat Insomnia in Depression,Manber R, et al. Sleep. 2008; 31:489-95.,Treat Insomnia in Depression,BzR agonists : BZDs, Non-BZD BzRA (z-drugs) Antihistamine: hydroxyzine, diphenhydramine Sedating antidepressants: trazodone, mirtazapine, amitriptyline, doxepin Antipsychotics: quetiapine, olanzapine Others: melatonin,Drugs Commonly Used As Hypnotics,The Relationship between Benzodiazepine Concentration and GABAA Concentration,The Patency of Chloride Ion Channel,Time,The curve of benzodiazepine concentration,The curve of GABAA concentration,Slide Courtesy by Prof. Winston Shen, 2008.,Commonly Used BzRA Hypnotics,全民健康保險藥品給付規定修正規定 第1章 神經系統藥物 Drugs acting on the nervous system （自98年5月1日生效）,備註：劃線部份為新修訂之規定。,Pre-Sleep Conditions: One By One Sleep-Wake Schedule: “When do you take sleeping pills?” Restrict the Dosage of Hypnotics: Objective vs. Subjective Avoid Continuous Use: As Needed Use or Scheduled Drug Holidays Set Treatment Goal: “What is your “Ideal Sleep”?”,Pharmacotherapy Plus Sleep Hygiene,THANKS,肝癌是指发生于肝脏的恶性肿瘤，包括原发性肝癌和转移性肝癌两种，人们日常说的肝癌指的多是原发性肝癌。原发性肝癌是临床上最常见的恶性肿瘤之一，根据最新统计，全世界每年新发肝癌患者约六十万，居恶性肿瘤的第五位。原发性肝癌按细胞分型可分为肝细胞型肝癌、胆管细胞型肝癌及混合型肝癌。按肿瘤的形态可分为结节型、巨块型和弥漫型。原发性肝癌在我国属于高发病，一般男性多于女性。中国是乙肝大国，我国的肝癌多在乙肝肝硬化的基础上发展而来，丙肝病人也在逐渐增加，乙肝后也会发展为肝癌。目前我国发病人数约占全球的半数以上，占全球肝癌病人的55%，已经成为严重威胁我国人民健康和生命的一大杀手，其危险性不容小视。1 发病原因 总的来说，原发性肝癌的病因至今未能完全阐明，但已证明与以下因素密切相关： 1、病毒性肝炎：流行病学统计表明，乙肝流行的地区也是肝癌的高发地区，患过乙肝的人比没有患过乙肝的人患肝癌的机会要高10倍之多。长期的临床观察中发现，肝炎、肝硬化、肝癌是不断迁移演变的三部曲。近