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Sleep Disorders – Something You Always Want Know About

Definition
A sleep disorder (somnipathy) is a medical disorder of the sleep patterns. It’s important to understand why sleep disorder can deteriorate your health and interfere with normal physical, mental and emotional functioning as it effects your nervous system in the production of the natural hormone melatonin which is necessary for sleep and wakefulness. Polysomnography testing can help to evaluate and detect the patterns of sleep disorder.

The basic of sleep
Why sleep is so important, you might already know that a normal night of sleep is about eight hours as recommended by most doctors. Why it is important, because during sleep our bodies repair the wear ant tear of muscle tissue, consolidate memories, and release hormones to regulate our growth and appetites and enhance the immune system, etc. The effect of disorder sleep can reduce the functions of the immune system in fighting against disease and sickness.

Most Common sleep disorders – The symptoms
1. Primary insomnia
Most of us might find hard to sleep and maintaining sleep sometime during our life time because of what ever reasons, but prolonged period of difficulty initiating or maintaining sleep, or both without primary reason is considered the medical issue as chronic insomnia. It effects about 10% of general population.

2. Bruxism
Bruxism is a condition in which you grind, gnash or clench your teeth while sleeping, involuntarily.

3. Delayed sleep phase syndrome (DSPS)
Delayed sleep phase syndrome affects about 10% of all chronic insomnia cases. It is defined as a sleep disorder of people who have a natural inclination to go to bed later other than normal sleep routine and difficult to wake up at the desired time as it also interferes with daily activities, such as school or work, that requires to wake up earlier than would otherwise be natural, leading to sleep deprivation and other issues.

4. Hypopnea syndrome
Hypopnea Syndrome is a condition in which an individual experiences overly shallow breathing or a abnormally slow rate of airflow during sleep, leading to disruption in breathing causes lower oxygen absorption that affect the blood oxygen level that disrupts the stages of sleep. Individual with hyponea syndrome even though get full night sleep but still feels tiredness at daytime.

5. Narcolepsy
Narcolepsy is a chronic neurological disorder caused by the brain’s inability to regulate sleep-wake cycles normally, causing overwhelming daytime drowsiness, leading to extreme fatigue and possibly falls asleep at inappropriate times that interferes with daily routine activities. People with narcolepsy often find it hard to stay awake for long periods of time.

6. Night terror
Night terror is defined as a health condition with characteristic of fear, flailing and screaming while asleep. It is most happened to children with age two to six and affects about fifteen percent of all children. Night terror often is paired with sleepwalking.
7. Parasomnias:
Parasomnias are sleep disorders characterized by abnormal and unnatural movements, behaviors, emotions, perceptions, etc. including bedwetting, sleepwalking, nightmares.

8. Periodic limb movement disorder (PLMD)
Periodic limb movement disorder (PLMD) is a condition in which a person crampsor jerks the legs repetitively and uncontrollably during asleep causing excessive daytime sleepiness and falling to sleep during the day. PLMD can occur at any age but happens most common in middle-aged and older people.

9. Rapid eye movement behavior disorder
Rapid eye movement behavior disorder is a sleep disorder characterized by abnormal behavior while sleeping with rapid eye movement. It is mostly associated with the elderly with neurodegenerative disorders.

10. Restless legs syndrome (RLS):
RLS is a neurological disorder characterized by an irresistible to move your legs while you’re sitting or lying down due to comforting if stop.

11. Situational circadian rhythm sleep disorders
Circadian rhythm sleep disorders is characterized as health condition of disruptions in a person’s circadian rhythm, leading to excessive sleepiness and a lack of daytime alertness that interferes with normal work, school, and social needs.

13. Sleep Apnea
Sleep Apnea is a common disorder in which you have one or more abnormal pauses in breathing or shallow breaths during sleep. Each pause in breathing called an apnea can last for a few seconds but sometime minutes. This types of abnormal breathing can occur 30 times or more in an hour.

14. Sleep paralysis
Sleep paralysis consists of a period of inability to perform voluntary movements either at sleep onset (called hypnogogic or predormital form) or upon awakening (called hypnopompic or postdormtal form). It can occur in healthy persons or may be associated with excessive daytime sleepiness, a sudden loss of muscle tone, etc.

