normal sleepimages3.wikia.nocookie.net/.../d/d9/sleep_disorders.pdf- delta (slow) waves; most occurs...
TRANSCRIPT
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Normal Sleep
Cornelia Pinnell, Ph.D.Argosy University/Phoenix
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Outline of Lecture
• Normal Sleep– Sleep-wake rhythm– REM & NREM sleep – physiological changes– Polysomnography – REM & NREM dreams– Developmental changes
• Sleep Disorders
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Normal sleep
Sleep is a regular, recurrent, easily reversible state that is characterized by relative quiescence, and by a great increase in threshold of response to external stimuli, relative to the waking state.
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Sleep research
1) Basic sleep mechanisms & sleep physiology
2) Sleep problems in clinical medicine
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Sleep-wake rhythm
• Endogenous sleep-wake cycle = 25 hours (Michel Siffre, 1972); external clues (light, social cues) entrain people in 24-hour cycles
• Circadian rhythms and sleep – during different times of the day sleep patterns differ greatly in their proportion of REM & NREM sleep
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Sleep patterns
•Sleep is cyclical: NREM & REM (rapid eye movement) sleep cycles
–NREM sleep – most physiological functions are markedly reduced; every 90-100 minutes of NREM sleep followed by REM sleep
–REM sleep – irregular patterns, similar toaroused waking patterns; periods increase from 10 minutes to up to 50 minutes throughout the night –up to a total of 2 ½ hours of REM activation/night
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Lifespan changes in sleep patterns
• Neonate: sleep 16h/day; EEG moves from alert state directly to REM; REM > 50% of sleep time
• 4 month old infant: REM < 40% of sleep time
• Young adult: REM = 25%; NREM: st.1= 5%, st.2=45%, st.3=12%; st.4=13%
• Old age: reduction in REM and slow-wave sleep
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Polysomnography
• Polysomnography is the monitoring of multiple electrophysiological parameters during sleep.
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Polysomnographic studies
• Night time – conducted during sleep hours• Daytime – to monitor daytime sleepiness• Multiple Sleep Latency Test (MSLT) – instructed to
lie down in a dark room and not resist falling asleep; sleep latency is measured on each trial, 5x - an index of physiological sleepiness
• Maintenance of Wakefulness Test (MWT) –instructed to lie down in a quiet dimly lit room and remain awake – sleep latency is measured – index of ability to stay awake
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Polysomnogram REM findings
• Thermoregulation – poik ilothermia (i.e., temperature varies with changes in the temperature of the surrounding medium).
• REM electromyograph – marked reduction in muscle tone – near total paralysis.
• Partial or full penile erection - (nocturnal penile tumescence study is one of the most frequently requested tests) accompanies almost every REM period.
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Polysomnogram REM findings
• REM EEG - low voltage, random fast activity with sawtooth waves, similar to waking patterns; pulse, respiration, blood pressure are high.
• REM latency (time lapse from sleep onset until the first REM period) = 90 minutes in normal adults; shorter latency in individuals with depression or narcolepsy. (If awakened, people are disoriented, disorganized thinking)
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Physiological changes during NREM sleep
• Respiration: regular, slowed down
• Cardiac function: regular pulse, reduced 5 -10 beats/min below the level of restful waking
• Blood pressure: lower, little variation
• Blood flow: slightly reduced
• Muscle tone: episodic involuntary body movements during NREM
• Temperature: slightly reduced
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Physiological changes during REM sleep
• Respiration: high
• Cardiac function: high pulse
• Blood pressure: high
• Brain oxygen use: increased
• Temperature: poor thermoregulation (Poikilothermia = changes in body temperature related to environment)
• In men: partial or full penile erection
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Stages of NREM sleep (electrophysiological criteria)
• Stage 1 – theta waves - low-voltage of 3-7 cycles/sec -lightest stage
• Stage 2 – sleep spindles – 12-14 cycles/sec. & K-complexes (slow triphasic waves)
• Stage 3 – delta (high amplitude slow) waves
• Stage 4 - delta (slow) waves ; most occurs during the first third of the night
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Stage 1 of NREM sleep
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Stage 2 of NREM sleep
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Stages 3 & 4 – delta waves (slow)
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REM sleep(electrophysiological criteria)
• Saw-tooth waves
• Theta waves activity
• Alpha waves activity
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REM dreams
• People awakened during REM sleep frequently report dreaming (60 to 90%)
• REM dreams are typically absurd and surreal – ‘dream logic’
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NREM dreams
People report occasional dreams during NREM sleep.
