Sleep Disorders PDF

Sleep-wake disorders Useful links https://www.sleepmedres.org/upload/pdf/smr-2017-00010.pdf https://www.med.upenn.edu/cbti/assets/user- content/documents/Sleep%20Quality%20Scale%20(SQS).pdf https://www.med.upenn.edu/cbti/assets/user- content/documents/Pittsburgh%20Sleep%20Quality%20Index%20(PSQI).p...

Sleep-wake disorders Useful links https://www.sleepmedres.org/upload/pdf/smr-2017-00010.pdf https://www.med.upenn.edu/cbti/assets/user- content/documents/Sleep%20Quality%20Scale%20(SQS).pdf https://www.med.upenn.edu/cbti/assets/user- content/documents/Pittsburgh%20Sleep%20Quality%20Index%20(PSQI).pdf https://sleep.pitt.edu/instruments/ https://www.cdc.gov/sleep/about_sleep/key_disorders.html https://wiregrass.libguides.com/c.php?g=1044445&p=7577651 https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders https://www.youtube.com/watch?v=VBcEz8bVbL0 https://www.youtube.com/watch?v=I8GTuvO3_Yk&pp=ygUac2xlZXAgZGlzb3JkZXJzIHBzeWNob2xvZ3k%3D Sleep stages  During day time SCN inhibits VLPO And activates LH LH secretion hypocretin/orexin activates the wakefulness promoting areas During night time, SCN will be supressed, and the adenosine activates VLPO which inhibits wakefulness promoting areas Both VLPO and TMN secretes GABA when activated, hence has a mutual inhibiting mechanism Brain activity during REM sleep and dreaming Why sleep? Functions of slow wave sleep -Essential for survival -Reduction of free radicals Functions of REM sleep -Promote brain development -Facilitate learning Sleep and Learning -Consolidation of long term memories 1. REM: Non-declarative memory 2. Slow-wave: Declarative memory Neural control of sleep-role of adenosin The stored glycogen in the astrocytes gets depleted as a result of increased metabolism during wakeful stage. Adenosine is accumulated as a result that induces sleep by activating VLPOA During slow wave sleep, this excessive adenosine is destroyed and astrocytes renews its glycogen reserve. Neural control of Wakefulness The role of orexin in sleep waking flip-flop What are sleep-wake disorders? According to DSM-5, People with a Sleep-wake disorder have complaints of dissatisfaction regarding the quality, timing, and amount of sleep; resulting in daytime distress and impairment. Sleep-Wake disorders (DSM 5-TR) include the following Insomnia disorder Hypersomnolence disorder Narcolepsy (cataplexy and Hypocretin) Breathing-related sleep disorders Circadian rhythm sleep-wake disorders Parasomnias: Non-rapid eye movement (NREM) sleep arousal disorders Nightmare disorder Rapid eye movement (REM) sleep behavior disorder Restless legs syndrome Substance/medication-induced sleep disorder Insomnia Insomnia - all disorders of initiating and maintaining sleep  Sleep onset insomnia (or initial insomnia) - difficulty initiating sleep at bedtime. Sleep maintenance insomnia (or middle insomnia) - frequent or prolonged awakenings throughout the night. Late insomnia - early-morning awakening with an inability to return to sleep. Nonrestorative sleep - a complaint of poor sleep quality that does not leave the individual rested upon awakening despite adequate duration Individual has adequate opportunity and circumstances for sleep, but not able to sleep The complaints are accompanied by significant distress or daytime consequences such as irritability, impaired concentration, or fatigue Risk factors: Female gender, age, comorbid depression, anxiety, and other medical conditions Biological Causes of Insomnia 1. Hereditary 2. Iatrogenic cause 3. Physiological and Cortical arousal 4. Sleep apnea 5. Periodic limb movement disorder 6. Restless legs syndrome Hereditary It runs in families. Maybe polygenetic More than 30 percent of cases may be inherited Fatal familial insomnia- A brain degenerative condition (due to impairements in prion proteins in the hypothalamus) Iatrogenic causes Many cases of insomnia are iatrogenic (physician-created) in large part because sleeping pills which are usually prescribed by physicians, are a major cause of insomnia - tolerance and withdrawal symptoms People who claimed to suffer from insomnia but slept more than 6.5 hours per night were believed to be neurotic (neurotic psuedoinsomnia)- However they were found to be suffering from sleep apnea, nocturnal myoclonus, or other sleep-disturbing problems. Insomnia is not necessarily a problem of too little sleep; it is often a problem of too little undisturbed sleep. Polysomnography Physiological and cortical arousal Hyperarousal in the physiological, emotional, or cognitive networks is believed to prevent sleep regulatory processes