Week 5 Lecture 5 - Disorders of Sleep (DN) Flashcards
What is normal sleep?
- Period quiescence
-
Dynamic
- constantly changing
-
Transient
- come in & out of sleep
-
Active
- brain & body are active (not an on/off switch)
-
Cyclical
- most people monophasic (one sleep session per day)
- some: biphasic
- babies: polyphasic
How is sleep regulated?
Two systems
- govern timing, quality, & duration of sleep
Homeostatic System
- linear sleep pressure builds (into day) & decreases (into night)
Circadian System
- operates simultaneously
- counteracts Homeostatic System
-
regulates alertness
- Builds in morning
- dips mid afternoon
- builds again 3-9pm (wake maintentance)
- counteracting increasing homeostatic sleep pressure)
Both systems come together in night to promote sleep
What is a Hypnogram?
- graph/chart of polysomnographic data (from sleep lab)
- brain, eye & muscle activity
- shows sleep stages (REM, 1, 2, 3, 4)
- also illustrates an individuals cycle length
- typically 90 mins
What should be considered with regard to classifying ‘normal’ sleep?
What do the hypnograms clearly show with regard to this consideration?
- sleep should always be considered relative to what is ‘normal’ for an age group
- always wax & waning from sleep to wake, cycles vary with age
Younger individuals:
- fall quickly into SWS (stage 3 & 4), come out, short REM, go back into SWS
- (one cycle 90mins)
- early in night more REM, less SWS
- later in night less SWS, more REM
Older individuals:
- less REM earlier in night
- not as much SWS (deep sleep)
- many more awakenings, more fragmented
- also nap during day
- circadian advances
- (shifts forward - i.e., go to sleep earlier)
What are the three classification systems which outline the Diagnostic Criteria for Sleep Disorders?
Sleep Disorders May be Categorized using Three Diagnostic Classification Systems:
-
The International Classification of Diseases (ICD-10);
* GP’s generally use
-
The International Classification of Diseases (ICD-10);
-
The International Classification of Sleep Disorders (ICSD).
* Sleep scientists use
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The International Classification of Sleep Disorders (ICSD).
-
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
* Mental health professionals use
-
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
14:40
slide9
How does the International Classification of Sleep Disorders (ICSD) classify the disorders?
- Insomnias
- Sleep-disordered breathing disorders
- Hypersomnia not due to sleep- disordered breathing.
- Circadian-rhythm disorders
- Parasomnias
- Sleep-related movement disorders
- Symptoms/normal variants 8. Other sleep disorders
What Sleep Disorders are coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)?
don’t think we need to memorise this…
- Insomnia Disorder
- Hypersomnolence Disorders
- Narcolepsy
- Obstructive Sleep Apnea/Central Sleep Apnea
- Sleep-Related Hypoventilation
- Circadian Rhythm Sleep- Wake Disorders
- Arousal Disorders
- Nightmare Disorder
- Rapid Eye Movement Sleep Behavior Disorder
- Restless Legs Syndrome
- Substance-Induced Sleep Disorder
Which of the Sleep Disorders were covered in the lecture?
note these are called ‘Sleep/Wake Disorders’ in DSM-5
- Insomnia
- Narcolepsy
- Circadian rhythm disorders
also covered
- Parasomnias
What two kinds of factors contribute to Insomnia?
-
Intrinsic: from within
- e.g., hyperarousal, changes in body clock
-
Extrinsic: external factors
- e.g., environmental noise, learned response
What are the most prevalent psychological complaints among British Adults?
Is there a gender difference in sleep complaints?
- Sleep & fatigue most prevalent
- Women have more sleep complaints & fatigue than men
17: 00
What is the DSM-5 criteria for Insomnia Disorder (Primary)?
no need to memorise.
- A. Predominant complaint of: Initiation/Maintenance/Early morning awakening
- B. Clinically significant distress/impairment in social/cognitive/occupational functioning
- C. Sleep difficulty occurs at least 3 times/week
- D. Sleep difficulty present for at least 3months
- E. Sleep difficulty occurs despite adequate opportunity for sleep
- F. Disturbance is not due to another sleep disorder
- G. Disturbance is not due to a mental disorder, substance, and/or general medical condition
17:45
slide13
What characterises an individual with Primary Insomnia Disorder?
