Sleeping disorders- mental health

Sleep categories

1) difficulty initiating sleep or staying asleep (insomnia) 2) difficulty staying awake during the day (hypersomnia) 3) abnormal movements or behaviors during sleep (parasomnia) 4) timing of the sleep/wake cycle - undesired or inappropriate times over a 24 hr day (circadian rhythm disorder)

Treatment of hypersomnia

> OSA - nalsal continuous positive airway pressure (NCPAP) or bilevel positive airway pressure (BIPAP) > Some narcoleptic pts - ahceive reasonable control of sleep attacks by sturcturing days with scheduled naps (many require stimulants - methylphenidate or pemoline and modafinil)

Chronic effects of alcohol on sleep

> also exacerbate sleep related respiratory disorders - by potentiating sleep related atonia > heavy alcohol dependence is commonly associated with chronic insomnia > alcohol induced sleep is usually characterized by shortened and fragmented sleep

treatment with alcohol sleep issues

> benzodiazepines - exhibit cross tolerance with alcohol, bear the risk of abuse and are not likely to be helpful on a long term basis > sedating antidepressnts - such as doxepin, trazadone and amitriptyline might be administered in low dosages - however their therapeutic effect has not been evaluated

Narcolepsy

> hypersomnia - uncontrollable sleep attacks in various/ dangerous situations - related sx: cataplexy (loss of muscle tone); hypnagogic hallucinations and sleep paralysis - believed to be the result of defective REM sleep regulation

snoring

> hypersomnia may lead to EDS - controleld with laser assisted uvulo-palatoplasty (LAUP)

Sleep lab eval

> most sleep c/o - managed by a nonspecialist > some conditions: sleep apnea, periodic limb movements, narcolepsy, parasomnias with potential for serious injury, or intractable insomnia - REFER to sleep center > nocturnal polysomnography - (PSG) - records pts sleep overnight in the sleep lab

acute effects of alcohol on sleep

> often self prescribed for insomnia, anxiety, stress and other disturbances > acute use of alcohol - initially increases slow wave sleep and decreases REM

Considerations with hypersomnia

> take many forms - atypical depression (sleep 14 hrs a day) - narcolepsy (fall asleep while riding a bike) differentiate b/t fatigue and general tiredness and excessive daytime sleepiness (EDS) > most common cause of EDS - chronic lack of sleep > pts with conditions that are not classified as hypersomnias (PLMS - periodic limb movements of sleep) and Obstructive sleep apnea - may present with EDS

Insomnia - considerations

> transient difficulty sleeping - more common than is chronic insomnia > dx of chronic insomnia - based on complaint of difficulty initiating or maintaining sleep or nonrestorative for 1 month > insomnia prevalence increases with age - associated with psychiatric disorders, abuse of alcohol, drugs and meds > primary insomnia - in its "pure" form = small number of the population

Potential tx complications with insomnia

> w/drawal from admin of HD benzo - insomnia, anxiety, seizures, psychosis, delirium tremens, and hyperpyrexia. > sx reduced by careful taper of med (25%) for days to wks b/f discontinuation > withdrawal sx - treated with BB (propranolol)

Circadian Rhythm Disorders

Jet Lag (Asynchronosis/Time Zone Changes) Syndrome > eastward travel (advances the biologic clock) - harder to adjust to then does westward travel (which is a phase delay - they are behind us in time)

Sleep stages

REM sleep > paradoxical sleep (brain is paradoxically activated) > sleep normally begins in stage 1 and goes thru stage 4 > EEG continues to synchronize / decline in frequency and increase in amplitude > stage 2 - defined by presence of sleep spindles and K complexes on EEG > stage 3/4 - delta sleep - slow wave sleep w/ delta waves on EEG

sleep apnea

hypersomnia > respiratory drive governed by the brainstem "shuts off" > OSA - d/t intermittent obstruction of the upper airway -- this is the most common dz causing excessive daytime sleepiness (overweight and middle aged men) > general risks with EDS (fatigue related accidents / impared judgement, risk of pulmonary HTN, right sided heart failure, CVA, MI, sudden death)

Clinical findings of hypersomnia

sleep apnea snoring narcolepsy

key element in sleep history

sleep diary - assess other factors (caffiene, alcohol or med use and naps)

Parasomnias

*unusual events or behaviors occurring either during sleep or during sleep-wake transitions *NREM sleep (sx) - sleep terrors, sleepwalking, sleep bruxism, and confusional arousals *parasomnias associated with REM include nightmares and sleep paralysis

Treatment of insomnia

Sedative hypnotics > most widely used - benzo's (shorten sleep latency, improve sleep continuity, decrease slow wave sleep and REM sleep) > abuse of benzo's - associated with simultaneous use with alcohol and stimulates (short term use to treat insomnia and long term use to treat anxiety are usually not associated w/ serious clinical problems) > benzo's are safer then barbituates