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Sleep and Dreams Lectures


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Sleep and Dreams Lectures

  1. 1. SLEEP DISORDERS There are 78 recognized sleep disorders described in the International Classification of Sleep Disorders, Diagnostic and Coding Manual, Published by the American Sleep Disorders Association. DYSSOMNIAS • These cause either difficult initiating or maintaining sleep, or cause excessive sleepiness. • Three Types: Intrinsic sleep disorders Extrinsic sleep disorders Circadian rhythm disorders INTRINSIC SLEEP DISORDERS 1. Psychophysiological insomnia People react to situations that are psychologically stressful with bodily tension or other physical complaints such as upset stomach, headaches. They learn to associate certain things ( i.e. going to bed) with emotions that prevent sleep (fear of going to sleep). They over focus on their sleep problems and that in itself interferes with sleep. 2. Sleep state misperception An honest complaint of insomnia or excessive sleepiness when there is no objective evidence that sleep is disturbed or lacking. People in middle or late adulthood can develop this disorder because they are not able to sleep as long or as well as they could in former years. 1
  2. 2. 3. Idiopathic insomnia A lifelong inability to get adequate sleep that has no observable cause. We assume that this difficult is due to an abnormality of sleep-wake control system sin the brain. It may be due to a problem in the sleep-inducing and – maintaining systems, or hyperactivity in the arousal system. 4. Narcolepsy This is characterized by excessive sleepiness, abnormal REM sleep, cataplexy (sudden muscle weakness), hypnagogic hallucinations, and problems sleeping at night. The cause is not known but researchers are closing in on a gene that contributes to the disorder. This is the only sleep disorder that we know is due to a flaw in the primary sleep systems in the brain. 5. Recurrent Hypersomnia People have recurrent episodes of extreme sleepiness and huge sleep needs. Episodes of hypersomnia usually last several days to several weeks, and occur twice a year, on average (although they can occur as many as 12 times a year). Patients sleep as much as 18-20 yours a day during these episodes, waking only to eat and go to the bathroom. The best described cause of this is Klein-Levin syndrome which mostly afflicts teenage boys. Patients with this syndrome have not only hypersomnia but also binge eating and hypersexuality. 6. Idiopathic hypersomnia The patient complains of excessive sleepiness and prolonged sleep at night. The sign that sets people with this disorder apart from normal long sleepers and narcoleptics is that there are numerous episodes of non-REM sleep that last for up to two hours. For this reason, this disorder is sometimes called non-REM narcolepsy. Since extreme sleepiness and large sleep need can be a symptom of many other sleep disorders, like narcolepsy and sleep apnea, it is important to rule out these before making this diagnosis. 2
  3. 3. 7. Posttraumatic hypersomnia This is excessive sleepiness that develops as the result of physical injury or disease in the central nervous system. It can be caused by brain injury, neurosurgery, infection, or spinal cord injury. The hypersomnia usually goes away over weeks or months. 8. Obstructive sleep apnea syndrome In obstructive sleep apnea, breathing is blocked during sleep when the airway pulls shut. This causes sleep disruption, dropping oxygen levels in the blood, and cardiovascular problems. 9. Central sleep apnea syndrome This is a rare type of apnea that occurs not when the throat is blocked but when the patient can not make the effort necessary to pull air into the lungs. It is usually the result of problems in the neurological control of breathing, or with the muscles associated with breathing. 10. Central alveolar hypoventilation syndrome. During sleep, everyone naturally takes less air into the lungs than when awake. If there are problems with gas exchange in the lungs (for instance, caused by emphysema), there may be problems getting enough oxygen during the night, and sleep is disturbed. Because we naturally take in a larger volume of oxygen during the day, there may not be similar problems during the day. 11. Periodic limb movement disorder PLM disorder occurs when the sleeper periodically moves a limb (usually a leg) in exactly the same way over the course of the night. A typical movement would be a kick or flex of the leg every 10 seconds. There movement disrupt sleep and lead to insomnia and daytime sleepiness. 3