Sleep disturbance is primary, predominant complaint
- Problem with:
- Sleep Initiation
- Maintenance
- Early Morning Awakenings
Causes distress & impairment
3 times week, 3 months
19:30
What are the top 7 Psychological Symptoms among British Adults?
- Sleep Problems
- Fatigue
- Irritability
- Worry
- Depression
- Poor concentration
- Anxiety
women higher on all
What are the two Insomnia sub-types?
-
Primary Insomnia:
- insomnia not associated with a known physical or psychological disorder
-
Secondary Insomnia:
- insomnia caused by a ‘co-morbid’ physical or psychological state
36:15
What do the prevalence rates of (Primary) Insomnia Disorder
demonstrate about sleep disturbance & diagnosis of Insomnia?
figures as reported by Ohayon, 2002
- Shows a disparity between those reporting sleep disturbance** **& those being diagnosed with Primary Insomnia
- So it may be underdiagnosed
- Although 25-30% have transient insomnia (e.g., jet lag)
- which could account for disparity
Disparity shown in figures below
Insomnia Symptoms = 30%
Insomnia Symptoms with Daytime Sleepiness = 9-15%
Sleep Dissatisfaction = 8-18% Insomnia Diagnosis = 6%
19:30
slide14
Discuss some issues which may be relevant to Primary Insomnia?
Are there gender differences?
Is timing a factor?
Is age a factor
Gender effects (27:00)
- yes more prevalent in women
The timing of sleep (28:30)
- we operate on a 24 hour day (society),
- our internal body clocks are all different
Is age a factor? (29:00)
- Yes, sleep becomes more fragmented with age.
- Circadian timing phase advances (sleep earlier), more awakenings, not as much SWS)
- Also, the gender difference ratio increases with age
slide15
What are the 6 types of Primary Insomnia according to the ICSD-10?
Psychophysiological
- most common
- heightened level on instrinsic arousal
- learned response
- associating not being able to sleep with bed
Sleep State Misperception (paradoxical insomnia)
- no objective evidence (PSG) of insomnia
- individual oversestimates impact of sleep
Idiopathic Insomnia
- appears in childhood, cause unknown, long lasting I
Inadequate Sleep Hygiene
- bad sleep habits - do wrong things to promote sleep
- e.g., late in day - caffeine, TV, iPad (bright stimulated light)
Adjustment Sleep Disorder
unable to adjust to stressors, psychological, physical pain, environmental
Behavioural Insomnia of Childhood
- refusal to sleep
- over-reliance on sleep onset aids
- i.e., learned response to sleep onset
22:50
What symptoms often coexist with insomnia?
- Poor appetite
- Guilt feelings
- Suicidal thoughts
- Decreased libido
- Slowed thinking
What are the different treatment approaches used for Insomnia?
- Restrict time in Bed
- Stimulus Control
- darken room, remove TV’s, iPads etc
- Relaxation Techniques
- progressive muscle relaxation
- Cognitive Therapy
- challenging thoughts & beliefs about sleep
- Pharmacological
- Benzodiaz.
- Sleep Promoting - Melatonin before bed
What did a cross cultural epidemiological study reveal about Secondary Insomnia?
What did the findings suggest about Sleep vulnerability?
Weissman et al., (1996)
Sleep was consistently comorbid with depression across all cultures
Sleep is vulnerable to other psychological disorders
39:30
Narcolepsy - DSM-5 Criteria
no need to memorise..
- A. Recurrent periods of an irrepressible need to sleep or lapsing into sleep.
- A. At least 3 times/week for 3 months.
- B.The presence of one of the following:
- A. Epidsodes of cataplexy
- B. Hypocretin deficiency
- C. REM sleep latency < 15minutes, OR MSLT <8minutes + two SOREMPs slide20
What did a study comparing Insomnia with congestive heart failure
suggest about the consequences of Insomnia?
