sleep disorder student for psycoreec.ppt

1. SLEEP DISORDERS
By;Y.B
(C&CMH Specialist )
1

2. OUTLINE
• Sleep disorders: definitions
• Insomnia
• Sleep apnea
• Narcolepsy
• PLMD (periodic limb movements)
• Circadian rhythm sleep disorders
2

3. KEY POINTS
• Cognitive-behavioral therapy is best for
chronic insomnia
• Hypnotics risks usually outweigh benefits
• Sleep apnea is the most common cause of
excess sleepiness
• Circadian rhythm disorders can be treated
using the light phase response curve
3

4. SLEEP DISORDERS
• Primary
• Comorbid:
– Related to Another Mental Disorder
– Due to a General Medical Condition
– Substance-Related
4

5. 5
SLEEP DISORDERS
• Insomnia
• Breathing disorders
• Hypersomnia & narcolepsy
• Circadian disorders
• Parasomnias
• Movement disorders

6. INSOMNIA: 1) Sleep Difficulty
• Complaints of disturbed sleep in the presence
of adequate opportunity and circumstance for
sleep
– (1) difficulty in initiating sleep
– (2) difficulty in maintaining sleep or
– (3) waking up too early
poor-quality sleep
6

7. 7
INSOMNIA: 2) Daytime Hyperarousal
Some patients with chronic insomnia
have daytime hyperarousal and are
not able to fall asleep in the day. They
might be fatigued, but they are not
sleepy.

8. INSOMNIA:
3) Functional Impairment Associated
• Several studies show decreased quality of life
and impaired daytime function associated with
insomnia.
• However, it is difficult to distinguish any causal
effects of insomnia from effects of
comorbidities such as depression and anxiety.
8

9. • Most insomnia is comorbid with other disorders, especially
depression, substance abuse and anxiety.
• In comorbid insomnia, it is unclear when treatment focus
should be on comorbidities.
• Primary insomnia is insomnia without comorbidities.
9

10. INSOMNIA TREATMENTS
• Cognitive-behavioral therapy: best
demonstrated long-term efficacy and least
side effects
• Sedative antidepressants: little data
10

11. CHRONIC INSOMNIA
• Most insomnia is chronic
• Lasts for years
• Natural history not well studied
• Primary and comorbid insomnia hard to
distinguish
11

12. • CBT is a practical approach; you may need only four or five
sessions. For insomnia, the primary goal is to recognize and
change irrational thoughts and beliefs about sleep that
elevate stress and anxiety and thus cause or exacerbate
sleeplessness.
12

13. • For example, the therapy may help you understand how
worrying about sleeplessness can keep you awake. You may
be able to train yourself to think of something else—or at
least to refrain from catastrophic thoughts
13

14. COGNITIVE-BEHAVIORAL
TREATMENT of INSOMNIA
• Cognitive treatment (why “Not to worry!”)
• Sleep hygiene (education and counseling)
• Relaxation therapies (e.g., deep breathing,
meditation, muscle relaxation)
14

15. COGNITIVE ELEMENT:
• The healthiest people sleep 6.5 – 7.5 hours. It is safer to
sleep 5-6 hours than 8-10 hours.
• The average adult in the U.S. sleeps 6.5 hours: most do
not need 8 hours.
• It is normal for older people to awaken often at night.
• People with insomnia live longer than people without
insomnia: Not to worry!
• Harmful to spend longer in bed than you can sleep
15

16. GOOD SLEEP HYGIENE
• Sleep hygiene
– consistent bedtime and wake time
– No long daytime naps (e.g. 90 min)
– Can try 15 - 40 min naps and closely follow sleep logs to decide
if naps are OK
– Don’t go to bed unless sleepy
• Avoid caffeine from mid afternoon on
• Limit alcohol in the evening
• Use bedroom only for sleeping and sex
16

17. AVOID ALERTING IN BED
• Mystery books and watching TV should be
avoided in bed.
• Where possible, do alerting activities outside the
bedroom
17

18. Hypnotics for Short-Term Use
SHORT Half - Life
Zolpidem
Triazolam
Zaleplon:
18

19. Hypnotics for Short-Term Use
MEDIUM Half – Life, Some Hangover:
Temazepam: onset ~1 hour, daytime sedation
Lorazepam: onset ~1 hour, daytime sedation
Estazolam: daytime sedation
Alprazolam?
19

20. Long Half-Life Hypnotics for
Short-Term Use:
• Flurazepam and quazepam
• Diazepam: rapid absorption, first-pass short half
life, but active metabolites accumulate
• Because of delayed accumulation and delayed
elimination risk, daytime sedation, increased
falls, and confusion, long half-life hypnotics are
not generally indicated, especially for elders
20

21. TCA ANTIDEPRESSANTS
• Not generally recommended for insomnia without
depression
• Orthostatic hypotension
• Daytime sedation
• Anticholinergic effects
– Dry mouth —Constipation
– Blurred near vision —Confusion
– Urinary retention
21
PDR 1993; Salzman C. J. Clin Psychiatry 1993; 54 (2 suppl):23-27;
Walsh JK et al. Am J Med 1990 88; (suppl 3A) 34s-38s

22. SLEEP APNEA
The most common cause of
complaints of excessive
sleepiness (falling asleep in the
day)
22

23. 23
APNEA SYMPTOMS
• Daytime somnolence
• Snoring, often loud
• Insomnia Sx (occasionally)
• Impaired concentration

24. 24
ASSOCIATED FEATURES
• obesity
• A narrowed air way
• hypertension (systemic and pulmonary
• Heart disorders

25. 25
Obstructive sleep apnea is a common and serious disorder in
which breathing repeatedly stops for 10 seconds or more during
sleep. The disorder results in decreased oxygen in the
blood and can briefly awaken sleepers throughout the night.
Sleep apnea has many different possible causes.
collapse of upper airway during inspiration

26. 26
In adults, the most common cause of
Obstructive sleep apnea is excess weight and obesity,
which is associated with soft tissue of the mouth and throat.
During sleep, when throat and tongue muscles are more
relaxed, this soft tissue can cause the airway to become
blocked. But many other factors also are associated with
the condition in adults.