15. Sleepwalking
Sleep walking or somnambulism is defined as an disorder of is a disorder of walking or doing any activity when sleeping.These activities can be as benign or extremely hazardous.

16. Nocturia
Nocturia or nycturiais a condition in which you need to get up during the night to go to washroom to urinate.

17. Somniphobia
Somniphobia or hypnophobia is an abnormal fear of sleep. It may result from a feeling of control loss, anxiety around bedtime, panic attacks, repeating nightmares, etc.

18. Etc.

Causes and Risk Factors
1. Genetics
Narcolepsy is a type of neurological sleep disorder caused by a number of genetic abnormalities such as Chromosome 6 also known as the human leukocyte antigen system, inherited from parents affecting certain biologic functions in the brain, together with other environmental factors during the child early brain’s development.

2. Working the night shift
Working night shift may interfere with the brain natural production of the sleep hormone serotonin and normal functions of the inner biological clocks, leading to drowsiness. If this type of problem happened in a prolonged period of time may cause sleep disorder.

3. Medications
Certain types of medicines such as medication for high blood pressure, oral contraceptives, diet pills, anti depression, etc. and medication with with caffeine can increase the risk of sleep disorder.

4. Aging
The risk of sleep disorder increases with age as over half of adults over the age of 65 have some sort of sleep disorder.

5. Smoking
Cigarette contains high amount of nicotine, a stimulant which can cause sleep disorder as researchers found that smokers enhances daytime sleepiness more than do nonsmokers, especially in younger age groups.

6. Illegal drugs
Illegal drugs interfere natural brain normal functions in productions of certain hormones and blocks certain chemicals’ function in transporting important neural signals, leading to sleep disorder.

7. Alcohol
Although it is considered as a sedative or calming drug, but it increases the number of times a person awakens in the later half of the night, leading to lead daytime fatigue and sleepiness causing alcohol-related sleep disorders.

8. Etc.

Improve your diet
1. Tryptophan rich foods
Tryptophan is an essential amino acid, the precursor to serotonin, in turn, converted to melatonin, via N-acetyltransferase and 5-hydroxyindole-O-methyltransferase activities which are necessary neurotransmitter responsible for transmitting nerve impulses in the brain and induce relaxation and natural sleep, but high levels of tryptophan can increase the risk of drowsiness and cause harmful harmful effects of the age-related increase in brain serotonin. Intake food rich of tryptophan from the food below.
a. Chicken breast and Turkey
b. Tuna
c. Soybean
d. Beef
e. Lamb
f. Halibut
g. Shrimp
h. Salmon
i. Etc.

2. Carbohydrate
Eating foods with
high in carbohydrate stimulates the pancreas in production and releasing insulin in the blood stream as it also reduce others amino acids which would otherwise complete with trytophan, leading to the production of serotonin, which in return enhances the production melatonin, the natural sleep induced hormone.
a. Bread and pasta
b. Whole gain cereal
c. Potatoes
d. Apple pie and
e. Ice cream
f. Oatmeal and raisin cookies
g. Etc.
High amount of simple carbohydrate over prolonged period of time can increase the risk of type II diabetes due to over work that diminishes the function of pancreas in production of insulin. It If you are any symptom of sleep disorder, eating turkey combined with complex carbohydrate rich foods would be a better choice for meat and glucose. What is your choice?

3. Chlorophyll
All green plants including algae contain at least one type of chlorophyll, the green pigment of plants which allows plants to absorb sun light and convert them into usable energy. Beside it is best known as oxygen uptaker to the blood, it is also important to calm the nervous system, to induce sleep due to rich amount of magnesium.
a. All dark green plants( Roman lettuce is the best choice)
b. Algae (Fresh water organic growth is the best choice)
c. Etc.

4. Magnesium
Magnesium is a natural sedative and stabilization of abnormal nerve excitation as it is used in conjunction with other medication to treat depressed elderly type 2 diabetics.. The mineral is important in manipulating of ATP, DNA, and RNA and many enzymes.
a. Leaf green vegetables (due to high amount of Chlorophyll)
b. Almonds
c. Sesame seed
d. Blackstrap molasses
e. Brewer’s yeast
f. Whole grains
g. Etc.

