Week 5 Lecture 5 - Disorders of Sleep (DN) Flashcards Preview

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What is normal sleep?

  • Period quiescence
  • Dynamic
    • constantly changing
  • Transient
    • come in & out of sleep
  • Active
    • brain & body are active (not an on/off switch)
  • Cyclical
    • most people monophasic (one sleep session per day)
    • some: biphasic
    • babies: polyphasic



How is sleep regulated?

Two systems

  • govern timing, quality, & duration of sleep

Homeostatic System

  • linear sleep pressure builds (into day) & decreases (into night)

Circadian System

  • operates simultaneously
  • counteracts Homeostatic System
  • regulates alertness
    • 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


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


Younger individuals:

  • 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


Older individuals:

  • less REM earlier in night
  • not as much SWS (deep sleep)
  • many more awakenings, more fragmented
  • also nap during day
  • circadian advances
    • (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?

1. Insomnias

2. Sleep-disordered breathing disorders

3. Hypersomnia not due to sleep- disordered breathing.

4. Circadian-rhythm disorders

5. Parasomnias

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...

  • Insomnia Disorder
  • Hypersomnolence Disorders
  • Narcolepsy
  • Obstructive Sleep Apnea/Central Sleep Apnea
  • Sleep-Related Hypoventilation
  • Circadian Rhythm Sleep- Wake Disorders
  • Arousal Disorders
  • Nightmare Disorder
  • 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

  • Insomnia
  • Narcolepsy
  • Circadian rhythm disorders


also covered 

  • Parasomnias


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


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

  • Problem with:
    • Sleep Initiation
    • Maintenance
    • Early Morning Awakenings

Causes distress & impairment

3 times week, 3 months




What are the top 7 Psychological Symptoms among British Adults?

  • Sleep Problems
  • Fatigue
  • Irritability
  • Worry
  • Depression
  • Poor concentration
  • Anxiety

women higher on all


What are the two Insomnia sub-types?

  • Primary Insomnia:
    • insomnia not associated with a known physical or psychological disorder
  • Secondary Insomnia:
    • 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


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
  • learned response
    • associating not being able to sleep with bed


Sleep State Misperception (paradoxical insomnia)

  • no objective evidence (PSG) of insomnia
  • individual oversestimates impact of sleep


Idiopathic Insomnia

  • 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?



  • Poor appetite
  • Guilt feelings
  • Suicidal thoughts
  • Decreased libido
  • Slowed thinking


What are the different treatment approaches used for Insomnia?

  • Restrict time in Bed
  • Stimulus Control
    • darken room, remove TV's, iPads etc
  • Relaxation Techniques
    • progressive muscle relaxation
  • Cognitive Therapy
    • challenging thoughts & beliefs about sleep
  • Pharmacological
    • Benzodiaz.
    • 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


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


  • Predisposing factors
    • not direct cause but increase risk
    • e.g., psychological - anxious personality type, biological - being female 


  • Precipitating factors
    • events that trigger insomnia
    • e.g., death of a loved one, exams some people just bounce back, but if there are


  • Perpetuating factors
    • 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?

  • Pharmacological
  • Sleep hygiene





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)




What stage of sleep is associated with Narcolepsy?

  • REM sleep
    • 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.




What is the Orexin (Hypocretin) Pathway?

  • our primary arousal pathway
    • 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)
  • Distress/Impairment