10

Question 1

Sleeping

Answer 1

About one-third of our lives spent sleeping

Many do not meet the recommended hours

Sleep energizes mentally and physically

Poor sleep leads to social, psychological, and health problems

Question 2

Sleep states

Answer 2

Two broad states of sleep:
1. Slow-wave (deep) sleep
2. Rapid eye movement (REM), brain is active

Four stages of sleep: stages 1–4

Sleep follows 90-minute cycles

Normal sleepers spend 20% in deep sleep, 30% dreaming, 50% light sleep

Question 3

Systems involved in sleep

Answer 3

Sleep problems contribute to psychological disorders

Limbic system involved with anxiety and sleep
- Mutual neurobiological connection suggests anxiety and sleep may be interrelated
- Poor sleep can raise cortisol
- Sleep deprivation has temporary antidepressant effects

Question 4

Sleep-wake disorders

Answer 4

Sleep-wake disorders categorized into:
- Dyssomnias: difficulty getting enough sleep
- Parasomnias: abnormal events that occur during sleep

Polysomnographic (PSG) evaluation includes EEG, EOG, EMG, ECG

Sleep efficiency: percentage of time actually spent sleeping

Sleep-wake disorders are highly prevalent in the general population and are of two types: dyssomnias (disturbances of sleep) and parasomnias (abnormal events such as nightmares and sleepwalking that occur during sleep).

The formal assessment of sleep disorders, a polysomnographic (PSG) evaluation, is typically done by monitoring the heart, muscles, respiration, brain waves, and other functions of a sleeping client in the lab.

Brain wave activity is measured by an electroencephalograph (EEG);
eye movements, measured by an electrooculograph (EOG);
muscle movements, measured by an electromyograph (EMG); and
heart activity, measured by an electrocardiogram (ECG).

Insomnia disorder is the most common disorder and involves the inability to initiate sleep, problems maintaining sleep, or failure to feel refreshed after a full night’s sleep.

Question 5

Insomnia Disorder

Answer 5

Microsleeps of several seconds or longer

Fatal familial insomnia (rare)

Insomnia “not sleeping”

Difficulty falling asleep or maintaining sleep

Clinical Description
Insomnia disorder (primary insomnia)
- Trouble initiating or maintaining sleep
- Inability to concentrate on daily activities
- Fear of falling asleep doing activities requiring concentration

Statistics
- Approximately one-fourth of population
- 15% of older adults report daytime sleepiness
- Associated with other disorders (depression, anxiety disorders, dementia)
- Women twice as likely: hormonal differences?

Causes
- Pain, physical discomfort, physical inactivity, problems with biological clock, light exposure
- Drug use, noise, temperature rhythm
- Psychological stresses, cognitions (thoughts)
- Cultural factors: co-sleeping
- Biological vulnerability (being a light sleeper)

An Integrative Model
- Biological vulnerability interacts with sleep stress
- Extrinsic influences (poor sleep habits, daily activities, jet lag)
- Rebound insomnia
- Daytime naps disrupt night sleep; anxiety

Insomnia disorder is the most common disorder and involves the inability to initiate sleep, problems maintaining sleep, or failure to feel refreshed after a full night’s sleep.

Fatal familial insomnia (a degenerative brain disorder), total lack of sleep eventually leads to death (Parchi et al., 2012).

People are considered to have insomnia if they have trouble falling asleep at night (difficulty initiating sleep), if they wake up frequently or too early and can’t go back to sleep (difficulty maintaining sleep), or even if they sleep a reasonable number of hours but are still not rested the next day (nonrestorative sleep).

Other sleep disorders, such as sleep apnea (a disorder that involves pauses in nighttime breathing that are sometimes caused by obstruction) or periodic limb movement disorder (excessive jerky leg movements), can cause interrupted sleep and may seem similar to insomnia.

Rebound insomnia may occur when the medication is withdrawn.

Question 6

Hypersomnolence Disorders

Answer 6

Hypersomnolence Disorders
- Disorders involve sleeping too much
—- Less successful academically, complain of tiredness; personally upsetting
- Sleep apnea: difficulty breathing at night
- Genetic factors, viral infections could be causes

Hyper means “in great amount” or “abnormal excess.”

Sleep apnea: People with this problem have difficulty breathing at night. They often snore loudly, pause between breaths, and wake in the morning with a dry mouth and headache.

Question 7

Narcolepsy

Answer 7

• Daytime sleepiness: 0.03%–0.16% population
• Cataplexy: sudden loss of muscle tone
• Caused by sudden onset of REM sleep
  — Sleep paralysis
  — Hypnagogic hallucinations
• Genetic, recessive trait; cluster of genes on chromosome 6

Sleep paralysis refers to a brief period after awakening when the person can’t move or speak that is often frightening to those who go through it.

Hypnagogic hallucinations are vivid experiences that begin at the start of sleep and are said to be unbelievably realistic because they include not only visual aspects but also touch, hearing, and even the sensation of body movement.

Question 8

Breathing-Related Sleep Disorders

Answer 8

Breathing disrupted during sleep

Experience brief arousals throughout night

Hypoventilation: laboured breathing
- Sleep apnea; 6% Canadians; men twice as likely
- Sleep attacks during the day
- Three types: obstructive sleep apnea hypopnea syndrome, central sleep apnea, sleep-related hypoventilation

Obstructive sleep apnea hypopnea syndrome occurs when airflow stops despite continued activity by the respiratory system (Mbata & Chukwuka, 2012). In some people, the airway is too narrow; in others, some abnormality or damage interferes with the ongoing effort to breathe.

Central sleep apnea involves the complete cessation of respiratory activity for brief periods and is often associated with certain central nervous system disorders, such as cerebral vascular disease, head trauma, and degenerative disorders (Badr, 2012).

Sleep-related hypoventilation is a decrease in airflow without a complete pause in breathing. This tends to cause an increase in carbon dioxide (CO2) levels, because insufficient air is exchanged with the environment.

Question 9

Circadian Rhythm Sleep-Wake Disorders

Answer 9

Brain unable to synchronize sleep patterns

Our internal clock is in the suprachiasmatic nucleus in the hypothalamus; connect to eyes
- Jet lag type: difficulty falling asleep at the proper time
- Shift-work type: working odd hours interferes with sleep cycles
- Delayed sleep phase: sleep later than normal bedtime
- Irregular sleep-wake type, and 24-hour sleep-wake type

Circadian rhythm sleep-wake disorder is characterized by disturbed sleep (either insomnia or excessive sleepiness during the day) brought on by the brain’s inability to synchronize its sleep patterns with the current patterns of day and night.

Melatonin contributes to the setting of our internal clocks that tell us when to sleep.

Researchers believe that both light and melatonin help set the internal clock (Stevens & Zhu, 2015). Thus, this hormone may help us treat some of the sleep problems people experience.

Question 10

Medical Treatments

Answer 10

10% Canadian adults use medication for sleep

Benzodiazepine medications
- Short-acting drugs

Newer medications work with melatonin system

Stimulants prescribed for narcolepsy

Weight loss recommended for breathing-related sleep disorders
- Continuous positive air pressure (CPAP) machine improves breathing

Benzodiazepine medications have been helpful for short-term treatment of many of the dyssomnias, but they must be used carefully, or they might cause rebound insomnia, a withdrawal experience that can cause worse sleep problems after the medication is stopped.

Short-acting drugs (those that cause only brief drowsiness) are preferred because the long-acting drugs sometimes do not stop working by morning, and people report more daytime sleepiness.

Any long-term treatment of sleep problems should include psychological interventions such as stimulus control and sleep hygiene.

Parasomnias such as nightmares occur during REM (or dream) sleep, and sleep terrors and sleepwalking occur during NREM sleep.

Question 11

Environmental Treatments

Answer 11

Phase delays (moving the bedtime later) easier than phase advances (moving bedtime earlier)

Bright light used to trick the brain into readjusting the internal clock

Page 301: Bright light therapy can help people with circadian rhythm sleep disorders readjust their sleep patterns.