Improve your Lifestyle
1. Cut down intake of alcohol, cigarettes and caffeine
Alcohol, cigarettes and caffeine are stimulant, some may have health benefits for the short time, but prolonged of period of using them can cause tension of nervous system, affecting the brain in transmitting information between nerve cells and cells in other parts of the body, causing many kinds of disorder, including sleep disorder.

2. Artificial ingredients
Artificial ingredients are man made chemical compounds which have been proven to be harmful to our health and sleep, if eating in measure amounts. Drinking water will keep the body hydrated, dilute toxins concentration and eliminate toxins. Always wash your fruit and vegetables in cold water before eating to prevent pesticides.

3. Toxins induced sleep disorder
Heavy metals and toxic chemicals in the blood can cause sleep disorder. Exposure to heavy metals and toxic chemicals over a prolonged periods of time also interrupt the normal function of brain in production of hormones and damage to the body organs, leading to diseases, including hormone imbalance and sleep disorder.

4. Improve sleep
There are some steps which you can do to improve healthy sleep and prevent to become a victim of sleep disorder. Researcher found that a good night’s sleep not only boosts the immune system in fighting against foreign invasion but also repairs all tear and wear of the body after daily activity in previous day and restore energy and keep you functioning during times when sleep is limited.

5. Eating healthy foods
Eating some kinds of healthy food above enhances the production of serotonin which induces sleep and protects us against the accumulation of toxins by promoting the immune system to cope with today out of our controllable environment hazard.

6. Exercise
Exercise not only improves blood circulation and enhance body movement but also help to cleanse our body organs by eliminating toxins from the blood and lymph system.

7. Weight loss
Weight loss for overweight or obesity person may reduce the symptoms of disorder or cure your sleep disorder entirely. Researcher found that overweight and obese individuals slept less than those of normal weight and sleeping less than 8 hours a day, time of sleeplessness increases proportionally with weight gain of BMI index.

8. Etc.

Detoxification
1. With nutritional supplements
There is no quick way in detoxification, fasting too fast may even harmful to your health. Nutritional supplements not only help to improve our health, restore our energy but also revitalize our metabolism, the chemical processes in our body by restoring and balancing the existing deficiencies of nutrition required by our organs to detox. Types of nutritional supplements used to detox include
a. Beta Carotene
b. Vitamin A
c. Vitamin C
d. Vitamin E
e. Calcium
f. Folate acid
g. Vitamin B Complexes
h. Selenium
i. Zinc
g. Lycopene
k. Etc.

2. With diet
Detox diet is a short-term diet, focused on cleansing environmental and dietary toxins accumulated in our body system, often focused on removing toxins from the body by increasing the frequency of bowel movements and urination, as it provides an optimal conditions for our bodies to focus on self-healing, retore and raise energy levels, enhance organs and system functions, stimulate optimal health, prevent premature aging, disease, etc. by minimizing intake of the amount of toxic chemicals, eating foods with high amount of vitamins, nutrients, antioxidants, high fiber and water.

3. Juice fasting
Juice fasting is a type of fasting and detox diet in which a person consumes only fruit and vegetable juices. Since juice contains little to no fiber, it is often used to cleanse your body toxins by expelling waste from the intestines and colon.The below are used generally in juice fasting
a. Vegetables
Celery, cucumber, bell pepper, etc.
b. Leaf Greens
Parsley, kale, beet greens, chard, spinach, etc.
c. Cruciferous vegetables
Broccoli, cabbage, cauliflower, etc.
d. Root vegetables
Carrots, beets, sweet potatoes, etc.
e. Fruits
Dark grapes, apples, lemon, etc.
f. Wheat grass
g. Etc.

For details of foods of above visit 100+ Healthy Foods Classification or
Super Food Health Effects

4. Organs detoxification
4.1. Liver detoxification
Liver is the first line of defense. It helps to regulate the level of cholesterol in the circulatory system by producing bile to the digestive system. It also help to balance our body hormones such as estrogen level in women as well as protecting our body from inflammation. Weakened liver will cause many types of diseases, such as cholesterol and triglyceride building up in our blood, inflammation, hormonal imbalance, etc. The natural remedies used for liver cleansing include
a. Milk thistle
Milk thistle, a flower plant of the daisy family have been traditionally claimed in treating chronic liver disease. It contains silymarin that helps to protect liver function and the liver in expelling toxins.

b. St. John wort
St. John wort is also known as tipton weed or klamath weed. It has been used traditionally in treating depression. It contains different flavonoids and 3-O-coumaroylquinic acid that has anti-inflammation and antioxidant effects by stimulating the immune system in fighting allergies and liver protection from toxins.

c. Fennel
Fennel contains anethole, polymers and essential oil that helps the liver and pancreas in the metabolism of fats and sugars. It also helps to dissolve fat deposits of the body and restore damaged liver cells that cause jaundice, hepatitis and other liver disorders.

d. Etc.

