Sleep disorders

What are the two important phases of sleep?

Slow-wave sleep

Rapid eye movement (REM)

Slow-wave sleep

The body-restorative sleep, which is what makes your body heal up and feel rested

Early in the night, you get lots of slow wave sleep. But, as you get closer and closer to the morning, you get more REM sleep

Dreaming does occur during slow-wave sleep, but is much more common during REM

REM Sleep

You memorize and consolidate stuff better during REM sleep

It’s also impossible to restrict REM sleep, because if you decrease it, then it will take over your slow-wave sleep

If you’re greatly sleep deprived, your eyes may begin to twitch and you slip into REM sleep

How does sleep effect other disorders?

Anxiety, mood, and psychotic disorders have sleep issues—it’s usually best to treat insomnia before stuff like depression, as the insomnia is more likely to cause the depression—sleep orders cause and/or precipitate these disorders

Gender prevalence for insomnia, hypersomnolence, and narcolepsy

Insomnia—about doubly common in women

Hypersomnolence disorder—seems to be equal between men and women, but extremely little research has been done on it

Narcolepsy—slightly more common in men

How long do you need to have sleep issues in order to have insomnia

For three nights a week for three months

Three DSM Criteria and definition of Insomnia

A predominant complaint of dissatisfaction with sleep quantity or quality, with at least 1 of the following:

Difficulty initiating sleep

Difficulty maintaining sleep

Early-morning awakening with inability to return to sleep

Three sub types of insomnia

Having all of the criteria, but they only last for:

Episodic—having the disorder for one month but less than three

Persistent—more than three months

Recurrent—two episodes in a year

Six etiological factors of insomnia

Delayed body temperature rhythm

Drug use

Hyperthyroidism

Environmental issues, recurrent napping

Association between bed and wakefulness cues

Dysfunctional beliefs regarding sleep

Delayed body temperature rhythm

Our bodies naturally get cool at night, but for some people, their body temperature doesn’t cool down

If you exercise before bed, that warms your body, so you can’t sleep

Eating a big meal cools your extremities down, which is why it appears that turkey makes you sleepy

Drug use

Long-term weed smoking tends to make things worse regarding sleep—it only appears to help in the short-term

Hyperthyroidism

Too much thyroid hormone

Environmental issues

i.e. Your sleep hygiene. Do you have bright lights in your room? Is your roommate noisy? Usually, most people address this before seeking therapy, and

Association between bed and wakefulness cues

Napping greatly screws up your sleep schedule; if you have insomnia, you’re not allowed to nap (but if you don’t have the disorder, it can be okay).

Blue light doesn’t have near as prominent of an effect, as the problems existed way before the blue light.

Three key treatment methods for insomnia

Sleeping pills

Melatonin

Antithyroid medications

NOTE: white noise machines don’t seem to help

Sleeping pills

Classically, benzodiazepines were commonly use as sleeping pills, but now, AmBien is much more common.

AmBien is okay for the short term, such as for flying, but in the long term, you get addicted to them, and you get rebound insomnia when you go off them.

It can have nasty side effects, such as causing you to hook up with your ex.

Melatonin

Melatonin levels are low when you wake up in the morning after a good sleep. As the day progresses, melatonin levels increase

For persistent long-lasting insomnia, melatonin does little

Anti-thyroid medications

Extremely rare

Three treatment methods for insomnia

Elimination of environmental issues/naps

Behavioural therapy for extinction of wakefulness cues

Cognitive therapy for beliefs

Behavioural therapy for extinction of cues

Try to eliminate cues that are associated with being awake, such as not making a phone call in bed, or reading in bed before night

Very effective

For people in hospitals that have to be in bed, they are supposed to talk and visit and on the right side of the bed, and sleep on the left side, and the body can make the distinction

What does idiopathic mean?

We don’t know the cause of whatever disorder

Ex. Idiopathic hypersomnia means they don’t know why you can’t sleep

Hypersomnia definition

Sleep dysfunction involving an excessive amount of sleep that disrupts normal routines

Hypersomnia Three DSM Criteria

Recurrent periods of sleep or lapses into sleep in the same day

Prolonged sleep of more than 9 hours that is unrefreshing

Difficulty being fully awake after abrupt awakening

Prolonged sleep of more than 9 hours that is unrefreshing

9 and a half hours is the regular amount of sleeping time for someone with this disorder, and you are still tired after it

Are naps refreshing for people with hypersomnia?

