Sleep/Wake Disorders REVIEW ASSIGNMENT

What is NOT a common cause of hypersomnolence disorder? A. Tumors or head injuries B. Alcohol or drug use C. Insomnia D. Mental health conditions

C. Insomnia

Non-pharmacological interventions for insomnia include all of the following, EXCEPT... A. Therapy such as cognitive behavioral therapy B. Limiting use of caffeine C. Taking naps to ensure adequate sleep D. Increasing physical exercise

C. Taking naps to ensure adequate sleep

Which medication is NOT used to treat restless leg syndrome? A. Opiates B. Anticonvulsants C. Anti-depressants D. Benzodiazepines

C. Anti-depressants

The hormone most associated with biological rhythms is... A. Follicle Stimulating Hormone (FSH) B. Luteinizing Hormone (LH) C. Growth hormone D. Melatonin

D. Melatonin

What typical symptom of sleep does not occur in REM sleep behavior disorder (RBD)? SELECT ONE OF THE FOLLOWING OPTIONS: A. Decrease in rate of respiration B. Rapid movements of the eyes C. Decrease in heart rate D. Paralysis of muscle systems

D. Paralysis of muscle systems

Which stage of sleep is associated with dreaming? A. One B. Two C. Three D. REM

D. REM

The most common treatment for sleep apnea is... A. Nasal surgery B. Continuous positive airway pressure (CPAP) device C. Excitatory positive air pressure (EPAP) device D. Weight loss

B. Continuous positive airway pressure (CPAP) device

Why do we sleep? A. To restore resources that are expended during the day B. To improve cognitive function and memory formation. C. It's unclear D. To protect against predatory risks at night

C. It's unclear

Describe the etiology, symptoms, and treatment of insomnia.

A person with insomnia has a consistent difficulty in falling or staying asleep and is the most common sleep disorders. Individuals with insomnia often experience long delays between the times that they go to bed and actually fall asleep. In addition, those with insomnia may wake up several times during the night only to find that they have difficulty getting back to sleep. As mentioned earlier, one of the criteria for insomnia involves experiencing these symptoms for at least three nights a week for at least one month's time (Roth, 2007). There may be many factors that contribute to insomnia, including age, drug use, exercise, mental status, and bedtime routines. Not surprisingly, insomnia treatment may take one of several different approaches. People who suffer from insomnia might limit their use of stimulant drugs (such as caffeine) or increase their amount of physical exercise during the day. Some people might turn to over-the-counter (OTC) or prescribed sleep medications to help them sleep, but this should be done sparingly because many sleep medications result in dependence and alter the nature of the sleep cycle, and they can increase insomnia over time. Individuals who continue to have insomnia, particularly if it affects their quality of life, should seek professional treatment. Treatment for insomnia includes both pharmacological and non-pharmacological treatment approaches. Common pharmacological treatment for insomnia includes Benzodiazepines; however, there also may be a withdrawal syndrome with rapid eye movement (REM) rebound. In addition, there are two newer benzodiazepine-like agents, zolpidem and zaleplon, which have fewer side effects, but good efficacy. Other agents for insomnia include sedating antidepressants and over-the-counter sleep products (sedating antihistamines).[1] Some forms of psychotherapy, such as CBT, can help sufferers of insomnia. CBT focuses on cognitive processes and problem behaviors. The treatment of insomnia likely would include stress management techniques and changes in problematic behaviors that could contribute to insomnia (e.g., spending more waking time in bed). CBT has been demonstrated to be quite effective in treating insomnia (Savard, Simard, Ivers, & Morin, 2005; Williams, Roth, Vatthauer, & McCrae, 2013). Cognitive therapies for insomnia can help a patient to identify disruptive thought patterns, examine their validity, then replace harmful thoughts using strategies such as shifting attention, decatastrophizing, or reappraisal.[3]

Describe the etiology, symptoms, and treatment of narcolepsy.