Katz et al., 2002
Global changes in cognitive and mental health related with insomnia
- Insomnia = increased pain, emotional effects, and mental health effects versus congestive heart failure
- Occupational accident risk
- more likely to have accident
- Decreased work productivity
-
Sleep disturbance showed a clear link with Mood disorders
- 56.2% of those who relapse into mood disorder have insomnia
- Changes in brain function e.g., arousal centres are active at night
- PET scan – enhanced CMR during wake/sleep in insomniacs
- PET scan – smaller differences in sleep-wake activity in arousal centres
34:30
What is the focus of Spielman et al.’s (1987) model of Insomnia?
It addresses the different risk factors for Insomnia
- Predisposing factors
- not direct cause but increase risk
- e.g., psychological - anxious personality type, biological - being female
-
Precipitating factors
- events that trigger insomnia
- e.g., death of a loved one, exams some people just bounce back, but if there are
-
Perpetuating factors
- factors that maintain or exascerbate Insomnia
- e.g., extending time in bed (poor sleep hygiene), exposing to light at wrong time of day
30:25 
What are some aspects of Sleep hygiene addressed in the treatment of Narcolepsy?
- Prophylactic (scheduled) short nap opportunities throughout day
- Regular sleep hours avoid late nights
- Avoidance of sleep deprivation
- Avoid caffeine, exercise if safe, control emotions
50: 44
slide22
What two types of treatment are used for Narcolepsy?
- Pharmacological
- Sleep hygiene
48:40
slide22
What characterises Narcolepsy?
- Recurrent, irrepressible need to or lapsing into sleep
- may lapse 2-6 times a day
- can last 30minutes
- partial or full loss of muscle tone during lapse
- Patients also report:
- a lot of dreaming during lapses
- intense visual imagery
- as falling asleep (Hypnagogic)
- as awaking (Hypnapompic)
40:15
What stage of sleep is associated with Narcolepsy?
- REM sleep
- When lapsing - goes straight into REM
- REM = muscle atonia
- switching off all motor activity so we don’t act out our dreams
- this is why it can be unsafe for Narcoleptic patients
- e.g., lapsing while driving, or crossing the road
- recall that REM is a dream-like state
- which explains why they report a lot of dreaming during lapses.
40:15
What is the Orexin (Hypocretin) Pathway?
- our primary arousal pathway
- governs arousal
- so a deficiency leads to the lapses seen in Narcolepsy
40:15
Circadian Rhythm Disorder - DSM-5 Criteria
no need to memorise….
- A. Persistent or recurrent pattern of sleep disruption primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required.
- B. Sleep disruption leads to excessive sleepiness or insomnia or both.
- C. Sleep disruption causes clinically significant distress or impairment in social, occupational, and other important areas of functioning. slide23
What features charcterise Circadian Rhythm Disorder?
- Persistent sleep disruption
- altered circadian system
-
internal clock misaligned to society
- e.g., awake at night, asleep during day
- Excessive sleepiness &/or Insomnia (secondary)
- Distress/Impairment
51:55
What are the different types of Circadian Rhythm Sleep Disorder (according to DSM-5)?
Shift work sleep disorder
- when individual cant entrain > chronic sleep curtailment
Irregular sleep-wake pattern
- lack of clear rhythm - constantly shifting sleep timing
Delayed sleep phase syndrome
- typically at least 2 hours out of phase
- adolescence
Advanced sleep phase syndrome
- middle & older age
Non-24-h sleep-wake disorder
- can’t entrain to day/night
- common in blind people (50%) with no light perception
58:15
What is free running?
How can it be achieved?
- Body is not designed to operate on 24 hour cycle
- we all have slightly shorter or longer internal cycle.
**Free running **
- is an expression of our individual timing (rhythm)
- in the absence of entrainment (i.e., all external cues)
Come into lab, remove all cues, clocks, time, they will gradually move to their own internal rhythm (free running)
54:50
What is Advanced sleep phase syndrome?
How is it treated?
Circadian rhythm shifts/comes forward from what is socially required
- (i.e., go to sleep earlier) common in elderly
Treatment
- Exposure to light later in the evening will push it back (i.e., helping the old gal stay awake for longer)
What is Delayed sleep phase syndrome?