  4. 4. 12. Restless leg syndrome This is characterized by uncomfortable feelings (tingling, itching, crawling, pulling, or aching) in the legs right before falling asleep. These feelings are relieved by moving the legs but return when movement stops. This interferes with falling asleep and can cause severe insomnia. Usually patients accumulate large sleep debts after many nights of restless legs, until the resulting powerful sleepiness overcomes the unpleasant feelings and the patient sleeps. Once enough sleep debt is worked off, however, the feelings once again interfere with sleep. EXTRINSIC SLEEP DISORDERS • These disorders are those that originate outside the body. These can be caused by environmental or behavioral factors. 1. Inadequate sleep hygiene Their habits are not compatible with good sleep or maximum daytime alertness. Caffeine or other drugs near bedtime, or stressful activities before bed, are common problems of sleep hygiene. 2. Environmental sleep disorder Insomnia is due to heat, cold, noise, light, or some other condition in the sleep environment. The patient’s own sensitivity to the stimulus is usually more important than the level of the stimulus itself. Sensitivity usually increases toward morning, when sleep debt is low. 3. Altitude insomnia This problem occurs when people sleep at high altitudes and are not accustomed to low air pressure and lower than normal oxygen levels. It is usually accompanied by fatigue, headache, and loss of appetite. 4
  5. 5. 4. Adjustment sleep disorder This is a transient insomnia caused by temporary stressful events. To be diagnosed with this disorder, the insomnia must appear at the same time as an usually stressful event, and must go away after the event is over. 5. Insufficient sleep syndrome This is the name given to the experience of someone who persistently fails to get enough steep or stay normally alert when awake. 6. Limit-setting sleep disorder Usually found in children, limit-setting sleep disorder occurs when someone stalls or refuses to go to bed. When an absolute bedtime is set and met, then the child falls asleep quickly. When limited (bedtimes) are not set and enforced, or enforced on sporadically, a child’s sleep will be delayed, and total sleep may not be enough to meet his/her sleep needs. 7. Sleep-onset association disorder This is another disorder usually associated with childhood. In this disorder, the individual is unable to sleep unless certain conditions are met: the light is on. The window is open, the presence of a favorite blanket. When the conditions are met, the child can sleep easily. This rigidity may not normally be a problem, except when the sleep conditions cannot be met (a different room, power outage, blanket is in the wash). 8. Food allergy insomnia Although the name of this disorder is “food allergy insomnia” it is usually a food intolerance, such as a lack of enzymes to easily digest milk, and leads to discomfort and difficulty sleeping. 5
  6. 6. 9. Nocturnal eating (drinking) syndrome This syndrome is characterized by repeated awakenings with an inability to return to sleep without eating or drinking. This is usually a disorder of childhood, but adults can also become conditioned to eating or drinking at certain times of the night. Once learned, this conditioning leads to repeated awakenings and reinforcement of the pattern. 10. Hypnotic-dependent sleep disorder This inability to sleep is caused by tolerance to or withdrawal from a drug used as a sleep inducer. Such medications commonly include members of the benzodiazepine group. 11. Stimulant-dependent sleep disorder Insomnia resulting from dependence on or withdrawal from stimulant drugs such as amphetamines, cocaine, caffeine, or asthma medications. 12. Alcohol-dependent sleep disorder As the name suggests, people with this problem depend on alcohol to get to sleep at night. This usually leads to tolerance – people need more and more alcohol to get to sleep. they also tend to wake up in the middle of the night as the alcohol wears off and or dehydration triggers an awakening. For this disorder to be diagnosed, the patient must have used alcohol to help them get to sleep for at least 30 days. 13. Toxin affected sleep disorder This is disturbed sleep because of toxins. In effect the individual is poisoned by heavy metals or organic poisons, and in some cities, by heavy air pollution. 6
  7. 7. CIRCADIAN RHYTHM SLEEP DISORDERS These disorders are grouped together because they share a common theme of disrupting the way sleep occurs over a 24 hour period. 1. Time zone change (jet-lag) syndrome This is the result of rapidly changing time zones, usually as the result of jet flight. The disagreement between the body’s internal clock and local time causes trouble getting to sleep at night, daytime sleepiness, and physical problems like stomach upset. 2. Shift-work sleep disorder This transient insomnia or excessive sleepiness results when work schedules change or are incompatible with non-work sleep-wake cycles. 3. Irregular sleep-wake pattern This is a disorder in which individuals have not set times for sleeping and for waking up, with the result that they can have trouble sleeping or waking when they try to do either. People who are restricted to bed, or who are in a n environment without a regular daily routine can be at risk for developing this disorder. 4. Delayed sleep-phase syndrome This is a disorder in which nightly sleep is delayed until long after the desired sleep time. This results in sleep-onset association disorder and trouble waking at the desired time. 5. Advanced sleep-phase syndrome This is a disorder in which nightly sleep and irresistible sleepiness come before the desired time, and the patient wakes up earlier than desired in the morning. 7