Typically NREM dreams are:• lucid
• purposeful
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Expected changes in sleep quality with aging
• Insomnia• Sleep-disordered breathing• REM sleep-behavior disorder
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Restorative functions of sleep
• Homeostatic functions– Role in protein synthesis & metabolism– Thermoregulation & energy conservation
• Hypothesized role in synthesizing information & making connections
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Sleep requirements
• Short sleepers – < 6 hours (abbreviated need for sleep; no difficulty falling asleep)
• Long sleepers – > 9 hours; longer REM & high density REM, vivid dreams
• Sleep deprivation – prolonged periods lead to ego disorganization, hallucination, delusions, irritability, lethargy
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Sleep regulation
• Serotonin & acethylcoline - sleep
• Melatonin = ‘sleep facilitator’• Dopamine – alerting effect• Depressed patients have marked REM sleep
disruptions: shortened REM latency; increased REM%, shift of REM to the first half of night– Antidepressants reduce REM sleep
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Sleep Disorders
• DSM – IV- TR
• International Classification of Sleep Disorders (ICSD) –
• http://www.typesofsleepdisorders.net/international-classification-of-sleep-disorders.html
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Outline of Lecture
• Sleep Disorders– Epidemiology– Major symptoms:
• Insomnia• Hypersomnia• Parasomnia• Sleep-wake disturbance
– Classification of sleep disorders
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Outline of Lecture
• Primary Sleep Disorders– Dyssomnias
• 307.42 Primary Insomnia• 307.44 Primary Hypersomnia• 347 Narcolepsy• 780.59 Breathing-Related Sleep Disorder• 307.45 Circadian Rhythm Sleep Disorder• 307.47 Dyssomnia NOS
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Outline of Lecture
• Primary Sleep Disorders– Parasomnias
• 307.47 Nightmare Disorder• 307.46 Sleep Terror Disorder• 307.46 Sleepwalking Disorder• 307.47 Parasomnia NOS
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Outline of Lecture
• Sleep Disorders Related to Another Mental Disorder (Axis I or Axis II)
• Other Sleep Disorders– Due to a medical condition (indicate)– Substance Induced (use specific codes)
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Epidemiology of sleep disorders
• More than 1/3 of US adults experience some type of sleep disorder
• Insomnia is the most common sleep disorder.
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Major symptoms of SD
• Insomnia• Hypersomnia• Parasomnia• Sleep-wake disturbance
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Insomnia
• Difficulty initiating or maintaining sleep. Often associated with apprehensive feelings or ruminative thoughts.
• Transient insomnia – may be related to grief, loss, stress, life changes
• Persistent insomnia – most often a difficulty falling asleep
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Hypersomnia
• Hypersomnia manifests as excessive amount of sleep, excessive daytime sleepiness (somnolence), or sometimes both – less common than insomnia.
• Transient/situational hypersomnia may be in response to an identifiable recent life change, conflict, or loss.
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Other symptoms of SD
• Parasomnia. Usually occurs in stages of deep sleep (3 & 4); strange behaviors may happen during sleep, associated with poor recall.
• Sleep-wake disturbance occurs when there is a displacement of sleep from its desired circadian period.
