ICL 10.2: Sleep

Question 1

what is the Epworth scale?

Answer 1

it gives you a score for how sleepy you are throughout the day and then it gives you a score

<10 is normal and you’re not having a problem with falling asleep at the wrong time

10-12: monitor and retest

13: evaluate further

> 13 or a score 3 on the last item which is about falling asleep as the driver at a stoplight which is a risky situation! you need to recommend a sleep study especially depending on what their job is

Question 2

what is insomnia?

Answer 2

problems initiating and maintaining sleep

Question 3

what is hypersomnolence?

Answer 3

too sleepy or sleeping too much

Question 4

what are parasomnias?

Answer 4

abnormal events during sleep

Question 5

what is a circadian rhythm disorder?

Answer 5

mismatch with normal cycle

Question 6

what is primary insomnia?

Answer 6

the predominant complaint is difficulty initiating or maintaining sleep, or non-restorative sleep, that occurs several times per week for 3 months

the insomnia is not a significant part of another psychiatric condition!

the sleep disturbance or associated daytime fatigue causes clinically significant distress or impairment in social, occupational or other important areas of functioning –> so this is important because there are some people who are naturally long or short sleepers and only sleep 6 hours or so and don’t have any of this criteria

Question 7

what are the exclusions for primary insomnia?

Answer 7

1. the sleep disturbance does NOT occur exclusively during the course of narcolepsy, breathing-related sleep disorder, a circadian rhythm sleep disorder, or a parasomnia –> it can’t occur exclusively during another sleep disorder that would better explain the problem
2. the sleep disturbance does NOT occur exclusively during the course of another mental disorder (e.g. depressive disorder, anxiety or bipolar disorder)
3. the sleep disturbance is NOT due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication), a general medical condition.

Question 8

what are the different time frames of primary insomnia?

Answer 8

these are the specifiers for insomnia

episodic: > one month and < 3 months

persistent (chronic): > 3 months

recurrent: 2 or more 3-month periods of insomnia in one year

Question 9

how can we define sleep deprivation by number of hours and length of deprivation?

Answer 9

1. based on number of hours of deprivation (fewer hours of sleep than normal for that person)

total = no sleep for days

partial = less sleep than usual

2. based on how long the problem has lasted (duration of deprivation)

acute = short periods of time

chronic = longer than three months

Question 10

what are the behaviors of people with insomnia?

Answer 10

1. feel sick
2. impaired concentration
3. irritability
4. more accident prone
5. over-eat
6. more pain sensitive
7. micro-sleeps** (spontaneous seconds of sleep at any time)

people who are chronically sleep deprived develop a strong sleep drive which is that sensation of falling asleep that you just can’t fight – this is horrible if you’re driving home from work when you’re sleep deprived

Question 11

poor sleep patterns lead are associated with what ill-health conditions?

Answer 11

1. depression
2. anxiety
3. diabetes
4. obesity
5. cardiovascular disease

Question 12

which people are at lowest risk for ill-health based on sleep?

Answer 12

adults sleeping 7 hours per night

on the otherhand, adults with short sleep or very long sleep are at higher risk of illness

we don’t understand why the very long sleepers also have a higher risk of illness….

Question 13

what is the relationship between hours of sleep and socioeconomic status?

Answer 13

people of lower SES sleep less

perceived racism and perceived unfair treatment has been associated with poor sleep in BOTH african americans and caucasian adults

Question 14

how do we treat insomnia?

Answer 14

1. medical management: benzodizepines/nonbenzodiazepines
2. full spectrum light therapy

patient sits next to this light for 30 minutes in the morning to help reset the timer for the patient being able to wake up and be alert in early morning hours

3. behavioral interventions

Question 15

what does it mean if a certain behavioral intervention for insomnia is “standard”?

Answer 15

standard = “generally accepted patient-care strategy, which reflects a high degree of clinical certainty based on research”

Question 16

what does it mean if a certain behavioral intervention for insomnia is “a guideline “?

Answer 16

guideline = “patient care strategy, which reflects a moderate degree of clinical certainty”

so maybe there weren’t as many clinical trials so it didn’t meet the criteria for being a standard therapy

Question 17

what does it mean if a certain behavioral intervention for insomnia is “no recommended”?

