Week 3 Lecture - Insomnia and mental health Flashcards
features of actigraph - what are they and what do they measure?
- Gives sleep outcomes
- Wearable device
- Measures things like duration of sleep, sleep onset latency etc
optimal sleep duration
7-9hours
normal sleep onset latency
15mins
features of the attogram/photometry - what do the different colours mean
- Black lines are movement (proprietary algorithm)
- Blue is sleep period
- Yellow is Light sensory so light intensity (essential in sleep regulation - can assist us in sleeping or inhibit sleeping, indicates whether we are asleep during a certain period)
- Green is the period of uncertainty (trying to measure sleep onset latency)
what is polysomnography (PSG) and what does it record?
- Electrodes on head/face (usually)
- Records electrical activity of brain
o Converted and interpreted
features of polyomnograph
amplitude and frequency to stage sleep
- The more asleep you are, the higher the amplitude and lower frequency
stages of sleep
N1 = drowsy
N2 = light sleep
N3 = deep sleep
R = REM sleep
how many sleep cycles per night
4-5
what is light sleep good for?
memory consolidation
what is deep sleep good for?
deep repair mode, growth hormone released in this period
what is REM sleep?
dream stage, closest to being awake, lots of brain areas active
when does most deep sleep occur?
during first part of night (before 2am)
when does most REM sleep occur?
towards end of sleep
how does the polysomnogram score sleep?
in 30s blocks
what happens to eyes during REM sleep
eyes move and roll during sleep
process behind REM sleep
Physiological process that paralyzes the body from neck down to stop us re-enacting dreams (EMG electrodes on body therefore have no activity)
how do we measure depth of sleep
auditory arousal threshold
auditory arousal threshold
the minimum amount of noise required to arouse someone from a given stage of sleep
stages of sleep and noise
- Deeper stages require more noise (and more energy)
o Important for fire alarms etc
what does a hypnogram show?
sleep cycles
what can anxiety do to sleep onset latency
may cause it to be longer
what can depression do to sleep cycle?
may cause people to wake up in middle of night and not go back to sleep
how many processes control sleep?
3
3 processes controlling sleep
- Homeostatic processes (physiological balance)
- Circadian processes (biological clock)
- Psychological processes (learning, cognitive arousal, automaticity)
what homeostatic process controls sleep?
sleep homeostasis: sleep pressure
sleep pressure
accumulation of hormone in brain called adenosine which starts building up as soon as you wake up. Builds up over day and highest in evening.
ways to combat adenosine
coffee which binds with adenosine and stops its action in brain
sleep homeostasis
sleep pressure
Builds up until critical level until wakefulness can no longer be maintained
Levels dissipate during sleep
Gone by morning and then process starts again upon waking
Accumulation of sleep pressure over the days of late nights where there is sleep deprivation (by the 3rd of 4th day you will need to catch up)
Napping can be used to dissipate adenosine
how long is the circadian process?
24h
how are circadian rhythms entrained?
mediated by non-image forming retinal cells (intrinsically photosensitive retinal ganglion cells or ipRGCs) (entrained to environment)
ipRGCs link directly to the suprachiasmatic nucleus in pineal gland
Light suppresses melatonin secretion, which rises in darkness and signals body to rest
interaction of homeostatic and circadian processes
- Adenosine accumulates in brain but circadian rhythm counteracts physiological process and stimulates other physiological to allow us to be alert and stay awake for at least 14-16 hours
optimal time for napping
- Between 2 and 4pm optimal time for nap as adenosine is high
o Keep less than 30mins so you don’t go into deep sleep
sleep onset is most probable when…
o We are appropriately sleepy (enough sleep pressure)
o We go to bed at the appropriate time
o We are appropriately calm (state of mind)
o The sleep environment is familiar and associated with restfulness
how common are sleep problems
Top psychological symptoms among UK adults
most mental health issues have sleep problems as one of their symptoms
use of hypnotic drugs
widely prescribed for insomnia as a first line of treatment
prevalence of sleep problems across the world
o Same story across the world, more in females and age.
o Gets more common with increasing age as sleep cycles change, less deep sleep, more lighter sleep, making opportunity to be woken in night more likely as sleep is lighter
insomnia and common mental health problems interactions
- Accompanies and is in diagnosis for lots of common mental health disorders like MDD and anxiety
insomnia before 2005
primary and secondary insomnia
primary insomnia
insomnia with no comorbidity
secondary insomnia
insomnia resulting from comorbid conditions (e.g. depression)
outcome evidence about primary and secondary insomnia (2006)
- 2 strong arguments against secondary insomnia
- [CBT-I] “…has been shown to be effective in treating patients with insomnia assumed to be secondary”
- “…insomnia often continues after the presumed primary disorder has remitted”.