Circadian rhythm shifts back
- (i.e, go to sleep later than socially required)
- common in teenagers
Treatment
Exposure to light in the morning hours
Taking Melatonin before bed
- will help bring the phase forward
- (i.e., get the cheeky buggas to go to sleep earlier!)
Are phase advances or delays a problem?
Not by themselves
They are a problem when society requires us to operate on a set 24-hr cycle.
- e.g., have to get up for work, school > curtail sleep
- chronic sleep curtailment has implications with work, driver safety & a whole lot of other issues
- then it becomes disordered
How is an individual treated for Circadian Rhythm Sleep Disorder?
- quite straight forward process
- in lab:
- look at melatonin timing with sleep onset
Chronotherapeutic Approach
- (scheduled resetting of biological clock)
Combination of:
Bright light exposure
Melatonin administration 103:10
What are the Parasomnias?
Disorders of REM & NREM sleep phases
Undesirable physical events which occur
- as falling asleep, waking up or transitioning through sleep stages
- Not influenced by judgement (no awareness of behaviours)
105:09
What is the prevalence of the Parasomnia in the general population?
Is there a gender difference?
- 4%
- higher in males
- although this may be due to males having more externalising behaviours,
- so it may just be more easily detected in men
107:35
What are some of the consequences of the parasomnias?
- Disruptive to patient, bed partner, & family
- day time sleepiness
- Legal implications: if behaviours are criminal (e.g., abuse or rape)
107: 35
What are the NREM Parasomnias?
When do they occur?
- Sleepwalking
- Night Terrors
They occur during Stage 3 & 4 (Slow Wave Sleep)
in the first third of the night
Which are the REM Parasomnias?
When do they occur?
- REM Sleep Behaviour Disorder
- Nightmare Disorder
- Sleep Paralysis
They occur during the REM sleep phase
110:20
What are the NREM Parasomnias also referred to as? Which two disorders are covered in the lecture?
Sleep Arousal Disorders Sleep Walking Sleep Terror
What characterises the NREM Sleep Arousal Disorders (Parasomnias)?
- recurrent, incomplete awakening during first third of night
- occurs during Slow Wave Sleep (NREM)
- no dreaming or recall
- cause distress
- not caused by a substance
- not explainable by any other condition
1:10:35
Briefly describe the features of Sleep Terrors?
Sleep Terror is a NREM - Sleep Arousal Disorder (Parasomnia)
- occur in Stage 3 & 4 (SWS)
- typically children
- no recall of event
- distinct from a nightmare (where there is recall)
- PSG - shows inc heart rate & blood pressure
- (genuine FEAR response)
- often co-exists with sleep walking
Prevalence (Age of onset)
- children 1-6% (4-12 years)
- adults <1% (20-30 years) 1:11:40
What are some recommended treatment options for Night Terrors?
What is the myth about waking a child from a night terror?
Strategies
- Scheduled awakenings
- Avoid
- excessive sleepiness
- play before bed
- too much heat
Avoid waking them: they awake to see you panicked, that panics them, they have no recall of it anyway
Myth: waking someone from a sleep terror causes damage to them 1:14:10
Briefly describe Sleep Walking?
Sleep Walking is a NREM - Sleep Arousal Disorder (Parasomnia)
- occur in Stage 3 & 4 (SWS)
- Complex motor movement
- reduced alertness, responsiveness limited recall
- Can be precipitated by anxiety
Prevalence 1-5%
children 10-30% (peaks 8-12yrs)
more in boys
What has been suggested for such high prevalence of Sleep Walking in children?
CNS immaturity
What pharmacological treatments are used in Narcolepsy?
Stimulants
- Ritalin/Adderall
- Provigil/Nuvigil (Modafinil)
- good as dont interfere with sleep
- Xyrem
- used to consolidate sleep period
- promotes SWS state
- related to GHB which works on GABA receptors
- very expensive ($3K per month)
- highly regulated as has been used as date rape drug
48:40
What are circadian rhythms?
