psychiatry lectures - u-szeged.hu · – move wake up time beyond rem sleep kálmán -psychiatry...

Psychiatry lecturesPsychiatry lectures

Prof. János Kálmán

Age-related Changes in pattern of Daily Sleep

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Sleep-wake disorders

Dyssomnias

1. Circadian Rhythm Sleep Disorders

2. Intrinsic Sleep Disorders

1. (Disorders that either originate or develop from within the body)

3. Extrinsic Sleep Disorders

1. (Disorders that either originate or develop from causes outside the body)

4. Parasomnias

1. (Disorder of arousal, partial arousal or sleep stage transition)


The synaptic homeostasis hypothesis of

sleep


The SHH posits that synapse accumulation during the day drives a need for synaptic

downscaling, which preferentially occurs during sleep.

Dramatic changes in sleep duration(Western cultures, /USA)

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3

4

5

6

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1960 2002 2004 2006

sleep duration

Kripke 2002; Keith 2006; Lauderdale 2006As sleep time fell in USA, average weights rose


• One or two abrupt

myoclonic flexion

jerks, often

accompanied by a

feeling of falling

• Cause:

– Insufficient sleep

Hypnic jerks = Sleep starts


• Occur at sleep onset

• Vivid perceptual experiences

• Sensation of hearing voices

• Feeling someone else is

nearby

• Precipitated by

� Sleep deprivation

� Excessive caffeine

� Emotional stress

� Narcolepsy

Hypnic hallucinations


• 50-80% of children

• 5% of Adults

• 50% sleep talk only a few

times per/year

• 10% sleep talk nightly

• Risk increases with:


� Stress

� Sickness (fever)

� Medications

� Family History

Sleep talking


• Transient inability to move,

despite being fully awake

• Brief persistence of atonia of

REM lingering into wakefulness

� 40% of teens and college

students

� 10% of adults

• Triggered by sleep deprivation

Sleep Paralysis


• 40% children

• 2% adults

• Individuals are:

� 95% family history

� 3-5 times more likely to have

OSA

� Have nightmares > once/month

� Prone injury-causing behaviors

during sleep

Sleep Terrors


• VBS occurs in 1.6% of adults

• VBS: Range from simple dream

enactment to complex behaviors

• VBS:

� Risk factors:

� Family member with VBS

� Age < 35


� Stress

� Alcohol

Violent Behavior During Sleep (VBS) 1.

Scucs et al, Medical Hypotheses 2014

Ohayon et al, Sleep Medicine 201011Kálmán - Psychiatry lectures

�Occur in the first 2

hours of sleep

�79% of people

have vivid dreams

�31% hurt

themselves or

someone else

�Few people consult

a physician

Violent Behavior During Sleep (VBS) 2.

Scucs et al, Medical Hypotheses 2014

Ohayon et al, Sleep Medicine 201012Kálmán - Psychiatry lectures

• 3% reported nocturnal

wandering at least once in the

previous year

• 30% lifetime prevalence

• 30% had a relative who had

nocturnal wandering

• 1% reported at least two

nocturnal wanderings in the

previous month

�4% sleep walked at least twice a year

�40% lifetime prevalence

�Highest incidence is ages 4-8

� Sleepwalking generally stops by age 13

Sleepwalking 1.

UK -4924 adults US-19,136 adults

Ohayon, Neurology 2012

Pressman, Neurology 2013


• Occurs in NREM III

• Patients arise from bed, walk

toward a sound or light

• Sleepwalkers may run through

the house

• Behavior is often followed by a

calm return to bed, or lying

down somewhere else in the

house

• Patients appear confused

• Eyes are open, but objects are

misidentified

• Patients are slow to respond

• Patients are difficult to arouse

• Patients often suffer retrograde

amnesia

Sleepwalking 2.


Sleepwalking 3.

• New onset or late recurrence in

teenage years warrants

consideration of other primary

sleep disorders


� Extreme fatigue

� Obstructive sleep apnea

� RLS

� RBD

� Infections

• Stressful life events often

precipitate sleepwalking

�Changes in sleep

environment

�Family conflicts

�Personal conflicts

�Medications


• Teeth grinding during sleep

• 30-40% of children

• 8% of young adults

• Symptoms of tooth-grinding

noises, jaw muscle discomfort,

abnormal wear of teeth on

dental exam

• Risk factors

� Emotional stress

� Caffeine

� Type A personalities

Sleep bruxism

Masuko et al, BMC Research Notes


Sleep Paralysis

• Has been reported to occur in families

• Treatment

– SSRIs can be effective when frequent and bothersome

– Key: sleep one more hour!