Question 12

Psychological Treatments

Answer 12

Progressive relaxation with cognitive relaxation techniques is effective

Stimulus control

Combination of medication and CBT

For young children setting up bedtime routines

Any long-term treatment of sleep problems should include psychological interventions such as stimulus control and sleep hygiene.

In stimulus control people are instructed to use the bedroom only for sleeping and for sex and not for work or other anxiety-provoking activities (e.g., watching the news on television).

Parasomnias such as nightmares occur during REM (or dream) sleep, and sleep terrors and sleepwalking occur during NREM sleep.

Question 13

Preventing Sleep Disorders

Answer 13

Sleep hygiene: changes in lifestyle to avoid insomnia

Educating young parents to prevent later difficulties

Question 14

Parasomnias and Their Treatment

Answer 14

DSM-5 identifies a number of parasomnias:
- Sleep terrors
- Sleepwalking
- Nightmares (nightmare disorder)

Genes implicated, trauma, medication
- Treatment: psychological intervention (CBT) and medication

Nocturnal eating syndrome: individuals rise from their beds and eat while they are still asleep (Yamada, 2015)

Sexsomnia: acting out sexual behaviours, such as masturbation and sexual intercourse, with no memory of the event (Béjot et al., 2010)

REM sleep behaviour disorder: the individual talks or moves while sleeping, sometimes acting out a dream

Parasomnias such as nightmares occur during REM (or dream) sleep, and sleep terrors and sleepwalking occur during NREM sleep.

Question 15

Basic sleep facts

Answer 15

We spend about one-third of our lives asleep. That means most of us sleep nearly 3000 hours per year.

Using data from the Canadian Health Measures Survey (CHMS), estimates have been calculated for Canadians between the ages of 6 and 79 years. Almost 80 percent of school-age children meet the requirements, but only 68 percent of teenagers meet them (Michaud & Chaput, 2016).

The downward trend in number of people meeting the recommended number of hours of sleep continues, with 65 percent of young adults and adults meeting the requirements and only 54 percent of older adults meeting them (Chaput et al., 2017).

Those not meeting the required number of hours of sleep were more likely to be short on hours of sleep— long sleepers tended to be rare.

Similar to the Canadian Commu- nity Health Survey (CCHS) referred to in earlier chapters, the CHMS excludes approximately 4 percent of the population (i.e., persons living in the territories or on reserves or other settlements, full-time members of the Canadian Forces, the institutionalized population, and residents of some remote regions).

For many of us, sleep is energizing, both mentally and physi- cally. However, you or someone you know may have a problem with sleep. Most of us know what it’s like to have a bad night’s sleep. The next day we’re a little groggy, and as the day wears on we may become irritable. Imagine, if you can, that it has been years since you’ve had a good night’s sleep. Your relationships suffer, it is difficult to do your schoolwork, and your efficiency and productivity at work are diminished. Lack of sleep might also affect you physically.

As noted by sleep researcher Charles Morin at Laval University, people who do not get enough sleep report more health problems and are more often hospitalized than people who sleep normally (Morin, 1993).

According to the research of Harvey Moldofsky, director of the University of Toronto Centre for Sleep and Chronobiology, and his colleagues, some chronic physical health problems are linked to insomnia: circulatory problems, digestive and respiratory disease, migraines, allergies, and rheumatic disorders (Sutton et al., 2001).

Why are health problems linked to sleep problems? Perhaps because immune system functioning is lost with the loss of a few hours of sleep

Question 16

OvervieW Of Sleep-WAke DiSOrDerS

Answer 16

Sleep can be divided into two broad states: (1) the slow-wave state in which the person sleeps deeply, and (2) the rapid eye movement (REM) state in which the brain appears as if it is awake and in which the sleeper experiences dreams.
- Between these two broad states are some transition stages.

Sleep researchers traditionally refer to four numbered stages of sleep that differ in the depth of sleep involved.

In Stage 1, the person transitions through wakefulness into drowsiness and then sleep. During this stage, the person drifts in and out of awareness of his or her surroundings.

In Stage 2, the person is truly sleeping, yet the sleep is light (i.e., the sleeper can easily be aroused). When awoken from this stage of sleep, 70 percent of people report that they didn’t think they were asleep but were just “dozing and thinking.”

Stages 3 and 4 make up deep, slow-wave sleep. Stage 3 involves moderately deep sleep and Stage 4 very deep sleep. Not only are people hard to awaken when in Stage 4 sleep, but when awoken, they may appear disoriented for a few minutes.

Throughout the night, we show a 90-minute cycle of sleep, progressing from light sleep to deeper sleep, then back to light sleep, and ending with REM sleep and dreaming. When we awaken in the morning, we typically awaken out of REM sleep during a dream. Normal sleepers spend about 20 percent of their sleep time in deep sleep, 30 percent dreaming, and 50 percent in light sleep

Several disorders covered in this book are frequently asso- ciated with sleep complaints, including schizophrenia, major depression, bipolar disorder, and anxiety-related disorders. Individuals with a wide range of developmental disorders are also at greater risk for having sleep disorders (Durand, 1998).

For example, Penny Corkum of Dalhousie University and her colleagues note that reports of sleep problems in children with attention-deficit/hyperactivity disorder (ADHD) are prevalent, although the exact nature of sleep problems in chil- dren with ADHD remains to be determined (Corkum et al., 1998; see also Weiss et al., 2006).

You may think at first that a sleep problem is the result of a psychological disorder. For example, how often have you been anxious about a future event (an upcoming exam, perhaps) and not been able to fall asleep? However, the relationship between sleep disturbances and mental health is more complex

Sleep problems may cause the difficulties people experience in everyday life, or they may result from some disturbance common to a psychological disorder.

For example, Mullane and Corkum (2006) examined the possibility that sleep problems contribute to ADHD symptoms in children.
- In a series of three cases, they implemented a behavioural treatment for children with sleep problems and ADHD.
- While the behavioural treatment was effective in treating the sleep problems, it had no impact on the ADHD symptoms.
- This study provides preliminary evidence that ADHD is not simply secondary to sleep problems in children with both disorders.

In Chapter 5, we explained how a brain circuit in the limbic system may be involved with anxiety.
- We know that this region of the brain is also involved with our dream sleep, or REM sleep (Verrier et al., 2000).
- This mutual neurobiological connection suggests that anxiety and sleep may be interrelated in important ways.

Insufficient sleep, for example, can stimulate overeating and may contribute to obesity (Hanlon & Knutson, 2014).

As explained by Toronto physician Jason Fund in his book The Obesity Code (2016), poor sleep can raise cortisol, which itself raises insulin, leading to weight gain.

Similarly, REM sleep seems to be related to depression, as noted in Chapter 7 (Emslie et al., 1994).

In one study, researchers found that cognitive-behavioural therapy improved depression in men and normalized their REM sleep patterns (Nofzinger et al., 1994).

Furthermore, sleep deprivation has temporary antidepressant effects on some people (Hillman et al., 1990), although in people who are not already depressed, sleep deprivation may bring on a depressed mood (Voderhozer et al., 2014).

In yet another example of the relation of sleep problems to psychological disorders, sleep difficulties are commonly reported by people with schizophrenia in the prodromal phase (i.e., just before the onset of the psychotic episode; see Herz, 1985).
- For example, in a study conducted at four sites in Canada and the United States, Miller and colleagues (2002) found that sleep disturbances were experienced by 37 percent of the patients with schizophrenia just before the onset of their psychotic episode.

We do not fully understand how psychological disorders are related to sleep, yet accumulating research points to the importance of understanding sleep if we are to complete the broader picture of abnormal behaviour.

