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Is Strep Linked to Scary Kids’ Behavior Disorder?

When Garrett Pohlman was diagnosed with strep throat in 2007, his illness didn’t respond to antibiotics. Then the strange behaviors began.

Diana Pohlman says her son, who was 7 years old at the time, had been easygoing up to that point. But he developed severe obsessive compulsive disorder (OCD) symptoms overnight. He became paranoid – worrying about things like radiation from the TV and light switches. He had tics and anorexia and started having frequent episodes of rage.

“He was not anyone I recognized. He was a completely different child,” she says. “It was a nightmare. At first I thought maybe he had been molested. Then I thought he had a brain tumor.

“He became so delusional he would climb on the roof thinking it was the front door. He would jump in front of cars and out of moving cars, and he had self-harm fantasies. He was afraid to leave the house. We had to pick him up and wrap him in a sheet to get him out of the house. At the age of 7,” Pohlman says.

 

He was not anyone I recognized.
He was a completely different child.
Diana Pohlman

The search for answers was long and expensive. After many months, the family found their way to a psychiatrist who knew about a disorder called pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS, a condition she says several specialists didn’t know about. That led to medical treatment that included long-term antibiotics, having his tonsils and adenoids removed, and eventually two rounds of immunoglobulin, or IVIG treatments.

Recovery was slow, but after 2 years, by the age of 9, Pohlman says the severe symptoms stopped. For another 2 years, he had what she calls mild and manageable symptoms that eventually dissipated.

But rather than move on from PANDAS, the boy’s mother decided she needed to help other parents trying to figure out these mysterious symptoms. She founded the nonprofit PANDAS Network in 2009 to raise awareness, support families, and push for more research to better understand how to diagnose and treat the condition.

“When I realized doctors didn’t understand it, I thought I better not quit working on this because how will anyone else ever get help,” Pohlman explains. “It is abysmal. It has been shocking how misinformed doctors are about the term ‘PANDAS.’ ”

Little is known about how or why the syndrome happens, and not all doctors believe there is a connection. The American Academy of Pediatrics does not recognize a link between strep and the syndrome.

“You will not find consensus from pediatric infectious disease doctors that PANDAS even exists, much less what to do about it and how to manage the patients,” says Meg Fisher, MD, a pediatrician and infectious disease specialist at Unterberg Children’s Hospital at Monmouth Medical Center in Long Branch, NJ. “We still haven’t had the definitive article or study or demonstration to really get some solid clinical evidence behind this. My problem is, even if you believe in the syndrome, it’s totally unclear what you should do to help those patients. All of the information is anecdotal.”

What Is PANDAS/PANS?

Susan E. Swedo, MD, at the National Institute of Mental Health (NIMH), first identified PANDAS in the 1990s after she reported on a link between the fast onset of OCD and group A streptococcus, more commonly known as strep.

You will not find consensus from pediatric infectious disease doctors that PANDAS even exists, much less what to do about it and how to manage the patients.
Meg Fisher, MD, Unterberg Children’s Hospital, Monmouth Medical Center

PANDAS happens when strep triggers a misdirected immune response that causes inflammation in a child’s brain. Pediatric acute-onset neuropsychiatric syndrome, or PANS, is a larger umbrella term that has to do with cases with a trigger other than strep, including infections like walking pneumonia or the flu.

Both disorders appear in childhood, typically between the ages of 3 and 12. While blood tests may help identify infections, there are no lab tests or other indicators for PANDAS or PANS.

Doctors diagnose the syndrome when children suddenly get severe OCD or eat a lot less food, along with at least two of the following symptoms: anxiety, depression, irritability or aggression, behavioral regression, ADD- or ADHD-like symptoms affecting schoolwork, sensory or motor problems, troubled sleep, and frequent urination.

The PANDAS Network says in some cases, the emotional symptoms can weaken children and make them homebound. Other children are OK at school but fall apart at home. The NIMH describes the start of symptoms as “dramatic,” happening “overnight and out of the blue.”

“The consensus of scientists and clinicians is that it needs to be sudden and severe,” says Margo Thienemann, MD, co-director of the PANS program at Stanford University Medical Center in California. “Sudden can be overnight. Some people can say exactly what time it started or that it happened over a couple of days. But they all say this isn’t their child anymore. Even if they don’t believe someone can be possessed, it feels that way. What happened? Why are they doing these things? Why can’t they stop?”