A person with narcolepsy cannot resist falling asleep at inopportune times. These sleep episodes are often associated with cataplexy, which is a lack of muscle tone or muscle weakness, and in some cases involves complete paralysis of the voluntary muscles similar to the kind of paralysis experienced by healthy individuals during REM sleep (Burgess & Scammell, 2012; Hishikawa & Shimizu, 1995; Luppi et al., 2011). Narcoleptic episodes take on other features of REM sleep. For example, around one-third of individuals diagnosed with narcolepsy experience vivid, dream-like hallucinations during narcoleptic attacks (Chokroverty, 2010). Surprisingly, narcoleptic episodes are often triggered by states of heightened arousal or stress. The typical episode can last from a minute or two to half an hour. Once awakened from a narcoleptic attack, people report that they feel refreshed (Chokroverty, 2010). Obviously, regular narcoleptic episodes could interfere with the ability to perform one's job or complete schoolwork, and in some situations, narcolepsy can result in significant harm and injury (e.g., driving a car or operating machinery or other potentially dangerous equipment). In order to make a diagnosis of narcolepsy, an individual must have symptoms occurring at least three times a week over the past three months. In addition, one of the following must be present: • hypocretin deficiency • episodes of cataplexy occurring at least several times a month • REM sleep latency of fewer than 15 minutes or two or more sleep-onset REM periods (SOREMPs) and a mean sleep latency of fewer than eight minutes. Narcolepsy may have several causes. Nearly all people with narcolepsy who have cataplexy have extremely low levels of the naturally occurring chemical hypocretin, which promotes wakefulness and regulates REM sleep. Hypocretin levels are usually normal in people who have narcolepsy without cataplexy. Although the cause of narcolepsy is not completely understood, current research suggests that narcolepsy may be the result of a combination of factors working together to cause a lack of hypocretin. These factors include:• Autoimmune disorders: When cataplexy is present, the cause is most often the loss of brain cells that produce hypocretin. Although the reason for this cell loss is unknown, it appears to be linked to abnormalities in the immune system. Autoimmune disorders occur when the body's immune system turns against itself and mistakenly attacks healthy cells or tissue. Researchers believe that in individuals with narcolepsy, the body's immune system selectively attacks the hypocretin-containing brain cells because of a combination of genetic and environmental factors. • Family history: Most cases of narcolepsy are sporadic, meaning the disorder occurs in individuals with no known family history. However, clusters in families sometimes occur—up to 10% of individuals diagnosed with narcolepsy with cataplexy report having a close relative with similar symptoms.• Brain injuries: Rarely, narcolepsy results from traumatic injury to parts of the brain that regulate wakefulness and REM sleep or from tumors and other diseases in the same regions. Although there is no cure for narcolepsy, some of the symptoms can be treated with medicines and lifestyle changes. When cataplexy is present, the loss of hypocretin is believed to be irreversible and lifelong. Excessive daytime sleepiness (EDS) and cataplexy can be controlled in most individuals with medications.

Describe the symptoms, prevalence, and treatment of restless leg syndrome.

A person with restless leg syndrome has uncomfortable sensations in the legs during periods of inactivity or when trying to fall asleep. This discomfort is relieved by deliberately moving the legs, which, not surprisingly, contributes to difficulty in falling or staying asleep. Restless leg syndrome is quite common and has been associated with a number of other medical diagnoses, such as chronic kidney disease and diabetes (Mahowald & Schenck, 2000). There are a variety of drugs that treat restless leg syndrome: benzodiazepines, opiates, and anticonvulsants.

What is NOT a difference between nightmare disorder and night terrors? A. During nightmares as symptomatic of nightmare disorder, individuals are asleep; when experiencing night terrors, individuals are awake. B. Nightmares as symptomatic of nightmare disorder have a storyline; night terrors do no. C. Nightmare disorder is highly comorbid with PTSD; night terrors are not. D. Nightmare disorder symptoms occur during REM sleep; night terrors occur during NREM sleep.

A. During nightmares as symptomatic of nightmare disorder, individuals are asleep; when experiencing night terrors, individuals are awake.

