10 Flashcards

Question

narcolepsy

Answer 1

In addition to daytime sleepiness, some people with narcolepsy experience cataplexy, a sudden loss of muscle tone (see DSM Table 10.3). - Cataplexy occurs while the person is awake, and it can range from slight weakness in the facial muscles to complete physical collapse. - Cataplexy lasts from several seconds to several minutes; it is usually preceded by strong emotion, such as anger or happiness. - Imagine that while cheering for your favourite team, you suddenly fall asleep, or while arguing with a friend, you collapse to the floor in a sound sleep! Cataplexy appears to result from a sudden onset of REM sleep. - Instead of falling asleep normally and going through the four nonrapid eye movement (NREM) sleep stages (i.e., Stages 1 to 4, discussed previously) that typically precede REM sleep, people with narcolepsy periodically progress right to this dream sleep stage almost directly from the state of being awake. - One outcome of REM sleep is the inhibition of input to the muscles, and this seems to be the process that leads to cataplexy. Two other characteristics distinguish people who have narco- lepsy (Ahmed & Thorpy, 2012), both of which were discussed in Chapter 5 in the context of Newfoundlanders’ experience of the “Old Hag” and African and Caribbean people’s experience of being “ridden by the witch.” Specifically, people with narcolepsy commonly report sleep paralysis and hypnagogic hallucinations. - Sleep paralysis refers to a brief period after awakening when the person can’t move or speak that is often frightening to those who go through it. - Hypnagogic hallucinations are vivid experiences that begin at the start of sleep and are said to be unbelievably realistic because they include not only visual aspects but also touch, hearing, and even the sensation of body movement. - Exam- ples of hypnagogic hallucinations, which, like sleep paralysis, can be quite terrifying, include the vivid illusion of being caught in a fire or flying through the air. Narcolepsy is relatively rare, occur- ring in 0.03 to 0.16 percent of the population, with the numbers approximately equal among males and females. - The problems associated with narcolepsy usually are first seen during the teen- age years. - Fortunately, the cataplexy, hypnagogic hallucinations, and sleep paralysis often decrease in frequency over time, although sleepiness during the day does not seem to diminish with age. Sleep paralysis and hypnagogic hallucinations may serve a role in explaining a most unusual phenomenon—UFO or alien abduction experiences (Sharpless & Doghramji, 2015). - Each year numerous people report seeing unidentified flying objects— UFOs—and some even tell of visiting with inhabitants of other planets (Sheaffer, 1986). - A group of scientists led by the late Nicholas Spanos, whose research was first discussed in Chapter 6, examined people who had had such experiences, sepa- rating them into those who had nonintense experiences (seeing only lights and shapes in the sky) and those with intense experi- ences (seeing and communicating with aliens; Spanos, et al., 1993). - They found that a majority of the reported UFO incidents occurred at night, and that 60 percent of the intense UFO stories were associated with sleep episodes. - Specifically, the reports of these intense accounts were often described in ways that resem- bled accounts of people experiencing a frightening episode of sleep paralysis and hypnagogic hallucination Specific genetic models of narcolepsy are now being developed (Peall & Robertson, 2014). Previous research with Doberman pinschers and Labrador retrievers, who also inherit this disorder, suggests that narcolepsy is associated with a cluster of genes on chromosome 6, and it may be an autosomal recessive trait. Advances in understanding the etiology and treatment of such disorders can be credited to the help of man’s best friend.

Answer 2

A. Recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months. B. The presence of at least one of the following: 1. Episodes of cataplexy defined as either (a) or (b), occurring at least a few times per month: (a) In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness, precipitated by laughter or joking. (b) In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers. 2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to 110 pg/ml). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection. 3. Nocturnal sleep polysomnography showing rapid eye move- ment (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep onset REM periods. Specify current severity: - Mild: Infrequent cataplexy (less than once per week), need for naps only once or twice per day, and less disturbed nocturnal sleep - Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily - Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep (i.e., movements, insomnia, and vivid dreaming)

