Management of Chronic Tinnitus and Insomnia with Repetitive Transcranial Magnetic Stimulation and Cognitive Behavioral Therapy – a Combined Approach

It has been estimated that up to 80% of people will experience symptoms of tinnitus over the courses of their lives, with rates of comorbid sleeping problems ranging from 50 to 77%. Because of a potential connection between tinnitus and sleep disorders as well as high rates of comorbid psychiatric disorders, interdisciplinary approaches to treatment seem to be the most efficient option. In this study, we present the case of a 53-year-old male patient, who started to experience symptoms of tinnitus at the age of 49, most likely caused by work-related stress. Over the course of his illness, the patient developed comorbid insomnia. He consulted us for treatment of both conditions and we developed a treatment plan with ten sessions of repetitive transcranial magnetic stimulation (rTMS) followed by 10 sessions of cognitive behavioral therapy (CBT). We used the Tinnitus Fragebogen (TF) to assess the severity of the tinnitus, the Beck Depression Inventory (BDI-II) for depressive symptoms, and the WHO Well-being Index (WHO-5) for subjective well-being. Improvements could be achieved with regard to both diagnoses and the patient went from severe (48) to clinically negligible (12) TF scores, from minimal (BDI-II score 10) to no (0) depressive symptoms, and from just above critical (WHO-5 percentile 52) to above average (84) well-being. The combination of technological and psychological approaches to treat tinnitus and insomnia thus proved successful in this case. One may therefore conclude that rTMS may be considered an effective first therapeutic step for tinnitus treatment prior to CBT. To our knowledge this is the first published case in which rTMS and CBT were combined for tinnitus therapy. The approach proved successful since it led to a considerable increase in well-being and everyday functioning. To gauge the effect on a more general level, large-scale studies are still needed to cancel out potential placebo effects. Likewise, the importance of the order of the two treatments, and the possibility of using other therapies in combination with CBT to address certain tinnitus subtypes and different etiologies must be studied in greater detail

Cognitive function in soccer athletes determined by sleep disruption and self-reported health, yet not by decision-reinvestment

BackgroundSleep disruption (SD) increases sympathetic activity and cortisol secretion, and delays cognitive functions such as reaction-time (RT). Sympathetic activity of disturbed sleepers, is similar to those of so-called decision-reinvesters. Decision-reinvestment refers to traits in individuals with greater tendency to ruminate and reinvest in their decisions, with significant decrease in both motor-control and cognitive performance. Decision-making quality is a crucial attribute to athletic performance which relies on RT. Consequently, SD affects pitch-performance negatively, particularly in decision-reinvesters. This observational pilot-study examined the relationship between SD and cognitive function, perceived health, as well as reinvestment strategies. The hypothesis was that athletes with lower SD perceive their health better, report lower stress levels, perform better in cognitive tasks, and show lower tendency for decision-reinvestment.MethodsTwenty-one football player recorded their sleep with fit-trackers for 7 nights. Participants self-reported their mental and physical health, decision-reinvestment strategy, sleep behaviour, and perceived stress levels. Athletes then performed a set of cognitive tests to examine memory function (Backwards Corsi), selective attention (STROOP), and cognitive flexibility (Wisconsin Card Sorting Test, WCST). Normality was tested with a Shapiro-Wilk test, and analysed with a Pearson's or Spearman's correlation test.ResultsSignificant correlation appeared between extended sleep-interruptions and Backwards Corsi RT, r = 0.66, p = 0.010, as further in total sleep time and wellbeing r = 0.50, p = 0.029. A negative correlation exist in regard of pain scores and Backwards Corsi scores r = −0.57, p = 0.110. Physical health correlated with error-rates in the WCST, r = 0.69, p ≤ 0.001. Also, reinvestment negatively correlated with physical health, r = −0.80, p ≤ 0.001.ConclusionWellbeing relies on total sleep-time. Athletes with extended sleep-interruptions are slower in recalling memory, and those with greater reported pain have lower memory scores. Participants who rate physical health greater, have more error-rates in the WCST; indicating that cognitive flexibility is enhanced in individuals with inferior perceived health. However, individuals with lower physical health scores also have greater tendency to ruminate and reinvest in decisions, suggesting interrelation between reinvestment and physical health