4.2. Lung detoxification
The best lung cleansing method is exercise. Moderate exercise such as walking, Tai chi only helps to improve the respiratory muscle functions, but also helps our lung to expel toxins accumulated through the air. Natural remedies used for lung detoxification include
a. Wild Cherry Bark
Wild cherry bark traditionally has been used to treat irritable and persistent, cough of bronchitis, and pertussis due to increased irritability of respiratory mucosa. Since it has antispasmodic qualities, it has been used with other herbs to treat asthma and enhance relaxation as well as removing toxins from the lung.

b. Platycodon
Root Platycodon has been used in Chinese medicine for over a century in treating abscesses, respiratory disorders, and intestinal disorders. Study shows that platycodon roots not only help to treat coughs due to purulent sputum and inflammation in the chest area but also removes toxins in the lung.

c. Mullein Mullein contains coumarin and rotenone. It has a long history of being used as a medicine and is an effective treatment for asthma and respiratory disorders. Mullein also helps in soothing the mucous membranes, reducing inflammation and encouraging healthy fluid production in the lungs.

d. Etc.

4.3. Bowl detoxification
Bowel detoxification is particularly helpful for improving body conditions and controlling weight loss. It brushes the intestine clean and helps the liver to cleanse toxins rapidly, so you can get rid of all parasites and plaques in your stomach, intestines and colon. The choice of bowl cleansing include
a. Flax seed
Flax seed contains high amounts of omega 3 fatty acid, fiber and lignan that not only helps in controlling cholesterol in the blood stream and provides essential nutrition to our body, its fiber also helps to soften the stool and promote bowel movements for relief of constipation by removing all toxins accumulated in the colon.

b. Psyllium
Psyllium contains about 70% soluble fiber and 30% insoluble fiber. Besides having proven record in Chinese medicine in treating high levels of cholesterol, its fiber portion has been used to treat constipation by softening stools and easing bowel movements.

c. Bentonite
Bentonite is a natural clay that comes from volcanic ash. Taken internally, the adsorbent action of bentonite helps to eliminate and remove toxic material from the intestine.

d. Liquid clay Liquid clay moves through our body and attaches to any bacteria, virus as well as toxins in our intestine and removes them out of our body as wastes resulting in improved intestinal regularity, easing chronic constipation and easing indigestion.

e. Etc.

4.4. Circulatory detoxification
Chelation therapy is the first choice of treatment, with the IV above your head, the substances in the IV help to cleanse the toxic chemicals such as lead, mercury, calcium, etc in your arteries and brain. It is usually applied to people with pre existing heart conditions and between ages of 35-45. Natural remedies include
a. Raw sauerkraut
Sauerkraut is finely shredded cabbage and has been fermented by various lactic acid bacteria with distinct sour flavor. It contains high amounts of vitamin C, lactobacilli and other nutrients that helps to improve blood circulation and increase level of oxygen in the blood stream. It also is said to have done a super job in purifying your blood as well as anti aging effects.

b. Garlic Garlic is nature’s super food. Besides having been used in strengthening the immune system, fighting inflammation and infection caused by bacteria, virus, and chronic illness. It also is a blood thinner, blood purifier as well as increasing the level of oxygen in the blood and improving blood circulation.

c. Dang Qui
Dang qui has been used in traditional Chinese medicine for thousand of years in improving blood quality and purity, and help strengthen the immune system as it supports the body’s removal of toxins in the blood.

d. Etc.