Answer 3

For some people, sleepiness during the day or disrupted sleep at night has a physical origin, namely, problems with breathing while asleep. In the DSM-5, these problems are diagnosed as breathing-related sleep disorders. People whose breathing is interrupted during their sleep often experience numerous brief arousals throughout the night and do not feel rested even after eight or nine hours asleep (Overeem & Reading, 2010). For all of us, the muscles in the upper airway relax during sleep, constrict- ing the passageway somewhat and making breathing a little more difficult. For some, unfortunately, breathing is constricted a great deal and may be very laboured (hypoventilation) or, in the extreme, there may be short periods (10 to 30 seconds) when they stop breathing altogether, called sleep apnea. Just over 6 percent of Canadians report having been diagnosed with sleep apnea; the diagnosis twice as likely among men than women, and three times more likely among older adults compared to those under 60 years of age (Edjoc & Gal, 2018). Often the affected person is only minimally aware of breathing difficulties and doesn’t attri- bute the sleep problems to the breathing. A bed partner usually notices loud snoring (which is one sign of this problem), however, or will have noticed frightening episodes of interrupted breathing. Other signs that a person has breathing difficulties are heavy sweating during the night, morning headaches, and episodes of falling asleep during the day (sleep attacks) with no resulting feeling of being rested (Hauri, 1982). As noted by Charles George at the University of Western Ontario and his colleagues, sleep apnea is associated with an increased number of motor vehicle accidents (Hartenbaum et al., 2006), likely because of these asso- ciated sleep attacks. There are three types of apnea, each with different causes, daytime complaints, and treatment: obstructive, central, and mixed sleep apnea. Obstructive sleep apnea hypopnea syndrome occurs when airflow stops despite continued activity by the respiratory system (Mbata & Chukwuka, 2012). In some people, the airway is too narrow; in others, some abnormality or damage interferes with the ongoing effort to breathe. Everyone in a group of people with obstructive sleep apnea hypopnea syndrome reported snoring at night (Goel et al., 2015). - Obesity is sometimes associated with this problem, as is increasing age. Some work now suggests that the use of MDMA (ecstasy) can lead to obstructive apnea hypopnea syndrome even in young and otherwise healthy adults (McCann et al., 2009). - Obstructive sleep apnea is most common in males and is thought to occur in approximately 20 percent of the popula- tion (Franklin & Lindberg, 2015). The second type of apnea, central sleep apnea, involves the complete cessation of respiratory activity for brief periods and is often associated with certain central nervous system disorders, such as cerebral vascu- lar disease, head trauma, and degenerative disor- ders (Badr, 2012). Unlike people with obstructive sleep apnea hypopnea syndrome, those with central sleep apnea wake up frequently during the night but they tend not to report excessive daytime sleepiness and often are not aware of having a seri- ous breathing problem. Because of the lack of daytime symptoms, people tend not to seek treat- ment, so we know relatively little about this disor- der’s prevalence or course. The third breathing disorder, sleep-related hypoventilation, is a decrease in airflow without a complete pause in breathing. This tends to cause an increase in carbon dioxide (CO2) levels, because insufficient air is exchanged with the environment. All these breathing difficulties interrupt sleep and result in symptoms similar to those of insomnia.

