What is normal sleep?
come in & out of sleep
brain & body are active (not an on/off switch)
most people monophasic (one sleep session per day)
- constantly changing
- come in & out of sleep
- brain & body are active (not an on/off switch)
- most people monophasic (one sleep session per day)
- some: biphasic
- babies: polyphasic
How is sleep regulated?
- govern timing, quality, & duration of sleep
- linear sleep pressure builds (into day) & decreases (into night)
- operates simultaneously
- counteracts Homeostatic System
- Builds in morning
- dips mid afternoon
- builds again 3-9pm (wake maintentance)
- counteracting increasing homeostatic sleep pressure)
Both systems come together in night to promote sleep
What is a Hypnogram?
graph/chart of polysomnographic data (from sleep lab)
brain, eye & muscle activity
shows sleep stages (REM, 1, 2, 3, 4)
also illustrates an individuals cycle length
typically 90 mins
- brain, eye & muscle activity
- typically 90 mins
What should be considered with regard to classifying 'normal' sleep?
What do the hypnograms clearly show with regard to this consideration?
sleep should always be considered relative to what is 'normal' for an age group
always wax & waning from sleep to wake, cycles vary with age
fall quickly into SWS (stage 3 & 4), come out, short REM, go back into SWS
- (one cycle 90mins)
- early in night more REM, less SWS
- later in night less SWS, more REM
- less REM earlier in night
- not as much SWS (deep sleep)
- many more awakenings, more fragmented
- also nap during day
- (shifts forward - i.e., go to sleep earlier)
What are the three classification systems which outline the Diagnostic Criteria for Sleep Disorders?
Sleep Disorders May be Categorized using Three Diagnostic Classification Systems:
1. The International Classification of Diseases (ICD-10);
- GP's generally use
2. The International Classification of Sleep Disorders (ICSD).
- Sleep scientists use
3. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
- Mental health professionals use
How does the International Classification of Sleep Disorders (ICSD) classify the disorders?
2. Sleep-disordered breathing disorders
3. Hypersomnia not due to sleep- disordered breathing.
4. Circadian-rhythm disorders
6. Sleep-related movement disorders
7. Symptoms/normal variants 8. Other sleep disorders
What Sleep Disorders are coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)?
don't think we need to memorise this...
Obstructive Sleep Apnea/Central Sleep Apnea
Circadian Rhythm Sleep- Wake Disorders
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
Substance-Induced Sleep Disorder
Which of the Sleep Disorders were covered in the lecture?
note these are called 'Sleep/Wake Disorders' in DSM-5
Circadian rhythm disorders
What two kinds of factors contribute to Insomnia?
Intrinsic: from within
e.g., hyperarousal, changes in body clock
Extrinsic: external factors
e.g., environmental noise, learned response
- e.g., hyperarousal, changes in body clock
- e.g., environmental noise, learned response
What are the most prevalent psychological complaints among British Adults?
Is there a gender difference in sleep complaints?
Sleep & fatigue most prevalent
Women have more sleep complaints & fatigue than men
What is the DSM-5 criteria for Insomnia Disorder (Primary)?
no need to memorise.
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
What characterises an individual with Primary Insomnia Disorder?
Sleep disturbance is primary, predominant complaint
- Sleep Initiation
- Early Morning Awakenings
Causes distress & impairment
3 times week, 3 months
What are the top 7 Psychological Symptoms among British Adults?
women higher on all
What are the two Insomnia sub-types?
insomnia not associated with a known physical or psychological disorder
insomnia caused by a ‘co-morbid’ physical or psychological state
- insomnia not associated with a known physical or psychological disorder
- insomnia caused by a ‘co-morbid’ physical or psychological state
What do the prevalence rates of (Primary) Insomnia Disorder
demonstrate about sleep disturbance & diagnosis of Insomnia?
figures as reported by Ohayon, 2002
Shows a disparity between those reporting sleep disturbance & those being diagnosed with Primary Insomnia
So it may be underdiagnosed
Although 25-30% have transient insomnia (e.g., jet lag)
which could account for disparity
- Although 25-30% have transient insomnia (e.g., jet lag)
- which could account for disparity
Disparity shown in figures below
Insomnia Symptoms = 30%
Insomnia Symptoms with Daytime Sleepiness = 9-15%
Sleep Dissatisfaction = 8-18% Insomnia Diagnosis = 6%
Discuss some issues which may be relevant to Primary Insomnia?
Are there gender differences?
Is timing a factor?
Is age a factor
Gender effects (27:00)
- yes more prevalent in women
The timing of sleep (28:30)
- we operate on a 24 hour day (society),
- our internal body clocks are all different
Is age a factor? (29:00)
- Yes, sleep becomes more fragmented with age.