Sleep-wake disorders are divided into two major categories: dyssomnias and parasomnias.
- Dyssomnias involve difficulties getting enough sleep—not being able to fall asleep until 2 a.m. when you have a 9 a.m. class—and complaints about the quality of sleep, such as not feeling refreshed even though you have slept the whole night.
- The parasomnias are characterized by abnormal events that occur during sleep, such as nightmares and sleepwalking.

The clearest and most comprehensive picture of your sleep habits can be determined only by a polysomnographic (PSG) evaluation (Mindell & Owens, 2015).
- The patient spends one or more nights sleeping in a sleep laboratory, being monitored on measures that include respiration; leg movements; brain wave activity, measured by an electroencephalograph (EEG); eye movements, measured by an electrooculograph (EOG); muscle movements, measured by an electromyograph (EMG); and heart activity, measured by an electro- cardiogram (ECG).
- Daytime behaviour and typical sleep patterns are also noted, for example, whether the person uses drugs or alco- hol, is anxious about work or interpersonal problems, takes after- noon naps, or has a psychological disorder.

A less time-consuming and less costly alternative to the comprehensive assessment of sleep involves using a wristwatch-size device called an actigraph, which records the number of arm movements.
- The data can be downloaded onto a computer to determine the length and quality of sleep (Monk et al., 1999).
- Actigraphs are useful aids in monitoring sleep in insomnia treatment outcome studies

In addition, clinicians and researchers find it helpful to know the average number of hours the individual sleeps each day, taking into account sleep efficiency, the percentage of time actually spent asleep, not just lying in bed trying to sleep.

sleep efficiency is calculated by dividing the amount of time sleeping by the amount of time in bed (Milner et al., 2006).
- A sleep efficiency of 100 percent would mean you fall asleep as soon as your head hits the pillow and do not wake up at all during the night.
- In contrast, a sleep efficiency of 50 percent would mean half your time in bed is spent trying to fall asleep.
- Such measurements help the clinician determine objectively how well you sleep.

One way to determine whether a person has a problem with sleep is to observe his or her daytime sequelae, or behaviour while awake.
- For example, if it takes you 90 minutes to fall asleep at night, but this doesn’t bother you and you feel rested during the day, then you do not have a problem.
- A friend who also takes 90 minutes to fall asleep but finds this delay anxiety provoking and is fatigued the next day might be considered to have a sleep problem.

Question 17

InsomnIa DIsorDer - intro

Answer 17

Insomnia is one of the most common sleep-wake disorders. You may picture someone with insomnia as being awake all the time. It isn’t possible to go completely without sleep, however. For example, after being awake for about one or two nights, a person begins having microsleeps that last several seconds or longer (Roehrs et al., 2000).

In the very rare occurrences of fatal familial insomnia (a degenerative brain disorder), total lack of sleep eventually leads to death (Parchi et al., 2012).

Despite the common use of the term insomnia to mean “not sleeping,” it actually applies to a number of complaints (Savard et al., 2003).

People are considered to have insomnia if they have trouble fall- ing asleep at night (difficulty initiating sleep), if they wake up frequently or too early and can’t go back to sleep (difficulty maintaining sleep), or even if they sleep a reasonable number of hours but are still not rested the next day (nonrestorative sleep).

Question 18

Insomnia - Clinical Description

Answer 18

Kathryn’s symptoms meet the DSM-5 criteria for insomnia disorder (also referred to as primary insomnia) because her sleep problems were not related to other medical or psychiatric prob- lems (see DSM Table 10.1).

Kathryn’s is a typical case of insom- nia disorder. She had trouble both initiating and maintaining sleep.

Other people sleep all night but still feel as if they’ve been awake for hours.

Although most people can carry out necessary daily activities, their inability to concentrate can have serious consequences, such as debilitating accidents when they attempt to drive long distances (like truck drivers do).

Kathryn wouldn’t drive her car on the highway because she feared falling asleep at the wheel. Students with insomnia may do poorly in school because of difficulty concentrating.

Question 19

Insomnia - Statistics

Answer 19

According to data from the 2014–2015 cycle of the CHMS, almost a quarter of Canadians (24 percent) between the ages of 6 and 79 have experienced nighttime insomnia symptoms that have lasted at least one year (Chaput et al., 2018). This was an increase over the 17 percent in the 2007–2009 cycle of the survey.

Women report insomnia symptoms more often than men.
- Thirty percent of women reported experiencing nighttime insomnia symptoms for at least one year, compared to 21 percent of men.

For many individuals, sleep difficulties are a lifetime affliction (Lind et al., 2015).

In one study, 31 percent of the people who expressed concern about sleep continued to experience difficul- ties a year later (Ford & Kamerow, 1989), a result showing that sleep problems may become chronic (Lind et al., 2015).

Approximately 15 percent of older adults report excessive daytime sleepiness, and this contributes to increased risk for falling in older women

Just as normal sleep needs change over time, complaints of insomnia differ in frequency among people of different ages. Approximately one in five young children experiences insomnia (Calhoun et al., 2014).
- As children move into adolescence, their biologically determined sleep schedules shift toward a later bedtime (Skeldon et al., 2015).
- At least in North America, however, children are still expected to rise early for school, causing sleep deprivation.

As people age, the percentage who complain of sleep problems rises to more than 25 percent for people over the age of 65 (Mellinger et al., 1985).
- This change across age groups was apparent in the 2014–2015 cycle of the CHMS (Chaput et al., 2018).

The percentage of Canadians experiencing nighttime insomnia symptoms for at least a year increased with age: it was lowest at 9 percent among young Canadian children (ages 6 to 13), rose to 15 percent among those 14 to 17 years of age, and hit highs of 25 percent among adults (ages 18 to 64) and 22 percent for seniors (ages 65 to 79).

Several psychological disorders are associated with insomnia (Benca et al., 1992).
- Total sleep time often decreases with depression, substance use disorders, anxiety disorders, and dementia of the Alzheimer’s type.
- The interrelationship between alcohol use and sleep disorders can be particularly troubling. Alcohol is often used to initiate sleep (Morin et al., 2012). In small amounts it may work, but it also interrupts ongoing sleep. Interrupted sleep causes anxiety, which often leads to repeated alcohol use and an obviously vicious cycle

Question 20

Diagnostic Criteria for Insomnia Disorder

Answer 20

A. A predominant complaint of dissatisfaction with sleep quantity or quality associated with one or more of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as diffi- culty initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awaken- ings or problems returning to sleep after awakenings. (In chil- dren, this may manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.

B. The sleep disturbance causes clinically significant distress in social, occupational, educational, academic, behavioral, or other important areas of functioning.

C. The sleep difficulty occurs at least 3 nights per week.

D. The sleep difficulty is present for at least 3 months.

E. The sleep difficulty occurs despite adequate opportunity for sleep.

F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

G. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

H. Co-existing mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Specify if:
- With non-sleep disorder mental comorbidity, including substance use disorders
- With other medical comorbidity
- With other sleep disorder

Specify if:
- Episodic: Symptoms last at least 1 month but less than 3 months.
- Persistent: Symptoms last 3 months or longer.
- Recurrent: Two (or more) episodes within the space of 1 year.

Question 21

Insomnia causes

Answer 21

Insomnia accompanies many medical and psychological disorders, including pain and physical discomfort, physical inactivity during the day, and respiratory problems.

Sometimes insomnia is related to problems with the biological clock and its control of temperature.
- Light exposure causes an acute increase in human body temperature, which normally falls during the night (Song & Rusak, 2000).
- People who can’t fall asleep at night may have a delayed temperature rhythm: Their body temperature doesn’t drop and they don’t become drowsy until later at night (Morris et al., 1990).
- As a group, people with insomnia seem to have higher body temperatures than good sleepers, and their body temperatures seem to vary less; this lack of fluctuation may interfere with sleep

Among the other factors that can interfere with sleeping are drug use and a variety of environmental influences, such as changes in light, noise, or temperature.
- People admitted to hospi- tals often have difficulty sleeping because the noises and routines differ from those at home.
- Other sleep disorders, such as sleep apnea (a disorder that involves pauses in nighttime breathing that are sometimes caused by obstruction) or periodic limb movement disorder (excessive jerky leg movements), can cause interrupted sleep and may seem similar to insomnia.