- Self sustained, internally generated biological rhythm
- Internal body clock = suprachiasmatic nucleus (of the hypothalamus)
- Normally synchronised to external 24-hr day/night cycle
- (external synchronisation/entrainment)
- Also synchronises internal systems within body with each other
- so all systems have a fixed phase relationship
- (internal synchronisation)
53:15
Briefly describe Nightmare Disorder?
Disorder of REM
- repeated dysphoric, remembered dreams
- 2nd half of night
- causes distress/impairment
Aetiology:
unclear, but may be due to increased NS activity
Triggers:
may be stress, anxiety
Treatment:
CBT - take control of end of dream
Prognosis is good: often resolves by 10yrs of age
How do Night Terrors differ from Nightmare Disorder?
Night Terror
- NREM
- no recall
- occur: 1st third of night
Nightmare Disorder
- REM
- remembered
- occur: 2nd half of night
What is an associated risk of disorders of REM?
Elevated risk of developing other mental disorders
Briefly describe ‘Rapid Eye Movement Sleep Behaviour Disorder’?
Parasomnia Disorder of REM
- Appears awake & alert, not confused or disoriented
- but is actually in REM (PSG)
- vocalisation & complex motor behaviours
- sometimes associated with dream-like thoughts/images
- Muscle abnormally preserved
Usually: middle aged, elderly
highly associated with onset or risk of (within 5 yrs) Neurological disorders (e.g., Parkinsons)
How would Rapid Eye Movement Sleep Behaviour Disorder be diagnosed?
In the lab look for:
- abnormal behaviour during REM
- abnormally preserved muscle tone during REM
- if there is muscle atonia then its something else
- rule out Epilepsy
121:00
Briefly describe Sleep Paralysis?
Parasomnia disorder of REM
- preservation of REM activity during a wake state
- sense of being awake, but can’t move
- common when laying on back
occurs at
-
Sleep onset: hypnogogic and
- (wake > sleep)
-
Sleep offset: hypnopompic
- (sleep > wake)
- not codable in DSM-5 (so would be ‘not otherwise specified’)
- codable in ICSD 127:10
What are the warning signs for sleep disorder?
- Excessive daytime sleepiness
- Morning headaches
- Problems initiating/maintaining sleep
140:50
What other Sleep Disorders were mentioned briefly in the lecture?
Headbanging
- thought to be soothing
Bruxism
- teeth grinding
Enuresis
- bed wetting
Periodic Leg Movements/Restless Legs Syndrome
- crawling feeling
Sexomnia
- NREM behaviour disorder
- although presents with REM like behaviour
- may have history of sleep walking (also NREM)
133:15
What has changed in the thinking behind sleep abnormalities in psychiatric illness?
- Sleep abnormalities used to be considered secondary
- Now thought to share pathways
- e.g., mood shows daily rhythms, regulated by sleep & circadian processes
-
Arousal pathways shared
- e.g., Orexinergic pathway - takes a hit in Parkinsons
141:40
Which psychiatric disorders have clear sleep pathology?
Major Depressive Disorder
- 90% patients report altered sleep
- Insomnia increases risk of depression relapse
Bipolar Disorder
- irregular sleep timing & reduced sleep can trigger mania
- sleep management now regular part of treatment
Schizophrenia
- act comparably to someone with total sleep deprivation
- sleep disturbance most common symptom
- reduction in all phases of sleep
Anxiety/Panic/OCD/PTSD
cause & effect difficult to establish (didn’t go into Neuropeptide S)
Neurodegenerative Disorders
(didn’t go into this as we covered it in week 4)
What approach is now commonly used in treating psychiatric disorders involving sleep disturbance?
Multi-modal approach
Management of both psychiatric disorder & the **sleep disturbance **
e.g., Depression
**Tricyclic antidepressant **- used for depression, also good for sleep disorder (example of common pathways)
Melatonin agonists - to consolidate sleep cycles
- Modafinil/Provigil - stimulants that don’t interfere with sleep
What has been suggested with regard to REM latency & depression?
short REM onset latency
- may be a phenotype for depressive illness
supports the notion of common pathways operating in sleep disorders & psychiatric disorders
144:40