4.5. Skin detoxification
Skin is our body third line of defense. If the weaken liver and kidney can not completely eliminate all the toxins in our body, our body will try to eliminate them through the skin causing certain types of skin diseases such as free radicals.
a. Chromium
Chromium is very important in rejuvenating the skin condition. It helps to balance the blood sugar, and lower stress and depression. Both are main factors that impact skin problems. It also helps to get rid of skin toxins caused by bacteria and virus infection.

b. Zinc
Deficiency of zinc causes the thickening of skin. It is also a powerful antibiotic in treating acne and other forms of skin diseases caused by skin inflammation and toxins accumulation as a resulting of stimulating the release of vitamin A from the skin.

c. Lecithin
Lecithin is a fat-like substance, or phospholipid, produced by every healthy liver that is needed for a healthy skin. Lecithin helps the body in utilizing vitamins A, D, E in fighting against the bacteria and virus that causes skin problems. It also helps to eliminate the toxins on the skin or around the eyes caused by fatty deposits.

d. Strawberry leaf
Strawberries come in endless varieties but all leaves of all strawberries contain healing tannins. It has also been used to aid in the treatment of anemia, eczema, jaundice and other skin problems caused by weakening of the liver.

e. Etc.

4.6. Kidney detoxification
Our kidneys process a special function to eliminate waste products and extra fluids from our blood. The waste and extra fluids flow through ureters as you urinate. If your kidneys are damaged or weakened, the wastes would build up in the blood causing blood poison and damaging other organs. Natural remedies used to cleanse kidney include

a. Dandelion leaf
Dandelion is a rich source of vitamins A, B complex, C, and D, as well as minerals such as iron, potassium, and zinc. Dandelion root has been used for centuries in traditional Chinese medicine in treating liver disease by stimulating the removal of liver toxins. Dandelion leaf on the other hand are used as a diuretic to stimulate the excretion of urine in removing the toxin accumulated in the kidney.

b. Echinacea
Commonly called purple coneflower. It contains a wide variety of chemicals that not only helps to strengthen the immune system but also stimulates the removal of toxins that causes kidney inflammation and infection.

c. Corn silk
Corn silks are the silky fibers that are found under the leaves and on top of an ear of corn. It contains flavonoids, essential oil and minerals that helps effectively in treating acute and chronic inflammation of the urinary system caused by toxins accumulated in the kidney.

d. Etc.

4.7. How to sharpen your brain
The best method to cleanse your brain is oxygen therapy. By providing the oxygen necessary for brain cells needs, it helps to rejuvenate and sharpen the brain cells. Study shows that oxygen therapy helps to restore some cells in patient with Alzheimer diseases. Natural remedies used to sharpen brain functions include
a. Gingko
Ginkgo is perhaps the most widely currently used herbal treatment in memory enhancing. Extracts of Ginkgo leaves contain active and potent form of terpenoids such as bilobalides and ginkgolides that help to enhance the central nervous system functions. Ginkgo should only be taken under the guidance of a knowledgeable medical professional because of risk of bleeding .

b. Rosmary
Rosemary is a hardy bushy perennial shrub with aromatic, evergreen leaves and pale-blue flowers around the stem. It contains phenolic acids , bitter diterpenes, triterpenes, and flavonoids. it is used for headaches, nervous system disorder as well as preventing forming of free radical with its amazing antioxidant properties.

c. Etc.

5. With Melatonin
Beside it is used as a supplement in promoting immune system and anti-aging, melatonin supplement also benefits for varies sleep-wake rhythm. Melatonin pills work quickly, usually people taking the pill fall into sleep in less than an hour. Unfortunately, prolonged period of using the supplement may reduce the functions of endocrine system in production its own melatonin in regulating the sleep cycle if you constantly supply the body with external sources.
Synthetic melatonin is different than natural one, it can cause some unknown long term effects.
Also researcher have not found out the optimal dose to make the supplement working in perfect objective, it is up to individual to experiment with different dose before finding the right dose for their needs.

Treatments
Treatments for sleep disorders generally can be grouped into four categories:
1. Psychotherapeutic treatments
a. Behavior therapy
Behavior therapy is a psychotherapy pproach based on learning theory with purpose to treat sleep disorder by reinforceing desirable habits and eliminating undesired behaviors by replcaing them with more satisfying behavior.

b. Congnitive behavior therapy
Cognitive behavior therapy is another psychotherapy approach and mental health counseling with a purpose to solve problems concerning dysfunctional emotions, behaviors that affect the the sleep patterns by teaching people specific cognitive and behavioral skills to help them control and preventing dysfunctional emotions, behaviors and cognition through a systematic method.

c. Interpersonal therapy
Interpersonal therapy is another form of psychotherapy approach has been used successfully with depressed patients causes of sleep disorder by improving the quality of patient’s interpersonal world, relationships, etc.

d. Gestalt therapy
Gestalt therapy is a psychotherapy approach based on the philosophy of existentialism and phenomenology by emphasizing personal responsibility, focussing upon the individual’s experience in the present and working together (The therapist and patient) work together to help the patient understand the environmental and social contexts of a person’s life. The theory was developed by Fritz Perls, Laura Perls and Paul Goodman in the 1940s and 1950s.

e. Etc.