Answer 4

“Spring forward; fall back”: Many Canadians use this mnemonic device to remind themselves to turn the clocks ahead one hour in the spring and back again one hour in the fall. Most of us consider the shift to daylight savings time a minor inconvenience and are thus surprised to see how disruptive this time change can be. - For at least a day or two, we may be sleepy during the day and have difficulty falling asleep at night, almost as if we had jet lag. The difficulty has to do with how our internal clocks adjust to this change in time. - Convention says to go to sleep at this new time while our brains are saying something different. If the struggle continues, you may have what is called a circadian rhythm sleep-wake disorder. This disorder is characterized by disturbed sleep (either insomnia or excessive sleepiness during the day) brought on by the brain’s inability to synchronize its sleep patterns with the current patterns of day and night. In the 1960s, German and French scientists identified several bodily rhythms that seem to persist without cues from the environment—rhythms that are self-regulated (Aschoff & Wever, 1962; Siffre, 1964). Because these rhythms don’t exactly match our 24-hour day, they are called “circadian” (from circa meaning “about” and dian meaning “day”). If our circadian rhythms don’t match the 24-hour day, why isn’t our sleep completely disrupted over time? Fortunately, our brains have a mechanism that keeps us in sync with the outside world. As noted by Michael Antle at the Univer- sity of Calgary, our internal clock is in the suprachiasmatic nucleus in the hypothalamus (Antle & Silver, 2005). - Connected to the suprachiasmatic nucleus is a pathway that comes from our eyes. The light we see in the morning and the decreasing light at night signal the brain to reset the internal clock each day (see also Coren, 1996). - Unfortunately, some people have trouble sleeping when they want to because of problems with their circadian rhythms, since sleep onset is closely related to circadian rhythms (Mistlberger & Rusak, 2005). - The causes may be outside the person (e.g., crossing several time zones in a short amount of time) or internal. Not being synchronized with the normal sleep-wake cycles causes people to be interrupted when they do try to sleep, and to be tired during the day. There are several different types of circa- dian rhythm sleep disorders. Jet lag type is, as its name implies, caused by rapidly crossing multiple time zones (Abba et al., 2014). People with jet lag usually report difficulty going to sleep at the proper time and feeling fatigued during the day. Travelling more than two time zones westward usually affects people the most. Travelling eastward and/or less than three time zones is usually tolerated better (Kolla et al., 2012). Research with mice suggests that the effects of jet lag can be quite serious—at least among older adults. When older mice were exposed to repeated artificial jet lag, a significant number of them lived shorter lives (Davidson et al., 2006), and artificial jet lag has also been shown to increase cancer risk in mice (van Dycke et al., 2015). Shift- work-type sleep problems are associated with work schedules (Abba et al., 2012). Many people, such as hospital employees, police, or emergency personnel, work at night or must work irregular hours; as a result, they may have problems sleeping or experience excessive sleepiness during waking hours. Unfortu- nately, the problems of working (and thus staying awake) at unusual times can go beyond sleep and may contribute to cardio- vascular disease, ulcers, and breast cancer in women (Truong et al., 2014). Working rotating shifts is consistently predictive of poor sleep In contrast with jet lag and shift-work sleep-related problems, which have external causes such as long-distance travel and job selection, several circadian rhythm sleep problems seem to arise from within the person experiencing the problems. - Extreme night owls, people who stay up late and sleep late, may have a problem known as delayed sleep phase type. - Sleep is delayed or later than normal bedtime. At the other end of the extreme, people with an advanced sleep phase type of circadian rhythm disorder are “early to bed and early to rise.” Here, sleep is advanced or earlier than normal bedtime. Finally, two other types, irregular sleep-wake type (people who experience highly varied sleep cycles) and non- 24-hour sleep-wake type (e.g., sleeping on a 25- or 26-hour cycle with later and later bedtimes ultimately going throughout the day), illustrate the diversity of circadian rhythm sleep-wake problems some people experience Research on why our sleep rhythms are disrupted is advancing quickly, and we are now beginning to understand the circadian rhythm process. Scientists believe the hormone melatonin contributes to the setting of our internal clocks that tell us when to sleep. - This hormone is produced by the pineal gland, in the centre of the brain. Melatonin has been nicknamed the “Dracula hormone” because its production is stimulated by darkness and ceases in daylight. - When our eyes see it is nighttime, this information is passed on to the pineal gland, which, in turn, begins producing melatonin. Researchers believe that both light and melatonin help set the internal clock (Stevens & Zhu, 2015). Thus, this hormone may help us treat some of the sleep problems people experience. For example, melatonin may be used as a treatment for people who experience severe jet lag and other sleep problems associated with circadian rhythm disruption

