Transcript Sleep Disorders 2010

2010 MindBlock & B-to-B
Sleep & Psychiatry
Alan B. Douglass MD, FRCPC, Dip. ABSM
Director, Sleep Disorders Clinic & Lab
Royal Ottawa Hospital
Goals for today
• Avoid duplicating the Neurology sleep
lecture!
• Show International Classification of Sleep
Disorders (ICSD), with examples.
• Show examples specific to psychiatry.
• Physiology of orexin / hypocretin, with
narcolepsy as illustration.
ICSD
summary
1990,
1997
(WHM p. 202)
ICSD 1990, -97
International Classification of Sleep Disorders
• DYSSOMNIA: “either too awake at night or too sleepy
in the day.” Subtypes:
– Intrinsic (physiological or psychological cause): insomnia,
narcolepsy, sleep apnea, PLMD.
– Extrinsic (cause is outside the body): altitude, allergy,
alcohol, noise, sleep deprivation.
– Circadian Rhythm Disturbance: jet travel, shift work,
delayed sleep phase.
ICSD, cont’d
• PARASOMNIA: a “grab bag” of undesirable
physiology associated with sleep:
– Arousal Disorders: sleepwalking, sleep terrors (“night
terrors”), confusional arousals
– Sleep-Wake Transition Disorders: somniloquy, hypnic
jerks, rhythmic movement disorder (pediatrics)
– REM Parasomnias: RBD, nightmares, sleep paralysis
– Other: bruxism, enuresis, SIDS
ICSD, cont’d
• MEDICAL-PSYCHIATRIC disorders: a
sleep abnormality is a major symptom of the
disorder, but not the primary problem:
–
–
–
–
–
Depression (short RL, high RD, insomnia)
Schizophrenia (long initial insomnia)
Alcoholism (REMS and SWS suppression)
Dementias (“sundowning”, RBD)
Infection (sleeping sickness, encephalitis)
“Bad Dreams”
• PTSD:
Traumatic experience that is re-experienced
in the dream. Any sleep stage. Very terrifying, worse
than nightmares. Daytime symptoms also.
• Anxiety Dreams: REM, “bad regular dream”
• Nightmares: REM, intense emotion, awaken with
full alertness / terrified / emotional++ / SNS active.
• Night Terrors: NREM early in night, mainly kids.
Scream++, inconsolable, thrashing, dazed, SNS+++, no
recall in morning. Benign.
Sleepwalking vs. RBD
• Sleepwalking:
– NREM sleep, first 1/3 of night, children and teens; may
persist to adulthood. Not a dream. Confused if awoken.
Simple to very complex behaviour. Rarely violent.
• Sleep Talking:
– Children; NREM; rarely intelligible; often sleepwalk too.
Can persist to adulthood.
• REM Behaviour Disorder:
– Old men; brainstem stroke or degeneration; loss of normal
REM paralysis nuclei; frequently severe injuries; mostly
last 1/3 of night.
NARCOLEPSY
• Remarkable discovery in 2000: a deficit of
orexin (hypocretin) in lat. (perifornical)
hypothalamus is the cause – equal in
importance to discovery of DA deficit in
Parkinson’s Disease in 1960s.
• 1980-99: HLA-DQB1*0602 shows 90%
specificity for narcolepsy in all racial
groups, suggesting auto-immune basis (RR
highest in all of medicine!)
. . . Cont’d
• Understanding the deficit in Narcolepsy
exposes a previously unknown control
system: how circadian information from the
SCN is transduced into alertness &
sleepiness at appropriate times of day.
• Narcolepsy is nothing more than the
randomization of NREM and REM
tendency throughout the 24 hours.
Worm in
lateral
hypothalamus
causing
narcolepsy.
(neurocysticercosis)
J. Clin. Sleep Med.
1(1) 2005, p. 41.
SCN
clock
DA (+)
+/-
Orexin /
Hypocretin
Histam.
(+)
5HT
(+)
NA
(+)
Monoamine
Control by
Hypocretin
Onset of REM Sleep
Onset of REM
R & K 1968
Narcolepsy: MSLT, SOREMs
REM- on / off neurons
REM Control Nuclei
PGO waves trigger EMs
in REM sleep
Periodic Limb Movement Dis.
