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Sleep: an active process
- A widespread, primitive system
- Not a single centre that causes us to be awake.
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Homeostatic and circadian sleep
- Homeostatic: with each hour we are awake, the drive to sleep increases
- Circadian: promotes wakefulness in morning, promotes wakefulness at nighttime also until about 9pm to counteract sleep drive, is at it's lowest at 3am
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Sleep cycle
- 60-90min
- More deep wave at start and more rem at end.
- Older people: reduction in slow wave sleep, increased fragmentation (wake up more)
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Sleep Disorders May be Categorized using Three Diagnostic Criteria:
- 1. The International Classification of Diseases (ICD-10);
- 2. The International Classification of Sleep Disorders (ICSD).
- 3. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
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Insomnia Disorder DSM-5
- 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
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Primary insomnia disorder
- Characteristics: repeated difficulty with sleep initiation, sleep consolidation, sleep quality, daytime impairment
- Prevalence: probably underdiagnosed.
- Gender: more likely in women. Menopause, different circadian rhythm
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Insomnia disorder- effect of timing?
- Sleep should be ALIGNED with the biological signal for sleep
- Insomnia often happens when people try to go to sleep when biological timing isn't right
- Graph shows that highest quality of sleep when body temp is lowest and circadian rhytm
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Types of insomnia
- Psychophysiological (most common): Associated with heightened arousal. Associate trying to sleep with arousal, which exacerbates insomnia.
- Sleep State Misperception (paradoxical insomnia): a person who reports problems sleeping but objectively sleep well
- Idiopathic Insomnia: no real cause, starts in childhood
- Inadequate Sleep Hygiene: doing wrong thing during bed time. Irregular sleep/wake timing, doing alerting things before bed (phone), caffeine
- Adjustment sleep disorder: associated with stressor you have not coped with or adjusted to. Illness, psychological
- Behavioural insomnia of childhood: child who has learned the wrong associations with sleep
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Insomnia: the Spielman Model
- A model which looks at risk factors of Insomnia
- 1. Predisposing factors: psychological/biological characterisitcs that increase your vulnerability to insomnia
- eg. female, having anxiety, arousal
- 2. Precipitating factors: certain life events that trigger a bout of insomnia. Can be environmental/psychological/biological.
- Eg. trauma, stress, illness, noise
- 3. Perpetuating: factors that turn into chronic insomnia. Nap, caffeine, factors that perpetuate insomnia
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Consequences of Insomnia
- Increased pain, worse emotional regulation and mental health effects compared to those with congestive heart failure.
- More likely to have occupational accident risk
- Decreased productivity
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Treatment of insomnia
- CBTI (Cognitive behavioural therapy of Insomnia)
- Mainly psychological/behavioural interventions
- Sleep restriction: to increase association between sleep and bed
- Stimulus control: no phones, tv, alarm clocks. Anythign stimulating
- Relaxation techniques: progressive muscle relaxation, meditation
- Cognitive therapy: challenge people's beliefs about sleep, stop over worrying
- Sleep hygiene
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Insomnia is comorbid with
Symptoms occurring in over 60% of people with major depression
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Narcolepsy DSM
- 1. Recurrent periods of an irrepressible need to sleep or lapsing into sleep.
- A. At least 3 times/week for 3 months.
- 2.The presence of one of the following:
- A. Episodes of cataplexy- where people drop to the ground quickly, loss of muscle tone
- B. Hypocretin/orexin deficiency
- C. REM sleep latency < 15minutes, OR MSLT <8minutes + two SOREMPs
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Narcolepsy diagnosis
- 1 in 2000
- Diagnosis 3 defining features:
- 1. Extreme daytime sleepiness
- Multiple sleep latency test: put you in dark room, nice bed, electrodes over different times of day. Normal person is 15min, abnormal is less than 8min.Have to make sure EDS is not because of another disorder
- 2. Orexin deficiency: orexin is key neuropeptide that controls wake systems. Compromises ability to stay awake
- Also involved with eating. People with narcolepsy tend to gain weight.
- Type 1 narcolepsy: severe reduction in orexin and have cataplexy
- Type 2: orexin deficiency without cataplexy
- 3. Cataplexy: loss in muscle tone, dropping to ground
- Normally triggered by strong emotional response
- Partial cataplexy: face/mouth
- Complete cataplexy
Have hypnagogic hallucinations, sleep paralysis,
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Narcolepsy cause
- Immune response: Onset typically occurs in spring/late spring thus thought most likely to be immune response
- Winter of 2009/10: H1N1 virus, after there was huge spike in people diagnosed with narcolepsy.