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Classification of SD
• DSM-IV-TR –1) Primary sleep disorders; 2) Sleep disorders related to another mental disorder; 3) Other sleep disorders
• ICD-10 – only sleep disorders non-organic type are included
• ICSD - The American Sleep Disorders Association’s International Classification of Sleep Disorders: Diagnostic and Coding Manual – 1) Dyssomnias; 2) Parasomnias; 3) Sleep disorders associated with medical-psychiatric disorders; 4) Proposed sleep disorders
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Primary sleep disorders
Cause significant distress or impairment in social, occupational, or other important area of functioning.
Not caused by another mental disorder, physical condition, or substance.
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Primary sleep disorders
Dyssomnias• 307.42 Primary Insomnia• 307.44 Primary Hypersomnia• 347 Primary Narcolepsy• 780.59 Primary Breathing-Related Sleep Disorder• 307.45 Primary Circadian Rhythm Sleep Disorder• 307.47 Dyssomnias NOS
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307.42 Primary Insomnia
• Prevalence in general adult population:1- 10%• Prevalence in the elderly:up to 25%• May include repeated Rapid Eye Movement
(REM) sleep interruptions & atypical polysomnographic features – poor sleep, nonrestorative.
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DSM-IV Criteria for 307.42 Primary Insomnia • A - Chief complaint is difficulty initiating or
maintaining sleep or nonrestorative sleep for at least 1 month.
• B – Sleep disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning
• C & D - Sleep disturbance does not occur exclusively during the course of other SDs or other mental disorder
• E – Not due to a substance or medical condition
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Assessment of insomnia
• Sleep diaries• Sleep questionnaires• Sleep interview• Polysomnography
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Treatment for chronic insomnia
• Pharmacotherapy:– Sedatives– Antidepressants– Anxiolytics (benzodiazepines)– OTC (over-the-counter) medication –
melatonin, valerian, antihistamines
• Non-pharmacological interventions:
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Treatment for chronic insomnia
• Non-pharmacological interventions:– Sleep hygiene– Environmental (stimulus) control– Relaxation– Cognitive-behavioral therapy
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307.44 Primary Hypersomnia
• Excessive sleep episodes or daytime sleep episodes occurring almost daily
• Sleep is normal in architecture and physiology.
• Specifier: Recurrent, if periods of excessive sleepiness of at least 3 days occur several times a year for at least 2 years.
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DSM-IV Criteria for 307.44 Primary Hypersomnia
• A - Diagnosed when no other cause can be found for excessive somnolence which occurs for at least 1 month.
• B – Excessive sleepiness causes significant distress or impairment in social, occupational, or other important areas of functioning
• C, D, E – as for Primary Insomnia
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347 Primary Narcolepsy
• Prevalence in adults: 0.02 – 0.16%
• Onset typically in adolescence - may occur at any age.
• Excessive daytime sleepiness & abnormal REM sleepdaily for at least 3 months. REM sleep onset within 10 minutes from sleep onset includes hypnagogic & hypnopompic hallucinations, cataplexy (i.e., sudden loss of muscle tone) & sleep paralysis(conscious, awake, unable to move)
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DSM-IV Criteria for 347 Narcolepsy
• A – Irresistible attacks of refreshing sleep that occur daily over at least 3 months
• B – Presence of both of the following – Cataplexy (sudden loss of muscle tone, bilaterally –
often due to intense emotion)– Recurrent intrusion of elements of REM sleep during
the transition between sleep & wakefulness
• C – Not due to another substance or mental disorder
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780.59 Primary Breathing-Related SD
• Sleep apnea is considered pathological if patients have at least 5 apneic episodes during the night.
• Obstructive sleep apnea syndrome – pure central sleep apnea (airflow and respiratory effort cease); pure obstructive sleep apnea (airflow ceases, but respiratory effort increases during the apneic episode).
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DSM-IV Criteria for 780.59 Breathing-Related Sleep Disorder
• A - Sleep disruption leading to excessive sleepiness or insomnia related to apnea, hypopnea, or oxygen desaturation.