Answer 5

Perhaps the most common treatments for insomnia are medical. According to a Statistics Canada report, based on the 2002 CCHS, among those people with insomnia symptoms, 29 percent use sleep medications: 23 percent use prescribed sleep medications and 6 percent use over-the-counter sleep aids. - Thus, an estimated 4 percent of Canadians in the general population use medications for insomnia (Tjepkema, 2005). - This estimate was higher in a recent study of 2000 Canadian adults wherein 10 percent had used prescribed medications to help them sleep, 9 percent used natural products, 6 percent used over-the-counter medications, and 5 percent used alcohol to help them sleep People who complain of insomnia to a medical professional are likely prescribed one of several benzodiazepine medications, which include short-acting drugs, such as triazolam (Halcion) and long-acting drugs such as flurazepam (Dalmane). - Short-acting drugs (those that cause only brief drowsiness) are preferred because the long-acting drugs sometimes do not stop working by morning, and people report more daytime sleepiness. - The long- acting benzodiazepines are sometimes preferred when negative effects, such as daytime anxiety, are observed in people taking the short-acting drugs (Neubauer, 2009). Newer medications, such as those that work directly with the melatonin system (e.g., ramelteon [Rozerem]), are also being developed to help people fall and stay asleep. People over the age of 65 are most likely to use medica- tion to help them sleep. - A study by Keith Brownlee and his colleagues at Lakehead University showed that older patients were significantly more likely than younger patients to be prescribed benzodiazepines for insomnia (Brownlee et al., 2003). Benzodiazepine prescriptions for insomnia are a particularly important problem among seniors in nursing homes Medical treatments for insomnia have several drawbacks. - First, benzodiazepine medications can cause excessive sleepiness. - Second, people can easily become dependent on them and rather easily misuse them, deliberately or not. - Third, these medications are meant for short-term treatment and are not recommended for use longer than four weeks. Longer use can cause dependence and rebound insomnia. A newer concern for some medications (e.g., Ambien) is that they may increase the likelihood of sleepwalking-related problems, such as sleep-related eating disorder (Nzwalo et al., 2013). - Therefore, although medications may be helpful for sleep problems that will correct themselves in a short period (e.g., insomnia because of anxiety related to hospitalization), they are not intended for long-term chronic problems. To help people with hypersomnolence or narcolepsy, physicians usually prescribe a stimulant, such as methylphenidate Cataplexy, or loss of muscle tone, can be treated with antidepressant medication, not because people with narcolepsy are depressed but because antidepressants suppress REM (or dream) sleep. - Sodium oxybate is also recommended to treat cataplexy Treatment of breathing-related sleep disorders focuses on helping the person breathe better during sleep. - For some, this means recommending weight loss—in some people who are obese, the neck’s soft tissue compresses the airways. Unfortu- nately, this treatment has not proven to be very successful for breathing-related sleep disorders (Guilleminault & Dement, 1988). For mild or moderate cases of obstructive sleep apnea, treatment can involve medications, including those that help stimulate respiration (e.g., medroxyprogesterone) or the tricyclic antidepressants, which are thought to act on the locus coeruleus, which affects REM sleep such that the respiratory muscles do not relax as much The gold standard for the treatment of obstructive sleep apnea involves the use of a mechanical device—called the continuous positive air pressure (CPAP) machine—that improves breathing (Patel et al., 2003). - Patients wear a mask that provides slightly pressurized air during sleep and it helps them breathe more normally throughout the night. - Unfortunately, many people have difficulty using the device because of issues of comfort and some even experience a form of claustrophobia. To assist these individu- als, a variety of strategies are tried, including the use of psychologi- cal interventions, such as desensitization for claustrophobia, patient and partner education, and motivational interviewing (a counsel- ling technique used to help patients match their goals with their behaviours) (Olsen et al., 2012). Severe breathing problems may require surgery to help remove blockages in parts of the airways

Answer 6

Because medication as a primary treatment isn’t usually recom- mended (Doghramji, 2000; Roehrs & Roth, 2000), other ways of getting people back in step with their sleep rhythms are usually tried. One general principle for treating circadian rhythm disorders is that phase delays (moving the bedtime later) are easier than phase advances (moving bedtime earlier). - Scheduling shift changes in a clockwise direction (going from day to evening schedule) seems to help workers adjust better. People can best readjust their sleep patterns by going to bed several hours later each night, until bedtime is at the desired hour (Sack et al., 2007). A drawback of this approach is that it requires the person to sleep during the day for several days, which is obviously difficult for people with regularly scheduled responsibilities. Another recent effort to help people with sleep problems involves using bright light to trick the brain into readjusting the internal clock. - Very bright light may help people with circadian rhythm problems readjust their sleep patterns (Burkhalter et al., 2015). - People typically sit in front of a bank of fluorescent lamps that generate light greater than 2500 lux, an amount significantly different from normal indoor light (250 lux). - Several hours of exposure to this bright light have successfully reset the circadian rhythms of a number of individuals (Czeisler & Allan, 1989). - Although this type of treatment is still new, it provides some hope for people with sleep problems.

