Insomnia and other conditions Flashcards
DSM-5: Sleep - Wake disorders
What are the 10 disorders or groups of sleep conditions it is compromised of?
- Insomnia
- Hypersomnolence (a lot of sleepiness)
- Narcolepsy (caused by lack of orexin, stabilizes the flip flop switch)
- Breathing-related disorders (most prevalent is sleep apnea/ obstructive sleep apnea- struggling to breath during the night)
- Circadian rhythm sleep-wake disorders (going to sleep and waking up at odd times)
- Parasomnias (Rem Behaviour Disorder,- don’t have muscle atonia we have in rem sleep, so people are moving around, Restless Leg Syndrome- moving legs around)
According to the DSM-5…
- what are sleep disorders accompanied by?
- both insomnia and excessive sleepiness …
- Sleep disorders are often accompanied by depression, anxiety and cognitive changes that must be addressed in treatment plans
- Both insomnia and excessive sleepiness “are established risk factors for the subsequent development of mental illnesses and substance use disorders”
- “They may also represent a prodromal expression of an episode of mental illness, allowing the possibility of early intervention to preempt or to attenuate a full-blown episode.”
Diagnostic Criteria for Insomnia
Dissatisfaction with sleep quantity or quality associated with one or more of the following:
- Difficulty initiating sleep (staying awake/ tossing and turning)
- Difficulty maintaining sleep* (frequent awakenings, or trouble re-initiating sleep following awakening)
- Early morning awakening with inability to return to sleep
- Causes significant distress or impairment in social, occupational functioning etc.
- The sleep difficulty occurs at least 3 nights/week for at least 3 months.
Insomnia:
- the diagnosis is based on….
- term used
- useful associated features
- what is it also associated with
- The diagnosis is based on the person’s subjective perception of sleep
- Non-restorative sleep – often the complaint of one not feeling rested upon awakening despite adequate sleep duration
- Useful associated features:
– Difficulty initiating sleep: when more than 20-30min
– Difficulty maintaining sleep: when awake for more than 20-30min
– Morning awakening: when at least 30min before the scheduled time and before the total time reaches 6.5hrs - Also associated with daytime impairments such as fatigue or daytime sleepiness (less common), cognitive impairments, mood disturbances (irritability, lability)
Insomnia development and course
- Onset usually in young adulthood (less so in childhood or adolescence) and it is more prevalent in middle-aged and older adults.
– In those older, it is usually associated with other health problems - In women may occur during menopause and may persist even when other symptoms stop
- Insomnia can be situational (acute), persistent (recurrent)
- Some may be more vulnerable than others to precipitating events
Acute: have an important day the next day and excited about it. Happens because of a reason during that time and then it goes away, and everything returns to normal
Recurrent/ chronic: continually experience this very often
Prevalence of Insomnia
- According to the DSM-5 about 33% of adults report insomnia symptoms, and about 6-10% meet the criteria for insomnia disorder
- It is the most common sleep disorder
- More prevalent complaint in females compared to males 1.4:1
- 40-50% of those with insomnia also have comorbid mental disorder
Burden of Psychiatric Illness in Europe
(Wittchen et al 2011)
The most common mental health condition is anxiety
Insomnia ranks number 2 – showing it is quite prevalent
- 7% best estimate for insomnia prevalence (18+)
- Female to male ratio 2:1
Genetic correlations between insomnia and other variables/conditions from GWAS, 2017
- Although there is evidence for heritability, data do not support Mendelian genetics for insomnia
- Evidence that those who suffer from insomnia will have other family members who also suffer from it
- Concordance rates for DZ twins are higher than MZ twins.
Hammerschlag et al 2017, Nat Genet
(looking at genetic correlation)
Using people look at SNPs (single nucleotide polymorphisms- one base in genetic code may be different) having a lot of points of aspects of genome that are different will lead to accumulating- many SNPs means can start to infer genetic diffs
There is a genetic component- concordance rates that are higher with MZ than DZ conditions
Those who suffer with insomnia are more likely to suffer from depression, anxiety, major depression (red scale) whereas on the other side those with insomnia are less likely to experience subjective wellbeing, longevity ect. (blue scale)
Behavioural Model of Insomnia Spielman, 1987
- Spielman’s 3P model of insomnia
- Insomnia occurs by a combination of factors:
- Predisposing factors: personality, demographics and biological traits of the person
- Precipitating factors: triggering events (acute or short-term insomnia)
- Perpetuating factors: behaviours that the person adopts to tackle insomnia such as going to bed early, staying in bed while awake, napping, etc
— These behaviours are maladaptive and perpetuate the problem, as being in bed is increasingly associated with wakefulness and not sleep (chronic insomnia)
The factors that play a role in insomnia all start with a P
Perpetuating factors: Turning acute phase into a longer-term condition (eg. maybe ill have a nap in the afternoon to get sleep so you don’t miss out- this is counter productive and creates a worsening of the situation)
Behavioural Model of Insomnia Spielman, 1987
What can predisposing factors be?