Treatment of insomnia in elderly patients

Introduction: Insomnia is one of the most common health conditions amongst the elderly population. It causes suffering and numerous health problems for those affected. Objectives: To review published results of common non-pharmacological and pharmacological interventions of insomnia and to discuss their application in older patient groups. Methods: We conducted a systematic literature review for the topic non-pharmacological treatment of Insomnia in Elderly and non-systematic review on the topic of pharmacological treatment using the electronic databases PubMed, PsycInfo, Google Scholar and Web of Knowledge. Only published articles and reviews were included. Results: Sleep education can support the onset of sleep. As a simple and side-effect-free measure, sleep education should be offered to all elderly individuals with sleep-onset insomnia including those living in retirement homes. Stimulus control means that the bed or the bedroom should only be visited, if there is sufficient tiredness, or left, when tiredness is not sufficient, which is very challenging and sometimes impossible due to the decreasing mobility of the elderly, especially under treatment with hypnotics. Sleep restriction can be conducted in a moderate way, reducing the time spent in bed every week for 30 minutes. Light therapy supports the regulation of the circadian body rhythm by exposing the patients to bright artificial light during the day. As a simple measure with only a few side effects, it is suitable when treating elderly individuals in institutions. Digital therapies are an emerging trend in the treatment of sleep disorders and require further empirical investigation of their effectiveness in the treatment of insomnia in the elderly. Non-pharmacological therapy should be the first-line therapy according to guidelines. Prescribing of sleep medication should take into account the period of time until the maximum effective level is reached, the half-life of the preparation, the binding behaviour to receptors and the metabolism of the preparation, which is especially relevant for elderly populations due to polypharmacy. Conclusion and implications: A modified, short cognitive behavioural therapy for insomnia combined with light therapy is the treatment of choice for elderly patients. However, a short-term pharmacological therapy is recommended as a temporary solution to immediately reduce high levels of distress. It is suggested to integrate both therapeutic approaches into a comprehensive therapeutic concept for insomnia in elderly people. Key words: Insomnia, cognitive behavioural therapy for insomnia, CBT-I, Hypnotics, light therapy, elderl

Психијатрија за студенти по медицина

Учебникот е наменет за студенти по медицина, стоматологиј, како и за студенти на Високите медицински школи. Целта на учебникот е, на што поедноставен и структуриран начин да се опишат главните групи на психијатриски заболувања со особен осврт на оние заболувања со кои што идните лекари и професионалците од подрачјето на високиот медицински персонал ќе се сретнат во својата секојдневна практична работа. Поради тоа, описот на психијатриските заболувања следи аналогно на класификацијата МКБ 10 (Меѓународна класификација на заболувањата, 10–ревизија, издадена од Светската здравствена организација). Освен описот на етиологијата, епидемиолошките податоци, главните клинички симптоми, дијагнозата, диференцијалната дијагноза и терапијата, во поголемиот дел од поглавјата се прикажани случаи со прашања кои што треба да им бидат помагала на студентите при подготвување за исптните прашања. Психијатријата е мултидисциплинарна професија во која што, освен лекарите и медициснкиот персонал се вклучени и други академски професии како што се психолозите, социјалните терапевти и работните терапевти. Поради тоа, поглавјата за терапија, освен описот на медикаментната терапија, содржат и препораки за примена на психотерапијата и социотерапијата, а едно цело поглавје е посветено на психолошките мерни инструменти. Менталното здравје на поединецот е вмрежено со менталното здравје во семејството, а децата на лица со ментални заболувања се изложени на особен ризик и самите да заболат. На овие системски-психијатриски подрачја се посветени две поглавја од учебникот. Сите оние кои што работат со ментални заболувања треба особено да внимаваат на своето ментално и физичко здравје. Оваа тема е разработена во поглавјето за превенција на професионално согорување. Во последното поглавје опишана е актуелната организација на менталното здравје во Македонија која што е полна со предизвици за позитивни промени. Се надевам дека студентите со леснотија и задоволство ќе го читаат нашиот учебник, а знаењето ќе им користи за полагање на испити, но, што е многу поважно, дека ќе се разбуди професионален интерес и позитивно љубопитство за работа со лица со ментални заболувања

Behandlungseffekte der repetitiven transkraniellen Magnetstimulation (rTMS) bei Patienten mit chronischem Tinnitus aurium: Erste Ergebnisse der Behandlung mit niederfrequenter rTMS

Einleitung: In der Bundesrepublik Deutschland erkranken jährlich über 350.000 Patienten behandlungsbedürftig an Tinnitus. Die repetitive transkranielle Magnetstimulation (rTMS) wird in den letzten Jahren in verschiedenen Kliniken innerhalb einer Multicenterstudie als eine innovative technische Behandlungsmethode bei chronischen Ohrgeräuschen erprobt. Methode: An einer Stichprobe von 28 ambulanten Patienten mit chronischem Tinnitus aurium wurde die Wirksamkeit der niederfrequenten Magnetstimulation (1 Hz) bei Tinnitus im Rahmen der Routineversorgung überprüft. Ergebnisse: Im Prä-Post-Vergleich zeigte sich im Stichprobendurchschnitt eine 7 Punkte umfassende Reduktion des Tinnitus-Wertes, erfasst anhand des Tinnitus-Fragebogens (TF, Göbel und Hiller) sowie eine signifikante Reduktion der depressiv gefärbten Stimmung der Patienten im Fremd- (MÅDRS) wie im Selbsturteil (BDI II). 57% der mit rTMS Behandelten konnten als Responder eingestuft werden (Response-Kriterium: Abnahme des TF-Scores um mindestens 5 Punkte). Schlussfolgerung: Die Ergebnisse erlauben mit Einschränkungen einen positiven Ausblick in die Zukunft der rTMS in der Tinnitus-Behandlung