Answer 17

not enough evidence

this doesn’t mean that it’s bad or harmful, it just mean there wasn’t enough evidence or it was really hard to study

Question 18

how do you recommend a treatment for someone with insomnia?

Answer 18

Your recommendation is based on your theory of why the person is not sleeping

so if you think someone isn’t sleeping because they’re low SES, you can’t really fix that but you can educate them

but if you think they aren’t sleeping because they’re tense and have a lot of muscle tension and have some pain, then the goal is clear that the person should be recommended a therapy to reduce tension which will decrease onset insomnia

Question 19

what is relaxation therapy for insomnia?

Answer 19

this is a standard insomnia treatment!

premise: patient’s sleep disorder is due to excessive muscle tension and because their muscles are tense, they can’t sleep
goal: reduce tension to decrease onset insomnia
procedure: teach relaxation procedure and encourage daily practice; refer for stress management; use relaxation at bedtime

Question 20

what is stimulus control for insomnia?

Answer 20

this is a standard insomnia treatment!

premise: insomnia is a conditioned response to (bed) time and (bedroom) environmental cues that are usually associated with sleep; the cues and rituals of the person going to sleep have become a maladaptive conditioned response
goal: retrain the patient to associate the bed and bedroom with rapid sleep onset and unlearn the maladaptive responses

reassociate the bed, bedroom and rituals with sleep

procedure:
go to bed only when sleepy, use the bed only for sleep and sex, get out of bed when can’t sleep, no naps

you’re trying to condition an adaptive response to the site of the bedroom and the rituals associated with it

Question 21

what is CBT for insomnia?

Answer 21

this is a standard insomnia treatment!

premise: people with insomnia have faulty beliefs, expectations, attitudes about sleep
goal: replace the vicious cycle of insomnia, distress, dysfunctional cognitions….
procedure: identify negative thoughts and replace, lessen catastrophic thinking, test assumptions “I never sleep”

CBT is now commonly recommended as first line treatment for chronic insomnia and it’s without the risk for tolerance or adverse effects associated with pharmacologic approaches

Question 22

what is sleep restriction therapy?

Answer 22

this is a guideline insomnia treatment!

premise: patient’s sleep efficiency is poor; so time in bed must be decreased (it should be 90%; aka when the person is in bed, they should be sleeping 90% of the time)
goal: increase sleep efficiency to 90%

procedure:
limit time spent in bed awake

patient goes to bed at 11 but doesn’t fall asleep till 2

so the new plan is now the patient goes to bed at 1:30 because the sleep drive very strong and they’ll fall asleep at 2

next nights, patient goes to bed at 1:30, falls asleep at 1:45 –> you’re trying to fool the system to program a stronger sleep drive earlier in the night

keep moving bedtime up by 15 minute intervals until you reach a sleep efficiency of 90%

Question 23

what is the sleep hygiene approach to insomnia?

Answer 23

this is a “no recommendation” treatment for insomnia

it’s goal is to re-establish normal sleep/wake rhythms by:

1. arise at the same time every day
2. discontinue stimulants: caffeine
3. avoid daytime naps
4. use hot baths near bedtime; helps relax muscles and brain cools body after = sleep onset
5. avoid large meals and exercise near bedtime

there’s no way to test this as a package so that’s why it’s a “no recommendation” treatment –> but just remember that your treatment suggestions are related to the history that you get from the patient! so if you find out they’re working out at 9:30 PM, then maybe sleep hygiene is something you could suggest vs. a different treatment

Question 24

what is the efficacy of behavioral interventions for insomnia?

Answer 24

overall, these standard therapies are effective for 70-80% of patients with insomnia

the result of these standard therapies is that sleep onset time and awakening during the night decrease significantly

Question 25

what is the diagnostic criteria for a circadian rhythm sleep disorder?

Answer 25

A. a persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to mismatch between the sleep-wake schedule required by a person’s environment and his or her usual circadian sleep-wake pattern

the major driver of sleep-wake is light-dark

B. the sleep disturbance causes clinically significant distress or impairment in important areas of functioning

Question 26

what are the types of circadian rhythm disorders?