from naturally occurring in patients with insomnia Quantitative electroencephalographic analyses - greater high-frequency electroencephalography power relative to good sleepers both around the sleep onset period and during non-rapid eye movement sleep, a feature suggestive of increased cortical arousal. Increased arousal and a generalized activation of the hypothalamic-pituitary- adrenal axis (e.g., increased cortisol levels, heart rate variability, reactivity to stress, metabolic rate). However literature is inconsistent regarding this hyperarousal theory Sleep apnea Apnea means cessation of breath - breathing stops for periods of 20 seconds to 2 minutes. The patient with sleep apnea stops breathing many times each night. Each time, the patient awakens, begins to breathe again, and drifts back to sleep. As the need for oxygen becomes intense the person wakes a little and gulps in air. He then settles back to sleep but soon breathing starts again. This cycle is repeated hundreds of times a night. So ‘apnea’ victims complain of hypersomnia-excessive daytime sleep. Sufferers of sleep apnea are unaware of their problem. They complain of being tired all day, but they believe that they sleep too much.  Sleep apnea disorders are of three types: ○ (1) obstructive sleep apnea results from obstruction of the respiratory passages by muscle spasms or atonia (lack of muscle tone) and often occurs in individuals who are vigorous snorers Snoring that is loud, frequent, and accompanied by gasping, choking, or pauses in breathing may be a sign of sleep apnea ○ (2) central sleep apnea results from the failure of the central nervous system to stimulate respiration Apnea is produced because the brain stops sending signal to the diaphragm to maintain breathing; another cause is the blockage of the upper air passage. (3) Sleep related hypoventilation ▪ Episodes of decreased respiration associated with elevated CO2 levels.  Periodic limb movement disorder a.k.a NOCTURNAL MYOCLONUS – Twitching in sleep periodic, involuntary movements of the limbs, often involving twitches of the legs during sleep ○ stereotyped sleep-related movements of the lower limbs and occasionally also upper limbs, ranging from simple dorsiflexion (occurs in your ankle when you draw your toes back toward your shins) of the big toe and foot to a triple flexion of the entire leg (flexion of the thigh, leg, and dorsiflexion of the foot) Most patients suffering from this disorder complain of poor sleep and daytime sleepiness but are unaware of the nature of their problem. Note: Myo - muscle; Clonus - involuntary and rhythmic muscle contractions caused by a permanent lesion in descending motor neurons ) Restless legs syndrome condition that causes a very strong urge to move the legs - nearly irresistible urge to move the legs, typically in the evenings. Restless legs syndrome typically occurs while resting and having unpleasant feelings in your legs. It generally worsens with age and can disrupt sleep. People with restless legs syndrome are all too aware of their problem. They complain of a hard to-describe tension or uneasiness in their legs that keeps them from falling asleep. Treatment Sleep restriction therapy Hypnotic pills Progressive muscle relaxation techniques CBT Insomnia - https://www.youtube.com/watch?v=LUt42r5- 5AE&pp=ygUQaW5zb21uaWEgb3Ntb3Npcw%3D%3D https://youtu.be/hZIIAHE63Jc Sleep apnea - https://www.youtube.com/watch?v=zdk7XvfM0Ys&pp=ygUTc2xlZXAgYXBuZWEg b3Ntb3Npcw%3D%3D Restless leg syndrome - https://www.youtube.com/watch?v=D6WmNTQTAfc&pp=ygUdcmVzdGxlc3MgbG VnIHN5bmRyb21lIG9zbW9zaXM%3D Hypersomnolence excessive sleepiness despite a main sleep period lasting at least 7 hours It's also known as excessive daytime sleepiness (EDS). The need for sleep is not easily explained by something as simple as staying up late, and it does not resolve by catching up on your sleep. There are a number of medical causes of hypersomnia, including breathing disorders, neurological conditions, and certain medications. Common symptoms of hypersomnia (and hypersomnolence) include: Sleepiness Irritability Trouble concentrating Headaches Inadequate performance at work or in school Increased or decreased appetite Weight gain Hallucinations Falling asleep immediately after lying down Trouble waking up from sleep If you have hypersomnia, these problems can persist for several consecutive months or even longer. Over time, you may begin to accept these symptoms, and you may not recognize that they signal a medical condition. For this reason, many people do not seek medical attention for hypersomnia. However, it's