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Sleep Disorders Medicine In Psychiatry

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Sleep Disorders Medicine In Psychiatry Alan B. Douglass MD, FRCPC, Dip. ABPN, Dip. Amer. Board of Sleep Medicine Asst. Professor, Dept of Psychiatry, University of Ottawa – PowerPoint PPT presentation

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Title: Sleep Disorders Medicine In Psychiatry


1
Sleep Disorders Medicine In Psychiatry
  • Alan B. Douglass
  • MD, FRCPC, Dip. ABPN, Dip. Amer. Board of Sleep
    Medicine
  • Asst. Professor, Dept of Psychiatry, University
    of Ottawa
  • Medical Director, Sleep Disorders Service, Royal
    Ottawa Hospital

2
Introduction
  • Financial Disclosure Nothing to declare
  • Today we will cover
  • Basic sleep physiology
  • Narcolepsy a disorder of the REM control system
  • Periodic Limb Movement Disorder
  • Obstructive Sleep Apnea
  • Insomnia diagnosis treatment

3
DSM-IV-TR
4
Great clinical textbook (Mayo Clinic, 2004)
5
Sleep waveform schematic
6
Sleep Stage by Age
7
Stg
8
EEG Frequencies
EEG Type Hz. Sleep Stg.
Delta 0.5 - 3 SWS
Theta 3 - 7 REM
Alpha 8 - 12 Wake
Beta 16 - 25 Wake
Spindle 12 - 14 Stg. 2 - 4
Gamma 20 - 50 REM, wake
9
10-20
The 10 20 system of EEG electrode placement
(C3 / C4 in yellow where sleep is scored).
10 20 electrodes
10
Wake gt Sleep Transition
Wake gt Sleep Transition
R K 1968
11
Stage 2 Sleep
R K 1968
12
Stage 4 Sleep
13
REM sleep onset
Onset of REM
R K 1968
14
Sleep Histogram
RL
15
24-hr Sleepiness Profile
16
Multiple Sleep Latency Test (MSLT)
17
Sleep Restriction
MSLT
18
Narcolepsy MSLT, SOREMs
19
Whole Brain
mid-saggital section. Netter / CIBA
20
Neurotransmitters in Sleep
REM only time of day when monoamines not firing
!
21
REM Control Nuclei
Biological Clock
OREXIN
REM induces muscle paralysis
22
Monoamines controlled by Orexin
SCN clock
DA ()

Orexin / Hypocretin
Histamine ()
5HT ()
NA ()
23
REM Control
REM Trigger nucleus reticularis pontis
oralis
24
Orexin-Hypocretin projections
25
Narcolepsy -- Cataplexy
26
Narcolepsy night sleep
27
Narcolepsy Tetrad (4 symptoms)
  • True sleep attacks
  • Falls asleep without warning, unusual situations
  • Cataplexy
  • Flaccid muscle paralysis eyes and diaphragm OK
    pt. remains awake but paralyzed.
  • Hypnagogic / Hypnopompic hallucinations
  • Multimodal visual, tactile, auditory, smell.
    Often highly emotional, sexual, frightening
  • Sleep Paralysis
  • Awakes unable to move anything but eyes. Cant
    breathe voluntarily or talk. HH often occur here
    too.

28
Narcolepsy age of onset
Silber 2004, p.97.
29
Narcolepsy Biology
HUMAN DOG
Orexin / Hypo-cretin cells Destroyed by immune system Normal
Orexin receptors Normal Genetic abnormality, inactive
REM intrusion (SP, Cataplexy)
30
Narcolepsy Treatments
  • SLEEPINESS
  • Stimulants (noradrenalin receptor agonists)
    amphetamine, methylphenidate, modafinil.
  • CATPLEXY
  • Antidepressants that increase serotonin and or
    noradrenaline and block ACh, i.e. clomipramine,
    venlafaxine.

31
Narcolepsy versus Schizophrenia
Apparent Schizophrenic Hallucinations

Actually Daytime REM sleep intrusion
Narcolepsy
  • 90 aassociation of narcolepsy with an HLA
    antigen DNA fragment (DQB10602) allows inverse
    screening of schizophrenics for narcolepsy
  • Narcolepsy is detectable in sleep lab (MSLT) but
    pt. must be medication-free for at least 3 weeks.

32
Worm in lateral hypothalamus causing
narcolepsy. (neurocysticercosis) J. Clin. Sleep
Med. 1(1) 2005, p. 41.
33
Obstructive Sleep Apnea
34
(No Transcript)
35
Normal
36
Sleep Apnea
37
OSA Clinical Symptoms
38
Clinical Applicability Apnea
  • Sleep apnea and depression share clinical
    features apnea can produce secondary depression.
  • Serious sleep apnea can cause sufficient
    impairment to suggest dementia severe snoring in
    a demented patient could be a treatable
    illness.
  • Apnea or PLMD can cause sleep deprivation which
    can cause relapse of mania or depression.