Answer 7

As you can imagine, the limitations of using drugs to help people sleep better has led to the development of psychological treat- ments. Table 10.1 lists and briefly describes some of the psycho- logical approaches to insomnia. Given the links of anxiety to insomnia, Viens, De Koninck, Mercier, St-Onge, and Lorrain (2003) from the University of Ottawa compared progressive relaxation with a treatment they referred to as anxiety management training (which basically combined progressive relaxation with cognitive relaxation tech- niques). - Both groups were able to get to sleep more quickly follow- ing therapy. - Furthermore, lab-based sleep evaluations showed that participants in both groups increased in slow-wave sleep and sleep satisfaction. - Both groups also showed decreases in anxiety and depression. The two treatments were equally effective. Other research shows that some psychological treatments for insomnia may be more effective than others. - For adult sleep prob- lems, stimulus control may be recommended. - People are instructed to use the bedroom only for sleeping and for sex and not for work or other anxiety-provoking activities (e.g., watching the news on television). Kathryn’s sleep problems were addressed with several tech- niques. - She was instructed to limit her time in bed to about four hours of sleep time (sleep restriction), about the amount of time she actually slept each night. - The period was lengthened when she began to sleep through the night. - Kathryn was also asked not to listen to the radio while in bed and to get out of bed if she couldn’t fall asleep (stimulus control). - Finally, therapy involved confronting her unrealistic expectations about how much sleep was enough for a person of her age (cognitive therapy; see Bélanger et al., 2006). - Within about three weeks of treatment, Kathryn was sleeping longer (six to seven hours per night as opposed to four to five hours previously) and had fewer interruptions in her sleep. She felt more refreshed in the morning and had more energy during the day. Kathryn’s results mirror those of studies by Charles Morin and his colleagues that find combined treatments to be effective in older adults with insomnia (e.g., Morin, Kowatch, et al., 1993). - One such study, using a randomized placebo-control design, found that both medical and psychological approaches were effective in improving the sleep of older adults (Morin et al., 1999). - Over the long term, however, the psychological treatment was better able to maintain its effectiveness with this group (see also review by Morin & Wooten, 1996). Morin has examined the effectiveness of sequential (CBT and medication) treatments for insomnia. Partici- pants received either (1) medication and then combined medication and CBT; (2) combined treatment and then CBT alone; or (3) CBT alone. - For the first treatment group, significant improve- ments only appeared after the introduction of CBT, while in the other two groups improvement appeared near the beginning of treatment. - The study also showed that the treatment involving combined treatment followed by CBT alone led to the best outcomes. - These findings show that sleep improvement seems to be affected by the way in which medication and CBT are combined. For young children, some of the cognitive treatments may not be possible. - Instead, treatment often includes setting up bedtime routines, such as a bath, followed by a parent reading a story, to help children go to sleep at night. - Graduated extinction (described in Table 10.1) has been used with some success for bedtime prob- lems as well as for waking up at night (Hill, 2011). - Integrating both medical and behavioural treatments seems especially important for insomnia. - Research suggests that short-term use of medication in combination with other types of interventions may prove to be a quick and lasting treatment for insomnia (Milby et al., 1993; Morin & Azrin, 1988). Importantly, researchers are now examining the treatment of both sleep problems and psychological disorders (e.g., depres- sion) together, because the link appears to be strong, and treat- ing one type of problem alone may not be enough (e.g., Carney et al., 2017). Colleen Carney, for example, mentions that insom- nia may remain during the treatment of depression, it may inter- fere with the treatment of depression, and it makes it more likely that depression will return (https://psychlabs.ryerson.ca/ carney/).

Answer 8

Cognitive This approach focuses on changing the sleepers’ unrealistic expectations and beliefs about sleep (“I must have eight hours of sleep each night”; “If I get less than eight hours of sleep it will make me ill”). The therapist attempts to alter beliefs and attitudes about sleeping by providing information on topics such as normal amounts of sleep and a person’s ability to compensate for lost sleep. Cognitive relaxation Because some people become anxious when they have difficulty sleeping, this approach uses meditation or imagery to help with relaxation at bedtime or after a night of waking. Graduated extinction Used for children who have tantrums at bedtime or wake up crying at night, this treatment instructs the parent to check on the child after progressively longer periods, until the child falls asleep on his or her own. Paradoxical intention This technique involves instructing individuals in the opposite behaviour from the desired outcome. Telling poor sleepers to lie in bed and try to stay awake as long as they can is used to try to relieve the performance anxiety surrounding efforts to try to fall asleep. Progressive relaxation This technique involves relaxing the muscles of the body in an effort to introduce drowsiness.

