Psychiatry lecturesPsychiatry lectures
Prof. János Kálmán
Age-related Changes in pattern of Daily Sleep
4025
20
18.915 3.8
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Sleep-wake disorders
Dyssomnias
1. Circadian Rhythm Sleep Disorders
2. Intrinsic Sleep Disorders
1. (Disorders that either originate or develop from within the body)
3. Extrinsic Sleep Disorders
1. (Disorders that either originate or develop from causes outside the body)
4. Parasomnias
1. (Disorder of arousal, partial arousal or sleep stage transition)
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The synaptic homeostasis hypothesis of
sleep
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The SHH posits that synapse accumulation during the day drives a need for synaptic
downscaling, which preferentially occurs during sleep.
Dramatic changes in sleep duration(Western cultures, /USA)
0
1
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3
4
5
6
7
8
9
10
1960 2002 2004 2006
sleep duration
Kripke 2002; Keith 2006; Lauderdale 2006As sleep time fell in USA, average weights rose
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• One or two abrupt
myoclonic flexion
jerks, often
accompanied by a
feeling of falling
• Cause:
– Insufficient sleep
Hypnic jerks = Sleep starts
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• Occur at sleep onset
• Vivid perceptual experiences
• Sensation of hearing voices
• Feeling someone else is
nearby
• Precipitated by
� Sleep deprivation
� Excessive caffeine
� Emotional stress
� Narcolepsy
Hypnic hallucinations
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• 50-80% of children
• 5% of Adults
• 50% sleep talk only a few
times per/year
• 10% sleep talk nightly
• Risk increases with:
� Sleep deprivation
� Stress
� Sickness (fever)
� Medications
� Family History
Sleep talking
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• Transient inability to move,
despite being fully awake
• Brief persistence of atonia of
REM lingering into wakefulness
� 40% of teens and college
students
� 10% of adults
• Triggered by sleep deprivation
Sleep Paralysis
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• 40% children
• 2% adults
• Individuals are:
� 95% family history
� 3-5 times more likely to have
OSA
� Have nightmares > once/month
� Prone injury-causing behaviors
during sleep
Sleep Terrors
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• VBS occurs in 1.6% of adults
• VBS: Range from simple dream
enactment to complex behaviors
• VBS:
� Risk factors:
� Family member with VBS
� Age < 35
� Sleep deprivation
� Stress
� Alcohol
Violent Behavior During Sleep (VBS) 1.
Scucs et al, Medical Hypotheses 2014
Ohayon et al, Sleep Medicine 201011Kálmán - Psychiatry lectures
�Occur in the first 2
hours of sleep
�79% of people
have vivid dreams
�31% hurt
themselves or
someone else
�Few people consult
a physician
Violent Behavior During Sleep (VBS) 2.
Scucs et al, Medical Hypotheses 2014
Ohayon et al, Sleep Medicine 201012Kálmán - Psychiatry lectures
• 3% reported nocturnal
wandering at least once in the
previous year
• 30% lifetime prevalence
• 30% had a relative who had
nocturnal wandering
• 1% reported at least two
nocturnal wanderings in the
previous month
�4% sleep walked at least twice a year
�40% lifetime prevalence
�Highest incidence is ages 4-8
� Sleepwalking generally stops by age 13
Sleepwalking 1.
UK -4924 adults US-19,136 adults
Ohayon, Neurology 2012
Pressman, Neurology 2013
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• Occurs in NREM III
• Patients arise from bed, walk
toward a sound or light
• Sleepwalkers may run through
the house
• Behavior is often followed by a
calm return to bed, or lying
down somewhere else in the
house
• Patients appear confused
• Eyes are open, but objects are
misidentified
• Patients are slow to respond
• Patients are difficult to arouse
• Patients often suffer retrograde
amnesia
Sleepwalking 2.
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Sleepwalking 3.
• New onset or late recurrence in
teenage years warrants
consideration of other primary
sleep disorders
� Sleep deprivation
� Extreme fatigue
� Obstructive sleep apnea
� RLS
� RBD
� Infections
• Stressful life events often
precipitate sleepwalking
�Changes in sleep
environment
�Family conflicts
�Personal conflicts
�Medications
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• Teeth grinding during sleep
• 30-40% of children
• 8% of young adults
• Symptoms of tooth-grinding
noises, jaw muscle discomfort,
abnormal wear of teeth on
dental exam
• Risk factors
� Emotional stress
� Caffeine
� Type A personalities
Sleep bruxism
Masuko et al, BMC Research Notes
201416Kálmán - Psychiatry lectures
Sleep Paralysis
• Has been reported to occur in families
• Treatment
– SSRIs can be effective when frequent and bothersome
– Key: sleep one more hour!