27. 27
APNEA

28. Sleep Apnea Epidemiology
In Normal Populations
• Workers age 30 – 60 years (hypersomnia with apnea)
– 2 - 4 % in women
– 4 - 8 % in men
• Over age 65, 80% have at least some mild apneas
28

29. SLEEP APNEA DETECTION
• Observed patient stops breathing 10 or more
seconds
• Patient notices waking up unable to breathe or
gasping for air
29
 Snoring, a common sign

30. APNEA Diagnosis
• Electroencephalogram
• Electromyogram
• Respiratory Tracing
– (e.g., measurements of oral and nasal airflow
with thermistors)
• Always Useful:
– Electrocardiogram (possibly 24-hour-monitoring)
30

31. TREATMENT of MILD
OBSTRUCTIVE SLEEP APNEA
• Weight loss
• Avoid sedative-hypnotics including alcohol at
night
• Avoid sleeping supine
31

32. SEDATIVE HYPNOTICS and
SLEEP APNEA
• Can push snorer into sleep apnea
• Can worsen sleep apnea
• Same risks with alcohol
• BUT, there may be situations where
sedative may help
32

33. 33
NARCOLEPSY
• Irresistible attacks of refreshing sleep that occur
almost daily over at least 3 months
• Cataplexy
• Recurrent intrusions of elements of rapid eye
movement sleep into the transition between sleep
and wakefulness, as manifested by either
sleep paralysis at the beginning or end of sleep
episodes
Nocturnal sleep disturbed

34. Causes
Many cases of narcolepsy are thought to be caused by a lack of
the brain chemical hypocretin (also known as orexin), which
regulates sleep.
• This deficiency is thought to result from the immune system
mistakenly attacking parts of the brain that produce
hypocretin. However, a lack of hypocretin isn't the cause in all
cases.
34

35. • Immune system problem
• Normally, antibodies are released by the body to destroy
disease-carrying organisms and toxins. When antibodies
mistakenly attack healthy cells and tissue, it's known as an
autoimmune response.
35

36. NARCOLEPSY TREATMENT
A. Modafinil: rarely associated with
substance dependence
B. Stimulants
• Methylphenidate
• Amphetamine: Tolerance more common;
highest potential for illicit use
C. Anti-cataplexy agents
• Trycyclic or SSRI antidepressants
36

37. • Periodic limb movement disorder (PLMD) is repetitive
cramping or jerking of the legs during sleep . It is the only
movement disorder that occurs only during sleep, and it is
sometimes called periodic leg (or limb) movements during
sleep
37

38. • . "Periodic" refers to the fact that the movements are
repetitive and rhythmic, occurring about every 20-40 seconds.
PLMD is also considered a sleep disorder , because the
movements often disrupt sleep and lead to daytime
sleepiness.
38

39. Cause
• Periodic limb movement disorder can be primary or
secondary. Secondary PLMD is caused by an underlying
medical problem. Primary PLMD, on the other hand, has no
known cause. It has been linked to abnormalities in regulation
of nerves traveling from the brain to the limbs, but the exact
nature of these abnormalities is not known.
39

40. • Secondary PLMD has many different causes, including the
following. Many of these are also causes of restless legs
syndrome.
• Diabetes mellitus
• Iron deficiency
• Spinal cord tumor
• Spinal cord injury
40

41. Periodic Limb Movement Disorder (PLMD)
• Benzodiazepines or narcotics
– Palliative, not curative
– Increases sleep continuity in PLMD
• Dopaminergic drugs such as ropinirole and
pramipexole
• Iron supplementation for ferritin<50
41

42. CIRCADIAN RHYTHM SLEEP DISORDERS
• Definition
• Circadian rhythm sleep disorder is a persistent or recurring
pattern of sleep disruption resulting either from an altered
sleep-wake schedule or an inequality between a person's
natural sleep-wake cycle and the sleep-related demands
placed on him or her.
42

43. • The term circadian rhythm refers to a person's internal sleep
and wake-related rhythms that occur throughout a 24-hour
period. The sleep disruption leads to
• insomnia or excessive sleepiness during the day, resulting in
impaired functioning.
43

44. Causes
• The delayed sleep phase type of circadian rhythm sleep
disorder is marked by a delay of the sleep-wake cycle . It is
often due to a psychosocial stressor (an event in a person's
environment that causes stress or discomfort),
44

45. • especially for adolescents. The delayed sleep-wake cycle leads
to chronic sleep deprivation and habitually late sleeping
hours. Individuals with this type often have difficulty changing
their sleeping patterns to an earlier and more socially
acceptable time. Their actual sleep, once it begins, is normal.
It is the timing of their sleeping and waking that is persistently
delayed.
45

46. SYMPTOMS of
DELAYED SLEEP PHASE
• Can’t get to sleep at night
• Can’t get up in the morning
• Tired most of the day
• More alert in the evening
46