  8. 8. 6. 24-hour sleep-wake syndrome People with this syndrome have a kind of sleep pattern usually seen in experiments where people are isolated from time cues. They sleep as if they have a free-running biological clock, and have a daily sleep delay of one to two hours after the previous night’s sleep time. PARASOMNIAS • These disorders are not primarily disorders of sleep and wake states per se – rather, they are disorders of partial arousal or disorders that interfere with sleep stage transitions. AROUSAL DISORDERS 1. Confusional arousals Also called sleep drunkenness or excessive sleep inertia, this disorder is an extreme example of the slowness most people feel upon awakening. People with confusional arousals respond poorly to commands or questions, and they have major memory impairment of things that have just happened or happened a short time before. Behaviors are often strange, such as picking up a lamp and talking because the person believes it is a phone. These typically occur when someone is aroused from a deep sleep in the first part of the night or they awaken in the middle rather than at the end of a 90 minute cycle. 2. Sleepwalking Sleepwalkers engage in behaviors not usually associated with sleep, such as sitting up in bed, walking about, or even frantic attempts to “escape”. These actions are apparently initiated during slow-wave sleep. Sleepwalking may end by itself when the sleepwalker returns to bed and goes back to sleep, but if the sleepwalker wakes, he is often extremely confused. 8
  9. 9. 3. Night terrors This disorder is characterized by sudden arousal from slow-wave sleep with a piercing scream or cry and signs of intense fear. The individual usually sits up in bed with eyes open, but is unresponsive to other people or stimuli. If awakened, the patient is confused and disoriented. People usually can not remember the event or have vague, dreamlike images of it. This is usually a disorder of childhood. SLEEP-WAKE TRANSITION DISORDERS 1. Rhythmic movement disorder This is a group of repeated movements (usually in the head and neck) that typically occur immediately before sleep. This disorder is usually found in children age one or younger. The child may lie prone and repeatedly lift the head or entire upper body, and then forcibly bang the head back on the pillow. Or the child may sit against the wall or headboard and repeatedly bang the back of his/her head against it. Because of this, the disorder is sometimes called “head banging” but it can involve other movements, such as a body rolling or rocking on hands and knees. 2. Sleep starts These are sudden, brief contractions of muscles in the legs, arms, or head, which occur just as people are falling asleep. These hypnagogic jerks are felt by most people at some time, but when they are very strong or frequent they can lead to insomnia. 3. Sleep talking This problem can be precipitated by emotional stress, fever, or sleep disorders such as night terrors or even sleep apnea. Sleep talk is usually benign, although it may bother bed partners or family members. The talk is usually brief and devoid of emotional content, but it can be a long speech or infused with anger and hostility. Sleep talking can be spontaneous or induced by conversation with the sleeper. 9
  10. 10. 4. Nocturnal leg cramps As the name suggests, these are leg cramps (usually in the calf) that occur spontaneously during sleep. They may last for only a few seconds or as long as 30 minutes. The cramps cause arousal and disturb sleep. Their cause is not well understood. PARASOMNIAS USUALLY ASSOCIATED WITH REM SLEEP 1 Nightmares These are frightening dreams that usually awaken the sleeper from REM sleep. 2. Sleep paralysis This is a common part of REM sleep itself but is a disorder when it strikes outside REM sleep. Usually, people with sleep paralysis are unable to perform voluntary movements either right before they go to sleep or upon waking in the morning. Sleep paralysis most often lasts for several minutes and then disappears. 3. Impaired sleep-related penile erections In men, erections are a natural part of REM sleep. When REM-related erections are not present, it indicates a physical cause of impotence. Diagnosis of this disorder can be a useful way of differentiating between psychological and physiological impotence. 4. Sleep-related painful erections Sometimes the erections associated with REM sleep can be so intense as to be painful. This may cause nighttime awakenings during REM sleep, and subsequent sleep loss. 10
  11. 11. 5. REM sleep-related sinus arrest This is a rare disorder in which the heart will periodically stop beating during REM sleep. Heart stoppages can last up to nine seconds before starting again. The cause of this disorder is unknown and is different from cardiac arrest caused by sleep apnea. 6. REM sleep behavior disorder In this disorder, the usual REM-associated muscle paralysis is absent, so that people act out the dreams they are having. Punching, kicking, leaping, and running from the bed are common. OTHER PARASOMNIAS 1. Sleep bruxism Grinding or clenching teeth during sleep. The sound of grinding teeth can be unpleasant to others who hear it and can cause excessive tooth wear. It can also lead to jaw pain and headaches while awake. 