Finally, various psychological stresses can also disrupt your sleep (Morin, 1993).
- Poll your friends around the time of final exams to see how many of them are having trouble falling asleep or are not sleeping through the night. The stress you experience during such times may interfere with your sleep, at least tempo- rarily.

A survey study by Sutton and colleagues (2001) found that having a very stressful life was one of the three strongest predic- tors of insomnia among Canadians.

A study by Morin and colleagues (2003) compared 40 individuals with insomnia to 27 good sleepers. They found that those with insomnia reported a greater impact of daily minor stressors and a greater intensity of major negative life events than the good sleepers. Not only did the insomniac people perceive their lives to be more stressful, they also reported greater levels of arousal before sleep than did the good sleepers.

Many studies illuminate the role of cognition in insomnia, suggesting that our thoughts alone may disrupt our sleep.
- Indeed, people with insomnia may have unrealistic expecta- tions about how much sleep they need (“I need a full eight hours”) and about how disruptive disturbed sleep will be (“I won’t be able to think or do my job if I sleep for only five hours”) (Morin, Stone, et al., 1993).
- Ryerson University psychologist Colleen Carney and her colleagues have found that unhelpful sleep-related beliefs and ruminations about sleep are present even during the daytime in people with insomnia

Is poor sleeping a learned behaviour? It is generally accepted that some people associate the bedroom and bed with the frustration and anxiety that go with insomnia.
- Eventually, the arrival of bedtime itself may cause anxiety (Morin & Benca, 2012).
- Interactions associated with sleep may contrib- ute to children’s sleep problems. F
- or example, one study found that a parent’s depression and negative thoughts about child sleep negatively influenced infant night waking (Teti & Crosby, 2012).
- Researchers think that some children learn to fall asleep only with a parent present; if they wake up at night, they are frightened at finding themselves alone and their sleep is disrupted.

It is unlikely that learning alone accounts for chil- dren’s sleep difficulties, however.
- Instead, biological and psychological factors are likely reciprocally related.
- For exam- ple, Adair and colleagues (1991) noted that a child’s temperament (or personality) may play a role in explaining the relation between parental presence when a child is going to sleep and sleep problems in the child.
- The children with sleep problems had comparatively more difficult temperaments, and their parents were presumably present to attend to sleep initiation difficulties.
- In other words, personality characteristics, sleep difficulties, and parental reaction interact in a reciprocal manner to produce and maintain sleep problems.

Cultural factors may also play a role. Cross-cultural sleep research has focused primarily on children.
- In the predominant culture in North America, infants are expected to sleep on their own, in a separate bed, and, if possible, in a separate room.
- However, in many other cultures as diverse as rural Guatemala and Korea and urban Japan, the child spends the first few years of life in the same room and sometimes the same bed as the mother (Burnham & Gaylor, 2011).
- In many cultures, mothers report that they do not ignore the cries of their children (Giannotti & Cortesi, 2009), in stark contrast to North America, where most pediatricians recommend that parents ignore the cries of their infants at night (Moore, 2012).
- Recent data from Canada suggest that bed-sharing is more common than we thought: about one-third of Canadian mothers says they very frequently sleep with their infant in their first year, to assist breastfeeding but also to make sleeping easier for them or their infants

People may be biologically vulnerable to disturbed sleep.
- This vulnerability differs from person to person and can range from mild to more severe disturbances.
- For example, a person may be a light sleeper (easily aroused at night) or have a family history of insomnia, narcolepsy, or obstructed breathing.

All these factors can lead to eventual sleeping problems. Such influences have been referred to as predisposing conditions (Spielman & Glovinsky, 1991); they may not, by themselves, always cause problems, but they may combine with other factors to interfere with sleep

Question 22

Insomnia - An Integrative Model

Answer 22

Biological vulnerability may in turn interact with sleep stress (Durand, 2008), which includes a number of events that can negatively affect sleep.

For example, poor bedtime habits (such as having too much alcohol or caffeine) can interfere with falling asleep (Morin et al., 2012).

Note that biological vulnerabil- ity and sleep stress influence each other (see the double arrows in the integrative model of sleep disturbance in Figure 10.2).

Although we may intuitively assume that biological factors come first, extrinsic influences such as poor sleep hygiene (the daily activities that affect how we sleep) can affect the physio- logical activity of sleep.
- One of the most striking examples of this phenomenon is jet lag, in which people’s sleep patterns are disrupted, sometimes seriously, when they fly across several time zones.
- Whether disturbances continue or become more severe may depend on how they are managed.
- For example, many people react to disrupted sleep by taking over-the-counter sleeping pills. Unfortunately, most people are not aware that rebound insomnia may occur when the medication is with- drawn. This rebound leads people to think they still have a sleep problem, re-administer the medicine, and go through the cycle repeatedly. In other words, taking sleep aids can perpetuate sleep problems

Other ways of reacting to poor sleep can also prolong problems.
- It seems reasonable that a person who hasn’t had enough sleep can make up for this loss by napping during the day.
- Unfo tunately, naps that alleviate fatigue during the day can also disrupt sleep that night.
- Anxiety can also extend the problem. Lying in bed worrying about school, family problems, or even about not being able to sleep will interfere with your sleep

Question 23

Hypersomnolence DIsorDers

Answer 23

Insomnia disorder involves not getting enough sleep (the prefix in means “lacking” or “without”), and hypersomnolence disor- ders involve sleeping too much (hyper means “in great amount” or “abnormal excess”).

Many people who sleep all night find themselves falling asleep several times the next day.

The DSM-5 diagnostic criteria for hypersomnolence include not only the excessive sleepiness that Ann described but also the subjective impression of this problem

Remember that whether insomnia disorder is a problem depends on how it affects each person individually.
- Ann found her disorder very disruptive because it interfered with her driving and paying attention in class.
- Hypersomnolence caused her to be less successful academically and also upset her personally, both of which are defining features of this disorder.
- She slept approximately eight hours each night, so her daytime sleepiness couldn’t be attributed to insufficient sleep.

Several factors that can cause excessive sleepiness would not be considered hypersomnolence.
- For example, people with insomnia disorder (who get inadequate amounts of sleep) often report being tired during the day.
- In contrast, people with hyper- somnolence sleep through the night and appear rested on awakening but still complain of being excessively tired throughout the day.
- Another sleep problem that can cause a similar excessive sleepiness is a breathing-related sleep disorder called sleep apnea. People with this problem have difficulty breathing at night. They often snore loudly, pause between breaths, and wake in the morning with a dry mouth and headache. In identifying hypersomnolence, you need to rule out insomnia, sleep apnea, or other reasons for sleepiness during the day

We are just beginning to understand the nature of hypersomnolence, so relatively little research has been done on its causes.
- Genetic influences seem to be involved in a portion of cases.
- A significant subgroup of people diagnosed with hypersomnolence disorder previously were exposed to a viral infection, such as mononucleosis, hepatitis, and viral pneumonia, which suggests there may be more than one cause

Question 24

Diagnostic Criteria for Hypersomnolence Disorder

Answer 24

A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
1. Recurrent periods of sleep or lapses into sleep within the same day.
2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
3. Difficulty being fully awake after abrupt awakening.

B. The hypersomnolence occurs at least three times per week, for at
least 3 months.

C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.

D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).

E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

F. Co-existing mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.

Specify if:
- With mental disorder, including substance use disorders
- With medical condition
- With another sleep disorder

Specify if:
- Acute: Duration of less than 1 month. - Subacute: Duration of 1–3 months.
- Persistent: Duration of more than 3 months.