Shiftwork and Alcohol Consumption: A Systematic Review of the Literature

Introduction: Shiftwork can be a risk factor for a number of different somatic and psychological health conditions, especially sleep disorders. Shiftworkers sleep less than dayworkers, and 20–40% of them suffer from difficulties initiating and maintaining sleep, which result in reduced capacity for work and social life. A common coping strategy might be the use of alcohol, which presents a health and safety hazard as it further impairs sleep quality and exacerbates sleepiness in the workplace. This review aimed to assess the extent of such possible connections. Methods: We performed a systematic search of the scientific literature on shiftwork and alcohol consumption in PubMed, PsycInfo, and Cochrane Library. Only original studies comparing shiftworkers with non-shiftworkers were included. The recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-Analyses were followed. Results: Fourteen articles are included in this review. Six studies report some kind of connection between shift- or nightwork and alcohol consumption, especially as a sleep aid. Conflicting or negative results are reported by 3 studies. Discussion: Shiftwork, especially working at night and in rotation shifts, is associated with binge drinking disorder in different professions. The reasons for pathological consumption of alcohol can be self-medication of sleep problems or coping with stress and psychosocial problems typical for shiftwork. Nurses aged over 50 years represent one important risk group. These results can be important for preventive programs against sleep disorders, including measures other than drinking alcohol as a sleep aid in the workplace of shiftworkers

Analysis of metals in the serum of professionally exposed population of blood-donors from the Buchim-Radovish mine and unexposed general population from the municipality of Shtip

Aims:To determine the concentration of heavy metals in the serum of professionally exposed blood donor population from Buchim-Radovish mine and the unexposed general population (control group) from Shtip. To estimate the potential difference of heavy metals concentration and their impact on the health of blood recipients. Methods and materials:The concentration of heavy metals (Mn, Cr, Zn, Cu, Pb, Ni, Co, Cd) was analyzed in the serum of 30 professionally exposed miners blood donors from active Buchim mine, located nearby the town of Radovish. The control group comprised of 30 samples from the general population from Shtip, not directly exposed to heavy metals. The research was conducted in the chemical-biochemical laboratory at the University “Goce Delchev” in Shtip, using the equipment ISP-AES, Liberty 110, Varian. Results and discussion:Concentrations of Mn, Zn, Cu, Pb were significantly higher in the group of miners compared with the control group. The concentration of Cu correlates significantly with the concentration of Zn. This result is in line with the known fact that Cd, Cu, Zn bond to metallothionein in vivo, while Mn does not. Concentrations of Co and Cd were not significantly different between the analyzed groups, only Ni concentration is higher in the control group. Average values of analyzed metals were higher in the exposed group than in control group as reported in several studies on miners and other professionally exposed workers. Conclusion:Heavy metals have major impact of human health and environment. Strict legislation aiming to solve raising problems in this area gives vital importance to the monitoring of heavy metals. It is necessary to undertake further detailed analysis on the impact of higher concentrations of heavy metals in the blood of miners blood donors and on the health of blood recipients

Insomnia: Comorbidities from the Field of Sleep Medicine and Psychiatry in a Sample of an Interdisciplinary Center for Sleep Medicine

In dieser Untersuchung wurde die Komorbidität der Insomnie mit anderen schlafmedizinischen und psychiatrischen Diagnosen untersucht. Hierzu wurden die Schlaflaborbriefe von 102 Insomniepatienten eines schlafmedizinischen Zentrums (mittleres Alter: 49 Jahre; 64 Frauen, 38 Männer) nach diesbezüglich relevanten Diagnosen durchsucht. Die höchste Komorbidität zeigte sich mit depressiven Störungen (50%) gefolgt von schlafbezogenen Atmungsstörungen (17,6 – 37,3%) und schlafbezogenen Bewegungsstörungen (12,7 – 21,5%). Dieser Befund spricht bei Vorliegen einer Insomniesymptomatik für die routinemäßige Durchführung einer fundierten Diagnostik mit sowohl Polysomnographie als auch psychiatrischer Exploration.In this study comorbidity of insomnia and other relevant diagnoses from the field of sleep medicine and psychiatry was analysed. For this purpose relevant diagnoses from physician´s letters of an interdisciplinary department of sleep medicine were documented in a sample of 102 patients with insomnia. Insomnia showed the highest comorbidity with depressive disorders (50%) followed by sleep related breathing disorders (17.6 – 37.3%) and sleep related movement disorders (12.7 – 21.5%). In case of subjectively reported insomnia symptom-atology this result indicates a profound diagnostic investigation with polysomnographic sleep recording and psychiatric exploration as a matter of clinical routine