- Circadian timing phase advances (sleep earlier), more awakenings, not as much SWS)
- Also, the gender difference ratio increases with age
What are the 6 types of Primary Insomnia according to the ICSD-10?
- most common
- heightened level on instrinsic arousal
- associating not being able to sleep with bed
Sleep State Misperception (paradoxical insomnia)
- no objective evidence (PSG) of insomnia
- individual oversestimates impact of sleep
- appears in childhood, cause unknown, long lasting I
Inadequate Sleep Hygiene
- bad sleep habits - do wrong things to promote sleep
- e.g., late in day - caffeine, TV, iPad (bright stimulated light)
Adjustment Sleep Disorder
unable to adjust to stressors, psychological, physical pain, environmental
Behavioural Insomnia of Childhood
- refusal to sleep
over-reliance on sleep onset aids
- i.e., learned response to sleep onset
What symptoms often coexist with insomnia?
What are the different treatment approaches used for Insomnia?
Restrict time in Bed
darken room, remove TV's, iPads etc
progressive muscle relaxation
challenging thoughts & beliefs about sleep
Sleep Promoting - Melatonin before bed
- darken room, remove TV's, iPads etc
- progressive muscle relaxation
- challenging thoughts & beliefs about sleep
- Sleep Promoting - Melatonin before bed
What did a cross cultural epidemiological study reveal about Secondary Insomnia?
What did the findings suggest about Sleep vulnerability?
Weissman et al., (1996)
Sleep was consistently comorbid with depression across all cultures
Sleep is vulnerable to other psychological disorders
Narcolepsy - DSM-5 Criteria
no need to memorise..
A. Recurrent periods of an irrepressible need to sleep or lapsing into sleep.
A. At least 3 times/week for 3 months.
B.The presence of one of the following:
A. Epidsodes of cataplexy
B. Hypocretin deficiency
C. REM sleep latency < 15minutes, OR MSLT <8minutes + two SOREMPs slide20
- A. At least 3 times/week for 3 months.
- A. Epidsodes of cataplexy
- B. Hypocretin deficiency
- C. REM sleep latency < 15minutes, OR MSLT <8minutes + two SOREMPs slide20
What did a study comparing Insomnia with congestive heart failure
suggest about the consequences of Insomnia?
Katz et al., 2002
Global changes in cognitive and mental health related with insomnia
- Insomnia = increased pain, emotional effects, and mental health effects versus congestive heart failure
Occupational accident risk
- more likely to have accident
- Decreased work productivity
Sleep disturbance showed a clear link with Mood disorders
- 56.2% of those who relapse into mood disorder have insomnia
Changes in brain function e.g., arousal centres are active at night
- PET scan – enhanced CMR during wake/sleep in insomniacs
- PET scan – smaller differences in sleep-wake activity in arousal centres
What is the focus of Spielman et al.'s (1987) model of Insomnia?
It addresses the different risk factors for Insomnia
- not direct cause but increase risk
- e.g., psychological - anxious personality type, biological - being female
- events that trigger insomnia
- e.g., death of a loved one, exams some people just bounce back, but if there are
- factors that maintain or exascerbate Insomnia
- e.g., extending time in bed (poor sleep hygiene), exposing to light at wrong time of day
What are some aspects of Sleep hygiene addressed in the treatment of Narcolepsy?
Prophylactic (scheduled) short nap opportunities throughout day
Regular sleep hours avoid late nights
Avoidance of sleep deprivation
Avoid caffeine, exercise if safe, control emotions
What two types of treatment are used for Narcolepsy?
What characterises Narcolepsy?
Recurrent, irrepressible need to or lapsing into sleep
may lapse 2-6 times a day
can last 30minutes
partial or full loss of muscle tone during lapse
Patients also report:
a lot of dreaming during lapses
intense visual imagery
as falling asleep (Hypnagogic)
as awaking (Hypnapompic)
- may lapse 2-6 times a day
- can last 30minutes
- partial or full loss of muscle tone during lapse
- a lot of dreaming during lapses
intense visual imagery
- as falling asleep (Hypnagogic)
- as awaking (Hypnapompic)
What stage of sleep is associated with Narcolepsy?
When lapsing - goes straight into REM
REM = muscle atonia
switching off all motor activity so we don't act out our dreams
this is why it can be unsafe for Narcoleptic patients
e.g., lapsing while driving, or crossing the road
recall that REM is a dream-like state
which explains why they report a lot of dreaming during lapses.
- When lapsing - goes straight into REM
- switching off all motor activity so we don't act out our dreams
this is why it can be unsafe for Narcoleptic patients
- e.g., lapsing while driving, or crossing the road
- which explains why they report a lot of dreaming during lapses.