Specify current severity:
Specify severity based on degree of difficulty maintaining daytime alertness as manifested by the occurrence of multiple attacks of irresistible sleepiness within any given day occurring, for example, while sedentary, driving, visiting with friends, or working.
- Mild: Difficulty maintaining daytime alertness 1–2 days/week
- Moderate:
Difficulty maintaining daytime alertness
3–4 days/week
- Severe: Difficulty maintaining daytime alertness 5–7 days/week

Question 25

narcolepsy

Answer 25

In addition to daytime sleepiness, some people with narcolepsy experience cataplexy, a sudden loss of muscle tone (see DSM Table 10.3).
- Cataplexy occurs while the person is awake, and it can range from slight weakness in the facial muscles to complete physical collapse.
- Cataplexy lasts from several seconds to several minutes; it is usually preceded by strong emotion, such as anger or happiness.
- Imagine that while cheering for your favourite team, you suddenly fall asleep, or while arguing with a friend, you collapse to the floor in a sound sleep!

Cataplexy appears to result from a sudden onset of REM sleep.
- Instead of falling asleep normally and going through the four nonrapid eye movement (NREM) sleep stages (i.e., Stages 1 to 4, discussed previously) that typically precede REM sleep, people with narcolepsy periodically progress right to this dream sleep stage almost directly from the state of being awake.
- One outcome of REM sleep is the inhibition of input to the muscles, and this seems to be the process that leads to cataplexy.

Two other characteristics distinguish people who have narco- lepsy (Ahmed & Thorpy, 2012), both of which were discussed in Chapter 5 in the context of Newfoundlanders’ experience of the “Old Hag” and African and Caribbean people’s experience of being “ridden by the witch.”

Specifically, people with narcolepsy commonly report sleep paralysis and hypnagogic hallucinations.
- Sleep paralysis refers to a brief period after awakening when the person can’t move or speak that is often frightening to those who go through it.
- Hypnagogic hallucinations are vivid experiences that begin at the start of sleep and are said to be unbelievably realistic because they include not only visual aspects but also touch, hearing, and even the sensation of body movement.
- Exam- ples of hypnagogic hallucinations, which, like sleep paralysis, can be quite terrifying, include the vivid illusion of being caught in a fire or flying through the air.

Narcolepsy is relatively rare, occur- ring in 0.03 to 0.16 percent of the population, with the numbers approximately equal among males and females.
- The problems associated with narcolepsy usually are first seen during the teen- age years.
- Fortunately, the cataplexy, hypnagogic hallucinations, and sleep paralysis often decrease in frequency over time, although sleepiness during the day does not seem to diminish with age.

Sleep paralysis and hypnagogic hallucinations may serve a role in explaining a most unusual phenomenon—UFO or alien abduction experiences (Sharpless & Doghramji, 2015).
- Each year numerous people report seeing unidentified flying objects— UFOs—and some even tell of visiting with inhabitants of other planets (Sheaffer, 1986).
- A group of scientists led by the late Nicholas Spanos, whose research was first discussed in Chapter 6, examined people who had had such experiences, sepa- rating them into those who had nonintense experiences (seeing only lights and shapes in the sky) and those with intense experi- ences (seeing and communicating with aliens; Spanos, et al., 1993).
- They found that a majority of the reported UFO incidents occurred at night, and that 60 percent of the intense UFO stories were associated with sleep episodes.
- Specifically, the reports of these intense accounts were often described in ways that resem- bled accounts of people experiencing a frightening episode of sleep paralysis and hypnagogic hallucination

Specific genetic models of narcolepsy are now being developed (Peall & Robertson, 2014).

Previous research with Doberman pinschers and Labrador retrievers, who also inherit this disorder, suggests that narcolepsy is associated with a cluster of genes on chromosome 6, and it may be an autosomal recessive trait.

Advances in understanding the etiology and treatment of such disorders can be credited to the help of man’s best friend.

Question 26

Diagnostic Criteria for Narcolepsy

Answer 26

A. Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.

B. The presence of at least one of the following:

1. Episodes of cataplexy defined as either (a) or (b), occurring
   at least a few times per month:

(a) In individuals with long-standing disease, brief (seconds
to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness, precipitated by laughter or joking.

(b) In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.

2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to
   110 pg/ml). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye move- ment (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep onset REM periods.

Specify current severity:
- Mild: Infrequent cataplexy (less than once per week), need for naps only once or twice per day, and less disturbed nocturnal sleep
- Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily
- Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming)

Question 27

BreatHIng-relateD sleep DIsorDers

Answer 27

For some people, sleepiness during the day or disrupted sleep at night has a physical origin, namely, problems with breathing while asleep.

In the DSM-5, these problems are diagnosed as breathing-related sleep disorders.

People whose breathing is interrupted during their sleep often experience numerous brief arousals throughout the night and do not feel rested even after eight or nine hours asleep (Overeem & Reading, 2010).

For all of us, the muscles in the upper airway relax during sleep, constrict- ing the passageway somewhat and making breathing a little more difficult.

For some, unfortunately, breathing is constricted a great deal and may be very laboured (hypoventilation) or, in the extreme, there may be short periods (10 to 30 seconds) when they stop breathing altogether, called sleep apnea.

Just over 6 percent of Canadians report having been diagnosed with sleep apnea; the diagnosis twice as likely among men than women, and three times more likely among older adults compared to those under 60 years of age (Edjoc & Gal, 2018).

Often the affected person is only minimally aware of breathing difficulties and doesn’t attri- bute the sleep problems to the breathing.

A bed partner usually notices loud snoring (which is one sign of this problem), however, or will have noticed frightening episodes of interrupted breathing.

Other signs that a person has breathing difficulties are heavy sweating during the night, morning headaches, and episodes of falling asleep during the day (sleep attacks) with no resulting feeling of being rested (Hauri, 1982).

As noted by Charles George at the University of Western Ontario and his colleagues, sleep apnea is associated with an increased number of motor vehicle accidents (Hartenbaum et al., 2006), likely because of these asso- ciated sleep attacks.

There are three types of apnea, each with different causes, daytime complaints, and treatment: obstructive, central, and mixed sleep apnea.

Obstructive sleep apnea hypopnea syndrome occurs when airflow stops despite continued activity by the respiratory system (Mbata & Chukwuka, 2012). In some people, the airway is too narrow; in others, some abnormality or damage interferes with the ongoing effort to breathe. Everyone in a group of people with obstructive sleep apnea hypopnea syndrome reported snoring at night (Goel et al., 2015).
- Obesity is sometimes associated with this problem, as is increasing age. Some work now suggests that the use of MDMA (ecstasy) can lead to obstructive apnea hypopnea syndrome even in young and otherwise healthy adults (McCann et al., 2009).
- Obstructive sleep apnea is most common in males and is thought to occur in approximately 20 percent of the popula- tion (Franklin & Lindberg, 2015).

The second type of apnea, central sleep apnea, involves the complete cessation of respiratory activity for brief periods and is often associated with certain central nervous system disorders, such as cerebral vascu- lar disease, head trauma, and degenerative disor- ders (Badr, 2012). Unlike people with obstructive sleep apnea hypopnea syndrome, those with central sleep apnea wake up frequently during the
night but they tend not to report excessive daytime sleepiness and often are not aware of having a seri- ous breathing problem. Because of the lack of daytime symptoms, people tend not to seek treat- ment, so we know relatively little about this disor- der’s prevalence or course.

The third breathing disorder, sleep-related hypoventilation, is a decrease in airflow without a complete pause in breathing. This tends to cause an increase in
carbon dioxide (CO2) levels, because insufficient air is exchanged with the environment. All these breathing difficulties interrupt sleep and result in symptoms similar to those of insomnia.

Question 28

cIrcaDIan rHytHm sleep-Wake DIsorDers

Answer 28

“Spring forward; fall back”: Many Canadians use this mnemonic device to remind themselves to turn the clocks ahead one hour in the spring and back again one hour in the fall.