• Due to low brain iron stores, esp. in basal
ganglia. Low ferritin, B12, folate -- these
are needed to make dopamine.
• Electrodes on anterior tibialis musc. (shins)
• RLS = leg cramps / movements in evening,
before bed. PLMD = same, but in sleep.
• Day symptoms similar to UARS – result of
sleep fragmentation, loss of stages 3 & 4.
PLMD, cont’d
• Worsened by: caffeine, red wine, spices,
SSRI antidepressants
• Helped by: exercise, warm baths, opiates,
stretching, massage, some sleeping pills
• Medical Treatment: dopamine agonists
(ropinirole, pramipexole), or dopamine
“feedstock” L-DOPA.
Sleep
fragmentation due
to PLMD.
(note Stg. 1%)
PLMs
(60
sec.
Page)
REM Behaviour Disorder
• Older men, esp. those with Parkinson’s, or
Lewy Body dementia
• Brainstem damage: n. magnocellularis, n.
paramedianus (REM paralytic pathways)
• Severe brain injuries
• Usually no daytime psychopathology
• This is how the general public conceives of
“sleepwalking” (incorrect: it’s in NREM).
REM Behaviour Disorder
RBD, Treatment
• Antidepressants are almost all REM
suppressants, but they worsen RBD (not
known why).
• Clonazepam (anti-epileptic BZD) is the
treatment of choice.
• RBD can be seen in alcohol withdrawal and
various drug abuse withdrawal.
INSOMNIA
• Lifetime prevalence 30 – 35% (“serious” in 15%)
Much worse in elderly. Sex ratio: F > M.
• Short-term insomnia: days to a few weeks
• Persistent insomnia: months to years. Types:
–
–
–
–
1.) Medical
2.) “Psychological” (co-morbid Psychiatric diagnosis)
3.) Persistent psycho-physiological +/or substances
4.) Primary
Persistent Insomnia Types
• Due to medical problems (i.e.:pain, PLMD)
• 50%+ is due to active psychiatric illness:
(depression, bipolar, schizophrenia). 1/5
depressed patients have hypersomnia (“atypical
depression”, associated with bipolar spectrum
illness); 4/5 have insomnia. Short RL (<65 min,
normal=90), low SWS, high REM density.
Persistent Insomnia, cont’d
• Psychophysiological (“learned” or “behavioral”)
insomnia: patients have chronic muscle tension,
use bedroom for all their activities, “can’t turn my
mind off,” variable bedtime, start projects in late
evening, “neurotic.” May later develop into a
recognizable psychiatric illness. Tx: CBT, sleep
logs, correct erroneous ideas about sleep need,
progressive relaxation, sleep restriction therapy,
circadian rhythm hygiene (sleep study is rarely
necessary). Use of hypnotics to be short-term only.
Insomnia, cont’d
• Substance Abuse insomnia: alcohol, sedatives,
tranquilizers, MJ, cocaine, etc. Treatment is
directed to withdrawal and abstinence. Substances
destroy nearly all normal sleep architecture while
being abused.
• Primary Insomnia:
– Idiopathic, often from childhood
– Sleep state misperception
Insomnia Treatment
• Short-Term Insomnia: forms a huge fraction of
general practice (exam stress, marital breakup,
illness in family, financial). Rx: BZDs,
zopiclone, zaleplon for 1-4 weeks. Talk about the
stressor!! Do not Rx too long.
• Persistent Insomnias: Keep up your search for dx
of depression, bipolar, anxiety. Rx: sedating
antidepressants or mood stabilizers long-term.
Sleepiness & Driving
• Circadian risk:
– shift workers, “on-call” workers (i.e., doctors),
start / stop of daylight savings time ( + 7% change
in accident rate), long holiday drives.
• Alcohol Analogy:
– 17 h without sleep is same as blood alcohol 0.05%
(50 mg. alcohol / 100 ml of blood).
• Duration:
– decreased performance persists for a day or two
after sleep recovery.
Sleep Deprivation & Car
Accidents
(Silber 2004, p. 66)
Driving /Sleepiness: What Kills You
•
•
•
•
•
•
•
Cumulative sleep loss over a week
Speeding
Micro-sleeps (@ 30 m /sec. highway speed)
Decreased peripheral attention
Reduced reaction time
“Automatic driving”
Arousing activities only mask sleepiness;
any alcohol makes it much worse.