BH E1- Sleep & Trauma

What is the sleep requirement for the average adult?

7.5-8 hrs

What stage of sleep?

• Long periods of dreamless sleep

• Slow & rolling eye movements

• Stages divided according to depth of unconsciousness

NREM sleep

What stage of sleep?

• Vivid dreaming

• Majority of parasomnias occur here

• 2 phases: phasic Burts of rapid eye movements & tonic limited motor activity

REM sleep

What is a recording of the electrical activity of the brain that is used to assess conditions such as seizures and sleep disorders?

EEG

What type of wave?

• < 4 Hz frequency, high amplitude

• adult slow wave sleep; deeper stages of sleep

• pathologically: subcortical lesions, diffuse lesions, metabolic encephalopathy hydrocephalus

Delta

What type of wave?

• < 4 Hz frequency

• associated w/ emotions & drowsiness in adults

• pathologically: focal subcortical lesion, metabolic encephalopathy

Theta

What type of wave?

• 8-13 Hz

• associated w/ posterior region of head, both sides of head, higher amplitude on dominant side, relaxed/reflecting, closing eyes

• pathologically: coma

Alpha

What type of wave?

• 14-30 Hz

• associated w/ perception, concentration, mental activity, focused high alertness

• pathologically; benzodiazepines increase activity

Beta

What wave?

• 31-42 Hz

• associated w/

  • somatosensory cortex,

  • displayed during perception combined with/ 2 different senses such as sound and sight

  • short term memory, recognizing objects, sound or tactile sensations

• pathologically: cognitive decline (esp when associated with theta wave)

Gamma

How does a seizure appear on EEG?

generalized, hemispheric or focal spike; spike wave discharge or both

How does as structural lesion appear on EEG?

Focal slowing w/ possible focal spike activity

How do infectious disorders appear on EEG?

Diffuse, often synchronous, high voltage slowing

How do closed head injuries (subdural hematoma) appear on EEG?

Focal slowing or focal delta slowing

How do metabolic/endocrine disorders appear on EEG?

Diffuse generalized slowing of wake frequency

How does vascular pathology appear on EEG?

Slowed alpha wave frequencies and inc generalized theta slowing

What EEG waves are associated with ADHD?

Increased theta wave abnormality frontally

What stage of sleep?

• rapid steady alpha wave activity

• body temp is stable

Awake

What stage of sleep?

• lightest sleep, lasts 5-10 min

• falling asleep / drowsy, easily awakened

N1

What stage of sleep?

• light sleep, lasts 10-25 min

• HR slows, body temp drops, no eye movement

• dec wave frequency & muscle tone

N2

What stage of sleep?

• Deeper sleep / slow wave sleep, lasts 10-15 min

• slow, regular breathing , BP dec, no eye movement

• difficult to wake up, body begins preparing process

N3

What stage of sleep?

• Dream sleep; begins 70-90 min after falling sleep

• shallow breathing, HR/BP inc, rapid eye movement

• atonia, sleepwalking, night terrors

• memories are created

REM

What are disorders of initiating, maintaining sleep, or excessive sleepiness?

Dyssomnias

What are disorders characterized by abnormal behaviors during sleep or the transition between sleep and wakefulness (ex nightmare, sleep terror, & sleepwalking disorder)?

Parasomnias

How long does chronic insomnia last?

≥3 mos to years

How long does acute insomnia last?

≤ 3 mos

What is the most prevalent of all sleep wake disorders?

Insomnia

The following DSM-5 criteria is for what condition?

• complains of ≥1

  • difficulty initiating sleep

  • difficulty staying alseep

  • early morning awakenings & inability to return to sleep

• occurs atleast 3 days a week for atleast 3 mos

• occurs despite adequate opportunity to sleep

• causes clinically significant impairment in functioning & not due to a substance, medication, or medical condition

Insomnia disorder

What symptoms are associated with insomnia disorder?

Nonrestorative sleep, difficulty initiating/staying asleep, daytime sleepiness, memory loss, high BP, mood disturbance, etc

What is the first step in insomnia disorder treatment?

Treat underlying cause → proper sleep hygiene, therapy or CAM

What are the RX treatment options for insomnia disorder?