Most of us consider the shift to daylight savings time a minor inconvenience and are thus surprised to see how disruptive this time change can be.
- For at least a day or two, we may be sleepy during the day and have difficulty falling asleep at night, almost as if we had jet lag.

The difficulty has to do with how our internal clocks adjust to this change in time.
- Convention says to go to sleep at this new time while our brains are saying something different.

If the struggle continues, you may have what is called a circadian rhythm sleep-wake disorder. This disorder is characterized by disturbed sleep (either insomnia or excessive sleepiness during the day) brought on by the brain’s inability to synchronize its sleep patterns with the current patterns of day and night.

In the 1960s, German and French scientists identified several bodily rhythms that seem to persist without cues from the environment—rhythms that are self-regulated (Aschoff & Wever, 1962; Siffre, 1964). Because these rhythms don’t exactly match our 24-hour day, they are called “circadian” (from circa meaning “about” and dian meaning “day”). If our circadian rhythms don’t match the 24-hour day, why isn’t our sleep completely disrupted over time?

Fortunately, our brains have a mechanism that keeps us in sync with the outside world. As noted by Michael Antle at the Univer- sity of Calgary, our internal clock is in the suprachiasmatic nucleus in the hypothalamus (Antle & Silver, 2005).
- Connected to the suprachiasmatic nucleus is a pathway that comes from our eyes. The light we see in the morning and the decreasing light at night signal the brain to reset the internal clock each day (see also Coren, 1996).
- Unfortunately, some people have trouble sleeping when they want to because of problems with their circadian rhythms, since sleep onset is closely related to circadian rhythms (Mistlberger & Rusak, 2005).
- The causes may be outside the person (e.g., crossing several time zones in a short amount of time) or internal.

Not being synchronized with the normal sleep-wake cycles causes people to be interrupted when they do try to sleep, and to be tired during the day.

There are several different types of circa- dian rhythm sleep disorders. Jet lag type is, as its name implies, caused by rapidly crossing multiple time zones (Abba et al., 2014). People with jet lag usually report difficulty going to sleep at the proper time and feeling fatigued during the day. Travelling more than two time zones westward usually affects people the most. Travelling eastward and/or less than three time zones is usually tolerated better (Kolla et al., 2012). Research with mice suggests that the effects of jet lag can be quite serious—at least among older adults. When older mice were exposed to repeated artificial jet lag, a significant number of them lived shorter lives (Davidson et al., 2006), and artificial jet lag has also been shown to increase cancer risk in mice (van Dycke et al., 2015).

Shift- work-type sleep problems are associated with work schedules (Abba et al., 2012). Many people, such as hospital employees, police, or emergency personnel, work at night or must work irregular hours; as a result, they may have problems sleeping or experience excessive sleepiness during waking hours.

Unfortu- nately, the problems of working (and thus staying awake) at unusual times can go beyond sleep and may contribute to cardio- vascular disease, ulcers, and breast cancer in women (Truong et al., 2014). Working rotating shifts is consistently predictive of poor sleep

In contrast with jet lag and shift-work sleep-related problems, which have external causes such as long-distance travel and job selection, several circadian rhythm sleep problems seem to arise from within the person experiencing the problems.
- Extreme night owls, people who stay up late and sleep late, may have a problem known as delayed sleep phase type.
- Sleep is delayed or later than normal bedtime. At the other end of the extreme, people with an advanced sleep phase type of circadian rhythm disorder are “early to bed and early to rise.” Here, sleep is advanced or earlier than normal bedtime.

Finally, two other types, irregular sleep-wake type (people who experience highly varied sleep cycles) and non- 24-hour sleep-wake type (e.g., sleeping on a 25- or 26-hour cycle with later and later bedtimes ultimately going throughout the day), illustrate the diversity of circadian rhythm sleep-wake problems some people experience

Research on why our sleep rhythms are disrupted is advancing quickly, and we are now beginning to understand the circadian rhythm process.

Scientists believe the hormone melatonin contributes to the setting of our internal clocks that tell us when to sleep.
- This hormone is produced by the pineal gland, in the centre of the brain. Melatonin has been nicknamed the “Dracula hormone” because its production is stimulated by darkness and ceases in daylight.
- When our eyes see it is nighttime, this information is passed on to the pineal gland, which, in turn, begins producing melatonin.

Researchers believe that both light and melatonin help set the internal clock (Stevens & Zhu, 2015). Thus, this hormone may help us treat some of the sleep problems people experience. For example, melatonin may be used as a treatment for people who experience severe jet lag and other sleep problems associated with circadian rhythm disruption

Question 29

meDIcal treatments

Answer 29

Perhaps the most common treatments for insomnia are medical.

According to a Statistics Canada report, based on the 2002 CCHS, among those people with insomnia symptoms, 29 percent use sleep medications: 23 percent use prescribed sleep medications and 6 percent use over-the-counter sleep aids.
- Thus, an estimated 4 percent of Canadians in the general population use medications for insomnia (Tjepkema, 2005).
- This estimate was higher in a recent study of 2000 Canadian adults wherein 10 percent had used prescribed medications to help them sleep, 9 percent used natural products, 6 percent used over-the-counter medications, and 5 percent used alcohol to help them sleep

People who complain of insomnia to a medical professional are likely prescribed one of several benzodiazepine medications, which include short-acting drugs, such as triazolam (Halcion) and long-acting drugs such as flurazepam (Dalmane).
- Short-acting drugs (those that cause only brief drowsiness) are preferred because the long-acting drugs sometimes do not stop working by morning, and people report more daytime sleepiness.
- The long- acting benzodiazepines are sometimes preferred when negative effects, such as daytime anxiety, are observed in people taking the short-acting drugs (Neubauer, 2009).

Newer medications, such as those that work directly with the melatonin system (e.g., ramelteon [Rozerem]), are also being developed to help people fall and stay asleep.

People over the age of 65 are most likely to use medica- tion to help them sleep.
- A study by Keith Brownlee and his colleagues at Lakehead University showed that older patients were significantly more likely than younger patients to be prescribed benzodiazepines for insomnia (Brownlee et al., 2003).

Benzodiazepine prescriptions for insomnia are a particularly important problem among seniors in nursing homes

Medical treatments for insomnia have several drawbacks.
- First, benzodiazepine medications can cause excessive sleepiness.
- Second, people can easily become dependent on them and rather easily misuse them, deliberately or not.
- Third, these medications are meant for short-term treatment and are not recommended for use longer than four weeks. Longer use can cause dependence and rebound insomnia.

A newer concern for some medications (e.g., Ambien) is that they may increase the likelihood of sleepwalking-related problems, such as sleep-related eating disorder (Nzwalo et al., 2013).
- Therefore, although medications may be helpful for sleep problems that will correct themselves in a short period (e.g., insomnia because of anxiety related to hospitalization), they are not intended for long-term chronic problems.

To help people with hypersomnolence or narcolepsy, physicians usually prescribe a stimulant, such as methylphenidate

Cataplexy, or loss of muscle tone, can be treated with antidepressant medication, not because people with narcolepsy are depressed but because antidepressants suppress REM (or dream) sleep.
- Sodium oxybate is also recommended to treat cataplexy

Treatment of breathing-related sleep disorders focuses on helping the person breathe better during sleep.
- For some, this means recommending weight loss—in some people who are obese, the neck’s soft tissue compresses the airways. Unfortu- nately, this treatment has not proven to be very successful for breathing-related sleep disorders (Guilleminault & Dement, 1988).

For mild or moderate cases of obstructive sleep apnea,
treatment can involve medications, including those that help stimulate respiration (e.g., medroxyprogesterone) or the tricyclic antidepressants, which are thought to act on the locus coeruleus, which affects REM sleep such that the respiratory muscles do not relax as much

The gold standard for the treatment of obstructive sleep apnea involves the use of a mechanical device—called the continuous positive air pressure (CPAP) machine—that improves breathing (Patel et al., 2003).
- Patients wear a mask that provides slightly pressurized air during sleep and it helps them breathe more normally throughout the night.
- Unfortunately, many people have difficulty using the device because of issues of comfort and some even experience a form of claustrophobia. To assist these individu- als, a variety of strategies are tried, including the use of psychologi- cal interventions, such as desensitization for claustrophobia, patient and partner education, and motivational interviewing (a counsel- ling technique used to help patients match their goals with their behaviours) (Olsen et al., 2012).