A patient reports that they've has noticed food missing from the fridge and crumbs in their bed, but they have no memory of eating the food. What diagnosis would you consider evaluating for? A. Somnambulism B. REM sleep behavior disorder (RBD) C. Nightmare disorder D. Night terrors

A. Somnambulism

Describe the adaptive and cognitive theories of sleep.

Adaptive Function of SleepOne popular hypothesis of sleep incorporates the perspective of evolutionary psychology. Evolutionary psychology is a discipline that studies how universal patterns of behavior and cognitive processes have evolved over time as a result of natural selection. Variations and adaptations in cognition and behavior make individuals more or less successful in reproducing and passing their genes to their offspring. One hypothesis from this perspective might argue that sleep is essential to restore resources that are expended during the day. While this is an intuitive explanation of sleep, there is little research that supports this explanation. Another evolutionary hypothesis of sleep holds that our sleep patterns evolved as an adaptive response to predatory risks, which increase in darkness. Thus we sleep in safe areas to reduce the chance of harm. Again, this is an intuitive and appealing explanation for why we sleep. Comparative research indicates, however, that the relationship that exists between predatory risk and sleep is very complex and equivocal. Cognitive Function of SleepAnother theory regarding why we sleep involves sleep's importance for cognitive function and memory formation (Rattenborg, Lesku, Martinez-Gonzalez, & Lima, 2007). Indeed, we know sleep deprivation results in disruptions in cognition and memory deficits (Brown, 2012), leading to impairments in our abilities to maintain attention, make decisions, and recall long-term memories. Moreover, these impairments become more severe as the amount of sleep deprivation increases (Alhola & Polo-Kantola, 2007). Furthermore, slow-wave sleep after learning a new task can improve resultant performance on that task (Huber, Ghilardi, Massimini, & Tononi, 2004) and seems essential for effective memory formation (Stickgold, 2005). Sleep has also been associated with other cognitive benefits. Research indicates that included among these possible benefits are increased capacities for creative thinking (Cai, Mednick, Harrison, Kanady, & Mednick, 2009; Wagner, Gais, Haider, Verleger, & Born, 2004), language learning (Fenn, Nusbaum, & Margoliash, 2003; Gómez, Bootzin, & Nadel, 2006), and inferential judgments (Ellenbogen, Hu, Payne, Titone, & Walker, 2007).

A diagnosis of narcolepsy can be made if the individual falls asleep involuntarily three times a week over the past three months. A. True B. False

B. False

Describe the etiology, symptoms, and treatment of hypersomnolence disorder.

Hypersomnia is a pathological state characterized by a lack of alertness during the waking episodes of the day. Hypersomnia is not to be confused with fatigue, which is a normal physiological state. Daytime sleepiness appears most commonly during situations where little interaction is needed. Hypersomnolence disorder affects approximately 5% of the population and is more common in men than females.[1] Hypersomnia may be caused by another sleep disorder (such as narcolepsy or sleep apnea), dysfunction of the autonomic nervous system, or drug or alcohol abuse. In some cases, it results from a physical problem, such as a tumor, head trauma, or injury to the central nervous system. Medical conditions including multiple sclerosis, depression, encephalitis, epilepsy, or obesity may contribute to hypersomnolence sleep disorder. Some people appear to have a genetic predisposition to hypersomnia; in others, there is no known cause. Typically, hypersomnia is first recognized in adolescence or young adulthood. Treatment is symptomatic in nature. Stimulants, such as amphetamine, methylphenidate, and modafinil, may be prescribed. Other drugs used to treat hypersomnia include clonidine, levodopa, bromocriptine, antidepressants, and monoamine oxidase inhibitors. Changes in behavior (for example, avoiding night work and social activities that delay bedtime) and diet may offer some relief. Patients should avoid alcohol and caffeine.

Identify the diagnoses classified as NREM sleep disorders and their symptoms.