best to make a point of discussing these issues with your healthcare provider—most of the causes are treatable. Causal factors Hypoactivity of wake- promoting systems, results in activation of sleep-promoting systems and promotion of sleep. In contrast, hyperactivity of wake- promoting systems results in inhibition of sleep promoting systems and promotion of wakefulness. Conti… Hypersomnolence due to central nervous system (CNS) disorders. CNS disorders include narcolepsy, Kleine-Levin syndrome (“sleeping beauty syndrome” or “familial hibernation syndrome,”a rare medical condition causing excessive sleep and other symptoms), or any number of idiopathic conditions that arise without a known cause. Medical disorders. This could include thyroid disorder, sleep apnea, encephalitis (brain inflammation), etc. Psychiatric disorders. Anxiety and/or depression can cause hypersomnolence. Drugs or drug withdrawal. Many drugs could cause hypersomnolence, including sedatives, anticonvulsants, opioids, antipsychotics, and alcohol—also, drug withdrawal can cause hypersomnolence. Hypersomnolence can also appear within 6-18 months following a head trauma (post traumatic hypersomnia) Narcolepsy Narcolepsy is the most widely studied disorder of hypersomnia. It occurs in about 1 out of 2,000 individuals (Arango, Kivity, & Schoenfeld, 2015; Mahoney et al., 2019) People with narcolepsy find it hard to stay awake for long periods of time. They fall asleep suddenly. This can cause serious problems in their daily routine. Sometimes narcolepsy also causes a sudden loss of muscle tone, known as cataplexy. This can be triggered by strong emotion, especially laughter. Hypnogogic hallucination Sleep paralysis Two conditions of narcolepsy Narcolepsy is divided into two types. Most people with type 1 narcolepsy have cataplexy. Most people who don't have cataplexy have type 2 narcolepsy. Narcolepsy has two prominent symptoms. ○ First, persons with narcolepsy experience severe daytime sleepiness and repeated, brief (10- to 15-minute) daytime sleep episodes. Individuals with narcolepsy typically sleep only about an hour per day more than average; it is the inappropriateness of their sleep episodes that most clearly defines their condition. The individuals with narcolepsy fall asleep in the middle of a conversation, while eating, while scuba diving, or even while having sex. ○ The second prominent symptom of narcolepsy is cataplexy (see Dauvilliers et al., 2014). Cataplexy is characterized by recurring losses of muscle tone during wakefulness, often triggered by an emotional experience. In its mild form, it may simply force the patient to sit down for a few seconds until it passes. In its extreme form, the patient drops to the ground as if shot and remains there for a minute or two, fully conscious.  In addition to daytime sleep attacks and cataplexy, people with narcolepsy often experience two other symptoms: sleep paralysis and hypnagogic hallucinations. Sleep paralysis is the inability to move just as one is falling asleep or waking up Hypnagogic hallucinations are dreamlike experiences during wakefulness. Many healthy people occasionally experience sleep paralysis and hypnagogic hallucinations https://youtu.be/UMxMatGeL44 https://youtu.be/DJU0CyDCETI https://www.youtube.com/watch?v=KV6HvzNf_jM&pp=ygUSbmFyY29sZXBzeS Bvc21vc2lz  Three lines of evidence suggested to early researchers that narcolepsy results from an abnormality in the mechanisms that trigger REM sleep. ○ First, unlike people without narcolepsy, those with narcolepsy often go directly into REM sleep when they fall asleep. ○ Second and third, as you have already learned, narcoleptics often experience two REM-sleep characteristics (dreamlike states and loss of muscle tone) during wakefulness (see Mahoney et al., 2019). Lack of orexin (sometimes called hypocretin) or reduced levels in CSF - autoimmune disorder (immune system mistakenly attacking parts of the brain that produce hypocretin) Lack of orexin receptors (orexin-B receptors) In huntington’s disease, parts of lateral hypothalamus that secrete orexin can be damaged Treatment For sleep attacks-Stimulants like Ritalin For symptoms like sleep paralysis, cataplexy, hypnogogic hallucinations- Antidepressants that facilitate serotonergic and noradrenergic activity Modafinil-it increases the expression of a protein, Fos, in the orexinergic neuron. REM-Sleep-Related Disorders REM-Sleep-Related Disorders Several sleep disorders are specific to REM sleep -> REM- sleep-related disorders. A sleep disorder called Rapid Eye Movement Sleep Behavior Disorder