Disorders of Sleep, Eating and Sex Flashcards
Describe normal sleep stages
-N1/S1: 5% duration, transition from wakefulness to sleep, EEG theta waves
-N2/S2: 45%, EEG sleep spindles and K-complexes
-N3/S3+4: 25%, deep sleep, occurs in first third to half of night, EEG delta waves, unusual arousal characteristics seen like disorientation, sleep terrors, sleepwalking
-R(REM): 25%, features include skeletal muscle paralysis, penile erection, surreal dreaming (including nightmares), EEG shows low amplitude, high freq, sawtooth wave, Occurs cyclically throughout night, around every 90mins, Each episode increases duration, most occurring in last third of night
Describe normal sleep cycles
-A typical night’s sleep has four or five cycles of these sequential stages, each lasting 90–110min.
-As the night progresses, the amount of time spent in delta sleep decreases, with consequent increase in REM sleep, hence the first REM period may last 5–10min, while the last, just before waking, may last up to 40min
Differential diagnosis of disturbed sleep
- Primary sleep disorders
a. Dyssomnias – abnormality in amount, quality or timing of sleep (including primary insomnia, primary hypersomnolence, narcolepsy, circadian rhythm sleep disorders, sleep-related breathing disorders, sleep-related movement disorders)
b. Parasomnias – abnormal episodes which occur during sleep or sleep-wake transitions (including non-REM sleep arousal disorders, nightmares, REM sleep behaviour disorder) - Sleep disorders secondary to another mental illness (e.g. depression, anxiety, mania, schizophrenia)
- Sleep disorders secondary to another medical condition (e.g. painful conditions, cardio resp discomfort, nocturia, metabolic and endocrine conditions, CNS lesions)
- Sleep disorders secondary to the use of a substance (e.g. alcohol, caffeine, SSRIs, antipsychotics, substance withdrawal)
Clinical presentation of insomnia
-Insomnia is defined as insufficient quantity of sleep or poor quality of sleep.
-Signs and symptoms include:
=Difficulty falling asleep
=Frequent awakening during sleep
=Early morning awakening and difficulty getting back to sleep
=Sleep not refreshing despite adequate length
=Daytime tiredness, napping
=Enlarged tonsils, tongue, small jaw retrognathia, lateral narrowing of oropharynx
=Effects on mood, behaviour, concentration and performance
-Diagnosis of chronic primary insomnia requires signs and symptoms to be present for at least 3 months. They cannot be attributable to a medical or mental illness, substance misuse or any other dyssomnia / parasomnia
Risk factors for insomnia
-Female, increased age, lower educational attainment, unemployed, economic inactivity, single
-Alcohol and substance abuse, stimulant use
-Medications like corticosteroids
-Poor sleep hygiene
-Chronic pain
-Chronic illness; patients with diabetes, CAD, hypertension, HF, BPH, COPD
-Psychiatric illness; anxiety and depression
Pathophysiology of insomnia
-Primary sleep disorders are presumed to be caused by a combination of:
1. A defect of the reticular activating system (the endogenous sleeping mechanism).
2. Unhelpful learned behaviours (e.g. worrying about being unable to sleep).
Lifestyle issues, resulting in poor sleep hygiene, are a significant factor in many cases of primary insomnia
Assessment of insomnia
-History:
=Assess for key symptoms of insomnia (Fall asleep quickly? Tossing and turning before sleep? Waking during night? Waking too early in the morning? Difficulty getting back to sleep? Feel refreshed or still tired in the morning?)
=Ask about sleep hygiene (sleeping times and patterns, caffeine consumption)
=Collateral information from sleeping partner (sleeping patterns, snoring, movements during night)
=PMH (physical and psychiatric), current medications, any substance misuse
-Investigations:
=Sleep diary if cause of insomnia is unclear
-Refer to a sleep specialist for further assessment if there is still diagnostic uncertainty or a suspicion of sleep apnoea, circadian rhythm disorders, parasomnias or narcolepsy (specialists will likely complete polysomnography)
Management of Primary Insomnia
-Education about good sleep hygiene and avoidance of recreational substances are key and may be all that is required.