- Biological: Hyperarousal
- Psychological: worry, tendency to ruminate (ruminate: think about/ worry about things in our mind without finding solutions)
- Social factors: bed partner, incompatible sleep schedule, social pressures
*insomniacs may get more sleep in novel sleep environments – perhaps fewer cues although little research has been done on this (Hauri et al 1989 reported the ‘reverse first-night effect’; Riedel et al 2001)
Harvey’s Cognitive Model of Insomnia 2002
1- what is chronic insomnia due to?
2- what does increased physiological arousal lead to?
3- leads to…
4- may be accompanied by…
5- what does chronic worry lead to?
1- Chronic insomnia is due to negative cognitive biases (i.e. sleep worry) which perpetuate the condition
2- Increased physiological arousal leads to attentional bias towards internal and external stimuli that may be threatening or will be interfering with sleep i.e. fatigue, or alarm clock
3- Leads to exaggerated perception of sleep continuity disturbance
4- May be accompanied by incorrect beliefs about the impact of reduced sleep and worrying i.e. cancelling appointments etc
5- Constant worry which leads to more increased arousal- (start to be a bit of a detective), scan environment internally or external -> leads to further arousal which makes it harder for them to go to sleep
Examples of reports from people suffering from insomnia
“oh no… it’s already 2 a.m… that means I’ll only get 4 hours of sleep tonight”
“If I can’t get to sleep soon there is no way I’ll cope tomorrow”
“Its 1:25 a.m… I’ve been lying here for 2 hours and 25 minutes!”
Heart pounding quickly, muscle tension
Explain the steps of Harvey’s Cognitive Model, 2002
Starts in bed when someone is not having a good night and they start to think about negative things about their sleep. Having excessive negatively toned cognitive activity leads to arousal and distress. Then this causes the individual to have selective attention and monitoring** (start paying attention to more things). Then they may have a distorted perception of their sleep deficit. They may exaggerate the consequences of this. That also leads to safety behaviours – they may start to cancel appointments/ get a nap during the day and also beliefs. This feeds back to the whole system and makes things worse. (real deficit in sleep)
This whole system makes a deficit in sleep due to arousal and neg thinking but also has a spill over effect for the next day. Same steps occur when person is awake (haven’t slept last night, what if I cant sleep again tonight). This shows they have a problem with sleep and eventually leads to a real deficit in performance/ functioning.
Neurocognitive Perspective to Chronic Insomnia Perlis et al 1997
- Evidence that patients with insomnia are physiologically hyperaroused prior to sleep onset and or during PSG sleep (Monroe 1967; Freedman and Sattler 1982; confirmed by Bonnet and Arand 1995)
- Also, patients with insomnia are prone to intrusive cognitions around sleep onset (Michel 1977; Lichstein and Rosenthal 1980).
- Model focuses on cortical arousal – elevated EEG activity in the beta and gamma range which allows for increased sensory processing, information processing etc. (they may be hyper aroused)
- Initially (acute insomnia) this increased activity may be associated with stress-induced worry and rumination however in chronic insomnia it is a result of classical conditioning (visual, temporal cues) associated with sleepiness and sleep in the absence of situational stressors
Becomes chronic condition- people lying down in bed start to associate lying down in bed and not sleep / lying down in bed and thinking and worrying. Everything in our environment (bedroom) becomes a cue/ stimulus to our situation. Conditioned to these which makes it more chronic.
The reverse first night effect can be explained using this as taking them out of typical environment = remove stimulus cues
Hyperarousal Hypothesis Riemann et al 2010
- what does the polysomnography show?
- what do sleep reports suggest
- how was insomnia viewed
- hyperarousal hypothesis
- what is this also
- normal sleep is largely…
- Polysomnography shows impairments in sleep continuity and sleep efficiency and increased time spent in NREM1 and less in NREM3.
- Sleep reports seem to suggest greater severity compared to polysomnography (subjective vs objective measures discrepancy)
- Insomnia was viewed as a psychological condition, and the pursuit of biological explanations for the condition was neglected
- Hyperarousal hypothesis: Those who tend to focus cognitively on insomnia and start to ruminate about their sleep are prone to develop “learned sleep-preventing associations” which may explain the chronicity of the problem
- There is also increased autonomic activity
- Normal sleep is largely an automatic and involuntary process that may be inhibited by directing attention to it. An increased effort to fall asleep is maladaptive
NREM1 (lighter sleep)
NREM3 (slow wave, deep restorative sleep)