What is the Orexin (Hypocretin) Pathway?
our primary arousal pathway
so a deficiency leads to the lapses seen in Narcolepsy
- governs arousal
- so a deficiency leads to the lapses seen in Narcolepsy
Circadian Rhythm Disorder - DSM-5 Criteria
no need to memorise....
A. Persistent or recurrent pattern of sleep disruption primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required.
B. Sleep disruption leads to excessive sleepiness or insomnia or both.
C. Sleep disruption causes clinically significant distress or impairment in social, occupational, and other important areas of functioning. slide23
What features charcterise Circadian Rhythm Disorder?
Persistent sleep disruption
altered circadian system
internal clock misaligned to society
e.g., awake at night, asleep during day
Excessive sleepiness &/or Insomnia (secondary)
- e.g., awake at night, asleep during day
What are the different types of Circadian Rhythm Sleep Disorder (according to DSM-5)?
Shift work sleep disorder
- when individual cant entrain > chronic sleep curtailment
Irregular sleep-wake pattern
- lack of clear rhythm - constantly shifting sleep timing
Delayed sleep phase syndrome
- typically at least 2 hours out of phase
Advanced sleep phase syndrome
- middle & older age
Non-24-h sleep-wake disorder
- can't entrain to day/night
- common in blind people (50%) with no light perception
What is free running?
How can it be achieved?
Body is not designed to operate on 24 hour cycle
we all have slightly shorter or longer internal cycle.
- is an expression of our individual timing (rhythm)
- in the absence of entrainment (i.e., all external cues)
Come into lab, remove all cues, clocks, time, they will gradually move to their own internal rhythm (free running)
What is Advanced sleep phase syndrome?
How is it treated?
Circadian rhythm shifts/comes forward from what is socially required
- (i.e., go to sleep earlier) common in elderly
- Exposure to light later in the evening will push it back (i.e., helping the old gal stay awake for longer)
What is Delayed sleep phase syndrome?
Circadian rhythm shifts back
- (i.e, go to sleep later than socially required)
- common in teenagers
Exposure to light in the morning hours
Taking Melatonin before bed
will help bring the phase forward
- (i.e., get the cheeky buggas to go to sleep earlier!)
Are phase advances or delays a problem?
Not by themselves
They are a problem when society requires us to operate on a set 24-hr cycle.
- e.g., have to get up for work, school > curtail sleep
chronic sleep curtailment has implications with work, driver safety & a whole lot of other issues
- then it becomes disordered
How is an individual treated for Circadian Rhythm Sleep Disorder?
quite straight forward process
look at melatonin timing with sleep onset
- look at melatonin timing with sleep onset
- (scheduled resetting of biological clock)
Bright light exposure
Melatonin administration 103:10
What are the Parasomnias?
Disorders of REM & NREM sleep phases
Undesirable physical events which occur
- as falling asleep, waking up or transitioning through sleep stages
- Not influenced by judgement (no awareness of behaviours)
What is the prevalence of the Parasomnia in the general population?
Is there a gender difference?
- higher in males
- although this may be due to males having more externalising behaviours,
- so it may just be more easily detected in men
What are some of the consequences of the parasomnias?
Disruptive to patient, bed partner, & family
day time sleepiness
Legal implications: if behaviours are criminal (e.g., abuse or rape)
What are the NREM Parasomnias?
When do they occur?
They occur during Stage 3 & 4 (Slow Wave Sleep)
in the first third of the night
Which are the REM Parasomnias?
When do they occur?
REM Sleep Behaviour Disorder
They occur during the REM sleep phase
What are the NREM Parasomnias also referred to as? Which two disorders are covered in the lecture?
Sleep Arousal Disorders Sleep Walking Sleep Terror
What characterises the NREM Sleep Arousal Disorders (Parasomnias)?
recurrent, incomplete awakening during first third of night
occurs during Slow Wave Sleep (NREM)
no dreaming or recall
not caused by a substance
not explainable by any other condition
Briefly describe the features of Sleep Terrors?
Sleep Terror is a NREM - Sleep Arousal Disorder (Parasomnia)
- occur in Stage 3 & 4 (SWS)
- typically children
- no recall of event
- distinct from a nightmare (where there is recall)
PSG - shows inc heart rate & blood pressure
- (genuine FEAR response)
- often co-exists with sleep walking
Prevalence (Age of onset)
- children 1-6% (4-12 years)
- adults <1% (20-30 years) 1:11:40
What are some recommended treatment options for Night Terrors?
What is the myth about waking a child from a night terror?
