SLEEP DISODERS

Americans

• 62% have sleep problems once wkly or more

• 40% sleepy enough during the day to interfere with activities

• 62% drive while drowsy• 27% have fallen asleep while

driving• 60% children feel parents are tired

during the day• 15% children admit falling asleep

at school

Women• 79% report sleep disturbance during

pregnancy• 36% peri-menopausal women have

disturbed sleep• 25% suffer from significant daytime

sleepiness• 30% disturbed sleep interferes with daily

activity, 27% job performance is impaired• 24% say sleep gets in the way of caring

for family

Males1/3 of men get less than 6 hours sleep (during week)

COMORBIDITIES

• 40-45% of those with insomnia & hypersomnia have another Axis I disorder

• Mood Disorders – 4x higher • Anxiety Disorders • Schizophrenia • Substance abuse

Normal Sleep

• Normal Sleep patterns (cycles)• Non REM• REM• Circadian rhythm • Drugs influence on sleep• Genetics of sleep

Sleep DisorderPhysiology of sleep • Sleep Stages

– NREM Sleep – REM Sleep

• Sleep-Regulating Processes – Circadian Rhythm

•Endogenous vs. exogenous factor– Homeostasis

•Balance o f sleep and awake

Influences on Sleep • Developmental Changes

– Newborns and Infants – Children – Adolescents – Young and Middle Adults – Older Adults – myth

• Amount of sleep=F (genetics, preferences, lifestyle, environment)

Influences on Sleep (Cont’d)

• Medical Disorders and Treatments i.e.. Asthma, hyperthyroidism, COPD

• Drugs and Chemical Substances i.e. alcohol, lithium, cocaine-> CNS was affected

• Jet lag

Sleep Disorders • Etiology• Signs and Symptoms/Diagnostic

Criteria • Dyssomnias: abnormalities in the

amount, quality, or timing of sleep – Narcolepsy– breathing-related sleep disorders– periodic limb movement disorder– insomnia

• Parasomnias: abnormal behavioral or physiological events associated with sleep– sleepwalking – tooth grinding

DYSSOMNIAS

PRIMARY INSOMNIA• difficulty initiating and maintaining

sleep • awakenings that occur much earlier

than desired • sleep that is non-restorative and of

poor quality • result in impairment in daytime

function.

• Prevalence rates are higher in women and increase with age.

• Associated with reduced quality of life, mood disorders and increased health services usage

• Represents a significant economic burden in the US, with estimated direct costs of $13.9 billion annually.

– Change in sleep environments– Jet lag– Changes in work shift– Excessive noise– Unpleasant room temperature– Stressful life events– Medical condition– Medications– Poor sleep hygiene

Causes of Insomnia

Behavioral Model of Insomnia

• Insomnia occurs acutely in relation to both predisposing and precipitating factors

• The chronic form of the disorder is maintained by maladaptive coping behaviors.

• A state of “conditioned arousal” may develop in which situations associated with sleep become alerting rather than relaxing- further impairing sleep.

Insomnia Cycle

MALADAPTIVE HABITS•Excessive time in bed•Irregular sleep schedule•Daytime napping•Sleep- incompatible activities

AROUSAL•Emotional•Cognitive

•Physiologic

DYSFUNCTIONAL COGNITIONS•Worrying over sleep loss

•Ruminating over consequences•Unrealistic Expectations

CONSEQUENCES•Mood Disturbances

•Fatigue•Performance impairments

•Social Discomfort

Cognitive Behavioral Therapy for Insomnia

• change poor sleep habits and faulty beliefs about sleep

• promote good sleep hygiene

THROUGH…….• sleep restriction, stimulus control,

relaxation techniques, education and good sleep practices.

• CBT is as successful as medications in the acute treatment (4-8 weeks) of insomnia.

• It is more effective than medications in the long term.

• Average of 50-60% improvement• Long term studies reveal a sustained

improvement in sleep quality and duration.

• Patients continued to experience improvement over follow-up periods of >1year.

Other Treatments

• Pharmacologic therapy– Benzodiazepines / related

hypnotics– Antidepressants– Antihistamines– Melatonin

• Light

BREATHING-RELATED SLEEP DISORDER• Unlike people with insomnia, this is a

structural/ anatomical problem with physiological consequences

• Treatment with oral appliance or surgery is needed

• Sleep maintenance, sleep walking, or other consequences are generally relieved after treatment but…..

• Co-occurring sleep disorders may need psychological treatment.

Sleep Apnea

• Obstructive sleep apnea– Clinical manifestations

• Central sleep apnea– Restrictive lung disease– Neuromuscular disease– Cardiac– Neurological

Other sleep disorders

Narcolepsy

– Genetic Aspects of narcolepsy– Irresistible attacks of refreshing sleep

daily for 3 months– Diagnosis

• Cataplexy- brief periods of loss of muscle tone

• REM disordered transitions- can report hallucinations, sleep paralysis at transitions between wakefulness and sleep

– Treatment of narcolepsy• Stimulants, REM suppressants • Behavioral adjustments

Circadian Rhythm Sleep Disorder

• Causes insomnia because of a lack of synchronization between an individual’s internal clock and the external schedule

• Treatment is best accomplished with chronotherapy and/ or phototherapy

Specifiers

• Delayed Sleep Type- late sleep onset & late awakening

• Shift Work Type

• Unspecified Type

• Jet Lag Type……

… Jet Lag Type

• Use activities (eating, exercise, sightseeing) and exposure to light to try to synchronize body rhythms with those of the new environment

• Melatonin 3 mg about 30 minutes before bedtime on the day of travel and for up to four days after arrival is appropriate

• A dose of 0.5 mg has less effect on sleep, but otherwise helps adaptation similarly

• Adult travelers crossing five or more time zones are likely to benefit from melatonin

DYSSOMNIA NOS

• Environmental Issues

• “Restless Legs Syndrome”

• Periodic Limb Movements

PARASOMNIAS

Parasomnias

• Sleep disorders characterized by abnormal behavioral or physiological events which occur during sleep or during sleep-wake transitions.

• Parasomnias typically do not cause insomnia or excessive sleepiness

• Sleep Terror- awakening with fear, dream amnesia and unresponsiveness VS.

• Nightmare- awakening with detailed threatening dream recall with rapid alertness

• Sleepwalking- activities without responsiveness and difficulty awakening

• NOS

GMC and Sleep

• Parkinsonism• Neuromuscular disease• Respiratory disease• Dementia• Epileptic seizures• Cardiovascular disease