– Move wake up time beyond REM sleep


• Long, involved frightening in REM

sleep

• Preceded by increased heart rate,

increased respiration, increased REM

– 10-15% of children ages 3-6

– 20-40% children overall

– 5-12% adults

• May be caused by a daytime

traumatic experience, medications, or

disruption in routine

Nightmare disorder


• Reduced movement during sleep

• Freezing:

– Heightened anxiety consistent with the suppression of movement exhibited by animals under conditions of perceived threat

• Treated

– Reassurance

– Medications that decrease REM sleep

Nightmare Disorder


Insomnia vs. Sleep Deprivation

• Sleep Deprivation

-adequate ability to sleep

-inadequate opportunity

-generally sleepy, at risk for accidents

• Insomnia

-inadequate ability

-adequate opportunity

-generally not sleepy

may report fatigue

Kálmán - Psychiatry lectures 20

What is Insomnia?

• Classified as the inability to get enough sleep

despite adequate time.

• Symptoms Include:

– Delayed Sleep Onset

– Early Morning Wake-Ups

– Unrefreshing Sleep

– Trouble Maintaining Sleep

• Causes many problems in daytime functioning


Classifications of Insomnia

• Primary vs.

Secondary

• Chronic vs. Acute


Acute Insomnia

• Insomnia fewer than 3 times a week for less

than a month

• Stems from changes in the environment and a

short illness


Chronic Insomnia

• More than 3 times a week for a period longer

than a month

• comorbid insomnia


CAUSES OF COMORBID INSOMNIA

www.sleepreviewmag.com/.../2004-05_04. 25Kálmán - Psychiatry lectures

Treatment of Sleep

Disorders

• Good Sleep Hygiene

• Medications

• Psychotherapy, stress management

• Relaxation techniques

• OSA treatment

– Mouth appliance

– Surgery-tonsils and/or adenoids

– Weight reduction if obese

– CPAP-Continuous positive airway pressure


Pharmacological treatment

• 4 Classes of Prescription Agents

– Benzodiazepines

– Benzodiazepine Receptor Agonists

– Melatonin Receptor Agonists

– Antidepressants/Antipsychotics

• Some supplements are thought to help

as well


References I.• Psychiatric Sequalae of Sleep Disorders, Mark Brown, http://web.stanford.edu/~davesv/Psychiatric_Sequalae_of_Sleep_Disorders%2008-10.ppt• Proseminar in Physiological Psychology (PSY 627),Chapter 9,University of Kentucky

http://www.uky.edu/~mbardo/psy627_files/Sleep%20Lecture.ppt• SLEEP and INSOMNIA, Lynn N. Stewart, http://www.fmdrl.org/index.cfm?event=c.getAttachment&riid=1234 • Sleep and neurology, Eric Frenette, http://www.powershow.com/view/3b6c79-

OGRjN/Sleep_and_neurology_AWAKE_group_meeting_11_05_2008_Eric_powerpoint_ppt_presentation

• Sleep and Our Health, Terri Prodoehl, https://www.jmu.edu/kinesiology/hpainstitute/documents/Sleep%20and%20Our%20Health.ppt• Sleep and Sleep Disorders, RaeAnnon Fairlie,

http://www.public.coe.edu/~mbaker/baker/neuro/lectures/~Sleep%20and%20Sleep%20Disorders%20-%20Raeannon%20Fairlie.ppt• Sleep and sleep disorders, Katalin Štěrbová, https://www.lf2.cuni.cz/info2lf/ustavy/kdn/eng/pred/sleep.ppt• Sleep Basics for Health Promotion, Barbara B. Richardson, http://www.pitt.edu/~super4/39011-40001/39321.ppt• Sleep Dysfunction and Sleep-Disordered Breathing P3 Research Summit, Klar Yaggi,

http://www.queri.research.va.gov/ptbri/docs/p3_research/yaggi.ppt • Sleep Disorders, Michael Babcock, http://www.mc.vanderbilt.edu/documents/neurology/files/Sleep%20Disorders%20Babcock.ppt• Sleep Disorders Medicine In Psychiatry, Alan B. Douglass,

http://www.med.uottawa.ca/students/backtobasics/Lectures/Lectures%202012/Psychiatry/• Sleeping well & Driving safely, 2011, Alex Bartle, http://www.aa.co.nz/assets/about/Research-Foundation/Symposium/14-ALEX-

BARTLE.ppt?m=1328557991%22%20class=%22type:%7Bppt%7D%20size:%7B2.7%20MB%7D%20file