2. Sleep enuresis (bedwetting) Urination at night is found in every infant, but as children are toilet trained, they become more able to control their bladder at night. Usually, though, regular bedwetting disappears after the age of five. It is estimated that regular bedwetting occurs in 40% of 4 year olds, 10% of 6 year olds, 5% of 10 year olds and 3% of 12 year olds. When there are no other neurological, psychiatric, or urological problems that may cause bedwetting, it is called “primary enuresis”. There is evidence that primary enuresis is hereditary. A single recessive gene is thought to be responsible, and there is a high prevalence of primary enuresis among blood relatives of a child with this disorder. If both parents were late bedwetters as children, their child has a 77% chance of being a bedwetter. If one parent was a late bedwetter, then the child has a 44% chance of having frequent bedwettings after the age of five. 11
  12. 12. 3. Sleep-related abnormal swallowing syndrome People with this disorder have inadequate swallowing of their saliva while sleeping. Saliva builds up in the mouth, then flows down the throat and is breathed into the lungs. This causes choking an coughing and wakes up the sleeper. 4. Sudden unexplained nocturnal death syndrome This syndrome is typified by sudden death in healthy young adults while they sleep. Neither clinical history nor autopsy provides an explanation for death. The first signs are labored breathing, gasping, and choking, but the disorder is not sleep apnea. Fibrillation (spasm) of the heart muscle has sometimes been detected. Southeast Asian men between 25 and 44 years of age are most often the victims of this disorder, and there are descriptive terms in many Asian languages that suggest sudden unexplained nocturnal death syndrome has long been popularly recognized. 5. Primary snoring Primary snoring is simply loud upper airway breathing sounds without signs of sleep apnea or diminished breathing. 6. Infant sleep apnea This refers to central or obstructive apneas during sleep in infants. Premature infants are more at risk for this disorder than infants born at term. Infants born before 31 weeks of gestation have about a 50-80% chance of developing apnea, whereas 7% of infants born at term have apnea. 7. Congenital central hypoventilation syndrome This is a failure of the automatic control of breathing, so that not enough air is pulled into the lungs. It is usually worse during sleep than during wakefulness. It usually gets better over 6 to 12 months, although children may have to be hospitalized when they get colds or the flu until they are four or five years old. 12
  13. 13. 8. Sudden infant death syndrome This is an unexplained sudden death during sleep for which there is no adequate explanation. The cause is till a mystery although risk factors include laying an infant on his stomach, respiratory infections, being one of a multiple birth, or being born to a substance-abusing mother. 9. Benign neonatal sleep myoclonus This is a jerking of the limbs and trunk, or repetitive stretching. The disorder is rare but harmless. The cause is not known. MEDICAL AND PSYCHIATRIC SLEEP DISORDERS SLEEP DISORDERS ASSOCIATED WITH MEDICAL DISORDERS 1. Alcoholism Alcohol abuse and dependency commonly disturbs sleep. After 30 minutes of alcohol consumption, subjective sleepiness increases and stays high for 4 hours. After that, sleep becomes fragmented as the lowered alcohol level increases arousals. When alcoholics abstain from alcohol, sleep can be severely disrupted, and the short episodes of sleep they do get are often plagues by nightmares and other anxiety dreams. 2. Sleeping sickness Also called African sleeping sickness or Gambian trypanosomiasis, this is a chronic protozoan brain infection that produces bouts of excessive sleepiness and delusional like outbursts in quick succession of each other. 3. Nocturnal cardiac ischemia Chest pains due to atherosclerotic heart disease that keeps the sleeper awake at night. 13
  14. 14. 4. Chronic obstructive pulmonary disease Lung or bronchial problems that inhibit lung function (like emphysema) can cause severe insomnia. 5. Asthma Asthma attacks during sleep usually awaken the sleeper. 6. Sleep-related gastroesophageal reflux Some people wake from sleep with a sour taste in their mouth or with heartburn. This is because some of the stomach contents have been regurgitated into the esophagus during the night. 7. Peptic ulcer The pain of ulcers can waken the sleeper frequently during the night. 8. Fibrositis syndrome Also called fibromyositis or fibromyalgia, this syndrome is characterized by diffuse muscle and bone pain, chronic fatigue during the day, and un- refreshing sleep at night. SLEEP PROBLEMS ASSOCIATED WITH NEUROLOGICAL DISORDERS 1. Degenerative brain disorders The many cerebral degenerative disorders can disrupt sleep at night. These include Huntington’s disease, Alzheimer’s disease, Pick’s disease, Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and others. Fatal familial insomnia is a rare, inherited degenerative disorder that begins with sleep troubles and progresses within a few months of total lack of sleep, and then death. 14