Valerian, Melatonin, Ramelteon 8mg, Zolpidem 5-10 mg, Zaleplon 5-20 mg, Trazodone 25-100mg, antihistmines (Benadryl, Unisom)

What condition is a repetitive or partial collapse of the upper airway during sleep mostly occurring during REM, N1, N2?

OSA

Who is OSA MC in?

Middle aged M

What is the absence of breathing?

Apnea

What is shallow or infrequent breathing?

Hypopneas

Is it worse for OSA to occur during REM or NREM sleep?

REM

The following DSM-5 criteria is for what condition?

• evidence of polysomnography showing:

  • ≥5 obstructive respiratory events per hour of sleep w/ either of the following

    • nocturnal breathing disturbances (snoring, gasping, pauses)

    • daytime sleepiness, fatigue, unrefreshing sleep despite sufficient opportunity & not better explained by another condition

  • OR

  • ≥15 obstructive respiratory events per hour of sleep, regardless of symptoms

OSA

What is the diagnostic workup for OSA?

Clinical presentation & polysomnography

The following ssx are associated with what condition?

• snoring, choking/gasping for air at night, frequent awakenings

• excessive sleepiness even with more sleep

• morning dry mouth, HA, irritability, sexual dysfunction,

• GERD

OSA

The following PE findings can be seen in what disorder?

• BMI > 35; age > 40 y/o

• short neck & large circumference (>17” in M, >15'“ in F)

• HTN

• enlarged tonsils/tongue/uvula, nasal polyps, deviated septum

OSA

What lifestyle modifications can be done for OSA?

Wt loss, avoid alcohol & sedative meds, elevate sleeping position 30° or side sleep

What is the treatment for OSA?

CPAP (preferred), oral appliance/splint, surgical intervention

The following DSM-5 criteria is for what condition?

• Irresistible sleep episodes, lapses into sleep, or napping atleast 3 days per week ≥3 mos

• associated w/ ≥1 of the following

  • Cataplexy

  • Hypocretin deficiency (< 110 pg/mL in CSF)

  • Polysomnography shows REM sleep latency of ≤ 15 minutes

Narcolepsy

What can cause narcolepsy?

Hypocretin / orexin deficit (neuropeptide that promotes wakefulness), genetics, HTN, DM, CVD, brain tumor or stroke

What condition is characterized by excessive daytime sleepiness & falling asleep at inappropriate times, MC in teens & early 20s?

Narcolepsy

What is the sudden loss of muscle tone MC affecting the face (if severe → can cause B/L weakness, paralysis & collapse) and is usually triggered by emotions such as laughter or grief, and resolves in 2 minutes?

Cataplexy

What are vivid auditory or visual hallucinations that occur as a person is falling asleep?

Hypnogogic hallucinations

What is the treatment for narcolepsy?

1st line: Modafinil or Armodafinil 200-400 mg

Alt: Methylphenidate 5 mg-50 mg, Dexedrine 5mg QD or BID

Lifestyle mods, no cure

What can be used to treat cataplexy associated with narcolepsy?

SSRIs- Venlafaxine (preferred) or Fluoxetine

TCAs- low dose PRN (anticholinergic SEs)

Describe the circadian rhythm

24 hours long; SCN in hypothalamus is exposed to light → pineal gland shuts off secretion of melatonin → melatonin secretion turns on at night

The following DSM-5 criteria is for what condition?

• insomnia and/or excessive sleepiness, w/ reduction of total sleep time, associated to recurring work schedule that overlaps with/ usual time for sleep

• sx have been present & associated w/ shift work schedule ≥3 mos

• sleep log for atleast 14 days shows disturbed sleep & wake pattern

• clinically significant distress or impairment & not caused by another condition or substance

Shift work sleep disorder

Why does shift work sleep disorder happen?

Sleep deprivation & misalignment of circadian cycle due to nontraditional work hours; affects people working night shift, rotating shifts, & shifts > 16 hrs

How can shift work sleep disorder manifest?

Risk MI, stroke, obesity (inc food & dec physical activity), DM, breast cancer, depression, anxiety, inc risk of accidents

What is the non pharmacological treatment for shift work disorders?

Sleep scheduling, improve daytime sleep hygiene, bright light therapy, small doses of caffeine at beginning of shift

What are the pharmacological treatment options for shift work sleep disorders?