or RBD involves the physical enactment of a vivid dream with sounds and movements (e.g. shouting, talking, or punching)—as in, literally living and acting out their dreams. Occasionally, patients have little or no REM sleep Some patients experience REM sleep without core muscle atonia. This condition is known as REM-sleep behavior disorder and is common in individuals with Parkinson’s disease It has been suggested that the function of REM-sleep atonia is to prevent the acting out of dreams. Symptoms Those with RBD physically act out their dreams, which tend to be vivid and often involve running or being chased, and defending themselves from aggressors. They may not be aware of the physical movements they were making during sleep, but unlike with sleep terrors, they are able to recall the dream when they wake up. Below are additional symptoms found among those with rapid eye movement sleep behavior disorder. 1. Depression 2. Changes in posture or manner of walking 3. Forceful arm and leg movement during sleep (jerking, kicking, twitching, arm flailing, jumping out of bed, etc.) 4. Loud vocalizations during sleep (laughing, grunting, swearing, screaming, etc.) 5. Not waking up confused or disoriented, plus the ability to recall vivid dreams 6. Sexual dysfunction and constipation Causes It is a neurodegenerative condition It can affect both the young and old; most common among the elderly - especially in males age 50 and above, who also suffer from neurodegenerative conditions like Parkinson’s, multiple sclerosis, or Lewy body dementia The brain regions Below are other factors that are known to cause, or have been significantly linked to, RBD. 1. it is likely that abnormal disinhibition occurs in the pyramidal motor tract during REM sleep, leading to execution of the complex movements “imagined” by the motor cortex. 2. It can also be accompanied by changes in multiple neurotransmitter systems, including the cholinergic, noradrenergic, and dopaminergic circuits. 3. Other sleep disorders – obstructive sleep apnea and narcolepsy. 4. Drug or alcohol use and/or withdrawal – alcohol withdrawal has been linked to the incidence of acute RBD. Use of certain antidepressants can also contribute or lead to the development of the disorder. 5. Brain damage or trauma – Those who have had a stroke or a tumor also have an increased risk of chronic rapid eye movement sleep behavior disorder. NREM sleep arousal disorders SOMNABULISM - Sleep walking ❖ Sleepwalking occurs when a person arises and wanders about while remaining asleep. ❖ Sleepwalking is more frequent among children than among adults. ❖ The sleepwalker’s eyes are usually open but a blank face reveals that the person is still in sleep. ❖ Earlier it was believed that sleepwalkers are acting out during dreams but remember that people are normally immobilized during the REM sleep. EEG studies have shown that somnambulism or sleep walking mostly occurs during N-REM sleep. ❖ Most people who sleepwalk, and many of their relatives, have one or more additional sleep difficulties such as chronic snoring, disordered sleep breathing, bed-wetting, and night terrors (Cao & Guilleminault, 2010). ❖ The causes of sleepwalking are not well understood, but it is more common when people are sleep deprived or under unusual stress (Zadra & Pilon, 2008). ❖ It is most common during slow-wave sleep early in the night and usually not accompanied by dreaming. (It does not occur during REM sleep, when the large muscles are completely relaxed.) ❖ During sleep walk the individual avoid obstacles, descent staircase, climb trees and on rare occasion may step out of windows or in front of an automobile. ❖ Sleepwalkers have been known to eat, rearrange furniture, fall off balconies, and drive cars—while disregarding lanes and traffic lights. Unlike wakeful actions, the deeds of sleepwalkers are poorly planned and usually not remembered. ❖ Evidently, some parts of the brain are awake and other parts are asleep (Gunn & Gunn, 2007). Sleep talking (somniloquy) Generally speaking most sleep talk occurs during Stage1, sometimes can occur during either rapid eye movement (REM) Although the cause is unclear, sleep talking may be triggered by stress and mental health conditions. Somniloquy is a sleep disorder defined as talking during sleep without being aware of it. Sleep talking can involve complicated dialogues or monologues, complete gibberish or mumbling. It’s common for people to experience at least one episode of sleep talking during their life, making it one of the most common abnormal behaviors that can occur during sleep. Night