Sleep Loss: Consequences and Physiological States

Sleep Loss Consequences

• Acute sleep loss can lead to excessive sleepiness, marked by a subjective feeling of difficulty staying awake.
• Chronic sleep loss also results in excessive sleepiness.
• Sleep deprivation happens when the hours of sleep obtained are less than the hours of sleep required, causing impaired functioning.
• Microsleeps, which are brief periods of sleep lasting 1-10 seconds while trying to stay awake, reduce quality of life and mimic neurocognitive disorders.
• Short-term effects of sleep loss include stress, somatic pain, and emotional distress.
• Long-term effects of sleep loss include cardiovascular disease, weight issues, and psychiatric comorbidities.
• Comorbidities associated with sleep loss include substance abuse, anxiety, asthma, pain, COPD, mood/cognitive disorders, and schizophrenia.
• The interaction between an individual and their environment influences sleep.

Physiological States of Sleep

• Sleep consists of two main physiological states: Non-Rapid Eye Movement (NREM) sleep and Rapid Eye Movement (REM) sleep.

Non-Rapid Eye Movement (NREM) Sleep

• NREM sleep has three stages: N1, N2, and N3

N1 Stage

• N1 is a brief transition period between wakefulness and sleep, marked by sleep latency, muscle relaxation, and decreased body temperature.
• During N1, eyes may roll slowly and individuals may experience a sensation of floating or see idle images, often denying that they were asleep.

N2 Stage

• N2 occupies 45-55% of total sleep time, with eyes potentially rolling, and decreased heart and respiratory rates.

N3 Stage

• N3, also known as slow-wave sleep or delta sleep, is the stage when hormones like growth hormone and serotonin are released, making it difficult to awaken someone.
• Snoring may occur during N3, sympathetic activity is very low, and dreams are less dramatic.

Rapid Eye Movement (REM) Sleep

• During REM sleep, episodic bursts of cortisol, ACTH, and catecholamines are released and dreams occur.
• Dreams during REM sleep are vivid and may function as a protective mechanism to prevent acting out dreams.
• REM sleep accounts for 20-25% of total sleep, associated with a decrease or absence of skeletal muscle tone.

Sleep Disorders

• Sleep disorders include insomnia, narcolepsy, and circadian rhythm sleep disorders.

Insomnia Disorder

• Insomnia involves dissatisfaction with the quantity or quality of sleep
• Characteristics include difficulty falling asleep, staying asleep, or achieving restful sleep, which may include waking up too early and being unable to fall back asleep.
• Insomnia is characterized by inadequate sleep quantity, quality, or both.
• The 3P's model explains insomnia through Predisposing, Precipitating, and Perpetuating factors.

Predisposing Factors for Insomnia

• Individual factors that create vulnerability to insomnia, such as a prior history of poor sleep, depression, anxiety, or hyperarousal.

Precipitating Factors for Insomnia

• External events that trigger insomnia, such as medical or psychiatric disorders, grief, personal or vocational difficulties, or changes in role/identity.

Perpetuating Factors for Insomnia

• Sleep practices and attributes that maintain the sleep complaint, such as excessive caffeine or alcohol consumption, prolonged time in bed, or napping.

Narcolepsy

• Narcolepsy is a rare condition characterized by an uncontrollable urge to sleep
• It involves disturbed nighttime sleep with multiple awakenings and automatic behaviors characterized by memory lapses.
• Individuals with narcolepsy generally feel refreshed upon awakening but become tired again within 2-3 hours.
• Narcolepsy may be accompanied by cataplexy, which involves brief episodes of bilateral loss of muscle tone while maintaining consciousness, often triggered by emotions.
• Other symptoms can include hypnagogic hallucinations and sleep paralysis.

Circadian Rhythm Sleep Disorder

• This occurs when there is a misalignment between an individual's normal circadian rhythm and external factors affecting the timing or duration of sleep.
• Shift work disorder is a common type, marked by difficulty sleeping when sleep is desired, needed, or expected
• Individuals may experience lack of productivity, falling asleep at work, and emotional dysregulation.
• Circadian rhythm sleep disorders include delayed sleep phase, advanced sleep phase, irregular sleep-wake rhythm, non-24-hour sleep-wake rhythm, and shift work disorder.