Swedo estimates that it impacts about 1% of elementary school-aged children and is likely under-diagnosed. The PANDAS Network estimates 1 in 200 children have it. Thienemann says her program at Stanford has seen more than 250 patients since it started in 2012. But she says that since their staff is small, they have to narrow down who gets in. One year, they turned away 1,000 patients because they couldn’t handle any more.

Thienemann says this is why they have helped write guidelines to allow health care providers to identify and treat these children. “It takes a multidisciplinary team to manage. A psychiatrist, pediatrician, or rheumatologist can’t do it alone. You need all these different vantage points to diagnose and coordinate care,” she says.

There are now PANS centers in California and Arizona, and some doctors around the country treat the disorder.

The NIMH says research suggests IVIG can ease symptoms and may be used in severe PANDAS cases, but it warns it has many side effects — including nausea, vomiting, headaches, and dizziness — and there is a chance of infection with this sort of procedure. Parents say it is also expensive and often not covered by insurance.

Some families say they also see improvement when they have their children’s tonsils and adenoids removed, although no studies show that works.

streptococcus pneumonia bacteria

Controversy

Not all in the medical community agree that strep or other infections can trigger these kinds of behaviors. There is also much debate about whether treatments are effective.

While the American Academy of Pediatrics does not recognize a link between strep and PANDAS, a March 2017 article in AAP News, sent to the group’s 66,000 pediatrician members, discusses the disorders and the controversy around them. While it’s not the group’s official policy, the article says pediatricians should consider PANS anytime a child “has an abrupt behavior change with obsessive thoughts,” and it points them to material that shows them how to diagnose it.

Fisher says it’s complicated for pediatricians, since there is no evidence that taking out tonsils and adenoids is helpful or that antibiotics work. She says many pediatricians worry that young patients will become resistant to antibiotics if you prescribe them long-term, and many have concerns about IVIG side effects.

“I understand the parents’ frustration, because finding a physician for these patients is very difficult. There are a lot of doctors who are, quote unquote, PANDAS specialists, but there is nothing that is evidence-based about what they are doing,” she says. “Our goal is first do no harm, and it is hard to know how best to help these patients. It is a very frustrating thing. I wish someone would come up with some solutions.”

Thienemann says most parents who find their way to her program are frantic because they can’t get help anywhere else. “Part of that desperation is nobody would listen to them. People say my pediatrician won’t do anything, and my child is trying to jump out of moving cars or a window. They can’t get out of the house, can’t sleep, are urinating on themselves, and have severe separation anxiety,” she says.

 

There is something medically wrong. There isn’t a finger to be pointed. There are questions to be asked and answered.
Ali Claypoole

Parents say it is obvious something isn’t right.

“I thought she had schizophrenia or severe mental illness,” says Kelly, a mother in Maryland who asked that we not use her last name to protect the privacy of her 7-year-old daughter, Maggie, who has PANDAS. “It was rapid-onset OCD, and then we were spending our entire life trying to keep her from jumping out of cars, hurting herself, biting us, and losing her mind.”

“There is something medically wrong. There isn’t a finger to be pointed. There are questions to be asked and answered,” adds Ali Claypoole, whose son, now 9 years old, first showed PANDAS symptoms at the age of 6. “Our world is turned upside down, and from where I am, it’s almost like parents are more informed than the doctors. I find the civilian community is much more understanding, interested, and willing to learn about this than the medical community. It makes me mad.”

Going Forward

More research is now being done.

In a 2017 large-scale study of key parts of the PANDAS theory, researchers looked at 17 years of data out of Denmark and found that young patients with a positive strep test had higher chances of having of mental disorders, especially OCD and tic disorders, compared with those without a positive strep test. Non-strep throat infections also carried a higher chance of these types of mental disorders in children, although it was less – perhaps pointing to the chance that other infections can trigger the symptoms.

It is really the brain inflammation  
that is central to this disease.
Dritan Agalliu, PhD, Columbia University Medical Center

In 2016,  Dritan Agalliu, PhD, an assistant professor in the Department of Neurology at Columbia University Medical Center in New York City, published a study showing that immune cells produced in the nose after multiple strep infections appear to be the culprit for the disease. These cells enter the brain via the nerves that are responsible for the sense of smell, and they damage the blood vessels and synapses in the brain.