terror Frightening dreamlike nocturnal NREM experience Imagine yourself comfortably sleeping in your bed, unaware of everything around you. Then you slowly regain enough consciousness to realize that you are suffocating, that some heavy weight on your chest and crushing your lungs (incubus). Realizing that your breathing has almost stopped, and that you are dying for air, you become terrified and scream. At once you seem to awaken and it is an classic example of a night terror Night terrors are experiences of intense anxiety from which a person awakens screaming in terror. A night terror is more severe than a nightmare, which is simply an unpleasant dream. Night terrors occur during NREM sleep and are more common in children than adults. Dream content, if any, is usually simple, such as a single image.  In night terrors especially the children wake-up from NREM deep sleep with the signs of total panic and show severe arousal reactions such as racing pulse and rapid respiration. The person awakens drenched in sweat but have no memory of the dream. Night terror occurs during deeper phase of Stage 4 of N-REM sleep and not during REM stage and victims may sit up, scream, get out of bed or run around the room, some people may experience “incubus”(In-cue-bus - meaning is “to have a devil on your back”). During incubus the person realize the suffocation that some heavy weight is lying on the chest and crushing the lungs. After a night terror, the person typically falls right back to sleep and does not recall the experience the next morning. As a result, a night terror can be more disturbing to the family members who are rudely awakened by it than to the person who has experienced it. Both somnambulism and night terrors appear to be related to disturbances in the functioning of autonomic nervous system, which plays a key role in regulating brain activity during sleep. Neurobiological Causes of NREM sleep disorders Alpha motor neurons control skeletal muscle fibers, which are responsible for the majority of body movements During sleep, inputs to these regions change the excitatory impulse reduces and inhibitory impulses increase. To reach the threshold potential in a hyperpolarized cell requires a significantly greater net depolarization, i.e., a much larger excitatory impulse, than achieving the threshold from resting potential. Therefore, transmitting an action potential to skeletal muscle is much less likely. During REM sleep, the alpha motor neuron membranes are significantly more hyperpolarized, making it even more difficult for impulses to fire and cause movement Regions of the brain stem and cerebellum are involved in intense emotional and motor behaviours, hence they are involved in regulating motor neurons. malfunctions/impairments in these regions can cause retention of muscle tone during REM. It fails to supress the motor activities. Nightmares Frightening dreams during REM sleep In contrast to night terrors, in nightmares a bad dream occurs during the REM sleep and we can recall the nightmares. Thus nightmare is simply a bad dream that takes place during REM sleep, particularly during early morning REM sleep. Causes Stress or anxiety. Sometimes the ordinary stresses of daily life, such as a problem at home or school, trigger nightmares. A major change, such as a move or the death of a loved one, can have the same effect. Experiencing anxiety is associated with a greater risk of nightmares. Trauma. Nightmares are common after an accident, injury, physical or sexual abuse, or other traumatic event. Nightmares are common in people who have post-traumatic stress disorder (PTSD). Sleep deprivation. Changes in your schedule that cause irregular sleeping and waking times or that interrupt or reduce the amount of sleep you get can increase your risk of having nightmares. Insomnia is associated with an increased risk of nightmares. Medications. Some drugs — including certain antidepressants, blood pressure medications, beta blockers, and drugs used to treat Parkinson's disease or to help stop smoking — can trigger nightmares. Substance misuse. Alcohol and recreational drug use or withdrawal can trigger nightmares. Other disorders. Depression and other mental health disorders may be linked to nightmares. Nightmares can happen along with some medical conditions, such as heart disease or cancer. Having other sleep disorders that interfere with adequate sleep can be associated with having nightmares. Scary books and movies. For some people, reading scary books or watching frightening movies, especially before bed, can be associated with nightmares.