- Scheduled awakenings
- excessive sleepiness
- play before bed
- too much heat
Avoid waking them: they awake to see you panicked, that panics them, they have no recall of it anyway
Myth: waking someone from a sleep terror causes damage to them 1:14:10
Briefly describe Sleep Walking?
Sleep Walking is a NREM - Sleep Arousal Disorder (Parasomnia)
- occur in Stage 3 & 4 (SWS)
- Complex motor movement
- reduced alertness, responsiveness limited recall
- Can be precipitated by anxiety
children 10-30% (peaks 8-12yrs)
more in boys
What has been suggested for such high prevalence of Sleep Walking in children?
What pharmacological treatments are used in Narcolepsy?
- good as dont interfere with sleep
- used to consolidate sleep period
- promotes SWS state
- related to GHB which works on GABA receptors
- very expensive ($3K per month)
- highly regulated as has been used as date rape drug
What are circadian rhythms?
Self sustained, internally generated biological rhythm
Internal body clock = suprachiasmatic nucleus (of the hypothalamus)
Normally synchronised to external 24-hr day/night cycle
Also synchronises internal systems within body with each other
so all systems have a fixed phase relationship
- (external synchronisation/entrainment)
- so all systems have a fixed phase relationship
- (internal synchronisation)
Briefly describe Nightmare Disorder?
Disorder of REM
- repeated dysphoric, remembered dreams
- 2nd half of night
- causes distress/impairment
unclear, but may be due to increased NS activity
may be stress, anxiety
CBT - take control of end of dream
Prognosis is good: often resolves by 10yrs of age
How do Night Terrors differ from Nightmare Disorder?
- no recall
- occur: 1st third of night
- occur: 2nd half of night
What is an associated risk of disorders of REM?
Elevated risk of developing other mental disorders
Briefly describe 'Rapid Eye Movement Sleep Behaviour Disorder'?
Parasomnia Disorder of REM
- Appears awake & alert, not confused or disoriented
- but is actually in REM (PSG)
- vocalisation & complex motor behaviours
- sometimes associated with dream-like thoughts/images
- Muscle abnormally preserved
Usually: middle aged, elderly
highly associated with onset or risk of (within 5 yrs) Neurological disorders (e.g., Parkinsons)
How would Rapid Eye Movement Sleep Behaviour Disorder be diagnosed?
In the lab look for:
- abnormal behaviour during REM
- abnormally preserved muscle tone during REM
- if there is muscle atonia then its something else
- rule out Epilepsy
Briefly describe Sleep Paralysis?
Parasomnia disorder of REM
- preservation of REM activity during a wake state
- sense of being awake, but can't move
- common when laying on back
Sleep onset: hypnogogic and
- (wake > sleep)
Sleep offset: hypnopompic
- (sleep > wake)
- not codable in DSM-5 (so would be 'not otherwise specified')
- codable in ICSD 127:10
What are the warning signs for sleep disorder?
Excessive daytime sleepiness
Problems initiating/maintaining sleep
What other Sleep Disorders were mentioned briefly in the lecture?
- thought to be soothing
- teeth grinding
- bed wetting
Periodic Leg Movements/Restless Legs Syndrome
- crawling feeling
- NREM behaviour disorder
- although presents with REM like behaviour
- may have history of sleep walking (also NREM)
What has changed in the thinking behind sleep abnormalities in psychiatric illness?
Sleep abnormalities used to be considered secondary
Now thought to share pathways
e.g., mood shows daily rhythms, regulated by sleep & circadian processes
Arousal pathways shared
e.g., Orexinergic pathway - takes a hit in Parkinsons
- e.g., mood shows daily rhythms, regulated by sleep & circadian processes
- e.g., Orexinergic pathway - takes a hit in Parkinsons
Which psychiatric disorders have clear sleep pathology?
Major Depressive Disorder
- 90% patients report altered sleep
- Insomnia increases risk of depression relapse
- irregular sleep timing & reduced sleep can trigger mania
- sleep management now regular part of treatment
- act comparably to someone with total sleep deprivation
- sleep disturbance most common symptom
- reduction in all phases of sleep
cause & effect difficult to establish (didn't go into Neuropeptide S)
(didn't go into this as we covered it in week 4)
What approach is now commonly used in treating psychiatric disorders involving sleep disturbance?
Management of both psychiatric disorder & the sleep disturbance
Tricyclic antidepressant - used for depression, also good for sleep disorder (example of common pathways)
Melatonin agonists - to consolidate sleep cycles
- Modafinil/Provigil - stimulants that don't interfere with sleep
What has been suggested with regard to REM latency & depression?
short REM onset latency
- may be a phenotype for depressive illness
supports the notion of common pathways operating in sleep disorders & psychiatric disorders