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Sleep Disorders

Sleep Disorders

 

Sleep deprivation is a major cause serious morbidity, including accidents, psychiatric sequelae and quality of life, and has a large economic impact

• v stages Sleep and EEG:

Non-REM Sleep (REM: Rapid Eye Movement)

• Stage 1: mixed frequency, low voltage. Alfa? (8-12 Hz) and Theta? (4-6 Hz.)
• Step 2: low voltage, slower frequency. It contains sleep spindles (12-14 Hz) and wide-ranging 'k' complex
• Stage 3 and 4: large amplitude, low frequency Delta? (2 Hz) waves. Stage 3, according to <50%? waves with sleep spindles. Stage 4 in> 50%? waves, but not sleep spindles. Phase 3 and 4 comprise slow-wave sleep (SWS). As the stages of sleep progress through 1-4 low frequencies increase at the expense of higher frequency that are characteristic of wakefulness.

REM sleep (paradoxical sleep):

The EEG shows a low voltage, the frequency spectrum is mixed with the characteristics of cortical activation. It is associated with rapid eye movements, signs of activation vegetative and paradoxical muscle tone, which is when dreams occur.

Architecture of the dream:

Of awakening, individuals pass through stages 1-4, then in REM sleep. REM sleep alternates with non-REM. REM commitment 20% total sleep time and occurs at intervals 80 to 90 minutes. Stages 3 and 4 constitute 15-20% of total sleep time. Most time is spent in stage 2. SWS occurs especially early on in the dream with REM sleep later. SWS and REM sleep are higher in newborns, and the decrease in amount with age.

Function Sleep:

Theories about the function of sleep include the conservation of energy compared to the brain or body restoration. REM sleep has been proposed to reflect brain functions, and SWS which will be associated with bodily functions (in relation to the amount of energy it expands, it increases with exercise and decrease with hypothyroidism). It has been suggested that sleep may be basic and optional sleep from observations that:

• Only 30% of the total recover lost sleep after deprivation of sleep, especially SWS and REM.
• Short sleepers have early sleep pattern similar to that already ties
• Gradual reduction up to five hours sleep is well tolerated.

Sleep Control:

The reticular activating system is involved in the excitement, and induction Sleep is active rather than passive process. The Yerkes-Dodson curve describes the phenomena of increasing decline in performance with increasing excitement. The peak is reached and faster to overcome the difficult tasks easy. Lack of sleep affects the ability to perform simple tasks, the mundane, but no more complex than require more attention. Drugs can affect performance (through drowsiness) and sleep, for example, antidepressants, antipsychotics, benzodiazepines, antihistamines and alcohol.

• v Clinical Syndromes:

Epidemiology:

• Insomnia: 30% in one year
• Nightmares: occasional in 50% of adults regularly at 1%
• Sleep apnea: 4-8% of men, 2-4% of women
• Narcolepsy: 0.15%

Classifications:

• Dysomnias: sleeplessness
• Medical / psychiatric sleep disorders: that is, secondary
• Parasomnias: abnormal sleep
• specific sleep disorders.

1. Insomnia: it represents lack of sleep, poor sleep quality or reduced daytime performance. It is probably the most common complaints to primary health care, for example in the U.S. prevalence% 42. hypnotic use remains common in spite of changes in the guidelines (especially in this country.) primary insomnia is rare. The causes of insomnia are:

• Psychiatric disorders (36%)
• psychophysiological insomnia "Lack of sleep phobia (16%). Features include: the complaint of insomnia and decreased performance when awake trying too hard to get to sleep, stress, physical symptoms, increased sleep latency, reduced sleep efficiency and increased number of awakenings.
• Drugs, illicit drugs and alcohol (12%)
• Periodic limb movement disorder (12%)
• Apnea sleep (6%)
• Pseudo-insomnia (6%)
• Sleep-wake disorder calendar (6%)
• Medical conditions (6%)

However, social and personal factors are also important in determining which are presented for insomnia report eg women twice as often as men, and rates are higher in the unemployed

2. Parasomnias: These are acute, undesirable phenomena specific physical occurring during episodic or exacerbated by sleep. There is an interaction between psychological (stress esp.), And biological factors. Generally quiet treatment, education and practical advice. They are produced in different stages of sleep:

• Ø SWS: arousal disorders, sleepwalking and night terrors. Sleepwalking is often exacerbated by an extreme sleepiness. Night terrors occur early in sleep, individual is difficult to wake up and in general has no recollection.
• Ø REM sleep: wake patients easily. These are usually nightmares or dream anxiety attacks and scary, with a clear recollection. They may be related to psychological precipitating factors, fever or withdrawal (BDZ, antidepressants, alcohol). Other conditions are the headaches associated with sleep and sleep-related asthma, REM sleep disorders involving the loss of normal atonia in REM sleep as the individual acts out the dreams that often violent.
• Ø Other Parasomnias: Enuresis (patients can have sleep patterns and therefore can not feel the need to urinate); bruxism (teeth-grinding), head banging, sleep paralysis familiar.

3. Capacities specific disorders:

• Ø Narcolepsy is characterized by hypersomnia, cataplexy, sleep paralysis and hypnagogic hallucinations (tetrad Gelineau's syndrome). 50% also have significant affective disorder and / or personality problems. Suggests a genetic etiology such as family history common and HLA-DR2 in 99%. The onset is usually in their teens or twenties. Sleep attacks are irresistible in boring situations (like this conference!) and cataplexy is often related to emotions. There is a short REM latency. The narcolepsy can be treated with psychostimulants, and support groups are helpful.
• Ø periodic limb movement disorder: there are repetitive and stereotyped movements during sleep and the patient is often unconscious. It may lead to poor sleep and daytime fatigue, depression and also anxiety. Located in narcolepsy, apnea, obstructive sleep Parkinson's disease and metabolic disorders. It can be aggravated by the tricyclic and BDZ withdrawal.
• Kline-Levine Ø syndrome: this generally occurs in adolescence and is characterized by periods of hypersomnia and overeating, often with changes in libido.

