integ: abpsych (sleep and wake disorders)

Sleep and Wake Disorders

• sleep-wake complaints of dissatisfaction regarding the quality, timing, and amount of sleep 

• Resulting daytime distress and impairment are core features

• accompanied by depression, anxiety, and cognitive changes

Rapid Eye Movement (REM) Sleep

• Also called dream sleep

• Involves the brain circuit in the limbic system

• intense brain activity, vivid dreaming, and temporary muscle paralysis

NREM Sleep Stage 1 (N1)

• transition from wakefulness to sleep and occupies about 5% of time spent asleep in healthy adults

• lightest stage of sleep

• Easy to wake someone

• Acts as a gateway to deeper sleep stages

NREM Sleep Stage 1 (N1)

• If you’re awakened during what, you might feel like you weren’t asleep at all

• It’s common to have fragmented thoughts or brief dream-like imagery

NREM Sleep Stage 2 (N2)

characterized by specific electroencephalographic waveforms (sleep spindles and K complexes), occupies about 50% of time spent sleep

deeper stage of light sleep and makes up the largest portion of your sleep cycle.

sleep spindles

brief bursts of rapid brain activity

K complexes

sudden high-amplitude brain waves

NREM Sleep Stage 2 (N2)

• You are fully asleep, but still easier to wake than in deep sleep (N3)

• The body is preparing for deep restorative sleep

• External awareness continues to decrease

NREM Sleep Stage 3 (N3)

• slow wave sleep; deepest level of sleep

• most restorative stage of sleep.

• Brain waves slow to delta waves (very low frequency, high amplitude)

• Heart rate, breathing, and blood pressure reach their lowest levels

• Muscles are relaxed, but not paralyzed (unlike REM)

• It’s very difficult to wake someone during this stage

NREM Sleep Stage 2 (N2)

• Heart rate slows down

• Body temperature drops

• Breathing becomes more regular

• Brain activity shows unique patterns:

  • Sleep spindles

  • K-complexes

NREM Sleep Stage 1 (N1)

• Slow eye movements begin

• Muscle activity decreases, but you may still twitch

• Brain waves slow down (from alpha to theta waves)

• You might experience hypnic jerks (sudden falling sensation)

• Awareness of surroundings starts to fade, but you can still be easily awakened

Sleep Continuity

• overall balance of sleep and wakefulness during night of sleep

• how smooth, uninterrupted, and stable your sleep is throughout the night.

• It’s a key measure of sleep quality, not just how long you sleep.

Sleep Latency

amount of time required to fall asleep

Wake After Asleep Onset

• amount of awake time between initial sleep onset and final awakening

• total amount of time you spend awake after you’ve already fallen asleep

• It tracks nighttime awakenings

• ex: If you fall asleep at 10:00 PM, wake up several times, and spend a total of 45 minutes awake during the night, your WASO = 45 minutes

Sleep Efficiency

ratio of actual time spent asleep to time spent in bed

percentage of time actually spent asleep

(Total Sleep Time ÷ Time in Bed) × 100

Dyssomnias

• involve difficulties in getting enough sleep, problems with sleeping when you want to, and complaints about the quality of sleep

• Abnormal sleep duration or timing

• Excessive daytime sleepiness

Parasomnias

• characterized by abnormal behavioral or physiological events that occur during sleep

• unusual behaviors, movements, emotions, or perceptions that occur during sleep or sleep–wake transitions

• Often occur when the brain is partly awake and partly asleep

• The person may have little or no memory of the event

Polysomnographic (PSG) Evaluation

determines the clearest and most comprehensive picture of sleep habits; usually shows impairments of sleep continuity

Electroencephalogram

measures brain wave activity

Electrooculogram

measures eye movements

Electromyogram

measures muscle movements

Electrocardiogram

measures heart activity

Actigraph

records the number of arm movements; alternative to PSG

SE of 100%

would mean you fall asleep as soon as your head hits the pillow

Insomnia Disorder

• difficulty initiating and maintaining sleep 

• Situational, persistent, or recurrent, episodic

• One of the most common sleep–wake disorders

Primary Insomnia

sleep problems that are not related to other medical or psychiatric problems

Sleep Onset Insomnia (or initial insomnia)

involves difficulty initiating sleep at bedtime

Sleep Maintenance Insomnia (or middle insomnia)

involves frequent or prolonged awakenings throughout the night

Late Insomnia

involves early-morning awakening with an inability to return to sleep

Nonrestorative Sleep

• poor sleep quality that does not leave the individual rested upon awakening despite adequate duration

• doesn’t leave you feeling refreshed or energized, even if you’ve slept for an adequate number of hours.

• You may sleep 7–9 hours, but still wake up feeling:

  • Tired

  • Unrefreshed

  • Mentally foggy

Microsleeps

sleep that last several seconds or longer; result of being awake for one or two nights

Insomnia Disorder

A. A predominant complaint of dissatisfaction witli sleep quantity or quality, associated with one (or more) of the following symptoms:

1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)

2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)

3. Early-morning awakening with inability to return to sleep.

B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.