Severe breathing problems may require surgery to help remove blockages in parts of the airways

Question 30

envIronmental treatments

Answer 30

Because medication as a primary treatment isn’t usually recom- mended (Doghramji, 2000; Roehrs & Roth, 2000), other ways of getting people back in step with their sleep rhythms are usually tried.

One general principle for treating circadian rhythm disorders is that phase delays (moving the bedtime later) are easier than phase advances (moving bedtime earlier).
- Scheduling shift changes in a clockwise direction (going from day to evening schedule) seems to help workers adjust better.

People can best readjust their sleep patterns by going to bed several hours later each night, until bedtime is at the desired hour (Sack et al., 2007).

A drawback of this approach is that it requires the person to sleep during the day for several days, which is obviously difficult for people with regularly scheduled responsibilities.

Another recent effort to help people with sleep problems involves using bright light to trick the brain into readjusting the internal clock.
- Very bright light may help people with circadian rhythm problems readjust their sleep patterns (Burkhalter et al., 2015).
- People typically sit in front of a bank of fluorescent lamps that generate light greater than 2500 lux, an amount significantly different from normal indoor light (250 lux).
- Several hours of exposure to this bright light have successfully reset the circadian rhythms of a number of individuals (Czeisler & Allan, 1989).
- Although this type of treatment is still new, it provides some hope for people with sleep problems.

Question 31

psycHologIcal treatments

Answer 31

As you can imagine, the limitations of using drugs to help people sleep better has led to the development of psychological treat- ments. Table 10.1 lists and briefly describes some of the psycho- logical approaches to insomnia.

Given the links of anxiety to insomnia, Viens, De Koninck, Mercier, St-Onge, and Lorrain (2003) from the University of Ottawa compared progressive relaxation with a treatment they referred to as anxiety management training (which basically combined progressive relaxation with cognitive relaxation tech- niques).
- Both groups were able to get to sleep more quickly follow- ing therapy.
- Furthermore, lab-based sleep evaluations showed that participants in both groups increased in slow-wave sleep and sleep satisfaction.
- Both groups also showed decreases in anxiety and depression. The two treatments were equally effective.

Other research shows that some psychological treatments for insomnia may be more effective than others.
- For adult sleep prob- lems, stimulus control may be recommended.
- People are instructed to use the bedroom only for sleeping and for sex and not for work or other anxiety-provoking activities (e.g., watching the news on television).

Kathryn’s sleep problems were addressed with several tech- niques.
- She was instructed to limit her time in bed to about four hours of sleep time (sleep restriction), about the amount of time she actually slept each night.
- The period was lengthened when she began to sleep through the night.
- Kathryn was also asked not to listen to the radio while in bed and to get out of bed if she couldn’t fall asleep (stimulus control).
- Finally, therapy involved confronting her unrealistic expectations about how much sleep was enough for a person of her age (cognitive therapy; see Bélanger et al., 2006).
- Within about three weeks of treatment, Kathryn was sleeping longer (six to seven hours per night as opposed to four to five hours previously) and had fewer interruptions in her sleep. She felt more refreshed in the morning and had more energy during the day.

Kathryn’s results mirror those of studies by Charles Morin and his colleagues that find combined treatments to be effective in older adults with insomnia (e.g., Morin, Kowatch, et al., 1993).
- One such study, using a randomized placebo-control design, found that both medical and psychological approaches were effective in improving the sleep of older adults (Morin et al., 1999).
- Over the long term, however, the psychological treatment was better able to maintain its effectiveness with this group (see also review by Morin & Wooten, 1996).

Morin has examined the effectiveness of sequential (CBT and medication) treatments for insomnia. Partici- pants received either (1) medication and then combined medication and CBT; (2) combined treatment and then CBT alone; or (3) CBT alone.
- For the first treatment group, significant improve- ments only appeared after the introduction of CBT, while in the other two groups improvement appeared near the beginning of treatment.
- The study also showed that the treatment involving combined treatment followed by CBT alone led to the best outcomes.
- These findings show that sleep improvement seems to be affected by the way in which medication and CBT are combined.

For young children, some of the cognitive treatments may not be possible.
- Instead, treatment often includes setting up bedtime routines, such as a bath, followed by a parent reading a story, to help children go to sleep at night.
- Graduated extinction (described in Table 10.1) has been used with some success for bedtime prob- lems as well as for waking up at night (Hill, 2011).
- Integrating both medical and behavioural treatments seems especially important for insomnia.
- Research suggests that short-term use of medication in combination with other types of interventions may prove to be a quick and lasting treatment for insomnia (Milby et al., 1993; Morin & Azrin, 1988).

Importantly, researchers are now examining the treatment of both sleep problems and psychological disorders (e.g., depres- sion) together, because the link appears to be strong, and treat- ing one type of problem alone may not be enough (e.g., Carney et al., 2017). Colleen Carney, for example, mentions that insom- nia may remain during the treatment of depression, it may inter- fere with the treatment of depression, and it makes it more likely that depression will return (https://psychlabs.ryerson.ca/ carney/).

Question 32

some psychological treatments for Insomnia

Answer 32

Cognitive
This approach focuses on changing the sleepers’ unrealistic expectations and beliefs about sleep (“I must have eight hours of sleep each night”; “If I get less than eight hours of sleep it will make me ill”). The therapist attempts to alter beliefs and attitudes about sleeping by providing information on topics such as normal amounts of sleep and a person’s ability to compensate for lost sleep.

Cognitive relaxation
Because some people become anxious when they have difficulty sleeping, this approach uses meditation or imagery to help with relaxation at bedtime or after a night of waking.

Graduated extinction
Used for children who have tantrums at bedtime or wake up crying at night, this treatment instructs the parent to check on the child after progressively longer periods, until the child falls asleep on his or her own.

Paradoxical intention
This technique involves instructing individuals in the opposite behaviour from the desired outcome. Telling poor sleepers to lie in bed and try to stay awake as long as they can is used to try to relieve the performance anxiety surrounding efforts to try to fall asleep.

Progressive relaxation
This technique involves relaxing the muscles of the body in an effort to introduce drowsiness.

Question 33

preventIng sleep DIsorDers

Answer 33

Sleep professionals generally agree that a significant portion of the sleep problems people experience daily can be prevented by following a few steps during the day.
- Referred to as sleep hygiene, these changes in lifestyle can be relatively simple to follow and can help avoid problems such as insomnia for some people (Goodman & Scott, 2012).

Some sleep hygiene recom- mendations rely on allowing the brain’s normal drive for sleep to take over, replacing the restrictions we place on our activities that interfere with sleep.

For example, setting a regular time to go to sleep and awaken each day can help make falling asleep at night easier.
- Avoiding the use of caffeine and nicotine— which are both stimulants—can also help prevent problems such as nighttime awakening.

Table 10.2 illustrates a number of the sleep hygiene steps recommended for preventing sleep problems. Although there is little controlled prospective research on preventing sleep disorders, practising good sleep hygiene appears to be among the most promising techniques available.

A few studies have investigated the value of educating parents about the sleep of their young children in an effort to prevent later difficulties.

Adachi and colleagues (2009), for example, provided ten minutes of group guidance and a simple educational booklet to the parents of four-month-old children.

They followed up on these children three months later and found that, compared with a randomly selected control group of children, the ones whose parents received education about sleep experienced fewer sleep problems.

Because so many children display disruptive sleep prob- lems, this type of preventive effort could significantly improve the lives of many families.

