Sleep difficulties and conversion and dissociation disorders Flashcards
What is insomnia?
Difficulty sleeping
What are primary sleep disorders?
Sleep apnoea, narcolepsy, restless leg syndrome, periodic leg movement disorder
What are delayed sleep phase syndromes?
Circadian pattern of sleep is delayed so patient sleeps from early hours until midday or later
What are parasomnias?
Night terrors, sleep walking and talking
What is psychophysiological insomnia?
Secondary to functional, mood and substance misuse disorders and frequently present in individuals under stress
Can be triggered by one of these factors but then becomes a habit of its own driven by anticipation of insomnia and daytime naps
What is hypersomnia?
Not uncommon in adolescents with depressive illness
Occurs in narcolepsy and may temporarily follow infections such as infectious mononucleosis
Sleeping too much
What are secondary sleep disorders?
Secondary to other conditions
- Psychiatric disorders
- Drug use or misuse
- Physical conditions - pain, nocturia, malnutrition
What should you ask in a sleeping disorder history?
Mood
Life difficulties
Drug intake - nicotine, alcohol, caffeine
Timing of insomnia
- Initial - trouble getting to sleep common in mania, anxiety, depressive disorders, substance misuse
- Middle - waking up in the middle of the night, apnoea, prostatism
- Late - early morning, waking, depressive illness, malnutrition
What are the risk factors for insomnia?
Female Over 60 Depression or anxiety Frequently travelling long distances Being under stress Working night shifts Pregnant or menopausal Family history of insomnia
What are the risk factors for restless leg syndrome?
Female Middle-age or older Family history Northern European descent Pregnancy
What are the risk factors for narcolepsy?
First degree relative with condition
Certain thyroid disorders
Diabetes
Autoimmune disorder
How common is insomnia?
1/3 adults complain of insomnia
In 1/3 it is severe
How common is delayed sleep phase syndrome?
More common in adolescents
How common are parasomnias?
Most commonly found in children
Recur in adults when under stress or suffering from mood disorders
How do sleep disorders present?
Daytime sleepiness and fatigue with consequences such as road traffic accidents
What is the pathology of sleep disorders?
Divided in REM and non-REM
As drowsiness being, alpha rhythm on EEG disappears and replaced by deepening slow wave activity (non-REM)
After 60-90 mins, slow wave pattern is replaced by low-amplitude waves on which are superimposed REM lasting a few minutes
Cycle repeated during the duration of sleep with REM periods becoming longer and slow-wave periods shorter and less deep
REM sleep accompanied by dreaming and physiological arousal
Slow-wave sleep associated with release of anabolic hormones and cytokines with increased cellular mitotic rate, helps maintain host defences, metabolism, and repair of cells
Slow-wave sleep increased in those conditions where growth or conservation is required eg adolescence, pregnancy, thyrotoxicosis
What is the management of sleep disorders?
Determined by diagnosis Simple - Decrease alcohol intake - Eating dinner earlier - Exercising daily - Hot bath prior to going to bed - Establishing a routine of going to bed at the same time Relaxation techniques and CBT Short half-life benzodiazepines Non-benzodiazepine hypnotics Certain antihistamines and antidepressants
What are dissociation disorders?
Profound loss of awareness or cognitive ability without medical explaination
What is dissociation?
Disintegration of different mental activities and convers phenomena such as amnesia, fugues, and pseudoseizures
What are conversion disorders?
Occurs when unresolved conflict converted into physical symptoms as a defence against it such as paralysis, abnormal movements, sensory loss, aphonia, disorders of gait and pseudocyesis (false pregnancy)
How common are conversion disorders?
Lifetime prevalence at 3-6 per 1000 in women
Lower prevalence in men
Most cases begin before age of 35
Unusual in the elderly
What is a differential diagnosis of dissociation disorders?
Often just co-morbid with mood and personality disorders
Fugue - post-epileptic automatism, depressive illness, alcohol misuse
What is a differential diagnosis of conversion disorders?
Changes in personality - personality disorder, rapid cycling manic-depressive disorders
How do dissociation disorders present?
Mental presentation
Amnesia - sudden, unable to recall long periods of their lives, may deny knowledge of previous life or personal identity
Fugue - loss of memory and wander away from usual surroundings
Pseudodementia
Dissociative identity disorder
3 characteristics necessary to make diagnosis
- Occur in absence of physical pathology that would fully explain symptoms
- Produced unconsciously
- Not caused by overactivity of sympathetic nervous system
How do conversion disorders present?
Physical symptoms Paralysis Disorders of gait Tremor Aphonia Mutism Sensory symptoms Globus Pseudoseizures Blindness
What is the pathology of dissociation disorders?
Involves different areas of the brain than stimulation
What is the pathology of conversion disorders?
Recalling past trauma activated emotional areas (amygdala) and reduced motor cortex activity
What is the management of conversion and dissociation disorders?
Graded and mutually agreed plan for a return to normal functioning - lead by appropriate therapist Psychotherapeutic assessment Hypnotherapy Stop drugs Treat underlying condition
What is the prognosis of conversion and dissociation disorders?
Those of recent onset recover quickly with treatment
If lasts long than a year then likely to persist with entrenched abnormal illness behaviour patterns
83% still unwell at 12 years follow-up
