Sleep Disorders

Audrea Elliott

What is sleep?

• Sleep is a behavior that follows a circadian rhythm.

• Sleep is not uniform, but organized into cycles.

• Sleep is defined behaviorally into four criteria: reduced motor activity, decreased response to activity, stereotypic postures, reversibility.

Sleep Cycle

• There are five stages of sleep; four stages are considered non-REM sleep and one stage of REM sleep

Allan & Bacon 2004

REM Sleep

• Accounts for about 25% of sleep.

• In humans, occurs once every 90 minutes.

• Brain activity is high during REM.

Sleep Deprivation

• Studies with humans have found that sleep deprivation takes it’s greatest toll on cognitive abilities.

• When allowed to sleep again, all stages of sleep are not made up evenly.

• Studies with lab animals have shown that with enough sleep deprivation the animals will become sick and eventually die.

Neural Control of Arousal and Sleep

Allan & Bacon 2004

Sleep Disorders DSM-IV-TR

• Primary Sleep Disorders- -Dyssomnias - Insomnia - Hypersomnia - Narcolepsy - Breathing-Related Sleeping Disorders - Circadian Rhythm Sleep Disorders - NOS

- Parasomnias - Nightmare Disorder - Sleep Terror Disorder - Sleepwalking Disorder - POS

• Secondary Sleep Disorders-

- Sleep Disorder Related to Another Mental Disorder

- Sleep Disorder Due to a General Medical Condition

- Substance- Induced Sleep Disorder

Insomnia

• Difficulty initiating and maintaining sleep; non restorative sleep.

• Clinically significant distress/impairment in social, occupational, or other important areas.

• Disturbance of sleep is not due to another sleep disorder.

• Disturbance of sleep is not due to another mental disorder

• Not due to direct effects of substance use or general medical condition.

• Affects about 60 million Americans have chronic insomnia. About two percent have excessive sleepiness. Most common sleep complaint.

• Affects 40% of women and 30 % of men.

• # 1 cause is thought to be sleep medication

• Acute or Chronic• Treatment: medication or

behavior modification.

Hypersomnia• Excessive sleepiness with one

month as evidence by either sleep episodes or day time sleep episodes that occur almost daily.

• Excessive sleepiness caused clinically significant distress/impairment in social, occupational, or other important areas

• Excessive sleepiness not better accounted for by insomnia, other sleep disorder, or inadequate sleep.

• Not a result of other mental disorder, physical condition, substance use, or medical condition.

• Recurrent: 3 days concurrent several times a year for at least two years.

• 5-10% of sleep clinic patients

• Lifetime prevalence of at least 16%.

• Adult population prevalence is 0.5- 5%.

• Four year prevalence about 8%.

Narcolepsy• Sleep attack must occur daily

over period of one year over a period of at least three months.

• Must experience either cataplexy or recurrent intrusions of elements of REM sleep.

• Disturbance not due to physical condition, substance use, or medical condition.

• A disorder characterized by sudden and uncontrollable, though often brief, attacks of deep sleep.

• Sometimes is accompanied by paralysis and hallucinations

• Chronic disease due to brains inability to regulate sleep-wake cycles.

• Hypocretin system implicated in development.

• Treatment: keep a regular schedule, take short daytime naps, drug therapy

• Many people go years before seeking treatment.

Cataplexy

• Neurological condition in which the person experiences sudden bilateral loss of muscle tone and falls, usually experienced right after a strong emotion (anger, fear, or excitement). Can last from seconds to minutes.

• Can be a symptom of Narcolepsy (60-100%)

• Treated with antidepressants; imipramine or desipramine

Sleep Paralysis

• A condition either at on set of sleep or at awaking when a person is aware of their surroundings, but not able to move.

• Often associated with Narcolepsy.

• Treated with antidepressants and SSRI’s

Sleep Apnea

• Sleep disruption leading to excessive sleepiness or less commonly insomnia due to abnormalities of ventilation during sleep.

• Sleep disruption not accounted for by another sleep disorder, mental disorder, physical condition, substance use, or medical condition.

• Physiological disorder in which reduced muscle tone results in blocked air passages.

• Apnea is the cessation of breath for ten or more seconds. This leads to frequent brief arousals from sleep.

• May be caused by decreased levels of Serotonin in the hypoglossal nucleus.

• Treatment: Continual Positive Airway Pressure (CPAP), Lifestyle Changes, and Surgery.