2. Rehabilitation
Polysomnography is one most common used sleep machine to record patients sleep behavior usually performed at night by monitoring the body functions including brain (EEG), eye movements (EOG), muscle activity or skeletal muscle activation (EMG) and heart rhythm (ECG) during sleep, etc. Once the symptoms of sleep disorder is identified, the specific rehabitation program is desired for the patient to obtain an optimal result.

3. Medications
Medication used depending to particular sleep problems of each individual
a. Anti-Parkinsonian drugs (dopamine agonists)
Used to treat restless legs syndrome and periodic limb movement disorder

b. Benzodiazepines, including in a class of drugs called hypnotics.
Used to treat parasomnias, bruxism (teeth grinding) and short-term insomnia.

c. Non-benzodiazepine hypnotics
Used to treat short-term insomnia.

d. Antinarcoleptics
Mainly used to reduce daytime drowsiness for shift workers or suffered from narcolepsy or sleep apnea.

e. Anticonvulsants
Used to treat nocturnal eating syndrome, restless legs syndrome, periodic limb movement disorder, and insomnia related to bipolar disorder.

f. Etc.

4. Other somatic treatments
a. Surgical treatments
Surgical treatment may sometime is necessary to treat breathing-related sleep disorders in some patients, such as obstruction or airway abnormality.

b. Phototherapy or light therapy
Phototherapy uses bright, specific wavelengths of light in a prescribed amount of time to change the timing of sleep and wakefulness. It is worked specially well for patient with Circadian rhythm sleep disorders such as chronic CRSD, and situational CRSD.

c. etc.

5. Etc.

We will come back with the same subject viewed under the microscope of Traditional Chinese Medicine. At the mean time, enjoy reading.

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Sleep Disorders

Sleep Disorders

 

Poor sleep is a major cause of serious morbidity including accidents, psychiatric sequelae and reduced quality of life, and has a major economic impact

v Stages of Sleep and the EEG:

Non-REM sleep: (REM: Rapid Eye Movement)

Stage 1: mixed frequency, low voltage. Alfa ? (8-12 Hz) and Theta ? (4-6 Hz). Stage 2: low voltage, slower frequencies. Contains sleep spindles (12-14 Hz) and high amplitude ‘k’ complexes Stage 3 & 4: high amplitude, low frequency Delta ? (2 Hz) waves. Stage 3 characterized by < 50% ? waves with sleep spindles. Stage 4 by > 50% ? waves but no sleep spindles. Stage 3 & 4 comprise slow wave sleep (SWS). As sleep progress through stages 1 to 4 low frequencies increase at the expense of the higher frequencies which are characteristic of waking.

REM sleep (paradoxical sleep):

The EEG shows a low voltage, mixed frequency spectrum with characteristics of cortical activation. It is associated with rapid eye movements, signs of autonomic arousal and paradoxical low muscle tones, and this is when dreams occur.

Sleep architecture:

From waking, individuals pass through stages 1 to 4, then into REM sleep. REM sleep then alternates with non-REM. REM compromise 20% of total sleep time, and occurs at 80 to 90 minutes intervals. Stages 3 and 4 comprise 15-20% of total sleep time. The majority of time is spent in stage 2. SWS occurs mainly early on in sleep with REM sleep later. SWS and REM sleep are highest in neonates, and decrease in amount with increasing age.

Function of sleep:

Theories about the function of sleep include conservation of energy versus brain or body restoration. REM sleep has been proposed to reflect brain functions, and SWS to be associated with bodily functions (related to the amount of energy expanded, it is increased with exercise and decrease with hypothyroidism). It has been suggested that sleep can be core and optional sleep based on observations that:

Only 30% of total sleep lost is regained after sleep deprivation, especially SWS and REM. Short sleepers have similar early sleep pattern to longer sleepers Gradual sleep reduction down to five hours is well tolerated.