Insomnia disorder DSM5 2013
- Persistent complaint (at least 3 times a week for at least the previous 3 months) of:
o Difficulty initiating or maintaining sleep despite opportunity to sleep which causes significant distress and is associated with impaired social or occupational functioning.
consequences of insomnia
- Chronic fatigue
- Emotional dysregulation
- Cog and psychomotor impairment
- Increased accident risk
- Delayed recovery from acute illness episode
- Increase healthcare utilisation
- Independent risk factor for other mental health conditions (below)
o Depression
o Anxiety
o Alcohol abuse
o Possible psychotic symptoms
insomnia effects what % of population?
approx 10%
what model do we use for insomnia
The Spielman 3P model
The Spielman 3P model
o Predisposing factors
* People with insomnia can be characterised by a behavioural phenotype showing: attentional bias, higher trait anxiety, a propensity to ruminate/catastrophise
o Precipitating factors
- triggers
o Perpetuating factors
- maintenance factors
3 key psychological factors influential in regulation of sleep
- Cognitive arousal (being appropriately calm, controlling arousal)
- Learning
- Automaticity (sleep is an automatic process, don’t think about it, habit)
2 psychological theories of cognitive arousal
- Harvey (2002): selective attention –> monitoring
- Espie et al (2006): selective attention –> the A-I-E pathway
Espies model of insomnia and arousal
- Arousal –>
- Selective attention to delayed sleep onset
- Compensatory intention to fall asleep
- Counterproductive deployment of sleep effort
- –> arousal
- Everything starts with a problem inhibiting wakefulness , disfunction in selective attention
- Realise you aren’t asleep (selective attention), then tell yourself you are going to sleep (intention) and therefore there is sleep effort as you try to shut down your mind but it does the opposite
- Intention makes sleep no longer automatic
the attention - intention - effort pathway automaticity
- Sleep effort means loss of ‘automaticity’
- Sleep effort generates performance anxiety and LONGER sleep latencies
So - We fall asleep best when we don’t ‘try’ to sleep
But - If chronic, arousal-delayed sleep onset can impact learning processes
learning takes place through…
o Reward/reinforcement (operant conditioning) or
o Pairing (classical conditioning)
stimulus control of sleep
- Adopting the state which leads to sleep is rewarded (reinforced) by sleep onset
- Through repeated episodes of reinforcement, the bedroom acquires discriminative stimulus properties for reinforcement
- Discriminative stimuli make behaviour (previously reinforced in their presence) more likely
- For people with chronic insomnia, bedroom environments stop promoting rest and sleep and they start promoting cognitive arousal
what does chronic insomnia do to learned interactions?
extinguishes learned associations between the bedroom and sleep onset
- As a result, the ability of the bedroom environment to signal sleep is diminished
- Doing other things in bedroom apart from sleep may weaken connection between bedrroom and sleep signal
conditioned emotional response and insomnia
- Repeated associations between the frustration of delayed sleep onset and the sleep environment
- Classical conditioning of negative emotions (conditioned arousal) on going to bed
CBT-I for insomnia - treatment outcomes of CBT-I
- Reviews/meta analyses of >40 studies
- “5 hours psychological treatment… produces reliable and lasting improvements …among 70-80% of treated patients”
Source: Morin et al (1999).
NICE and hypnotic use
o Should only be prescribed for short period of time or during time of crisis, not for ongoing problem with sleep
what is CBT-I?
- An integrated package of cognitive and behavioural interventions designed to:
o Reduce sleep latencies - main complaint of insomnia
o Increase sleep efficiency - don’t do anything in bed apart from sleep
o Re-establish stimulus control - relearn stimulus control and make discriminations of stimulus as bed is for sleep. What therapy is trying to do.
steps to CBT-I
first = sleep education
sleep hygiene
sleep restriction
stimulus control
relaxation
cognitive therapy
sleep hygiene
reducing dysfunctional beliefs/amplifying circadian control - expose yourself to light during day, engage in physical activity, regular meals etc
sleep restriction
increase homeostatic sleep pressure at bedtime - one of the most powerful steps, period of a few weeks where sleep is restricted so sleep pressure is accumulated due to sleep deprivation
stimulus control
managed wakefulness (and the 15 minute rule) - reassociating bed and sleep onset. If not asleep in 15 minutes, get up and do something and then try again
relaxation
reduce cognitive arousal/PMR - can follow an online recording
cognitive therapy stage
reduce cognitive arousal at night (restructuring - thought blocking)