4. Other sleep-related problems:

• Ø Circadian rhythm disorders: Explains the changes over time sleep, such shifts in people with jet lag.
• Ø daytime sleepiness: narcolepsy, apnea obstructive sleep motor disorders associated with sleep, depression, post-viral fatigue, head injury, metabolic disorders, toxic and factors drug related, essential hyper-drowsiness and older can cause daytime sleepiness.
• v Evaluation
• patient's description of the problem, including the onset, duration and sleep quality, daytime sleepiness or reduced performance and any
• Objective observations of the patient and spouse or family member.
• Possible general medical, psychiatric or drug problems.
• Details environment and sleep hygiene
• history of drugs, both prescription and recreational.
• Current circumstances and stress
• The daily sleep including caffeine, alcohol and drugs.

People often overestimate the amount of time to sleep, even to the extent in good sleepers and poor sleep patterns may be similar. However the amount of sleep can be invoked in assessing the presence of insomnia.

• v Management

1. General Tips:

• Treatment of any underlying cause.
• Education and advice on sleep hygiene.
• Optimization of the temperature in the room
• Develop a regular routine
• The afternoon exercise
• small food intake in night
• Relaxation techniques
• Advice on solving problems and dealing with intruders thoughts (CBT can be used and has a good evidence-based results.)

2. Role of drugs in the dream:

• a) The drugs used to enhance sleep:

In particular, benzodiazepines (BDZ), which can be used in short-term treatment of sleep deprivation associated with acute stress. BDZ reduce REM and SWS, increase stage 2. Tolerance and rebound of REM sleep occur when treatment is stopped. Barbiturates are and should not be used because of its narrow therapeutic range, the dependence high, tolerance and death in overdose.

Zopiclone (BDZ partial generation, only used as a hypnotic) SWS increase and although the first reports claimed less tolerance and dependence, this has been questioned recently.

New melatonin derivatives has been licensed medicines only for sleeping, some point the evidence towards better outcomes with the elderly, and may be autism. They have few side effects and do not interfere with the architecture of sleep.

• b) Medications used to reduce sleepiness:

These are the amphetamines example, pemoline and selegiline. These reduced total sleep, REM and SWS, delayed sleep onset and cause fragmented sleep.

• c) The drugs used to treat psychiatric disorders:

• Antidepressants: some are warning, for example, Prozac (fluxoetine), MAOIs, some are sedative, which is usually related to their anticholinergic properties (most of tricyclic) or antihistamines (Mirtazepine). In general, antidepressants suppress REM sleep. Interestingly, sleep deprivation is still used as a treatment for depression and the objective is to reduce REM sleep.
• Mood-stabilizers: Lithium reduces sleep REM and the emergence of delay. Carbamazepine reduces REM sleep and increased SWS, and may cause initial drowsiness.
• Anti-psychotic: These reduce the periods of wakefulness, increased or decreased REM sleep, depending on the dose. Total and REM sleep are reduced to the stop.

• d) "Psychotropic Drugs No:

These may affect sleep cross the BBB, or to cause or exacerbate a disorder that disrupt sleep (eg sleep apnea). Common causes of sleep disturbance are appetite suppressants, antiemetics, antihistaminics, corticosteroids, cardiovascular drugs, and hormones.

 

• e) recreational drugs:

• Alcohol promotes sleep in small quantities nut quantities major causes insomnia later in the night due to the recovery and withdrawal effects. Its effect depends on the level of sleep deprivation, and interactions with other drugs.
• Nicotine can disrupt sleep.
• Caffeine causes a number of increased arousal and decreased REM sleep. It has a half life of five hours. The withdrawal symptoms that occur also disrupt sleep.

• f) Illicit drugs:

• Cannabinoids reduce REM sleep and increased SWS at first, but decreases after several days. Regular use results in excessive sleepiness and fatigue, with sleep disturbances during withdrawal.
• Narcotic analgesics cause a state of drowsiness followed by reduced REM and SWS. Sleep disorders occur during the withdrawal.
• Cocaine reduces total sleep, SWS and REM sleep. Excessive sleepiness occurs withdrawal (bounce).
• Hallucinogens (LSD, for example) do not affect sleep directly, except for "bad trips"

• g), Drug withdrawal:

Sedatives and hypnotics cause rebound insomnia usually for a week, but can be up to two months. Insomnia is more serious but less protracted drugs with shorter half-life. Chloral hydrate gives less problems with the withdrawal, but is less effective.

Abrupt discontinuation of antidepressants may lead to rebound insomnia, short-lived and panic. Antipsychotic drugs rarely cause addiction or withdrawal (Therefore small doses, below the therapeutic doses for treatment of psychosis, are used to aid sleep in some patients)

Reference:

1. C. Shapiro ABC of sleep disorders. London: BMJ Publishing Group, 1993.

2. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

3. Smith G et al. Key topics in psychiatry. Biographies of scientists Publisher Limited, 1996.

4. Boyle D, Davies S. Psychiatric intensive Mosby 2002

About the Author

Prof. Saoud Al Mualla (M.B, MSC, M.D, Dip, MRCPsych)