39
Restless Legs Syndrome / Periodic Limb Movement
Disorder (RLS-PLMD)
40
Periodic Limb Movement Disorder
41
RLS PLMD neurochemistry
  • Likely due to iron deficiency in basal ganglia
    (Fe is co-factor for enzymes that synthesize
    DA).
  • May predict onset of syn-nuclein-opathies (REM
    behaviour disorder, PSP, Parkinsons, Lewy Body
    dementia).

42
RLS PLMD Sx and Tx
  • SYMPTOMS
  • Late evening / night
  • Legs cramp, squirm, move by themselves
  • Multiple awakenings
  • Charley Horses
  • Cant tolerate legs being immobilized
  • Worse in elderly
  • TREATMENT
  • Check Fe, ferritin, B12, folate
  • Dopamine agonists (L-DOPA, ropinirole,
    pramipexole)
  • Benzodiazepines or opiates now 2nd line
  • Quinine obsolete

43
Polysomnographic Abnormalities In Psychiatric
Patients
44
Sleep Abnormalities in Psychiatry
  • Benca, 1992
  • Meta-analysis of sleep in all major psychiatric
    disorders showed affective disorders had the
    largest and most consistent differences from
    controls.
  • Kaneko, 1981
  • Extremely short nocturnal REM latency is common
    to both psychiatric disorders and narcolepsy

45
Psychiatric Sleep Measurements
  • Sleep Latency (SL) sleep onset defined as first
    3 contiguous 30-sec. pages of Stage 1 sleep
  • REM Latency (RL) time from sleep onset to first
    epoch of REM sleep
  • REM Latency Minus Awake (RLMA) subtract any
    interposed pages of waking from the RL
  • Eye Movement Density in REM Sleep (REM Density,
    RD) the actual number of eye movements divided
    by minutes spent in REM

46
REM Latency (RL RLMA)
  • RL varies inversely with age is highly
    prevalent in affective disorders.
  • RLMA has statistical properties that are superior
    to RL (smaller variance, more normal
    distribution).
  • RL is shortened by cholinergic agonists
    (arecoline, pilocarpine, physostigmine).
  • Prolonged by anticholinergics (benztropine,
    trihexyphenidyl, diphenhydramine).

47
MDD sleep features
  • Long initial insomnia, early morning wakening
  • Shallow sleep, easily awakened
  • Non-refreshing sleep
  • Short RL RLMA normalized by SSRI
    (antidepressants are REM suppressants because
    they increase neurotransmission in serotonergic
    and adrenergic pathways).
  • High REM density (also a good predictor of
    eventual depression in a never-ill person)

48
MDD (cont.)
  • Some powerful sleep mechanism underlies the
    expression of depression
  • Total sleep deprivation or selective REM
    deprivation dramatically improves mood of
    severely depressed patients (benefit is lost
    after one nights sleep or even short nap)
  • Amount of Non-REM sleep in nap predicts worsening
    of mood

49
Bipolar Disorder vs. MDD
  • MDD patients typically have reduced total night
    sleep, but normal day alertness
  • Depressed bipolar patients in often have excess
    sleep (up to 18 hours/day), crushing fatigue when
    awake, ravenous appetite, weight gain
    atypical depression.
  • Switch process in bipolars often occurs during
    sleep.

50
Bipolar Disorder vs. MDD
Excessive sleeping Crushing fatigue Extreme
appetite
Actually Depressed Phase of Bipolar Disorder
Atypical Depression
DDx Narcolepsy, Idiopathic Hypersomnolence
51
Bipolar Disorder with Narcolepsy
These 2 illnesses when found together give a
misdiagnosis psychotic bipolar,
schizo-affective
52
Alcoholism
  • Acute administration of alcohol produces REM
    suppression, then

Hallucination visual, gustatory, tactile
dream-like imagery
Actually REM sleep without physiological
paralysis
Withdrawal after chronic alcohol intoxication
53
Management of Insomnia
54
Causes of acute insomnia
  • Stressful personal events child is sick,
    financial crisis, fire damages the house, natural
    disasters.
  • Impending stressors exams, marriage, moving
    away from home, court appearance.
  • Acute illness medical, surgical, especially if
    painful.

55
. . . acute insomnia 2
  • Note all of these conditions are likely to be
    self-limited, resolving in days to a couple of
    weeks, and could occur to almost anyone. This
    matches the federal licensing conditions for all
    marketed hypnotic drugs (CPS 2009, p. 1132)
    Treatment with Imovane should usually not
    exceed 7 10 consecutive days. Use for more
    than 2 3 consecutive weeks requires a complete
    reassessment of the patient. Prescriptions
    should be written for short-term use (7 10
    days) and should not be prescribed in amounts
    exceeding a 1-month supply. The use of hypnotics
    should be restricted to insomnia where disturbed
    sleep results in impaired daytime functioning.