• B – Disturbance not better accounted for by another mental disorder, substance or medical condition
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307.45 Primary Circadian Rhythm SD:• Delayed sleep phase type - sleep and wake
times that are intractably later than desired, inability to fall asleep and awaken at a desired earlier time
• Jet lag type– eastward travel more difficult to tolerate; disappears spontaneously in 2 to 7 days
• Shift work type - rapid change of work schedules & self-imposed chaotic sleep schedules lead to insomnia or excessive sleepiness
• Unspecified type
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DSM-IV Criteria for 307.45Circadian Rhythm Sleep Disorder
• A- Persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep-wake schedule required by a person’s environment and his or her circadian sleep-wake pattern.
• B - The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
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DSM-IV Criteria for 307.45Circadian Rhythm Sleep Disorder
• C - The disturbance does not occur exclusively during the course of another Sleep Disorder or other mental disorder.
• D - The disorder is not due to the direct physiological effect of a substance (e.g., a drug of abuse, or medication) or a general medical condition
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Consequences of disturbed sleep patterns• Shorter and poorer quality of sleep of
night shift workers (as compared to day or evening shift workers)
• Frequent shift rotation has more detrimental effects on sleep quality and duration
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Consequences of disturbed sleep patterns• Depression• Substance abuse• Anxiety• Decline in work performance• Disruption in interpersonal relationships
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307.47 Dyssomnias NOS
Nocturnal myoclonus Restless leg syndrome Sleep drunkenness Insufficient sleep Menstrual-associated syndrome
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Parasomnias
• Nightmare disorder - long, frightening dreams from which people awaken frightened, occur during REM sleep late in the night – prevalence: 50% of the population report occasional nightmares
• Sleep terror disorder - arousal in the first third of the night during deep non-REM sleep, accompanied by a piercing scream or cry and behavioral manifestations of intense anxiety bordering on panic – amnesia for the episode; polygraphic recordings similar to sleepwalking; prevalence: 1-6% of children
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Parasomnias
• Seepwalking disorder (Somnambulism) - a sequence of complex behaviors that are initiated in the first third of the night during deep NREM sleep – walking about without full consciousness; onset: ages 4-8, peak prevalence at age 12; more common in boys – familial disorder
• Parasomnias NOS – bruxism; REM sleep behavior disorder (dream enacting); sleeptalking - somniloqui; sleep-related head banging; sleep paralysis
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SD related to another mental disorder (Axis I or Axis II)
• Insomnia
• Hypersomnia
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Other sleep disorders
• Due to a general medical condition - epileptic seizures; cluster headaches; sleep-related asthma, cardiovascular symptoms, gastroesophageal reflux, hemolysis
• Specify type:– Insomnia Type– Hypersomnia Type– Parasomnia Type– Mixed Type (multiple sleep sxs, no sx clearly predominates)
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Treatment for sleep disorders
• Sleep medicine is a young discipline• Most common treatment: pharmacological
(undesired side effects)• Nonpharmacological:
– CBT - sleep hygiene, lifestyle changes– Relaxation, meditation, guided imagery– Dental guard (for bruxism)– Light therapy; exercise
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Sleep hygiene
• Maintain regular bedtime and waking schedule; avoid daytime naps
• Discontinue CNS-acting substances (e.g., caffeine, nicotine, alcohol, stimulants)
• Exercise daily, early in the day• Avoid evening stimulating activities• Avoid large meals near bedtime• Relaxation & meditation routines, hot bath• Comfortable sleeping conditions
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Treatment for sleep disorders
Primary insomnia the most difficult to treat: deconditioning techniques; relaxation, biofeedback, meditation; medication – benzodiazepines, hypnotics; sleep hygiene.
Primary Hypersomnia – With stimulant drugs.
Primary Narcolepsy – With stimulant drugs & forced naps at regular times during the day