  15. 15. 2. Sleep-related epilepsy Epileptic seizures can be found in either wakefulness or sleep, and there are some types that are found mostly in sleep. 3. Sleep-related headaches Headaches can also strike during sleep, and in some people sleep-related headache is more common than waking headaches. SLEEP DISORDERS ASSOCIATED WITH PSYCHIATRIC DISORDERS 1. Psychoses Psychoses like schizophrenia and those that are drug-induced are characterized by delusions, hallucinations incoherence, catatonic behavior, or inappropriate emotions. Insomnia or excessive sleepiness is also common in individuals suffering from such psychoses. 2. Mood disorders Mood disorders include depression, mania, and hypomania. Insomnia is usually the result, but excessive sleepiness can occur, too. 3. Anxiety disorders Anxiety disorders are characterized by unusually great anxiety and avoidance of whatever seems to cause it. Anxiety disorders can create sleep- onset association disorders or sleep-maintenance insomnia. 4. Panic Disorders Panic disorders are commonly called phobias: claustrophobia (fear of enclosed spaces), agoraphobia (fear of open spaces) and the like. Extreme fear and anxiety can occur unexpectedly and panic episodes can waken people from their sleep. 15
  16. 16. PROPOSED SLEEP DISORDERS • These are sleep problems for which there is not enough information available to firmly establish them as discrete disorders. 1. Short sleepers A short sleeper is someone who regularly takes less than 75% of the sleep time usually required in his or her age group, and feels no negative effects from this shortened sleep. Psychologically, short sleepers are basically normal, with a tendency to hypomanic behavior. They are usually smooth, efficient people who are distinct “non-worriers”. 2. Long sleepers Long sleepers need substantially more sleep than most people. This usually means sleeping 10hours or more for adults. The timing and structure of sleep is normal in true long sleepers –when making this diagnosis it is important to rule out other problems that might lead to long hours in bed. Long sleep is usually acquired in childhood, firmly established by adolescence, and remains a lifelong pattern. Psychologically, long sleepers tend to be more introverted than others, and often appear mildly depressed or anxious when interviewed by researchers. They are often described as worriers. 3. Sub-wakefulness syndrome Some people complain about a lack of daytime alertness, but they have no nighttime sleep disruption and seem to be getting adequate sleep. There is no objective evidence of severs, excessive sleepiness, but a display of daytime drowsiness can occur. This syndrome may be a less severe version of idiopathic hypersomnia, or may be caused by dome other, unrecognized medical or psychiatric disorder. 4. Fragmentary myoclonus Myoclonus is manifest by brief, involuntary jerks or twitches. Some people get this during non-REM sleep throughout the night. The proposed disorder is very rare and harmless. 16
  17. 17. 5. Sleep hyperhydrosis Also known as night sweats, this commonly afflicts people when they have a fever. There are some people, however, who seat heavily at night without any signs of fever or other disorders. Some people seat excessively during sleep all their lives. The worst problem is sleep disruption, and people often have to get up to change pajamas or sheets. 6. Menstrual-associated sleep disorder There are three forms of menstrual-associated sleep disorders: premenstrual insomnia, premenstrual hypersomnia, and menopausal insomnia. As these three names suggest, menstrual-associated sleep disorder can lead to either less or more sleep than usual. 7. Pregnancy-associated sleep disorder Pregnancy can also lead to either insomnia or excessive sleep and sleepiness. Pregnant women usually start the pregnancy feeling excessive need for sleep and end pregnancy with insomnia due to physical discomfort. In rare cases, pregnancy and the postpartum period may be associated with nightmares, 8. Terrifying hypnagogic hallucinations When people fall asleep normally, closed eyes and a state of drowsiness give way to reverie, and vague thoughts and images flow through the mind just as sleep is descending. Rarely, these common, unthreatening hypnagogic images can turn threatening and seem real, partly as a result of how quickly they follow wakefulness. These hallucinations are common in people with narcolepsy, who regularly go into REM sleep right after falling asleep. 9. Sleep-related laryngospasm Very rarely, some people have a spasm of the throat that closes off the airway and halts breathing during sleep. The result is similar to a single episode of apnea, but these patients do not have apnea. Typically, the patient will wake up chocking and jump out of bed, clutching the throat. Episodes can last anywhere from a few seconds to five minutes. People who get these laryngospasms typically experience them only two or three times per year. Drinking water usually speeds the relaxation of throat muscles. 17
  18. 18. 10. Sleep chocking syndrome This sleep disorder is also rare, but its victims have episodes of choking almost nightly, and sometimes more than once a night. The patient wakes with feelings of fear, anxiety, and impending death. Fear is always associated with the choking, but patients don’t suffer from nightmares, night terrors, or other forms of nocturnal anxiety attacks. They also don’t suffer from obstructive sleep apnea. The cause is unknown. 18