– Move wake up time beyond REM sleep
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• Long, involved frightening in REM
sleep
• Preceded by increased heart rate,
increased respiration, increased REM
– 10-15% of children ages 3-6
– 20-40% children overall
– 5-12% adults
• May be caused by a daytime
traumatic experience, medications, or
disruption in routine
Nightmare disorder
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• Reduced movement during sleep
• Freezing:
– Heightened anxiety consistent with the suppression of movement exhibited by animals under conditions of perceived threat
• Treated
– Reassurance
– Medications that decrease REM sleep
Nightmare Disorder
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Insomnia vs. Sleep Deprivation
• Sleep Deprivation
-adequate ability to sleep
-inadequate opportunity
-generally sleepy, at risk for accidents
• Insomnia
-inadequate ability
-adequate opportunity
-generally not sleepy
may report fatigue
Kálmán - Psychiatry lectures 20
What is Insomnia?
• Classified as the inability to get enough sleep
despite adequate time.
• Symptoms Include:
– Delayed Sleep Onset
– Early Morning Wake-Ups
– Unrefreshing Sleep
– Trouble Maintaining Sleep
• Causes many problems in daytime functioning
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Classifications of Insomnia
• Primary vs.
Secondary
• Chronic vs. Acute
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Acute Insomnia
• Insomnia fewer than 3 times a week for less
than a month
• Stems from changes in the environment and a
short illness
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Chronic Insomnia
• More than 3 times a week for a period longer
than a month
• comorbid insomnia
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CAUSES OF COMORBID INSOMNIA
www.sleepreviewmag.com/.../2004-05_04. 25Kálmán - Psychiatry lectures
Treatment of Sleep
Disorders
• Good Sleep Hygiene
• Medications
• Psychotherapy, stress management
• Relaxation techniques
• OSA treatment
– Mouth appliance
– Surgery-tonsils and/or adenoids
– Weight reduction if obese
– CPAP-Continuous positive airway pressure
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Pharmacological treatment
• 4 Classes of Prescription Agents
– Benzodiazepines
– Benzodiazepine Receptor Agonists
– Melatonin Receptor Agonists
– Antidepressants/Antipsychotics
• Some supplements are thought to help
as well
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References I.• Psychiatric Sequalae of Sleep Disorders, Mark Brown, http://web.stanford.edu/~davesv/Psychiatric_Sequalae_of_Sleep_Disorders%2008-10.ppt• Proseminar in Physiological Psychology (PSY 627),Chapter 9,University of Kentucky
http://www.uky.edu/~mbardo/psy627_files/Sleep%20Lecture.ppt• SLEEP and INSOMNIA, Lynn N. Stewart, http://www.fmdrl.org/index.cfm?event=c.getAttachment&riid=1234 • Sleep and neurology, Eric Frenette, http://www.powershow.com/view/3b6c79-
OGRjN/Sleep_and_neurology_AWAKE_group_meeting_11_05_2008_Eric_powerpoint_ppt_presentation
• Sleep and Our Health, Terri Prodoehl, https://www.jmu.edu/kinesiology/hpainstitute/documents/Sleep%20and%20Our%20Health.ppt• Sleep and Sleep Disorders, RaeAnnon Fairlie,
http://www.public.coe.edu/~mbaker/baker/neuro/lectures/~Sleep%20and%20Sleep%20Disorders%20-%20Raeannon%20Fairlie.ppt• Sleep and sleep disorders, Katalin Štěrbová, https://www.lf2.cuni.cz/info2lf/ustavy/kdn/eng/pred/sleep.ppt• Sleep Basics for Health Promotion, Barbara B. Richardson, http://www.pitt.edu/~super4/39011-40001/39321.ppt• Sleep Dysfunction and Sleep-Disordered Breathing P3 Research Summit, Klar Yaggi,
http://www.queri.research.va.gov/ptbri/docs/p3_research/yaggi.ppt • Sleep Disorders, Michael Babcock, http://www.mc.vanderbilt.edu/documents/neurology/files/Sleep%20Disorders%20Babcock.ppt• Sleep Disorders Medicine In Psychiatry, Alan B. Douglass,