No, people with hypersomnia tend not to wake up refreshed by naps either

Three subtypes of hypersomnolence

Acute—less than 1 month

Subacute is 1-3 months

Persistent is 3 months or more

Narcolepsy

Sleep disorder involving sudden and irresistible sleep attacks

Three DSM criteria for narcolepsy

Episodes of cataplexy

Hypocretin/orexin deficiency

Nocturnal REM sleep latency less than 15 minutes, or a mean sleep latency test of less than 8 minutes and two or more sleep onset REM periods

Episodes of cataplexy

A sudden loss of muscle tone but you maintain consciousness

Usually triggered by extremely intense emotions, such as anger or sadness

We all have cataplexy during REM sleep, which is why we don’t act out our dream

Nocturnal REM sleep latency less than 15 minutes, or a mean sleep latency test of less than 8 minutes and two or more sleep onset REM periods

These individuals have a whole bunch of REM at night and they have REM during the day

So, it’s a disorder characterized by too much REM

Other features of narcolepsy that AREN’T criteria

Sleep paralysis (the old hag)

Hypnagogic hallucinations

Restorative naps

Sleep paralysis

Sleep paralysis is when you wake up in the night but you are paralyzed. This is because you are in REM sleep

Hypnagogic hallucinations

Hypnagogic hallucinations are not real hallucinations. They are characterized by waking up during a super intense dream that you think the dream actually happened when you woke up

The dream feels like a memory

There is actually a connection between people who think they’re abducted by aliens and narcolepsy because of the hypnagogic hallucinations

Development of narcolepsy

If it onsents earlier, it tends to be more problematic (15-25 age vs 30-35). Some kids develop narcolsepy before puberty, but it’s super duper rare.

Narcolepsy and hyposomnia etiological factors

Genetics

Orexin deficiency

Hyperactivity of the histamine system

Hypothyroidism

Orexin deficiency

Only for narcolepsy

This is because there are cells in the hypothalamus that produce orexin, but a genetic auto-immune mutation causes you to not have those cells, thus you have the deficiency

Histamine system

Benadryl hits the histamine system way too hard for hyposomnia people, making the system too active

Treatment for hypersomnia/narcolepsy

Modafinil (Provigil) and amphetamines

Antidepressants for cataplexy

Thyroid medications

Modafinil (Provigil)

Modafinil (Provigil) work like an amphetamine, but are NOT amphetamines

The drug promotes wakefulness

Features of amphetamines

One feature of amphetamines that we don’t understand is that their effectiveness is dependent on the day

With women, it may have to do with the menstrual cycle

What is the most likely basis for hyposomnia and narcolepsy?

Both seem biologically based

Alex’s sleep as a coping mechanisms theory

Alex’s sleep used as a coping mechanism theory is that napping is a coping mechanism for anxiety and depression

Treatment for hypersomnia and narcolepsy

Psychoeducation regarding disorder

Development of coping strategies

Adjustment to life circumstances

Psychoeducation regarding disorder

Therapy is usually just used to help you realize that the disorder is part of your life—psychology doesn’t have a huge influence on the disorder, as CBT can’t make you less sleepy

Adjustment to life circumstances

These disorders are super hard to treat, so you have to explain to individuals that they may not be able to complete them

E.g. if you have narcolepsy, you likely won’t be able to be an ER surgeon

Circadian rhythm disorders

Sleep disruption due to alteration of the circadian system, or misalignment between endogenous circadian system and the individual’s required sleep-wake schedule

Circadian rhythm disorders

Delayed sleep type

Advanced sleep type

Non-24-hour type

Shift work type

Jet leg type

Delayed sleep type

Falling asleep later than you want to

Going to bed at 10 but not being able to fall asleep until 12

Advanced sleep type

When you’re falling asleep much earlier than you want to

We see this with seniors.

Non-24 hour type

This is when people’s normal clock is a 25 or 26 hour clock

What happens in this case you go to bed at 9, then the next week 10, and the next week 11, and the next week 12 etc…It slowly moves you around

Shift-work type

When you’re awake at the wrong time, and you’re sleepy at the wrong time

It’s mainly because your work schedule is super unpredictable

Jet lag type

When you fly somewhere and your clock doesn’t match the clock of where you are

Most commonly when you fly west to east

Etiology of circadian rhythm disorders

Suprachiasmatic nucleus (SCN)

Melatonin

Changing work schedules

Suprachiasmatic nucleus (SCN)

Part of the hypothalamus and sets your internal clock based on how much light hits your retina

With jet lag, your SCN likely hasn’t had enough light to reset your clock

Treatments for circadian rhythm disorders

Phase delaying—if you’re having trouble sleeping, you delay till the next evening to fall asleep

Exposure to sunlight/bright light therapy

Changing expectations regarding employment—if your SCN is too hard wired to fix, you then go to therapy to learn how to deal with not sleeping well