Agalliu says this research helped explain a crucial step in the disease: how antibodies that the body makes to attack strep or other infections cross the blood/brain barrier in these children and attack parts of their brain by mistake; similar to what happens in other autoimmune diseases of the brain, like multiple sclerosis.

The NIHM recently awarded Agalliu nearly $2 million to keep studying the disorder. He says it should be called post-streptococcal basal ganglia encephalitis, or inflammation of the brain. He’s also doing research funded by a private donor, looking at genetic chances of having the disorders to understand why a small number of children who get multiple strep infections are prone to get the disease.

“It is really the brain inflammation that is central to this disease. If we think about PANDAS/PANS this way, it will relieve a lot of controversy and make therapies more acceptable for patients,” Agalliu says. “I am hoping with our next publication, we can alleviate any potential question that this is an autoimmune disease.”

There’s also increasing interest in looking at PANDAS as a type of Sydenham chorea, defined by abnormal movements, OCD, mood swings, and other emotional symptoms that follow strep infection.

The NIMH now has a group for PANDAS and PANS. The PANDAS Network is working to make information about the disorders part of continuing medical education for pediatricians, and a working group has created handouts to educate school personnel nationwide to help children with these disorders get back to their classrooms.

So will children outgrow PANDAS? Like most other things associated with this disorder, there is no consensus.

Doctors who focus on the disorders say when patients can get to them, improvement is possible. “If we get people as early as possible, maybe even at the onset of illness, I think we do a good job of being able to tamp down inflammation and help them a lot and maybe get them all the way better,” Thienemann says. “If someone has been dealing with it for 10 years, I think they may develop ongoing autoimmune problems and there may be damage to their brain. Recovery might not be as complete, but I think we can still help them.”

Three years after he first showed symptoms, Claypoole’s son had a full remission at the age of 9 after IVIG treatments. But after a few months, he got strep again and the PANDAS symptoms returned, but they were less severe. Kelly’s daughter Maggie has seen her symptoms subside for a while, only to return. Her doctors prescribe antibiotics and anti-inflammatories after each new episode. She takes both medications daily for months on end. She has also had two rounds of IVIG. “Every time we do an intervention, the baseline gets better, but it doesn’t end the problem. She is not symptom-free,” Kelly says.

Pohlman says her son, now 17, is a straight-A student who plays football and the cello and is applying to college. He is symptom-free.

“Once I understood that Garrett’s brain was on fire from an infectious illness, I barely could believe his body would have the capacity for a full recovery,” she says. “Could he have the normal life I had expected for my child? So I look at him now in amazement.”

 

By Jennifer Clopton       Nov. 10, 2017     WebMD Article Reviewed by Hansa D. Bhargava, MD on November 10, 2017

Sources
Ali Claypoole, Maryland.
Kelly, Maryland. (Requested not using last name)
Dritan Agalliu, PhD, Columbia University Medical Center, New York City.
Meg Fisher, MD, Unterberg Children’s Hospital at Monmouth Medical Center, Long Branch, NJ.
Diana Pohlman, executive director, PANDAS Network, Stanford, CA.
Patricia Rice Doran, EdD, associate professor, Department of Special Education, Towson University, Maryland.
Margo Thienemann, MD, Stanford University School of Medicine, Stanford, CA.
AAP News: “PANDAS/PANS treatments, awareness evolve, but some experts skeptical.”
American Academy of Pediatrics Red Book: “Group A Streptococcal Infections.”
National Institute of Mental Health: “PANDAS, Questions and Answers.”
National Institute of Mental Health: “Guidelines published for treating PANS/PANDAS.”
PANDASNetwork.org: “What is PANS?” “What is PANDAS?” Symptoms,” “Statistics,” “Our Mission.”
K. Chang, Journal of Child and Adolescent Psychopharmacology, Feb. 1, 2015.
R. Kurlan, Pediatrics, June 2008.
S Orlovska, JAMA Psychiatry, July 1, 2017.
K.A. Williams, Brain Research, August 18, 2015.
T Dileepan, The Journal of Clinical Investigation, January 4, 2016.

source: WebMD 
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For Sleep Struggles, Women Urged to Alter Routines

March 2, 2012


By Dennis Thompson
HealthDay Reporter

FRIDAY, March 2 (HealthDay News) — Driven to sleeplessness by the effects of stress and the demands of their own biology, women are more likely than men to have serious sleep problems, experts say.