Answer 9

Sleep professionals generally agree that a significant portion of the sleep problems people experience daily can be prevented by following a few steps during the day. - Referred to as sleep hygiene, these changes in lifestyle can be relatively simple to follow and can help avoid problems such as insomnia for some people (Goodman & Scott, 2012). Some sleep hygiene recom- mendations rely on allowing the brain’s normal drive for sleep to take over, replacing the restrictions we place on our activities that interfere with sleep. For example, setting a regular time to go to sleep and awaken each day can help make falling asleep at night easier. - Avoiding the use of caffeine and nicotine— which are both stimulants—can also help prevent problems such as nighttime awakening. Table 10.2 illustrates a number of the sleep hygiene steps recommended for preventing sleep problems. Although there is little controlled prospective research on preventing sleep disorders, practising good sleep hygiene appears to be among the most promising techniques available. A few studies have investigated the value of educating parents about the sleep of their young children in an effort to prevent later difficulties. Adachi and colleagues (2009), for example, provided ten minutes of group guidance and a simple educational booklet to the parents of four-month-old children. They followed up on these children three months later and found that, compared with a randomly selected control group of children, the ones whose parents received education about sleep experienced fewer sleep problems. Because so many children display disruptive sleep prob- lems, this type of preventive effort could significantly improve the lives of many families.

Answer 10

Establish a set bedtime routine. Develop a regular bedtime and a regular time to awaken. Eliminate all foods and drinks that contain caffeine six hours before bedtime. Limit any use of alcohol or tobacco. Try drinking milk before bedtime. Eat a balanced diet. Go to bed only when sleepy and get out of bed if you are unable to fall asleep or back to sleep after 15 minutes. Do not exercise or participate in vigorous activities in the hours before bedtime. Do include a weekly program of exercise during the day. Restrict activities in bed to those that help induce sleep. Reduce noise and light in the bedroom. Increase exposure to natural and bright light during the day. Avoid extreme temperature changes in the bedroom (that is, too hot or too cold).