Short acting NON-BZD- Zolpidem, Zaleplon

Short acting BZD- Temazepam

Stimulants- Modafinil, Armodafinil

Low dose melatonin 0.3-1mg 3 hours prior to sleep

What are the 2 types of parasomnias?

NREM (Sleepwalking disorder, Sleep terror disorder) & REM (Nightmare disorder)

What condition is characterized by repeated episodes of rising from bed during sleep & walking about, starting around ages 8-12?

Sleepwalking disorder

The following RF are associated with what condition?

• Sleep deprivation / irregular sleep schedules

• Stress, fatigue, fever from infx

• OSA, nocturnal seizures

• Meds- sedatives, hypnotics, lithium, anticholinergics

Sleepwalking & sleep terror disorder

The following sx are associated with what sleep disorder?

• Walking w/ eyes open, blank stare, & glassy look

• Sits up & makes repetitive movements while in bed

• No response when spoken too, difficult to arouse

• Dreams aren’t remembered & pt can’t recall episode

• Has to be led back to bed

Sleepwalking disorder

What condition is characterized by recurrent episodes of abrupt terror arousals from sleep, usually onsets between ages 4-12?

Sleep terror disorder

The following symptoms are seen with what sleep condition?

• Autonomic arousal → tachycardia, tachypnea, diaphoresis, mydriasis

• Screaming, crying

• Difficulty waking, may go back to sleep after episode w/o waking up

• No memory of dream

Sleep terror disorder

What is the treatment for sleepwalking disorder?

Promote sleep hygiene, relaxation techniques, safety precautions

What is the treatment for sleep terror disorder?

Promote adequate amount of sleep & reassurance (self limiting)

What condition is characterized by recurrent frightening dreams that occur during the 2nd half of the sleep episode (REM), MC in children & onsets around ages 5-6?

Nightmare disorder

The following ssx are seen with what sleep condition?

• recurrent frighting & vivid dreams

• able to remember dream, no confusion or disorientation upon awakening but may feel anxiety/panic

• palpitations, inc BP & HR, sweating

• daytime sleepiness, fatigue, mood changes

• concentration impairment & behavioral problems (sleep resistance. fear of the dark)

Nightmare disorder

What is the treatment for nightmare disorder?

Reassurance, sleep hygiene, imagery rehearsal therapy

PTSD tx: Prazosin 1mg HS, Hydroxyzine

Other comorbids: Benzos, Risperidone

The following DSM-5 criteria is for what condition?

• feel an urge to move legs during rest or inactivity

• have some or total relief of sensation when moving the legs

• feel urges more (or only) in evening or at night

• have sx ≥ 3x a week for ≥3 mos

Restless leg syndrome (RLS)

Who is restless leg syndrome (RLS) MC in?

F > M, adults

What can cause RLS?

CNS alterations, dec CNS iron stores (dec ferritin), dec DA levels

What is the MC form of RLS?

Primary

What medication can cause RLS?

SSRIs, TCAs, antipsychotics, antihistamines, PD meds- levodopa, DA agonists

The following RF are for what condition?

• Iron deficiency- low ferritin < 50 mcg/L

• kidney failure- uremia, dialysis pts

• peripheral neuropathy, spinal cord dz, MS, PD

• pregnancy (low Fe)

• stress, sleep deprivation, increased caffeine intake

• varicose veins

RLS

The following sx are seen in what condition?

• hallmark complaint: unpleasant / uncomfortable urge ot move legs

• crawling, creeping, tingling, itching, restlessness of legs

• sx felt deep w/in legs between knee and ankle

• usually no pain

• most prominent in evening → disturbed sleep → fatigue & sleepiness during day

• sx relieved by movement or walking

RLS

What is the non-pharm treatment for RLS?

Reduce caffeine, proper sleep hygiene, moderate regular exercise (walking, biking), stop offending meds, CAM (soak limbs, leg massage, pneumatic compression), treat underlying condition

How should iron deficiency that is causing RLS be treated?

Ferrous sulfate 325 mg PO (qd or qod) + vit C 100-200 mg

Check level every 3 mos (goal >75 mcg/l, saturation > 20%)

What are the pharmacologic tx options for RLS?

DA agonist (*esp if DM or obese): Requip, Mirapex

Anticonvulsants: Gabapentin, Pregabalin

Who is PTSD MC in?