“We see insomnia much more frequently in women, probably at least 50 percent more often than men,” said Dr. Ryan Hays, an assistant professor of neurology at the University of Texas Southwestern Medical Center in Dallas.

In response, women have turned to medication for help. In the age range most affected by insomnia, ages 40 to 59, nearly 15.5 million American women got a prescription last year to help them sleep — nearly double the rate for men in the same age group, according to IMS Health, a health-care consulting firm in Danbury, Conn.

But sleep researchers believe there’s a better way. Changes to a person’s lifestyle and to the way they approach sleep can help in a more natural and more effective way than simply popping a sleeping pill.

And putting away the pills may be especially appealing in light of a report earlier this week in the journal BMJ Open that suggested prescription sleep aids may shorten your life or increase your risk of certain cancers.

“That’s the ideal, to not rely on a pill to help you get to sleep,” said Shelby Harris, director of the behavioral sleep medicine program in the Sleep-Wake Disorders Center at Montefiore Medical Center in New York City. “It’s always best to solve a problem without a pill. It really does depend on the patient, but we prefer if you can avoid medication.”

Two major factors make women more likely than men to suffer insomnia, Harris said.

The first factor is innate and ancient. “There are a lot of hormonal and biological changes throughout the life cycle that women experience, and those affect sleep,” she said.

These hormonal changes begin with menstruation and continue through menopause. Pregnancy also can hamper sleep, particularly in the third trimester, and many women find it very difficult in the first few post-partum months to maintain a deep, healthy slumber. “Every little noise keeps you awake or wakes you up,” Harris said, tracing the phenomenon back to evolution and a hypervigilance developed by our primitive ancestors to better protect their young.

But the second factor is external and modern. Much is required of women these days, as they juggle many different life roles, and the stress this creates can make it difficult to sleep, Harris said.

“It always seems like they’re trying to fit a 30-hour day into 24 hours,” she said. “There’s little time for moms in particular to relax and unwind, to be able to go to sleep at night.”

These problems can create a vicious cycle, where a woman who has trouble sleeping will begin to fret, which makes it even more difficult to sleep, Hays said.

“Patients often feel if they don’t get a good night’s sleep, the day after is going to be the worst,” he said. “They start to learn to dread the bed.”

Hays and Harris both recommend that their patients adopt changes in their routine to help them get better sleep. These behavior modifications go beyond the usual “sleep hygiene” recommendations — like getting to bed on time every night, partaking in regular exercise or using your bed only for sleep or sex.

For example, many women with insomnia will lie in bed thinking about all the things they need to get done the next day, Harris said. She recommends that these women write up a to-do list early in the evening and then prioritize it. “Write everything out, so it’s on paper and out of your head,” she said.

Other women wake up in the middle of the night and decide to get some work done or perform some chores, which sounds like a good use of time but might be making matters worse, Harris noted.

“If you do that every night at 3:00 in the morning, you’re just training your body to get up and do work at that hour,” she said.

The two sleep experts also recommend that women get out of bed if they wake up in the middle of the night and can’t get back to sleep within a half-hour or so. But instead of working, they recommend that women do something calming, monotonous or even boring: fold clothing, or read old magazines or books in dim light.

“They’re better able to fall back asleep quicker than if they stayed in bed and became frustrated,” Hays said.

Women with extreme insomnia might even consider trying a counter-intuitive approach in which they limit their time in bed, Hays said. If they’re only getting five hours of good sleep a night, for instance, they could allow themselves only four hours in bed.

“If they spend less time in bed, there’s a better chance they’ll spend more of that time sleeping,” Hays said.

Another little sleep trick involves body temperature. Researchers have found that sleep comes with a drop in a person’s core temperature, Hays noted. Taking a relaxing warm bath before bedtime could help aid sleep. “That may increase the amount the body’s temperature actually drops, which may help sleep continuity,” he explained.

Finally, women can help themselves fall asleep by “setting the table” for sleep by adopting a routine set of relaxing rituals just before bedtime.

“A lot of people treat sleep like an on/off switch,” Harris said. “You should set aside a half-hour to treat sleep like a dimmer switch.” Sit in a favorite chair, dim the lights and do something relaxing and enjoyable.

“You’re setting the stage for sleep,” she said. “Then get in bed when you’re actually sleepy.”