Types of Circadian Rhythm Sleep Disorders

• Delayed sleep phase involves a delay of more than 2 hours between desired and actual sleep times, causing delayed wakening.
• Advanced sleep phase involves sleep beginning several hours earlier than desired.
• Irregular sleep-wake rhythm involves sporadic and fragmented sleep, with the longest sleep period being about 4 hours, often associated with Alzheimer's and hospital environments.
• Non-24-hour sleep-wake rhythm involves a mismatch between the 24-hour environment and a person's internal clock, causing sleep to occur later and later, resulting in daytime sleepiness.
• Shift work disorder results from working outside normal shifts (night shift), causing excessive sleepiness at work and impaired function at home.

Diagnosing Sleep Disorders

• Diagnostic tests for sleep disorders include multiple sleep latency tests, maintenance of wakefulness tests, and actigraphy.

Integrative Care

Overview

• Integrative care encourages patients to actively participate in their health using holistic practices to promote wellness.

Mind-Body Practices

• Techniques like meditation, yoga, acupuncture, and exercise are utilized.

Natural Approaches

• Diet and nutrition are key components.

Manipulative Methods

• Spinal manipulation and massage therapy are employed.

Herbal Remedies

• St. John's Wort and lavender are common choices.

Complementary and Alternative Medicine (CAM)

• CAM encompasses medical practices and products that fall outside standard medical care
• Complementary medicine involves non-mainstream practices used alongside standard medical care.
• Alternative medicine involves non-mainstream practices used in place of standard medical care.
• Integrative medicine combines non-mainstream practices with standard medical care in a coordinated way.

Conventional vs. Integrative Medicine

• Conventional medicine traditionally defines health as the absence of disease and focuses on interventions performed on the patient.
• Integrative medicine is patient-centered, emphasizing patient participation with the provider to heal the body and mind, viewing health as a strong interrelation between physical, emotional, mental, social, and environmental factors.

History of CAM

Traditional Chinese Medicine (TCM)

• TCM rooted in Taoism promotes harmony to achieve health, aiming to bring order out of chaos (disease).
• It serves as a framework for acupuncture, meditation, Tai Chi, and Qi Gong.

Ayurvedic Medicine

• As the oldest medical system, Ayurvedic medicine focuses on the individual response to health, based on the elements of earth, water, fire, air, and space.
• The body is comprised of doshas (vital energies), dhatus (tissues), and malas (waste products)
• Health is attained when the doshas are balanced.

Holism

• Holism focuses on the person rather than the disease, understanding the individual as a unified whole in mutual process with the environment.

Personality Disorders

• Defined by significant challenges in self-identity or self-direction, and problems with empathy and intimacy.
• Requires assessment of the individual’s entire background.

Cluster A: Odd or Eccentric Behaviors

Paranoid Personality Disorder

• Characterized by long-standing distrust and suspiciousness of others based on unfounded beliefs that others intend to harm them.
• Bears grudges and is preoccupied with unjustified doubts about loyalty.
• Requires clear and straightforward communication, as excessive niceness may be viewed with suspicion.
• Psychotherapy is the first-line treatment, with individual therapy focusing on developing a trusting relationship.
• Anti-anxiety medications or antipsychotics may be used for severe agitation or delusions.

Schizoid Personality Disorder

• Involves a lifelong pattern of social detachment, expressionlessness, and restricted range of emotional expression.
• Individuals are reclusive, uncooperative, and show emotional coldness and detachment, with little to no interest in sexual experiences with others.
• Requires avoiding excessive friendliness.
• Psychotherapy may help if trust develops, allowing the patient to explore fantasies, fears, and imagined relationships.

Schizotypal Personality Disorder

• Individuals do not blend in with the crowd and present as strikingly strange or unusual with magical thinking, odd beliefs, and strange speech patterns.
• They experience extreme anxiety in social situations and blame others for their isolation.
• Often ramble with lengthy, unclear, and overly detailed speech.
• Patients often avoid treatment due to anxiety and paranoia
• Goals involve providing supportive care due to difficult therapeutic relationships
• Low-dose antipsychotics may be used.