Answer 26

1. jet lag
2. shift change at place of employment
3. dallied sleep phase syndrome (DSPS)
4. advanced sleep phase syndrome (ASPS)

Question 27

how would you treat jet lag?

Answer 27

use bright light two hours in the early morning

try melatonin at bedtime –> melatonin is a phase resetter; if you take melatonin in the new place, it’ll help reset the system to the new time zone

Question 28

what is the circadian rhythm disorder of shift change at place of employment?

Answer 28

try long main sleep after they get home from work in the morning and nap before work –> try to maintain on off days too till they can get the sleep cycle back on track

melatonin NOT effective in primary insomnia*

Question 29

what is dallied sleep phase syndrome (DSPS)?

Answer 29

teens stay up late then can’t get up in the morning

teens don’t get into a good sleep cycle until later and a lot of teenagers are sleep deprived

try melatonin but what’s better is to change the school day schedule so school starts later for teens! easier said than done though logistically

Question 30

what is advanced sleep phase syndrome (ASPS)?

Answer 30

elderly fall asleep early, wake up early

recommendations are to increase activity in the evening and use light later in the evening to keep them up

this is a huge problem with the elderly in nursing homes; the staff is feeding them dinner at 4 PM and then they go back to their rooms and there’s nothing much going on

Question 31

what are the effects on sleep of people with major depressive disorder?

Answer 31

1. terminal insomnia
2. reduced slow-wave sleep
3. faster REM onset
4. night-time awakenings

people with anxiety disorder are worriers but people with MDD have their sleep disrupted in different ways

Question 32

what are the effects on sleep of people with bipolar disorder manic phase?

Answer 32

1. decreased need for sleep

they won’t tell you they’re sleepy even if they haven’t slept for like 3 days

2. great difficulty falling asleep

Question 33

what are the effects on sleep of people with generalized anxiety disorder?

Answer 33

1. decreased sleep efficiency below 90%; somatized tension; muscle tension; onset insomnia = they go to bed worrying about the day that just ended and the next day as well
2. non-restorative sleep; patient is tired in the morning
3. increased sleep latency; worry delays sleep onset

sleep disruption is within context of GAD! it’s not a primary insomnia! so when you recommend treatment plans, you need to be treating the GAD first and then within that context, you try to treat the insomnia

Question 34

what are the effects of pain on sleep?

Answer 34

1. non-restorative sleep
2. decreased deep sleep
3. fragmented, broken sleep

so in your chronic pain patients you need to assess sleep!!

Question 35

what are the effects of sleep deprivation on pain?

Answer 35

1. increased pain sensitivity

2. increases spontaneous pain

Question 36

what is sleep disorder breathing?

Answer 36

kids who are sleep deprived because their breathing is disruptive have higher rates of anxiety and depression for these children with SDB compared to healthy controls

depression scores were significantly worse in both obese and non-obese children with habitual snoring than controls

aggression is twice as high

higher rates of conduct problems

so if you hear that a little kid is snoring, be aware of this!!

Question 37

brent is a 23 year old law student comes to you as his PCP. he complains of onset and terminal insomnia. for the past month it takes him more than hour to fall asleep several times a week even though he’s exhausted. he’s worried about completing his class requirements at the law school and thinks maybe he chose the wrong profession. he gets to class every day but struggles to stay awake. he drinks 4-6 cups of coffee a day and has been since he started school 8 months ago. he is on no medication and has no medical diagnoses.

diagnosis?

Answer 37

primary insomnia

no insomnia due to effects of substances because he’s been drinking coffee for 8 months but only started having sleep problems for a month

Question 38

julia is 30 years old hispanic woman who comes to you with complaints of poor sleep with lots of stress, sadness, loss of interest, poor appetite for the past 4 weeks. julias mother has cancer. although chemo has been recommended, julia believes her mother won’t recover and is already grieving her loss. julia has trouble getting to sleep and wakes up early, still feeling tired. she is sleepy during the day and has little motivation for her job as a real estate agent and can’t et moving in the morning.

diagnosis?

Answer 38

major depressive disorder

it’s not complicated grief reaction because it hasn’t been 1 year, it’s recent sadness