• A new medicine modafinil (Provigil) is some times given to prevent day time sleepiness along with CPAP

Circadian Rhythm Sleep Disorder

• Persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia due to mismatch between sleep-wake schedule.

• Clinically significant distress/impairment in social, occupational, or other important areas.

• Disturbance of sleep is not due to another sleep disorder.

• Disturbance of sleep is not due to another mental disorder

• Not due to direct effects of substance use or general medical condition.

• Delayed Sleep Phase Type - A persistent pattern of late sleep

onset and late awakening times with an inability to fall asleep and awaken at a desired earlier time.

Shift Work Type - Night shift or shift changes - Can start in adolescence and last

for years or decades without intervention.

- shift work: sleep back to normal within 2 weeks after shift change.

- Jet Lag: one day per time zone

Nightmares• Repeated awakening from the

major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats of survival, security, or self-esteem.

• On awakening from frightening dreams, person rapidly becomes oriented and alert.

• Dream experience or sleep disturbance resulting from the awakening results in clinically significant distress/impairment in social, occupational, or other important areas.

• Nightmares not due to another sleep disorder, mental disorder, physical condition, substance use, or medical condition.

• Dreams that occur in REM sleep, less intense then sleep terrors.

• Awakening usually occurs in second half of sleep period.

• Prevalence 10-50% kids 3-5 years old; 3% young adults; 50% adults suffer occasional nightmares.

• Likely to reoccur in children that are exposed to severe psychosocial stressors

Sleep Terrors• Recurrent episodes of abrupt

awaking from sleep.• Intense fear and signs of

autonomic arousal such as tachycardia, rapid breathing, & sweating.

• Relative unresponsiveness to efforts of others to comfort the person during the episode.

• No detailed dreams are recalled and there is amnesia for the episode.

• The episode causes clinically significant distress/impairment in social, occupational, or other important areas.

• Not due to another sleep disorder, mental disorder, physical condition, substance use, or medical condition.

• Abrupt autonomic arousal in Stage 3-4 sleep that is interpreted as fear.

• Often occurs between 4-12 years or 20-30 years.

• Often resolves in adolescence.• Chronic sleep terrors waxes and

wanes.• Psychopathology is likely to be

associated with PTSD and general anxiety.

• Prevalence 1-6% children; less then 1% adults.

• No treatment in children, usually go away. Can give sleep medication.

Sleep Walking (somnambulism)

• Repeated episodes of rising from bed during sleep and walking about.

• While sleep walking person has a blank staring face; is relatively unresponsive of others to communicate with him/her, and can be awakened only with great difficulty.

• On waking the person has amnesia.• Within several minutes after

awakening from sleep walking episode. There is no impairment, mental activity, or behavior. (May be a period of confusion disorientation.)

• Sleep walking causes clinically significant distress.

• Not due to another sleep disorder, mental disorder, physical condition, substance use, or medical condition.

• Stage 3 and 4 sleep• Prevalence 10-30% of

children at least once; 2-3% often. Occurs 1-7% of adults and 0.5%-0.7% have weekly or monthly attacks

• Gender differences occurs more often in females during childhood. Occurs mostly in males in adulthood.

REM Behavior Disorder• A neurological disorder in which a

person does not become paralyzed during REM sleep, and acts out dreams his/her dreams.

• Degenerative neurological illness in 50% of affected persons.

• Often give Clonazepam

Restless Leg Syndrome

• Neurological disorder that is characterized by unpleasant sensations of legs and an urge to move them when at the rest.

• Sleep movements can be so severe that causes chronic sleep disturbances and sleep deprivation

• Effects about 12 million Americans.• Causes: Mostly unknown (idiopathic)• Treatment: underlying cause, some meds, and

exercise.

Reference

• Abad, V.C. & Guilleminault, C.(2004). Emerging drugs for narcolepsy. Expert Opinion Emerging Drugs, 9(2), 281-291.

• Erman, M.K. (2005). Therapeutic options in the treatment of insomnia. The journal of clinical psychiatry, 66(9), 18-23.

• Lemon, M.D. (2006). New medication choices for the treatment of insomnia. South Dakota journal of medicine, 59(2), 66-67.

• Roth, T. (2005). Prevalence, associated risks, and treatment patterns of insomnia. The journal of clinical psychiatry, 66(9), 10-13.