In sleepwalking or somnambulism, the sleeper engages in relatively complex behaviors ranging from wandering about to driving an automobile. During periods of sleepwalking, sleepers often have their eyes open, but they are not responsive to attempts to communicate with them. Sleepwalking most often occurs during slow-wave sleep, but it can occur at any time during a sleep period in some affected individuals (Mahowald & Schenck, 2000). Night terrors result in a sense of panic in the sufferer and are often accompanied by screams and attempts to escape from the immediate environment (Mahowald & Schenck, 2000). Although individuals suffering from night terrors appear to be awake, they generally have no memories of the events that occurred and attempts to console them are ineffective. Typically, individuals suffering from night terrors will fall back asleep again within a short time. Night terrors apparently occur during the NREM phase of sleep (Provini, Tinuper, Bisulli, & Lagaresi, 2011). Generally, treatment for night terrors is unnecessary unless there is some underlying medical or psychological condition that is contributing to the night terrors (Mayo Clinic, n.d.).

Describe the four stages of sleep.

NREM Stages of Sleep 1. The first stage of NREM sleep is known as stage one sleep. Stage one sleep is a transitional phase that occurs between wakefulness and sleep, the period during which we drift off to sleep. During this time, there is a slowdown in both the rates of respiration and heartbeat. In addition, stage one sleep involves a marked decrease in both overall muscle tension and core body temperature. In terms of brain wave activity, stage one sleep is associated with both alpha and theta waves. The early portion of stage one sleep produces alpha waves, which are relatively low frequency (8-13Hz), and high amplitude patterns of electrical activity (waves) that become synchronized. As we move into stage two sleep, the body goes into a state of deep relaxation. Theta waves still dominate the activity of the brain, but they are interrupted by brief bursts of activity known as sleep spindles. Stage three of sleep is often referred to as deep sleep or slow-wave sleep because these stages are characterized by low frequency (up to 4 Hz), high amplitude delta waves. During this time, an individual's heart rate and respiration slow dramatically. REM SleepAs mentioned earlier, REM sleep is marked by rapid movements of the eyes. The brain waves associated with this stage of sleep are very similar to those observed when a person is awake, as shown in Figure 5, and this is the period of sleep in which dreaming occurs. It is also associated with paralysis of muscle systems in the body with the exception of those that make circulation and respiration possible. Therefore, no movement of voluntary muscles occurs during REM sleep in a normal individual; REM sleep is often referred to as paradoxical sleep because of this combination of high brain activity and lack of muscle tone. Like NREM sleep, REM has been implicated in various aspects of learning and memory (Wagner, Gais, & Born, 2001), although there is disagreement within the scientific community about how important both NREM and REM sleep are for normal learning and memory (Siegel, 2001).

Describe the symptoms of nightmare disorder.

Nightmare disorder is a sleep disorder characterized by frequent nightmares. The nightmares, which often portray the individual in a situation that jeopardizes his or her life or personal safety, usually occur during the REM stages of sleep (unlike night terrors, which occur during NREM sleep and do not follow a storyline in the way that nightmares do). Though most people have experienced at least one nightmare during their life, subjects with nightmare disorder experience them with a greater frequency. Nightmares also have to be distinguished from bad dreams, which are less emotionally intense. Furthermore, nightmares contain more stories of aggression than bad dreams and more unhappy endings. Finally, people experiencing nightmares feel more fear than for bad dreams.

Describe REM sleep behavior disorder (RBD) symptoms, prevalence, and treatment.