-Limited role for medication:
=Hypnotics may be useful short term; tolerance usually develops at around 2 weeks (short-acting benzo or z drugs, diazepam if daytime anxiety)
=Rebound insomnia can occur
=Avoid long half-lives as this can lead to daytime drowsiness and accumulation in repeated doses
=Commonly used agents include zopiclone, zolpidem, temazepam
=If there is no response to the first hypnotic do not prescribe an alternative as they are unlikely to experience any benefit
Principles of good sleep hygiene
-Avoid sleeping during the day
-Exercise during the day (but not within 4 hours of bedtime) and maintain a heathy diet
-Eliminate the use of stimulants (caffeine, nicotine, alcohol) within 6 hours of bedtime
-Condition the brain by only using the bed for sleeping and sex- not for reading, watching TV
-Go to bed and awaken at the same time each day
-Avoid stimulating activities before bedtime (TV, games). Engage in relaxation techniques or reading
-Try having a hot bathy or drinking a cup of warm milk near bedtime
-Avoid large meals near bedtime
-Ensure that the bed is comfortable and the bedroom is quiet
-Do not lie in bed awake for longer than 15 mins (do not watch cock)- get up and do another relaxing activity and try sleeping later
Sexual Response Cycle
-Phase 1: Desire
=Consists of sexual fantasies and desire to have sexual activity
-Phase 2: Excitement
=Consists of the subjective sense of sexual pleasure and the accompanying physiological changes (erection, vaginal lubrication)
-Phase 3: orgasm
=Consists of the peaking of sexual pleasure, release of sexual tension and rhythmic contraction of perineal muscles and pelvic reproductive organs (sensation of ejaculation followed by ejaculation/ contraction of outer third vagina)
-Phase 4: resolution
=Consists of sense of muscular relaxation and general well-being. Men refractory to further erection and orgasm for period of time, women capable of multiple orgasm
What is sexual dysfunction disorder?
Sexual dysfunction disorder Any reduction or failure in the sexual response cycle, where no medical or substance-related cause can be found, and it is causing distress for the patient
Clinical presentation of sexual dysfunction disorder
-Loss of desire to have/fantasise about sex
-Failure of genital response
=Inability to initiate or maintain sexual intercourse due to inadequate erection in men or poor lubrication-swelling response in women
-Orgasmic dysfunction
=Recurrent absence/delay or premature ejaculation
-Pain during sex
=Non-organic dyspareunia: Genital pain during sex not due to other sexual dysfunction
=Vaginismus: Recurrent, involuntary spasm of the vaginal muscles, occluding the opening
Epidemiology of sexual dysfunction disorders
-Studies show ~50% of the UK population report at least one problem with sexual response lasting at least 3 months; ~10% found this distressing
-Women
=Commonest problem is lack of sexual interest
=Prevalence reduces with age
-Men
=Commonest problems are lack of sexual interest and premature ejaculation
=Prevalence of erectile problems increases with age
-More common in those with poor physical/emotional health, especially depression
-Highly associated with negative sexual experiences and relationship difficulties
Aetiology of sexual dysfunction disorder
-Often dysfunctions are due to a combination of organic problems and psychosocial factors but here we will focus on the psychogenic causes
-Many different psychosocial factors
=Ambivalence toward sex/intimacy (anxiety, fear, guilt, shame)
=Hx of rape/childhood sexual abuse
=Fear of consequences of sex (pregnancy, STIs)
=Poor or deteriorating relationship
=Anxiety about performance or attractiveness
=Fatigue or stress
-More than one aspect of the sexual response cycle can be affected by a given psychosocial issue
Differential diagnosis of sexual dysfunction disorder
-Sexual dysfunction disorder
-Medical condition-related (diabetes, vascular disease, spinal cord injury)
-Prescribed medications or substance-use
=Antidepressants and antipsychotics
=Antiepileptic drugs
=b-blockers
=Alcohol
=Cannabis
-Psychiatric illness-related
=Esp. depression, anxiety and alcohol dependence