Cluster B: Dramatic, Emotional, or Unpredictable Behaviors

Histrionic Personality Disorder

• Characterized by attention-seeking behavior, shallow emotions, and excessive emotionality.
• Individuals tend to have limited ability to develop meaningful relationships, behaving impulsively and often acting flirtatious or sexually seductive.
• Relationships are often short-lived because partners feel "smothered."
• Psychotherapy may promote clarification of feelings.

Narcissistic Personality Disorder

• Characterized by a lack of empathy, grandiosity, and a sense of self-importance.
• Individuals believe they are special, entitled, and feel intense shame and fear of abandonment.
• More likely to be involved in couple/family therapy.
• Individual cognitive therapy can be helpful for deconstructing faulty thinking.

Borderline Personality Disorder

• Involves severe impairments in functioning, instability, impulsivity, identity or self-image distortions, and unstable mood swings or emotional lability.
• Tend to seek treatment for depression, anxiety, suicidal ideation, or self-harm.
• Clear and consistent boundaries promote safety.
• CBT, DBT, and schema-focused therapy used for treatment

Antisocial Personality Disorder

• Characterized by manipulative and callous disregard for the rights of others.
• Often involves a history of childhood maltreatment or parental abuse
• Individuals may be prone to criminal behavior or substance use disorders.
• Anger control also important

Cluster C: Anxious, Apprehensive, or Fearful Behaviors

Avoidant Personality Disorder

• Characterized by extreme sensitivity to rejection
• Shyness and avoidance of new people and activities due to fear of criticism and disapproval.
• Requires a relaxed, friendly, accepting, and reassuring approach.
• Assertiveness training can help the person learn to express their needs.
• SSRIs and SNRIs may be useful.

Dependent Personality Disorder

• Characterized by a pattern of submissive and clingy behavior related to an overwhelming need to be cared for, leading to an intense fear of separation and abandonment
• CBT can help patients develop more healthy and accurate thinking by examining challenging autonomic thoughts resulting in fearful behavior.

Obsessive-Compulsive Personality Disorder

• Characterized by limited emotional expression, stubbornness, and indecisiveness
• Projects are often left incomplete due to perfectionism.
• Individuals are preoccupied with rules and organization
• Group and behavioral therapy as well as Clomipramine for Obsession

Schizophrenia

• Requires the presence of two or more characteristic symptoms
• Results in impairments in thinking, emotion, and perception.
• Early assessment is key to improving outcomes
• Assess safety, risk factors such as history, suicide, substance use, content, relation to stress and anxiety: SMI

Positive Symptoms of Schizophrenia

• Include hallucinations, alterations in reality testing such as delusions, disorganized speech, associative looseness (word salad), and clang associations.
• Possible causes include sleep deprivation, substance use, bullying/abuse, and physical/mental illness.

Negative Symptoms of Schizophrenia

• The '6 A's' are:
  • Anhedonia: Reduced ability or inability to experience pleasure.
  • Avolition: Decreased motivation.
  • Asociality: Decreased desire for social interaction.
  • Affective Blunting: Decrease or constricted affect.
  • Apathy: Decrease desire in activities that would be interesting to the patient.
• Alogia - Decrease in speech

Cognitive Symptoms of Schizophrenia

• Includes concrete thinking with impaired ability to think abstractly
• May include impaired memory and attention difficulties

Affective Symptoms of Schizophrenia

• Involves emotional disturbances such as depression, hopelessness, and irritability.

Phases of Schizophrenia

Prodromal Phase

• Characterized by mild changes in thinking and mood and can include obsessive behaviors/Decreased social performance

Acute Phase

• Hallucinations, delusions, and social withdrawal may require hospitalization.

Stabilization and Maintenance Phases

• The focus is on moving toward a previous level of functioning.
• Education, support, and skills training for the patient and family is an essential aspect

Inpatient Hospitalization

• Provides 24-hour support to prevent harm.