REM sleep behavior disorder (RBD) occurs when the muscle paralysis associated with the REM sleep phase does not occur. Individuals who suffer from RBD have high levels of physical activity during REM sleep, especially during disturbing dreams. These behaviors vary widely, but they can include kicking, punching, scratching, yelling, and behaving like an animal that has been frightened or attacked. The prevalence of REM sleep behavior disorder (RBD) is approximately 0.5%-1% in the general population and 2% in older adults. A large number of people are undiagnosed. The male to female diagnosis ratio is as high as 9:1. People with REM sleep behavior disorder (RBD) often have a comorbidity with mental health illness like a mood disorder and take anti-depressants or a history of traumatic brain injury.[2] This disorder is associated with a number of neurodegenerative diseases such as Parkinson's disease. In fact, this relationship is so robust that some view the presence of RBD as a potential aid in the diagnosis and treatment of a number of neurodegenerative diseases (Ferini-Strambi, 2011). Clonazepam, an anti-anxiety medication with sedative properties, is most often used to treat RBD. It is administered alone or in conjunction with doses of melatonin (the hormone secreted by the pineal gland). As part of treatment, the sleeping environment is often modified to make it a safer place for those suffering from RBD (Zangini, Calandra-Buonaura, Grimaldi, & Cortelli, 2011).

Define sleep apnea, the two subtypes, and the most common treatment.

Sleep apnea is defined by episodes during which a sleeper's breathing stops. Sleep apnea episodes can last 10-20 seconds or longer and often are associated with brief periods of arousal. While individuals suffering from sleep apnea may not be aware of these repeated disruptions in sleep, they do experience increased levels of fatigue. Many individuals diagnosed with sleep apnea first seek treatment because their sleeping partners indicate that they snore loudly and/or stop breathing for extended periods of time while sleeping (Henry & Rosenthal, 2013). There are two main types of sleep apnea: obstructive sleep apnea, listed as obstructive sleep apnea hypopnea (OSAH) in the DSM-5, and central sleep apnea. Obstructive sleep apnea occurs when an individual's airway becomes blocked during sleep and air is prevented from entering the lungs. It is diagnosed if a person has at least five obstructive apneas per hour of sleep combined with breathing disturbances such as snoring and daytime sleepiness or at least fifteen obstructive apneas per hour of sleep without other symptoms. The apnea is characterized by at least ten-second disturbances in breathing. In central sleep apnea (CSA), disruption in signals sent from the brain that regulate breathing cause periods of interrupted breathing (White, 2005). Central sleep apnea is less common than obstructive sleep apnea hypopnea (OSAH) and is more commonly associated with illnesses. One of the most common treatments for sleep apnea involves the use of a special device during sleep. A continuous positive airway pressure (CPAP) device includes a mask that fits over the sleeper's nose and mouth, which is connected to a pump that pumps air into the person's airways, forcing them to remain open, as shown in Figure 1. Some newer continuous positive airway pressure (CPAP) masks are smaller and cover only the nose. This treatment option has proven to be effective for people suffering from mild to severe cases of sleep apnea (McDaid et al., 2009). However, alternative treatment options are being explored because consistent compliance by users of continuous positive airway pressure (CPAP) devices is a problem. EPAP (excitatory positive air pressure) device has shown promise in double-blind trials as one such alternative (Berry, Kryger, & Massie, 2011). Treatment of sleep apnea also involves treading comorbid medical conditions, sometimes through surgery or medications.

Describe how hormones and sleep interact.

Sleep-wake cycles seem to be controlled by multiple brain areas acting in conjunction with one another. Some of these areas include the thalamus, the hypothalamus, and the pons. As already mentioned, the hypothalamus contains the SCN—the biological clock of the body—in addition to other nuclei that, in conjunction with the thalamus, regulate slow-wave sleep. The pons is important for regulating REM sleep (National Institutes of Health, n.d.). Sleep is also associated with the secretion and regulation of a number of hormones from several endocrine glands, including melatonin, follicle stimulating hormone (FSH), luteinizing hormone (LH), and growth hormone (National Institutes of Health, n.d.). You have read that the pineal gland releases melatonin during sleep (Figure 2). Melatonin is thought to be involved in the regulation of various biological rhythms and the immune system (Hardeland et al., 2006). During sleep, the pituitary gland secretes both FSH and LH, which are important in regulating the reproductive system (Christensen et al., 2012; Sofikitis et al., 2008). The pituitary gland also secretes growth hormone during sleep, which plays a role in physical growth and maturation as well as other metabolic processes (Bartke, Sun, & Longo, 2013).