Control of sleep:

The reticular activating system is involved in arousal, and the induction of sleep is active rather than passive process. The Yerkes-Dodson curve describes the phenomena of increasing then decreasing performance with increasing arousal. The peak is reached and exceeded more quickly for difficult than easy tasks. Poor sleep affects the ability to perform simple, mundane tasks but not more complex ones which require more attention. Drugs can affect both performance (via 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, regular in 1% Sleep apnoea: 4-8% of men; 2-4% of women Narcolepsy: 0.15%

Classifications:

Dysomnias: poor sleep Medical/psychiatric sleep disorder: i.e. secondary Parasomnias: abnormalities during sleep Specific sleep disorders.

1. Insomnia: this represents lack of sleep, poor quality of sleep or reduced daytime performance. It is probably the commonest complaints presented to primary health care; for example in the USA 42% prevalence. Hypnotic use is still common despite changes in guidelines (esp. in this country). Primary insomnia is rare. Causes of insomnia include:

Psychiatric disorders (36%) Psychophysiological insomnia ‘sleeplessness phobia’ (16%). Features include: the complaint of insomnia and reduced performance when awake, trying too hard to get to sleep, tension, physical symptoms, increased sleep latency, reduced sleep efficiency and increased number of awakenings. Medications, illicit drugs and alcohol (12%) Periodic limb movement disorders (12%) Sleep apnoea (6%) Pseudo-insomnia (6%) Sleep-wake schedule disorder (6%) Medical disorders (6%)

However, social and personal factors are also very important in determining who present, for example women report insomnia twice as often as men, and rates are higher in the unemployed

2. Parasomnias: these are acute, undesirable, specific, episodic physical phenomena which occur during, or are exacerbated by sleep. There is an interaction between psychological (esp. stress) and biological factors. Generally treat with reassurance, education and practical advice. These occur in different stages of sleep:

Ø SWS: disorders of arousal; sleepwalking and night terrors. Sleepwalking is often exacerbated by excessive sleepiness. Night terrors occur early in sleep, the individual is difficult to rouse and generally has no recall. Ø REM sleep: patients rouse easily. These are usually nightmares or dream anxiety attacks which are frightening, with clear recall. They may be related to psychological precipitants, fever or drug withdrawal (BDZ, antidepressant, alcohol). Other disorders are sleep-related cluster headaches and sleep related asthma; the REM sleep behaviour disorders which involve loss of the usual atonia in REM sleep so the individual acts out dreams which are often violent. Ø Other Parasomnias: Enuresis (patients may have different sleep patterns and therefore not able to sense the need to urinate); bruxism (teeth-grinding); head banging; familial sleep paralysis.

3. Specific sleeps disorders:

Ø Narcolepsy: characterized by hypersomnolence, cataplexy, sleep paralysis and hypnogogic hallucinations (tetrad is Gelineau’s syndrome). 50% also have major affective disorder and / or personality problems. Aetiology suggests genetic cause as family history is common and HLA-DR2 found in 99%. Onset is generally in the teens or twenties. Sleep attacks are irresistible in boring situations (like this lecture!), and cataplexy is often related to emotions. There is a short REM latency. Narcolepsy can be treated with psychostimulants, and support groups are helpful. Ø Periodic limb movement disorder: there are repetitive and stereotyped movement during sleep and the patient is often unaware. It may lead to poor sleep and daytime fatigue, also depression and anxiety. Found in narcolepsy, obstructive sleep apnoea, Parkinson’s disease and metabolic disorders. It can be aggravated by tricyclics and withdrawal from BDZ. Ø Kline-Levine syndrome: this occurs generally in adolescent boys, and is characterized by periods of hypersomnia and overeating, often with change in libido.

4. Other sleep-related problems:

Ø Circadian rhythm disorders: this describes changes in the timing of sleep, for example in people on shifts and with jetlag. Ø Daytime sleepiness: Narcolepsy, obstructive sleep apnoea, sleep-related motor disorders, depression, post-viral fatigue, head injury, metabolic, toxic and drug related factors, essential hyper-somnolence, and older age can all cause daytime sleepiness. v Assessment Patient’s description of the problem, including the onset, length and quality of sleep, and any daytime drowsiness or reduced performance Objective observations by patient and spouse/relative. Possible general medical, psychiatric or drug problems. Details of sleep environment and hygiene Drug history, both prescribed and recreational. Current circumstances and stress Sleep diary including caffeine, alcohol and drugs.