Answer 11

Have you ever been told that you walk in your sleep? Talk in your sleep? Have you ever had troublesome nightmares? Do you grind your teeth in your sleep? If you answered yes to one or more of these questions (and it’s likely you did), you have experienced sleep problems in the category of parasomnia. Parasomnias are not problems with sleep itself but abnormal events that occur either during sleep or during that twilight time between sleeping and waking. Some of the events associ- ated with parasomnia are not unusual if they happen while you are awake (walking to the kitchen to look into the refrigerator) but can be distressing if they take place while you are sleeping. The DSM-5 identifies a number of different parasomnias (American Psychiatric Association, 2013). As you might have guessed, nightmares (or nightmare disorder) occur during REM or dream sleep (Augedal et al., 2013). - The prevalence of nightmare disorder is unknown, but we do know that between 10 and 50 percent of children aged three to five years have nightmares that are severe enough to concern their parents. - About 9 to 30 percent of adults experience them regularly (Schredl, 2010). The research of Tore Nielsen, Philippe Stenstrom, and Ross Levin (2006) in Montréal indicates that women experience more frequent nightmares than men do. To qualify as a DSM-5 nightmare disorder, these nightmares must be so distressful that they impair a person’s ability to carry on normal activities (see DSM Table 10.4). Some researchers distinguish nightmares from bad dreams by whether or not you wake up as a result. Nightmares are defined as very disturbing dreams that awaken the sleeper; bad dreams are those that do not awaken the person experiencing them. - According to Montréal researchers Antonio Zadra and Don Donderi (2000), university students report an average of 30 bad dreams and 10 nightmares per year. Nightmares are thought to be influenced by genes (Barclay & Gregory, 2013), trauma, and medication use and are associated with some psychological disorders (e.g., substance abuse, anxi- ety, borderline personality disorder, and schizophrenia spectrum disorders; Augedal et al., 2013). Research on the treatment of nightmares suggests that both psychological intervention (e.g., cognitive behaviour therapy) and pharmacological treatment (i.e., prazosin) can help reduce these unpleasant sleep events (Augedal et al., 2013; Aurora et al., 2010). Disorder of arousal includes a number of motor movements and behaviours during NREM sleep, such as sleepwalking, sleep terrors, and incomplete awakening. Sleep terrors, which most commonly afflict children, usually begin with a piercing scream. - The child is extremely upset, often sweating, and frequently has a rapid heartbeat. On the surface, sleep terrors appear to resemble nightmares—the child cries and appears frightened—but they occur during NREM sleep and therefore are not caused by frightening dreams. - During sleep terrors, chil- dren cannot be easily awakened and comforted, as they can during a nightmare. - Children do not remember sleep terrors, despite their often dramatic effect on the observer (Durand, 2008). As many as one-third of 18-month-old children may experience sleep terrors, but this number drops to 13 percent by age 5 and just 5 percent by age 13 (Petit et al., 2015). - We know relatively little about sleep terrors, although several theories have been proposed, including the possibility of a genetic component because the disorder tends to cluster in families (Durand, 2008). Treatment for sleep terrors usually begins with a recommen- dation to wait and see if they disappear on their own. - If the problem is frequent or continues for a long time, sometimes antidepressants (imipramine) or benzodiazepines are recom- mended, although their effectiveness has not yet been clearly demonstrated (Mindell, 1993). - In an approach called scheduled awakenings, parents of children experiencing chronic sleep terrors are instructed to awaken their child briefly approximately 30 minutes before a typical episode. - In a controlled study, this simple technique was shown to be successful in almost completely eliminating these disturbing events (Durand & Mindell, 1999). It might surprise you to learn that sleepwalking (also called somnambulism) occurs during NREM sleep (Perrault et al., 2014). - Thus, when people walk in their sleep they are probably not acting out a dream. - This parasomnia typically occurs during the first few hours while a person is in the deep stages of sleep. - The DSM-5 criteria for sleepwalking require that the person leave the bed. Because sleepwalking occurs during the deepest stages of sleep, waking someone during an episode is difficult; if the person is wakened, he or she typically will not remember what has happened. It is not true, however, that waking a sleep- walker is somehow dangerous. Sleepwalking is primarily a problem during childhood, affect- ing more than 10 percent of school-age children (Petit et al., 2015), but a small proportion of adults are affected. For the most part, the course of sleepwalking is short, and few people over the age of 15 continue to exhibit this parasomnia. When sleepwalking occurs among adults, it is often associated with other psychologi- cal disorders We do not yet clearly understand why some people sleep- walk, although factors such as extreme fatigue, previous sleep deprivation, the use of sedative or hypnotic drugs, and stress have been implicated (Shatkin & Ivanenko, 2009). On occasion, sleepwalking episodes have been associated with violent behaviour, including homicide and suicide (Cartwright, 2006). - In one case in Toronto, a 23-year-old man, Kenneth Parks, drove to his in-laws’ house, killed his mother-in-law, and attempted to kill his father-in-law. He was acquitted of the charges of murder and attempted murder, using sleepwalking as his legal defence (Broughton et al., 1994). - Such cases are controversial, although there is evidence for the legitimacy of some violent behaviour coinciding with sleepwalking episodes. There also seems to be a genetic component to sleepwalking, with a higher incidence observed within families (Petit et al., 2015). In a related disorder, nocturnal eating syndrome, individu- als rise from their beds and eat while they are still asleep (Yamada, 2015). - This problem may be more frequent than previously thought; it was found in almost 6 percent of indi- viduals in one study who were referred because of insomnia complaints (Manni et al., 1997; Winkelman, 2006). Another uncommon parasomnia is sexsomnia; acting out sexual behav- iours, such as masturbation and sexual intercourse, with no memory of the event (Béjot et al., 2010). - This rare problem can cause relationship problems and, in extreme cases, legal prob- lems when cases occur without consent or with minors (Howell, 2012; Schenck et al., 2007). - An Ottawa man was found not criminally responsible for the sexual assault of his daughter on the basis of testimony by psychiatrists that he suffered from sexsomnia The DSM-5 also includes a disorder that occurs during REM sleep. In the case of REM sleep behaviour disorder, the individual talks or moves while sleeping, sometimes acting out a dream. In contrast to NREM disorders, when awakened, the person is not confused or anxious. There is an increasing awareness that sleep is important for both our mental and our physical well-being. Sleep problems are also comorbid with many other disorders and therefore can compound the difficulties of people with significant psychologi- cal difficulties. Researchers are coming closer to understanding the basic nature of sleep and its disorders, and we anticipate significant treatment advances in the years to come.

Answer 12

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security or physical integrity and that generally occur during the second half of the major sleep episode. B. On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert. C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication). E. Co-existing mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams. Specify current severity: Severity can be rated by the frequency with which the nightmares occur: Mild: Less than one episode per week on average. Moderate: One or more episodes per week but less than nightly. Severe: Episodes nightly.

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