http://www.med.uottawa.ca/students/backtobasics/Lectures/Lectures%202012/Psychiatry/• Sleeping well & Driving safely, 2011, Alex Bartle, http://www.aa.co.nz/assets/about/Research-Foundation/Symposium/14-ALEX-
BARTLE.ppt?m=1328557991%22%20class=%22type:%7Bppt%7D%20size:%7B2.7%20MB%7D%20file
• Sleep When a cup of warm milk is not enough, K. Van Gundy, http://www.fresno.ucsf.edu/newsroom/public_education/sleep_disorders_3-11-03.ppt
• Teaching Abnormal Psychology: Getting Ready for DSM-5, Jeff Nevid, http://caade.org/sites/default/files/Jeff%20Nevid%20Webinar%20PPT%20Teaching%20Abnormal%20Psychology%20(1).ppt
• Treatment for Insomnia, JJ Wojcik, http://faculty.smu.edu/jbuynak/Insomnia_2010a.ppt• To Sleep…Perchance To Dream” The Diagnosis and Treatment of Children and Adolescents with Sleep Disorders, Jess P. Shatkin,
https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/cap_resources_for_medical_student_educators/Sleep%20Disorders%20in%20Children%20and%20Adolescents.ppt
• Why sleep? The origins and development of Sleep Medicine, A.W.A.K.E., NOVEMBER 4, 2009 http://web.stanford.edu/~davesv/HistoryOfSleepMed.ppt
• 2010 MindBlock & B-to-B, Sleep & Psychiatry, Alan B. Douglass, http://www.med.uottawa.ca/students/backtobasics/Lectures/Lectures%202011/Psychiatry/Sleep%20Disorders%202011/Sleep%20Disorders%202010.ppt
References II.• Cognitive-Behavioral Treatment of Insomnia, Martita Lopez,
http://homepage.psy.utexas.edu/HomePage/Class/Psy352/Fromme/Info%20relevant%20to%20previous%20exams/Insomnia.ppt• Counting sheep: evaluation and treatment of sleep issues in the college-age population, Amanda Finegold Swain,
http://www.acha.org/Midatlantic/presentations/Counting_Sheep_sleep.ppt• Diagnostic and Statistical Manual Of Mental Disorders, Changing from DSM-IV to DSM-5, Steve Franklin, Shelly Justison,
Kathleen McMullan, http://stevefranklinmsw.com/DSM-5Final.ppt • Drugs for Anxiety and Insomnia, http://nursing--
pharmacology.pbworks.com/w/file/64820074/Anxiety%20Insomnia%20Ch%2014.ppt• EEG patterns during sleep http://www.cogsci.ucsd.edu/~chiba/Sleep07.ppt• Hypersomnolence in children, M Maldonado,
http://www.kaimh.org/Websites/kaimh/images/Documents/Hypersomnolence_in_Children.pdf• Insomnia, B. Wayne Blount, http://www.fpm.emory.edu/Family/didactics/powerpint/insomnia%20nc.ppt• Insomnia, Jeffrey Lin, http://web.stanford.edu/~davesv/Insomnia%2012-08• Insomnia, Jennifer Glover, Cathleen Gallagher, Margaret Gaines, Paul Garrett, Matthew Gayford,
http://people.uncw.edu/clementsc/Insomnia.ppt• Insomnia, Liphard O. D’Souza, http://www.healthsciences.okstate.edu/college/clinical/crh/rural_clinic/docs/Insomnia.ppt• Insomnia, Victoria E Judd, http://www.acha.org/AnnualMeeting/webhandouts_2011/FR126-Judd.ppt• Insomnia in the Elderly, Cause, Approach and Management,
http://www.si.mahidol.ac.th/project/geriatrics/jour nal%20club_grand%20round/slide(PDF)/06%20Insomnia%20in%20the%20Elderly.pdf
• Intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep disorders, Emerson M. Wickwire, http://www.warrelatedillness.va.gov/WARRELATEDILLNE SS/education/conferences/2011-aug/slides/20110810_wickwire.ppt
• Medications for Insomnia: A Story of Risks and Benefits, Sarah M. Richey, http://web.stanford.edu/~davesv/Medications%20for%20Sleep%2009-08.ppt
• Narcolepsy and Other Hypersomnias, Marietta B. Bibbs, http://foocus.com/power-point/Narcolepsy-and-other-hypersomnias.pptx• Neurobiology of Sleep, Subimal Datta, http://www.uams.edu/m2006/AMSSLEEP.PPT• Parasomnia: Night Terrors, Kelsey Carrio, http://www.cogsci.ucsd.edu/~pineda/COGS175/presentations/cs175-07/Parasomnia.ppt• Parasomnias and sleep related movement disorders An Overview, Frank M. Ralls, http://familydoctornm.org/presentations/57-
presentations/20140801-1030-1.pptx• Pediatric Sleep Problems and ASD: Types, Assessment, & Intervention, Kathleen Armstrong, http://card-
usf.fmhi.usf.edu/symposium/docs/CARD%202013%20Sleep%20and%20ASD.ppt
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