People often overestimate the length of time to get to sleep, even to the extent that good and poor sleepers can have similar sleep pattern. However the quantity of sleep can be relied on in assessing the presence of insomnia.

v Management

1. General advice:

Treatment of any underlying cause. Education and advice on sleep hygiene. Optimizing the temperature at the room Encouraging a regular routine Exercising late in the afternoon Small food intake in the evening Relaxation techniques Advice about problem solving and dealing with intrusive thoughts (CBT can be used and has good evidence based results).

2. Role of drugs in sleep:

•a)    Drugs used to improve sleep:

Particularly benzodiazepines (BDZ), which can be used in short-term treatment for poor sleep associated with acute stress. BDZ reduce REM and SWS, increase stage 2. Tolerance and REM sleep rebound occur on discontinuation. Barbiturates are no longer should be used due to its narrow therapeutic window, high addictiveness, tolerance and death in overdose.

 Zopiclone (new generation partial BDZ, only used as hypnotic) increase SWS, and although early reports claimed less tolerance and dependence, recently this has been disputed.

New Melatonin derivatives medication has been just licensed for sleep, some evidence point toward better results with elderly, and may be autism. These have few side effects and do not interfere with sleep architecture.

•b)    Drugs used to reduce sleepiness:

These are for example amphetamine, pemoline and selegiline. These reduce total sleep, REM and SWS, delay sleep onset and cause fragmented sleep.

•c)     Drugs used to treat psychiatric disorders:

Antidepressants: some are alerting e.g. Prozac (fluxoetine), MAOI; some are sedatives, which is generally related to their anticholinergic properties (most tricyclic), or antihistaminic (Mirtazepine). In general, antidepressants suppress REM sleep. Interestingly, sleep deprivation is still used as treatment for depression and the target is to reduce REM sleep. Mood-stabilizers: Lithium reduces REM sleep and delay onset. Carbamazepine reduces REM sleep and increase SWS, and can cause initial drowsiness. Anti-psychotics: These reduce periods of wakefulness, increase or decrease REM sleep, depending on the dose. Total and REM sleep are reduced on stopping.

•d)    Non-psychotropic drugs:

These can affect sleep by crossing the BBB, or by causing or exacerbating a disorder which disrupt sleep (e.g. sleep apnoea). Common causes of sleep disturbance include appetite suppressants, anti-emetics, anti-histamine, corticosteroids, cardiovascular drugs and hormones.

 

•e)     Recreational drugs:

Alcohol promotes sleep in small amounts nut in larger amounts causes insomnia later in the night due to rebound and withdrawal effects. Its effect depends on the level of sleep deprivation, and interactions with other drugs. Nicotine can disrupt sleep. Caffeine causes an increase number of arousal and decrease REM sleep. It has a half-life of five hours. Withdrawal symptoms also occur which disrupt sleep.

•f)      Illicit drugs:

Cannabinoids reduce REM sleep, and increase SWS initially but decrease it after several days. Habitual use leads to excessive sleeping and lassitude, with sleep disturbance on withdrawal. Narcotic analgesics cause a drowsy state followed by reduce REM and SWS. Sleep disturbance occurs on withdrawal. Cocaine reduces total sleep, SWS and REM sleep. Excessive sleeping occurs on withdrawal (rebound). Hallucinogens (e.g. LSD) do not affect sleep directly except by ‘ bad trips’

•g)    Drugs withdrawal:

Sedatives and hypnotics cause rebound insomnia usually for one week but can be for up to two months. Insomnia is more severe but less prolonged for drugs with shorter half-life. Chloral hydrate gives fewer problems with withdrawal but is less efficacious.

Abrupt withdrawal of antidepressant can lead to short-lived rebound insomnia and panic. Antipsychotics rarely cause dependence or withdrawal (therefore small dose, below the therapeutic dose for psychosis treatment, are used to aid sleep in some patients)

Reference:

1. Shapiro C. 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. Bios scientific publisher limited, 1996.

4. Boyle D, Davies S. Psychiatry, Mosby’s crash course 2002

 

 

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