C. The sleep difficulty occurs at least 3 nights per week.

D. The sleep difficulty is present for at least 3 months.

E. The sleep difficulty occurs despite adequate opportunity for sleep.

F. This is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

G. This is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Episodic

Symptoms last at least 1 month but less than 3 months.

persistent

Symptoms last 3 months or longer.

recurrent

Two (or more) episodes within the space of 1 year.

Acute and short-term insomnia

symptoms lasting less than 3 months but otherwise meeting all criteria with regard to frequency, intensity, distress, and/or impairment) should be coded as an other specified insomnia disorder.

insomnia

given whether it occurs as an independent condition or is comorbid with another mental disorder (e.g., major depressive disorder), medical condition (e.g., pain), or another sleep disorder (e.g., a breathing-related sleep disorder).

new-onset insomnia

In women, what may occur during menopause and persist even after other symptoms (e.g., hot flashes) have resolved.

insomnia disorder With non-sleep disorder mental comorbidity

insomnia specifier: (e.g., depression, anxiety, substance use disorders)

insomnia disorder With other medical comorbidity

insomnia disorder specifier (e.g., chronic pain, cardiovascular disease)

insomnia disorder With other sleep disorder

insomnia disorder specifier (e.g., sleep apnea, restless legs syndrome)

Delayed temperature rhythm

• Body temperature doesn’t drop

• They don’t become drowsy until later at night

• People with insomnia seem to have higher body temperatures than good sleepers

temperemental risks in insomnia disorder

• Anxiety or worry-prone personality or cognitive styles, 

• Increased arousal predisposition

• Tendency to repress emotions

psychological risks in insomnia disorder

• Psychological Stress

• Parent’s depression and negative thoughts about child sleep negatively influenced infant night waking

• Children learn to fall asleep only with a parent present

An Integrative Model

Personality characteristics, sleep difficulties, and parental reaction interact in a reciprocal manner to produce and maintain sleep problems

predisposing conditions

• People may be biologically vulnerable to disturbed sleep

• This vulnerability differs from person to person and can range from mild to more severe disturbances

Rebound Insomnia

sleep problems reappear, sometimes worse

Psychopharmacology in isomnia

• Benzodiazepine

• Triazolam (Halcion)

• Zaleplon (Sonata)

• Zolpidem (Ambien)

• Flurazepam (Dalmane)

Guided Imagery Relaxation

uses meditation or imagery to help with relaxation at bedtime or after a night waking

Graduated Extinction

• Used for children who have tantrums at bedtime or wake up crying at night

• delaying your response to a child’s crying at bedtime or during night awakenings for increasing intervals, rather than responding immediately.

• Teach the child to self-soothe and fall asleep without assistance.

Paradoxical Intention

• instructs poor sleepers to lie in bed and try to stay awake as long as they can

• doing the opposite of what you’re trying to achieve

• Instead of trying hard to fall asleep, you intentionally try to stay awake.

Progressive Relaxation

involves relaxing the muscles of the body in an effort to introduce drowsiness

Hypersomnolence Disorder

• excessive sleepiness despite having at least 7 hours of main sleep

• Take longer naps, have trouble waking from naps, and do not feel alert afterward

• Includes symptoms of excessive quantity of sleep, deteriorated quality of wakefulness, and sleep inertia

Sleep Inertia

• prolonged impairment of alertness at the sleep-wake transition

• feeling of grogginess, confusion, and reduced alertness right after waking up, especially if you wake from deep sleep.

Hypersomnolence Disorder

• They often snore loudly, pause between breaths, and wake in the morning with a dry mouth and headache

• Has a persistent course, with a progressive evolution in the severity of symptoms

Hypersomnolence Disorder

A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:

1. Recurrent periods of sleep or lapses into sleep within the same day.

2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).

3. Difficulty being fully awake after abrupt awakening.

B. This occurs at least three times per week, for at least 3 months.

C. This is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.

D. This is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).

E. This is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of t^ypersomnolence.

hypersomnolence disorder — acute

Duration of less than 1 month

hypersomnolence disorder — subacute

Duration of 1-3 months

hypersomnolence disorder — Persistent

Duration of more than 3 months.

Hypersomnolence — mild

Difficulty maintaining daytime alertness 1-2 days/week.

Hypersomnolence — Moderate

Difficulty maintaining daytime alertness 3-4 days/week.

Hypersomnolence — Severe

Difficulty maintaining daytime alertness 5-7 days/week.

20 hours

In most extreme cases of Hypersomnolence, sleep episodes can last up to

9 ½ hours.

the average nighttime sleep duration in Hypersomnolence is around

10-15 years

Individuals with hypersomnolence disorder are diagnosed, on average, how many years after the appearance of the first symptoms.

15 and 25 years

Hypersomnolence has a progressive onset, with symptoms beginning between ages what, with a gradual progression over weeks to months.