Outpatient Treatment

• Community-based centers and support groups

Antipsychotics

• Used to treat schizophrenia
• First-generation antipsychotics (dopamine antagonists) are used for positive symptoms.
• Second-generation antipsychotics (dopamine/serotonin antagonists) are generally first-line medications, treating both positive and negative symptoms.
• General side effects of antipsychotics can include metabolic syndrome and prolonged QT interval.

Extrapyramidal Side Effects of Antipsychotics

• Include acute dystonia and akathisia
• Can be treated with antiparkinsonian medications
• Neuroleptic malignant syndrome is caused by excess dopamine blockade.
• Anticholinergic toxicity can cause bowel obstruction and altered mental status
• Agranulocytosis can increase risk of infection

Mood Disorders

• Characterized by disruption of general emotional state or mood.
• Mania is a wonderful feeling that may turn dark (psychotic).

Bipolar I Disorder

• Defined by at least one week-long manic episode for most of the day.
• Episodes may be followed by depressive episodes.
• Psychotic features (radical changes in personality), hallucinations, delusion, thought disturbance.

Bipolar II Disorder

• Defined by one hypomanic and one major depressive episode.
• Risk for suicide during depressive episodes is high.
• Last 4 consecutive days
• Often misdiagnosed with depression.

Cyclothymic Disorder

• Hypomania alternates with mild-to-moderate depression for at least 2 years in adults and 1 year in children.
• Hypomania = high mood and energy, low sleep, high self-esteem
• Pediatric onset may include separation anxiety
• Misdiagnosis

Assessment for Bipolar

• #1 is danger to self or others

Treatment for Mood Disorders

• Mood stabilizers like lithium carbonate are a gold standard
• Alter sodium and potassium maintenance
• Monitor lithium levels every 3-5 days after initiation, then every 3-6 months.
• Anticonvulsants, such as carbamazepine, can be used.

Electroconvulsive Therapy (ECT)

• A electric current through brain is faster than medication.

Substance Use and Addiction

• Addiction is a chronic medical condition with cycles of relapse if untreated, potentially leading to premature death or disability.
• Codependence involves family dynamics with a person who misuses alcohol. _ Over responsible behavior with negative consequences

Spectrum of Substance Use

• Ranges from negligible health effects to chronic dependence.
• Use can range through negligible health or social effects/positive or non problematic
• Problematic Negative effects on life
• Chronic-use is habit forming

Potential Reasons for Abuse

• Other co-occuring substance
• Mental Health issues such as Depression

Common Abused Substances and Interventions

Caffeine

• Most widely used psychoactive
• Intervention: Hydration, medication to increase HR+BR
• Excess intake is not an official disorder

Cannabis

• Cannabis is #1 most used drug that does not have to be prescribed
• Intervention: Abstinence, psychotherapy, antianxiety medication
• Withdrawal: Fever, shaky

Hallucinogen

• Cause profound disturbance in Reality
• Intervention: Hydration and Reality+ Safety

Opiods

• Intervention: Monitor ABC
• TX metnadone, nattrexone, bupreporphine.
• Withdrawl symptoms include nausea, vommit, diarrhea

Sedatives, Hypnotics, and Anti-Anxiety Medications

• benzodiazepines.

Stimulants

• Amphetamines
• Used for student studying for example

Therapeutic Groups

• Any group of people who meet for personal development and psychological growth.

Therapeutic Group Restrictions

• Least Restrictive to most restrictive : primary care, speciality care, patient centered homes, community mental health centers. psych home care, Assertive community tx.intetnsive out pt. Programs+Partial
• Psych mental Health nurses provide meds, inaividual therapy, group therapy, rehab _Psych home care= home bound
• Assertive community tx.- frequent pt admissions for patients who don't engage

Group Phases

• Planning: leaders identified the successful objective, location, setting and responsibility
• orientation- Group forming confidentially+ trust
• working- leader facilities communication+ members
• Termination -summarizes personal accomplishments, future goals

Group Participant Roles

• Task Role: Keep group focused on main purpose. reliable info relevant to issue.
• maintenance: Keeps group together [valuable and included
• Individual: Have nothing to do w/ group. Personal needs.

Leadership Styles

• Autocratic, Democratic and , Laissez-faire

Expected Outcomes

– depends on group with change in insight/benaviot

• medication awareness in side effects and dosing