56
. . . acute insomnia 3
  • These conditions also illustrate that a state of
    stress / hyper-arousal is intrinsic in acute
    insomnia. This has been confirmed by measured
    elevations of the following in such patients
  • Whole body metabolic rate
  • Heart rate variability
  • Adrenalin dopamine metabolites
  • Cortisol, ACTH, and CRF
  • Cerebral glucose metabolism (via PET scan).
  • However, some patients have a chronic trait of
    hyper-arousal that can lull the doctor into
    prescribing hypnotics for the long term. This
    may or may not amount to a psychiatric illness.

57
Chronic Insomnia
  • Studies indicate that 45 85 of chronic
    insomnia (defined as lasting 6 months or more) is
    due to psychiatric illness, even if the patient
    will not endorse or admit it. DSM-IV diagnoses
    these patients Insomnia related to another
    mental disorder, which includes
  • Anxiety Disorders
  • Obsessive compulsive disorder
  • Panic disorder PTSD
  • Generalized anxiety disorder
  • Hypochondriasis
  • Substance Abuse (especially alcohol cocaine)

58
. . . Chronic insomnia 2
  • Mood Disorders
  • Bipolar disorder, especially mania or hypomania
  • Major depression
  • Dysthymic disorder
  • Psychoses
  • Schizophrenia Schizo-affective disorder
  • Delusional disorder
  • Psychotic affective disorders.
  • Remaining insomnia patients mainly have painful
    or disruptive chronic medical conditions (i.e.,
    diarrhea) or a diagnosable sleep disorder (i.e.,
    sleep apnea).

59
. . . Chronic insomnia 3
  • Yet there appears to be a type of patient with
    chronic insomnia in whom no psychiatric or
    physical diagnosis can be found. These patients
    often have
  • Erratic sleep-wake schedules
  • Poor sleep hygiene
  • Unreasonable expectations about their sleep (I
    have to get 9 hours of sleep each night or Ill
    get sick).
  • A belief that they are not sleeping when sleep
    recordings show that they are.
  • Hyper-vigilance regarding bodily functions
  • Increased sensitivity to the consequences of
    reduced night sleep (I.e., distorted perception
    of daytime deficits).

60
. . . Chronic insomnia 4
  • In the International Classification of Sleep
    Disorders (ICSD), these patients have been
    variously called psycho-physiological / learned
    insomnia, sleep state misperception,
    idiopathic insomnia and inadequate sleep
    hygiene.
  • DSM-IV-TR lumps all of these under Primary
    Insomnia places the threshold for diagnosis at
    one month of symptoms or more.
  • Certain patterns of insomnia have diagnostic
    specificity, I.e., early morning awakening in
    Major Depression, and initial insomnia in anxiety
    disorders.

61
Assessment of Insomnia
  • The Interview is critical. It must include
  • Amount of insomnia (at least 31 min. 3x /week).
  • When did it begin (recent life events and
    stressors).
  • What time do the lights go out when does alarm
    ring in AM?
  • Is there napping in the daytime (causes insomnia
    at night).
  • Is there Shiftwork? How long on one shift before
    rotation?
  • In what part of night does insomnia occur?
  • Is it associated with physical or environmental
    causes?
  • Is there alcohol consumption after 1900h?
  • Is there caffeine consumption after 1400h?
  • Is there stimulant drug use or abuse?
  • If indicated, do a full psychiatric diagnostic
    screening.
  • Consider pain and physical illnesses that could
    cause it.

62
Treatment Plan for Insomnia
Does reassurance support help?
Y
Is the insomnia acute?
Y
Is it ACUTE?
end
N
N

Rx benzos short-term
Identify treat medical, surgical, or
environmental causes
No better? Go to next page
63
Ask psychiatric questions substance abuse,
depression, anxiety
Treat psychiatric illness or refer to
psychiatrist.

-
Physical sleep disorders? Refer to sleep lab if
().
-
Ask sleep hygiene, naps, caffeine, shifts

Counsel pt. yourself
Refer to sleep psychologist, esp. if primary
insomnia

64
When to refer to sleep clinic
  • Symptoms of sleep apnea (obese, snores, HTN,
    weight gain, awakens choking, morning headache).
  • Symptoms of RLS / PLMD legs squirm, cramp,
    tingle after supper and especially at night
  • If nocturnal injuries could be sleepwalking,
    REM Behaviour Disorder, or nocturnal epilepsy.
  • Any chronic insomnia that does not have an
    obvious cause after reasonable investigations are
    negative.

65
Questions ?
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