Question 34

good sleep Habits

Answer 34

Establish a set bedtime routine.
Develop a regular bedtime and a regular time to awaken.
Eliminate all foods and drinks that contain caffeine six hours before bedtime.
Limit any use of alcohol or tobacco.
Try drinking milk before bedtime.
Eat a balanced diet.
Go to bed only when sleepy and get out of bed if you are unable to fall asleep or back to sleep after 15 minutes.
Do not exercise or participate in vigorous activities in the hours before bedtime.
Do include a weekly program of exercise during the day.
Restrict activities in bed to those that help induce sleep.
Reduce noise and light in the bedroom.
Increase exposure to natural and bright light during the day.
Avoid extreme temperature changes in the bedroom (that is, too hot or too cold).

Question 35

parasomnIas anD tHeIr treatment

Answer 35

Have you ever been told that you walk in your sleep? Talk in your sleep? Have you ever had troublesome nightmares? Do you grind your teeth in your sleep? If you answered yes to one or more of these questions (and it’s likely you did), you have experienced sleep problems in the category of parasomnia.

Parasomnias are not problems with sleep itself but abnormal events that occur either during sleep or during that twilight time between sleeping and waking.

Some of the events associ- ated with parasomnia are not unusual if they happen while you are awake (walking to the kitchen to look into the refrigerator) but can be distressing if they take place while you are sleeping.

The DSM-5 identifies a number of different parasomnias (American Psychiatric Association, 2013).

As you might have guessed, nightmares (or nightmare disorder) occur during REM or dream sleep (Augedal et al., 2013).
- The prevalence of nightmare disorder is unknown, but we do know that between 10 and 50 percent of children aged three to five years have nightmares that are severe enough to concern their parents.
- About 9 to 30 percent of adults experience them regularly (Schredl, 2010).

The research of Tore Nielsen, Philippe Stenstrom, and Ross Levin (2006) in Montréal indicates that women experience more frequent nightmares than men do.

To qualify as a DSM-5 nightmare disorder, these nightmares must be so distressful that they impair a person’s ability to carry on normal activities (see DSM Table 10.4).

Some researchers distinguish nightmares from bad dreams by whether or not you wake up as a result.

Nightmares are defined as very disturbing dreams that awaken the sleeper; bad dreams are those that do not awaken the person experiencing them.
- According to Montréal researchers Antonio Zadra and Don Donderi (2000), university students report an average of 30 bad dreams and 10 nightmares per year.

Nightmares are thought to be influenced by genes (Barclay & Gregory, 2013), trauma, and medication use and are associated with some psychological disorders (e.g., substance abuse, anxi- ety, borderline personality disorder, and schizophrenia spectrum disorders; Augedal et al., 2013).

Research on the treatment of nightmares suggests that both psychological intervention (e.g., cognitive behaviour therapy) and pharmacological treatment (i.e., prazosin) can help reduce these unpleasant sleep events (Augedal et al., 2013; Aurora et al., 2010).

Disorder of arousal includes a number of motor movements and behaviours during NREM sleep, such as sleepwalking, sleep terrors, and incomplete awakening.

Sleep terrors, which most commonly afflict children, usually begin with a piercing scream.
- The child is extremely upset, often sweating, and frequently has a rapid heartbeat.

On the surface, sleep terrors appear to resemble nightmares—the child cries and appears frightened—but they occur during NREM sleep and therefore are not caused by frightening dreams.
- During sleep terrors, chil- dren cannot be easily awakened and comforted, as they can during a nightmare.
- Children do not remember sleep terrors, despite their often dramatic effect on the observer (Durand, 2008).

As many as one-third of 18-month-old children may experience sleep terrors, but this number drops to 13 percent by age 5 and just 5 percent by age 13 (Petit et al., 2015).
- We know relatively little about sleep terrors, although several theories have been proposed, including the possibility of a genetic component because the disorder tends to cluster in families (Durand, 2008).

Treatment for sleep terrors usually begins with a recommen-
dation to wait and see if they disappear on their own.
- If the problem is frequent or continues for a long time, sometimes antidepressants (imipramine) or benzodiazepines are recom- mended, although their effectiveness has not yet been clearly demonstrated (Mindell, 1993).
- In an approach called scheduled awakenings, parents of children experiencing chronic sleep terrors are instructed to awaken their child briefly approximately 30 minutes before a typical episode.
- In a controlled study, this simple technique was shown to be successful in almost completely eliminating these disturbing events (Durand & Mindell, 1999).

It might surprise you to learn that sleepwalking (also called somnambulism) occurs during NREM sleep (Perrault et al., 2014).
- Thus, when people walk in their sleep they are probably not acting out a dream.
- This parasomnia typically occurs during the first few hours while a person is in the deep stages of sleep.
- The DSM-5 criteria for sleepwalking require that the person leave the bed. Because sleepwalking occurs during the deepest stages of sleep, waking someone during an episode is difficult; if the person is wakened, he or she typically will not remember what has happened. It is not true, however, that waking a sleep- walker is somehow dangerous.

Sleepwalking is primarily a problem during childhood, affect- ing more than 10 percent of school-age children (Petit et al., 2015), but a small proportion of adults are affected. For the most part, the course of sleepwalking is short, and few people over the age of 15 continue to exhibit this parasomnia. When sleepwalking occurs among adults, it is often associated with other psychologi- cal disorders

We do not yet clearly understand why some people sleep- walk, although factors such as extreme fatigue, previous sleep deprivation, the use of sedative or hypnotic drugs, and stress have been implicated (Shatkin & Ivanenko, 2009).

On occasion, sleepwalking episodes have been associated with violent behaviour, including homicide and suicide (Cartwright, 2006).
- In one case in Toronto, a 23-year-old man, Kenneth Parks, drove to his in-laws’ house, killed his mother-in-law, and attempted to kill his father-in-law. He was acquitted of the charges of murder and attempted murder, using sleepwalking as his legal defence (Broughton et al., 1994).
- Such cases are controversial, although there is evidence for the legitimacy of some violent behaviour coinciding with sleepwalking episodes. There also seems to be a genetic component to sleepwalking, with a higher incidence observed within families (Petit et al., 2015).

In a related disorder, nocturnal eating syndrome, individu- als rise from their beds and eat while they are still asleep (Yamada, 2015).
- This problem may be more frequent than previously thought; it was found in almost 6 percent of indi- viduals in one study who were referred because of insomnia complaints (Manni et al., 1997; Winkelman, 2006).

Another uncommon parasomnia is sexsomnia; acting out sexual behav- iours, such as masturbation and sexual intercourse, with no memory of the event (Béjot et al., 2010).
- This rare problem can cause relationship problems and, in extreme cases, legal prob- lems when cases occur without consent or with minors (Howell, 2012; Schenck et al., 2007).
- An Ottawa man was found not criminally responsible for the sexual assault of his daughter on the basis of testimony by psychiatrists that he suffered from sexsomnia

The DSM-5 also includes a disorder that occurs during REM sleep. In the case of REM sleep behaviour disorder, the individual talks or moves while sleeping, sometimes acting out a dream. In contrast to NREM disorders, when awakened, the person is not confused or anxious.

There is an increasing awareness that sleep is important for both our mental and our physical well-being. Sleep problems are also comorbid with many other disorders and therefore can compound the difficulties of people with significant psychologi- cal difficulties. Researchers are coming closer to understanding the basic nature of sleep and its disorders, and we anticipate significant treatment advances in the years to come.

Question 36

Diagnostic Criteria for Nightmare Disorder

Answer 36

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security or physical integrity and that generally occur during the second half of the major sleep episode.

B. On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
E. Co-existing mental and medical disorders do not adequately
explain the predominant complaint of dysphoric dreams.

Specify current severity:
Severity can be rated by the frequency with which the nightmares occur:
Mild: Less than one episode per week on average.
Moderate: One or more episodes per week but less than nightly.
Severe: Episodes nightly.