sleep disorder student for psycoreec.ppt

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
•Severalstudiesshowdecreasedqualityoflife
andimpaireddaytimefunctionassociatedwith
insomnia.
•However,itisdifficulttodistinguishanycausal
effectsofinsomniafromeffectsof
comorbiditiessuchasdepressionandanxiety.
8

9. •Mostinsomniaiscomorbidwithotherdisorders,especially
depression,substanceabuseandanxiety.
•Incomorbidinsomnia,itisunclearwhentreatmentfocus
shouldbeoncomorbidities.
•Primaryinsomniaisinsomniawithoutcomorbidities.
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. •CBTisapracticalapproach;youmayneedonlyfourorfive
sessions.Forinsomnia,theprimarygoalistorecognizeand
changeirrationalthoughtsandbeliefsaboutsleepthat
elevatestressandanxietyandthuscauseorexacerbate
sleeplessness.
12

13. •Forexample,thetherapymayhelpyouunderstandhow
worryingaboutsleeplessnesscankeepyouawake.Youmay
beabletotrainyourselftothinkofsomethingelse—orat
leasttorefrainfromcatastrophicthoughts
13

14. COGNITIVE-BEHAVIORAL
TREATMENT of INSOMNIA
•Cognitivetreatment(why“Nottoworry!”)
•Sleephygiene(educationandcounseling)
•Relaxationtherapies(e.g.,deepbreathing,
meditation,musclerelaxation)
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
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17. AVOID ALERTING IN BED
•Mystery books and watching TV should be
avoided in bed.
•Where possible, do alerting activities outside the
bedroom
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18. Hypnotics for Short-Term Use
SHORT Half -Life
Zolpidem
Triazolam
Zaleplon:
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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:
•Flurazepamandquazepam
•Diazepam:rapidabsorption,first-passshorthalf
life,butactivemetabolitesaccumulate
•Becauseofdelayedaccumulationanddelayed
eliminationrisk,daytimesedation,increased
falls,andconfusion,longhalf-lifehypnoticsare
notgenerallyindicated,especiallyforelders
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
Manycasesofnarcolepsyarethoughttobecausedbyalackof
thebrainchemicalhypocretin(alsoknownasorexin),which
regulatessleep.
•Thisdeficiencyisthoughttoresultfromtheimmunesystem
mistakenlyattackingpartsofthebrainthatproduce
hypocretin.However,alackofhypocretinisn'tthecauseinall
cases.
34

35. •Immunesystemproblem
•Normally,antibodiesarereleasedbythebodytodestroy
disease-carryingorganismsandtoxins.Whenantibodies
mistakenlyattackhealthycellsandtissue,it'sknownasan
autoimmuneresponse.
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. •Periodiclimbmovementdisorder(PLMD)isrepetitive
crampingorjerkingofthelegsduringsleep.Itistheonly
movementdisorderthatoccursonlyduringsleep,anditis
sometimescalledperiodicleg(orlimb)movementsduring
sleep
37

38. •."Periodic"referstothefactthatthemovementsare
repetitiveandrhythmic,occurringaboutevery20-40seconds.
PLMDisalsoconsideredasleepdisorder,becausethe
movementsoftendisruptsleepandleadtodaytime
sleepiness.
38

39. Cause
•Periodiclimbmovementdisordercanbeprimaryor
secondary.SecondaryPLMDiscausedbyanunderlying
medicalproblem.PrimaryPLMD,ontheotherhand,hasno
knowncause.Ithasbeenlinkedtoabnormalitiesinregulation
ofnervestravelingfromthebraintothelimbs,buttheexact
natureoftheseabnormalitiesisnotknown.
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
•Circadianrhythmsleepdisorderisapersistentorrecurring
patternofsleepdisruptionresultingeitherfromanaltered
sleep-wakescheduleoraninequalitybetweenaperson's
naturalsleep-wakecycleandthesleep-relateddemands
placedonhimorher.
42

43. •Thetermcircadianrhythmreferstoaperson'sinternalsleep
andwake-relatedrhythmsthatoccurthroughouta24-hour
period.Thesleepdisruptionleadsto
•insomniaorexcessivesleepinessduringtheday,resultingin
impairedfunctioning.
43

44. Causes
•Thedelayedsleepphasetypeofcircadianrhythmsleep
disorderismarkedbyadelayofthesleep-wakecycle.Itis
oftenduetoapsychosocialstressor(aneventinaperson's
environmentthatcausesstressordiscomfort),
44

45. •especiallyforadolescents.Thedelayedsleep-wakecycleleads
tochronicsleepdeprivationandhabituallylatesleeping
hours.Individualswiththistypeoftenhavedifficultychanging
theirsleepingpatternstoanearlierandmoresocially
acceptabletime.Theiractualsleep,onceitbegins,isnormal.
Itisthetimingoftheirsleepingandwakingthatispersistently
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
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