- Specific brand of vaccination for H1N1 increased chances of getting narcolepsy 12x, onset 1-2 months after vaccination
- Genetic: most with narcolepsy have DQB1 gene
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Treatment for Narcolepsy
- Pharmacological: stimulants (Ritalin/adderall, modafinil), Xyrem (GHB really affective at keeping someone asleep and increase slow wave) (keep asleep at night)
- Sleep hygiene: scheduled nap, regular sleep hours
- Management of: sleep deprivation, caffeine/alcohol, exercise, emotions
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Parasomnias
- Abnormal behavioural, experiential or physiological events occurring in association with sleep, specific sleep stages, or sleep-wake transitions.
- Can be associated with any stage of sleep
- Prevalence: 4%, higher in males
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Parasomnia disorders and sleep stages
- Disorders from arousal/NREM: Sleepwalking, Night Terrors
- Disorders from REM:
- REM Sleep Behaviour Disorder
- Nightmare Disorder
- Sleep paralysis
- Other:
- Enuresis
- Sleep-related eating
- Head banging
- Restless legs
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Disorders from NREM
- A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the sleep episode, accompanied by:
- 1. SLEEP WALKING
- 2. SLEEP TERROR
- B. No or little dream imagery recalled
- C. Amnesia for episodes
- D. Episodes cause clinically significant distress or impairment in social, occupational or other important area of functioning
- E. Not attributable to a substance
- F. Coexisting medical and/or mental health disorders to do explain the episodes.
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Sleep Terrors
- Distinctly different to nightmare disorder (chronic bad dreams)
- Diagnostic Criteria (DSM-IV-TR):
- Abrupt “awakening” from sleep
- Episodes accompanied by intense fear and autonomic response
- Unresponsiveness to wake or comfort
- No recall of dream
- Sleep Stage: SWS (S3/S4 or N3) – first third of the night
- Often co-exists with sleep walking
- Common in young children
- Prevalence: 1-6% children, <1% adults
- Treatment: avoid excessive sleepiness, avoid lots of play before bedtime, avoid overheat child
- Avoid waking child because it will scare them
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Sleep walking
- Diagnostic Criteria
- Complex motor movement during (SWS) sleep
- Reduced alertness and responsiveness
- Limited recall of events if awaken
- After the episode, regain full cognition and appropriate behaviour.
- Prevalence: 1-5% (10-30% children sleep walk)
- Prevalence peaks 8-12y
- Same advice as sleep terrors
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Nightmare disorder
- A. Repeated occurrence of extended, extremely dysphoric, and well remembered dreams, that generally occur in the second half of the night.
- B. On awakening, the individual becomes rapidly awake and alert
- C. The sleep disturbance causes clinically significant distress in social, occupational or other important areas of functioning
- D. The nightmare symptoms are not due to any other medical, physical or mental health problem.
- Causes: stress, anxiety, PTSD, medication
- Often begins in childhood and grow out
- Treatment: CBT (change endings of dream, reduce anxiety by increasing sense of control)
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Rapid Eye Movement Sleep Behaviour Disorder
- Complex, vigorous or violent behaviours sometimes associated with dreamlike thoughts/images, occurring in pathological REM sleep.
- Muscle tone is abnormally preserved during some or all of REM sleep.
- Patients usually middle-aged or elderly, with neurological disorder, usually men
- Usually around 5y after REM sleep disorder, diagnosis of neurological disorder such as parkinsons
- Injury 79% injured themselves or bed partner
- Recall of dreams (up to 93%)
- Diagnosis through PSG (polysomnography)
- Treatment: medication to eliminate behaviour
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Sleep paralysis
- Discrete period of time during which voluntary muscle movement is inhibited, yet ocular and respiratory movements are intact and ones sensorium remains clear.
- Occurs at sleep onset or offset (hypnogogic and hypnopompic hallucinations)
- Supine position
- Varied supernatural explanations
- Linked with:
- Hypertension; narcolepsy; seizure; anxiety
- Sleep disturbance; insufficient sleep; jetlag; shift work (isolated SP)
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