• Sleep When a cup of warm milk is not enough, K. Van Gundy, http://www.fresno.ucsf.edu/newsroom/public_education/sleep_disorders_3-11-03.ppt

• Teaching Abnormal Psychology: Getting Ready for DSM-5, Jeff Nevid, http://caade.org/sites/default/files/Jeff%20Nevid%20Webinar%20PPT%20Teaching%20Abnormal%20Psychology%20(1).ppt

• Treatment for Insomnia, JJ Wojcik, http://faculty.smu.edu/jbuynak/Insomnia_2010a.ppt• To Sleep…Perchance To Dream” The Diagnosis and Treatment of Children and Adolescents with Sleep Disorders, Jess P. Shatkin,

https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/cap_resources_for_medical_student_educators/Sleep%20Disorders%20in%20Children%20and%20Adolescents.ppt

• Why sleep? The origins and development of Sleep Medicine, A.W.A.K.E., NOVEMBER 4, 2009 http://web.stanford.edu/~davesv/HistoryOfSleepMed.ppt

• 2010 MindBlock & B-to-B, Sleep & Psychiatry, Alan B. Douglass, http://www.med.uottawa.ca/students/backtobasics/Lectures/Lectures%202011/Psychiatry/Sleep%20Disorders%202011/Sleep%20Disorders%202010.ppt

References II.• Cognitive-Behavioral Treatment of Insomnia, Martita Lopez,

http://homepage.psy.utexas.edu/HomePage/Class/Psy352/Fromme/Info%20relevant%20to%20previous%20exams/Insomnia.ppt• Counting sheep: evaluation and treatment of sleep issues in the college-age population, Amanda Finegold Swain,

http://www.acha.org/Midatlantic/presentations/Counting_Sheep_sleep.ppt• Diagnostic and Statistical Manual Of Mental Disorders, Changing from DSM-IV to DSM-5, Steve Franklin, Shelly Justison,

Kathleen McMullan, http://stevefranklinmsw.com/DSM-5Final.ppt • Drugs for Anxiety and Insomnia, http://nursing--

pharmacology.pbworks.com/w/file/64820074/Anxiety%20Insomnia%20Ch%2014.ppt• EEG patterns during sleep http://www.cogsci.ucsd.edu/~chiba/Sleep07.ppt• Hypersomnolence in children, M Maldonado,

http://www.kaimh.org/Websites/kaimh/images/Documents/Hypersomnolence_in_Children.pdf• Insomnia, B. Wayne Blount, http://www.fpm.emory.edu/Family/didactics/powerpint/insomnia%20nc.ppt• Insomnia, Jeffrey Lin, http://web.stanford.edu/~davesv/Insomnia%2012-08• Insomnia, Jennifer Glover, Cathleen Gallagher, Margaret Gaines, Paul Garrett, Matthew Gayford,

http://people.uncw.edu/clementsc/Insomnia.ppt• Insomnia, Liphard O. D’Souza, http://www.healthsciences.okstate.edu/college/clinical/crh/rural_clinic/docs/Insomnia.ppt• Insomnia, Victoria E Judd, http://www.acha.org/AnnualMeeting/webhandouts_2011/FR126-Judd.ppt• Insomnia in the Elderly, Cause, Approach and Management,

http://www.si.mahidol.ac.th/project/geriatrics/jour nal%20club_grand%20round/slide(PDF)/06%20Insomnia%20in%20the%20Elderly.pdf

• Intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep disorders, Emerson M. Wickwire, http://www.warrelatedillness.va.gov/WARRELATEDILLNE SS/education/conferences/2011-aug/slides/20110810_wickwire.ppt

• Medications for Insomnia: A Story of Risks and Benefits, Sarah M. Richey, http://web.stanford.edu/~davesv/Medications%20for%20Sleep%2009-08.ppt

• Narcolepsy and Other Hypersomnias, Marietta B. Bibbs, http://foocus.com/power-point/Narcolepsy-and-other-hypersomnias.pptx• Neurobiology of Sleep, Subimal Datta, http://www.uams.edu/m2006/AMSSLEEP.PPT• Parasomnia: Night Terrors, Kelsey Carrio, http://www.cogsci.ucsd.edu/~pineda/COGS175/presentations/cs175-07/Parasomnia.ppt• Parasomnias and sleep related movement disorders An Overview, Frank M. Ralls, http://familydoctornm.org/presentations/57-

presentations/20140801-1030-1.pptx• Pediatric Sleep Problems and ASD: Types, Assessment, & Intervention, Kathleen Armstrong, http://card-

usf.fmhi.usf.edu/symposium/docs/CARD%202013%20Sleep%20and%20ASD.ppt