Genetic and Physiological Risks of hypersomnolence

• Presence of the gene HLA-Cw2 and HLA-DR11

• Previous exposure to a viral infection such as mononucleosis, hepatitis, and viral pneumonia

• May also be familial, with an autosomal dominant mode of inheritance

Environmental Risks of hypersomnolence

• Increased temporarily by psychological stress and alcohol use

• Guillain-Barré syndrome

Narcolepsy

• irrepressible need to sleep

• suddenly fall asleep during the day, even in the middle of activities like talking, eating, or working.

catalepsy

Some people with narcolepsy experience

cataplexy

• Sudden loss of muscle tone

• Occurs while the person is awake

• Can range from slight weakness in the facial muscles to complete physical collapse

• Appears to result from a sudden onset of REM sleep

Narcolepsy

A. Recurrent periods of an 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 that are 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 movement (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.

Narcolepsy without cataplexy but with hypocretin deficiency

Criterion B requirements of low CSF hypocretin-1 levels and positive polysomnography/multiple sleep latency test are met, but no cataplexy is present

Narcolepsy with cataplexy but without hypocretin deficiency

In this rare subtype (less than 5% of narcolepsy cases), Criterion B requirements of cataplexy and positive polysomnography/multiple sleep latency test are met, but CSF hypocretin-1 levels are normal

Autosomal dominant cerebellar ataxia, deafness, and narcolepsy

This subtype is caused by exon 21 DNA (cytosine-5)-methyltransferase-1 mutations and is characterized by late-onset (age 30-40 years) narcolepsy (with low or intermediate CSF hypocretin-1 levels), deafness, cerebellar ataxia, and eventually dementia.

Autosomal dominant narcolepsy, obesity, and type 2 diabetes

Narcolepsy, obesity, and type 2 diabetes and low CSF hypocretin-1 levels have been described in rare cases and are associated with a mutation in the myelin oligodendrocyte glycoprotein gene.

Narcolepsy secondary to another medical condition

This subtype is for narcolepsy that develops secondary to medical conditions that cause infectious (e.g., Whipple’s disease, sarcoidosis), traumatic, or tumoral destruction of hypocretin neurons.

narcolepsy — mild

Infrequent cataplexy (less than once per week), need for naps only once or twice per day, and less disturbed nocturnal sleep.

narcolepsy — Moderate

Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily.

narcolepsy — severe

Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed noctumal sleep (i.e., movements, insomnia, and vivid dreaming).

Long-standing cases

brief, sudden bilateral loss of muscle tone triggered by laughter or joking, with preserved consciousness

Early onset (e.g., children or within 6 months of onset)

spontaneous grimaces, jaw-opening with tongue thrusting, or generalized hypotonia, without clear emotional triggers

Hypocretin deficiency

• CSF hypocretin-1 levels ≤ 110 pg/mL or ≤ 1/3 of normal levels

• Not due to acute brain injury, infection, or inflammation

REM sleep latency

≤ 15 minutes on nocturnal polysomnography

Mean sleep latency

≤ 8 minutes with ≥ 2 sleep-onset REM periods on multiple sleep latency testing (MSLT)

Temperamental Risks in narcolepsy

• Parasomnias, such as sleepwalking, bruxism, REM sleep behavior disorder, and enuresis

• Individuals commonly report that they need more sleep than other family members

environmental risks in narcolepsy

• Group A streptococcal throat infection, influenza), or other winter infections

• Head trauma and abrupt changes in sleep-wake patterns

Breathing-Related Sleep Disorders

problems with breathing while asleep

Hypoventilation

•  constricted and labored breathing

• breathing is too slow or too shallow, leading to increased carbon dioxide (CO₂) levels in the blood.

• Too little air moves in and out of the lungs

Sleep Apnea

individual stop breathing altogether

breathing repeatedly stops and starts during sleep, disrupting normal sleep and reducing oxygen levels.

Airflow stops for 10 seconds or longer

Sleep Attacks

episodes of falling asleep during the day

Obstructive Sleep Apnea Hypopnea

Occurs when airflow stops despite continued activity by the respiratory system

Apnea

absence of airflow

Hypopnea

reduction in airflow

Obstructive Sleep Apnea Hypopnea

A. Either (1) or (2):

1. Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:

a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.

b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.

2. Evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms.

Obstructive Sleep Apnea Hypopnea — Mild

Apnea hypopnea index is less than 15.

Obstructive Sleep Apnea Hypopnea — Moderate

Apnea hypopnea Index is 15-30

Obstructive Sleep Apnea Hypopnea — Severe

Apnea hypopnea index is greater than 30.

polysomnography or other overnight monitoring.

Disease severity is measured by a count of the number of apneas plus hypopneas per hour of sleep (apnea hypopnea index) using

10 seconds

two

Each apnea or hypopnea represents a reduction in breathing of at least how many in duration in adults or how many missed breaths in children