More information

The U.S. Centers for Disease Control and Prevention has more on sleep and sleep disorders.

SOURCES: Ryan S. Hays, M.D., assistant professor, neurology, University of Texas Southwestern Medical Center, Dallas; Shelby Harris, Psy.D., CBSM, director, behavioral sleep medicine program, Sleep-Wake Disorders Center, Montefiore Medical Center, New York City

source: health.com


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Insomnia Can Be Dangerous, But There’s Rest for the Weary

Behavioral Therapy, Prescription Drugs More Effective Than Over-the-Counter Sleep Aids in Treating Insomnia, Report Suggests

By Rita Rubin
WebMD Health News

Reviewed by Brunilda Nazario, MD

Jan. 19, 2012 — If you find yourself tossing and turning most nights, unable to fall asleep, you’re in good company.

Insomnia, which is twice as common in women as in men, affects 6% to 10% of adults. It’s the most common sleep disorder, yet often goes undiagnosed and untreated, according to a new report. The consequences can be much more serious than daytime sleepiness. Research has linked insomnia to high blood pressure, congestive heart failure, diabetes, and other ailments.

Public awareness of insomnia has grown in recent years, in part because of TV commercials for the prescription drugs Lunesta and Ambien, but rates have been stable over the last couple of decades, says researcher Charles Morin, PhD, a psychology professor at Laval University in Quebec City.

Although there’s no standard definition for insomnia, suggested criteria include taking more than 30 minutes to fall asleep, waking up too early, or sleeping less than 6.5 hours a night, write Morin and co-author Ruth Benca, MD, PhD, a sleep disorders doctor at the University of Wisconsin, Madison. If you meet any of those criteria and feel like you can’t focus during the day because you’re so tired, you might have insomnia, they say. But if you feel fine after sleeping less than 6.5 hours at night, you might just be a short sleeper.

Sleepless for Months

Although some people experience sleepless nights only occasionally, one study that followed people with insomnia over time found that nearly 70% said they were still dealing with it a year later, half up to three years later, according to the new report. The standard medical definition defines chronic insomnia disorder as at least three sleepless nights a week for at least three months.

There’s little evidence that over-the-counter sleep aids such as melatonin can give insomniacs a better night’s sleep, but behavioral therapy and prescription medications are effective, Morin and Benca write.

But people often are reluctant to seek help because they fear becoming physically dependent on the drugs used to treat insomnia, says Morin, who serves on the sleep disorders work group that defines mental conditions for the medical community.

“There are simple things that people can do to get a good night’s sleep,” he says. “Oftentimes, people think that the only thing that’s going to be done for their sleep problems is a drug prescription.”

Cognitive behavioral therapy, or “talk therapy,” has been shown to have long-lasting benefits in treating insomnia without any risk of bad side effects, Morin and Benca write. In treating insomnia, cognitive behavioral therapy involves such methods as relaxation techniques.

Behavioral sleep medicine is a fairly new field, Morin says, and, although it is cost-effective in the long run, it is not always a covered benefit.

People with insomnia often have other conditions, such as depression, anxiety, and chronic pain. “We should not treat just the depression” or the anxiety or the chronic pain, Morin says, “and assume the insomnia will go away.”

Morin and Benca published their report in The Lancet.

SOURCE: emedicinehealth

Charles Morin PhD, psychology professor, Laval University, Quebec City, Quebec, Canada.

©2012 WebMD, LLC. All Rights Reserved.


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Time and energy

I used to believe the weekend was for socializing and/or relaxing – an opportunity to recharge your batteries after the work week. These days it seems that the weekends are a chance just to catch up … to take care of chores and other responsibilities not attended to during the week.


Compared to many others I am actually quite lucky in some ways. I have no kids, no pets, no plants … I have a wonderful supportive, intelligent, loving partner … My only major formal locked-in time commitment is my Educational Assistant job weekday afternoons; my other job as a Web Designer is pretty flexible time wise. I play volleyball 3 or 4 times during the week.

What happens when we don’t get enough rest? We burn out. Our bodies need opportunities to recover from activity … we can become vulnerable to more problems – our immune systems can become compromised.

It’s important to be active, but it’s just as important to get enough sleep every night, and pace yourself. If you overwork yourself, you may become sick. It is important to listen to our bodies … You may have a lot on your plate, but it’s in your best interest to find a way of not over doing it.