W > M

What are the core symptoms of PTSD?

Intrusion (reoccurring memories, dreams, flashbacks)

Avoidance (thoughts, people, reminders of event)

Hyperarousal (exaggerated startle response, sleep disturbance)

Negative feeling (inability to remember event, alienation, dec interest, etc)

The following DSM5 criteria is for what condition?

• A. exposure to actual or threatened death, serious injury, or sexual violation

• B. ≥ 1 intrusion sx

• C. ≥ 1 avoidance sx

• D. ≥2 negative cognition/mood sx

• E. ≥ 2 arousal/reactivity sx

• F. duration of disturbance is more than 1 month

PTSD

For the diagnosis of PTSD, the trauma can have occurred at any time in the past & must be ______

Directly experienced, witnessed, occurred in close friend/relative, or an event that causes repeated exposure to its consequences (ex- cops)

What are the intrusion sx present in PTSD?

Intrusive memories, nightmares, flashbacks, intense distress to reminders, racing heart

What are the avoidance symptoms of PTSD?

Avoids triggers → memories, feelings, people, places, objects

What are the negative mood sx of PTSD?

Dissociative amnesia, negative feelings of self/others/world, self blame, anhedonia, feelings of detachment/estrangement, feelings of fear, anger or guilt

What are the increased arousal / reactivity sx present in PTSD?

Hypervigilance, exaggerated startle response, irritability or angry outburst, impaired concentration, reckless or self-destructive behavior, sleep disturbances

What is the pathophysiology of trauma & stress related disorders?

Biological factors, small hippocampus, amygdala or prefrontal cortex, dysfunction of HPA axis (dec cortisol and inc catecholamines)

The following physical ssx can be seen in what disorder?

• chronic fatigue

• suicidal behavior

• GERD, IBS

• heart, liver, or pulmonary dz

• HAs, TBI

PTSD

What behavioral conditions are often comorbid with PTSD?

MDD, anxiety, borderline personality disorder (BPD), substance use disorder

What symptoms can present in a child or adolescent with PTSD?

Regression (bedwetting), new onset nightmares, irritable/aggressive behavior, unusually clingy to parent or adult, avoidance of new activities or opportunities, reckless behavior

What screening tool for PTSD?

• 5 item screen

• no traumatic experience = 0 (low prob of PTSD)

• + traumatic experience = 3-5 (high prob PTSD)

Primary care PTSD screen (PC-PTSD-5)

What is a self report checklist used to screen patients for PTSD & monitor severity of sx?

PTSD checklist (PCL-5)

What is the gold standard for PTSD screening & monitoring of the severity of symptoms?

Clinician administered PTSD scale (CAPS)

What should be avoided in the treatment of PTSD?

Benzos → may inc sx & highly addictive

What is the first line treatment for PTSD?

SSRIs- Sertraline and Paroxetine

SNRIs- Venlafaxine

What is the 2nd line treatment/augmentation for PTSD?

Prazosin → dec nightmares & sleep disturbance

SGAs → severe cases/comorbidities

What are psychotherapy options for PTSD?

Trauma focused CBT: exposure therapy, stress inoculation training, EMDR

CAM: hypnosis, acupuncture, mediation

Substance abuse treatment for alcoholism

What factors predict a good prognosis for PTSD?

Rapid onset of sx, short duration of sx (< 6 mos), good premorbid functioning, strong social supports, no comorbidities, age of onset (middle age)

What is the duration of acute stress disorder?

3 days - 1 month after trauma

The following DSM5 criteria is for what condition?

• A. exposure to actual or threatened death, serious injury, or sexual violation

• B. presence of ≥9 sx in the intrusion, negative mood, dissociation, or arousal categories

• C. duration of disturbance is 3 days - 1 month after trauma exposure

Acute stress disorder

What are the dissociative sx associated with acute stress disorder?

Dissociative amnesia, anhedonia, altered sense of self/surroundings

What is the treatment for acute stress disorder?

First line: Trauma focused CBT → 6 weekly 60-90 min sessions starting 2 weeks after trauma

Adunct: Clonazepam for 2-4 weeks fora anxiety, agitation, or sleep disturbances

PTSD or acute stress disorder?

• trauma occurred any time in past

• sx dont begin immediately after (~3 mos after trauma)

• sx last > 1 mo

PTSD