My weekend to-do list often involves vacuuming, laundry, grocery shopping and a few computer related duties. If you are a working single mother, you likely have a much fuller to-do list than I … and at the same time it may be even more important that you need to take care of your health, so that you are not missing work and able to take care of all your responsibilities.

It can be a challenging balancing act, but without appropriate rest, the stress will take it’s toll. It may take the form of a cut that won’t heal, the common cold or maybe lay the ground work for something more serious.

When I find myself feeling run down, I know it’s time to slow down. I will postpone or rearrange things, delegate … I know that becoming run down could just lead to illness. I might examine my diet … perhaps it’s too much carbs, or not enough iron.

Our bodies will tell us when we are overdoing it … and if we don’t listen to it, we can often be forced to take a break- the next thing you know you are phoning in sick, missing work, not feeling well and not taking care of things around the house.

Rest and relaxation are an important part of health. It’s as crucial as exercise and diet. If you are not sleeping well or feeling stressed to the point of burn out, do yourself a favour and find a way of getting the rest you need to be at your best. Make it happen … if you can’t seem to find a way on your own, talk with your doctor. You’ll be no good to anyone if you run yourself ragged and end up getting sick : )

~ Pete Szekely ~


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Insomnia May Boost Heart Attack Risk

By Matt McMillen

MONDAY, October 24, 2011 (Health.com) — People who struggle with insomnia appear to be more prone to heart attacks than those who typically get a good night’s sleep, a large Norwegian study has found.

In the study, published today in the American Heart Association journalCirculation, researchers conducted a comprehensive health survey of more than 52,000 adults, which included questions about slee

p quality. Over the next 11 years, roughly 5% of the participants had a heart attack for the first time.

Compared to solid sleepers, those who had trouble falling or staying asleep nearly every night were 45% and 30% more likely to have a heart attack, respectively, even after the researchers took into account age, blood pressure,cholesterol levels, and other factors that can contribute to heart disease. People who reported feeling tired or unrefreshed after waking up at least two mornings per week were also at greater risk.

“Cardiologists do not talk regularly about sleep issues with their patients,” says lead researcher Lars Erik Laugsand, MD, an internist in the public health department of the Norwegian University of Science and Technology, in Trondheim. Although he and his coauthors suggest that these conversations may be helpful for assessing heart disease risk, Dr. Laugsand says that further research will be needed to determine how insomnia might affect heart health, and whether treating sleep problems can actually prevent heart attacks.

Cardiologist Suzanne Steinbaum, DO, who directs the Women and Heart Disease program at Lenox Hill Hospital, in New York City, agrees that more research in this area is needed, but she says she already discusses sleep issues with her patients. Stress reduction is a key to preventing heart attacks, she says, and lowering stress is all but impossible if you’re not getting enough sleep.

“We don’t know how significant the sleep disturbance must be, or how long it must persist for it to become significant for heart disease,” Steinbaum says. “But it is safe to say that there is some correlation.”

Stress, depression, and other psychological problems often overlap with sleep difficulties. Dr, Laugsand and his colleagues did factor depression and anxiety symptoms into their analysis, but neither condition had a substantial impact on the results. Other factors involving metabolism or blood-vessel health—such as inflammation—may be involved in the apparent link between insomnia and heart disease, the study notes.

Insomnia is the most common sleep problem in the United States. Roughly one-third of Americans experience occasional symptoms, and nearly 10% say they have chronic insomnia, according to the National Center on Sleep Disorders Research. Insomnia tends to occur more frequently with age, and some studies suggest it may be more prevalent in women.

Although insomnia is common, adequate and lasting treatment for it is not, says Susan Zafarlotfi, PhD, clinical director of the Institute for Sleep-Wake Disorders at Hackensack University, in Hackensack, N.J. “Clinicians often simply medicate their patients, but that is not the way to do it,” she says. “Pharmacology is only for the short term. They need to get at the depth of the problem.”

Previous research has reported a higher risk of heart attack among people with insomnia, but the new study is among the largest of its kind. It should be an eye-opener for cardiologists as well as for neurologists and doctors of all kinds, Zafarlotfi says, adding that future research is likely to strengthen the link between insomnia, heart disease, and related conditions such as stroke. “They have to ask their patients about sleep,” she says. “Sleep has to be a big part of working with patients.”

source: Health.com