Cancer

Patients with cancer also have an elevated likelihood of EDS. Studies indicate prevalence rates of 54-68 for feeling drowsy and 21-40 for being overly sleepy in this population 72,73 . Causes of EDS in this population may be related to an increased risk of primary sleep disorders due to age alone (the average age at onset of cancer is 55 years) or a complex combination of etiologies. These include insufficient sleep due to insomnia, depression, or pain disruption or erratic hormone secretion...

Sleep patterns

Although the assessment of bedtime and sleep patterns is important in the evaluation of any sleep-related complaint, it is a particularly essential component of the evaluation of insomnia (Table 6.1). Patients should be asked regarding these parameters on initial and follow-up visits. These patterns can also be assessed by utilizing patient-completed sleep logs or diaries that track sleep-wake patterns over time (Figure 6.2). Sleep logs and diaries may be more useful than subjective summaries...

Functions of dreaming

Prior to reviewing the major theories regarding dream function, two very important issues have to be discussed. First, it is crucial to differentiate between the physiological level (REM sleep) and the psychological level (dreaming). This was not clarified in one of the first publications on REM sleep deprivation 113 . Since dreaming as subjective experience which is recallable after awakening does not reflect the total brain activity during REM sleep or other sleep stages, the functions of...

Cognitive theories of sleep function memory synaptic plasticity and neurodevelopment

The prevailing view among the general public is that sleep is good for memory and brain plasticity but among sleep scientists this idea has been hotly contested for decades 156-164 . Early critics pointed out that the effects of sleep on various forms of animal learning were inconsistent and confounded by the use of stressful forms of sleep deprivation 61,160 . Nor were the results of early human studies particularly encouraging. Many studies found no effect of sleep loss (generally REM sleep)...

Social and occupational history

Several social or occupational factors can contribute to sleep-related complaints, necessitating evaluation. For example, ES and insomnia are common in shift workers and individuals whose occupations require frequent travel across time zones. Exposure to industrial toxins and chemicals can also produce sleep wake symptoms. Job loss and retirement can result in the loss of regularity in daily schedule, which is important in maintaining circadian rhythm consistency in some individuals, leading to...

Depression in OSA

Depression is the most commonly encountered affective disorder associated with OSA 68 . The prevalence of depression in OSA has ranged from 7 to 63 69 . Early investigations by Guilleminault and colleagues reported that 24 of male patients with OSA had previously seen a psychiatrist for anxiety and depression 70 . A recent epidemiological study of 18 980 subjects representative of the general population in the UK, Germany, Italy, Portugal, and Spain found that 17.6 of subjects with a Diagnostic...

The AIM model

As the reciprocal interaction and activation-synthesis hypotheses evolved, they metamorphosed into the AIM model based on findings in sleep and dream research 23 . Basic sleep research has identified three factors that interact to determine brain-mind state. Whether we are awake (with waking consciousness), in NREM asleep (with little or no consciousness), or in REM asleep (with dream consciousness) depends upon (1) activation level (A) (which is high in wake and REM) (2) input-output gates (I)...

Physical examination

The physical examination can contribute essential information to the process of understanding the etiology of the sleep complaint. Vital signs should include the measurement of neck circumference a thick and or muscular neck, as well as a neck circumference of 16 inches or greater in women and 17 inches or greater in men, are associated with an increased risk for sleep-related breathing disorders 33 . Body habitus should be inspected obesity with fat distribution around the neck or midriff...

Excessive sleepiness ES history of the chief complaint

Sleepiness, the tendency to fall asleep, is a normal phenomenon when it occurs at the desired time of the day. ES is the tendency to fall asleep at inappropriate times or settings 4 . ES should be distinguished from fatigue, which is classically defined as the inability to sustain performance over time and is typically associated with subjective reports of tiredness, Caffeine and alcohol prior to bedtime Nicotine (both smoking and cessation) Large meals or excessive fluid intake within 3 hours...

Insomnia history of the chief complaint

Insomnia is a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and results in some form of daytime impairment 5 . Stated in another way, an insomnia complaint can involve difficulty in initiating sleep, multiple nocturnal awakenings, a difficulty in reinitiating sleep, early morning awakening, or a combination of these. From the standpoint of diagnosis and treatment, it is important to identify the portions of...

Idiopathic hypersomnia

Idiopathic hypersomnia (previously labeled idio-pathic CNS hypersomnia) is a primary disorder of EDS that has historically been given as a diagnosis of exclusion to individuals who complain of EDS when other disorders that cause hypersomnolence have not been found or clearly characterized. There are Table 9.2 Common alerting agents for the treatment of EDS Table 9.2 Common alerting agents for the treatment of EDS Headache, nausea, anxiety, irritability Headache, anxiety, irritability,...

Sleep stages

Human sleep occurs in several cycles of NREM-REM sleep across the night, each approximately 90 to 110 minutes long, which can be further classified into different sleep stages 11 . Sleep stages are identified based on three electrophysiological parameters EEG, EOG, and EMG activity, the latter usually recorded from neck or chin muscles. For clinical and research purposes, sleep is usually scored in 30 second epochs. The criteria of sleep stage scoring, established by Rechtschaffen and Kales...

Neural systems involved in vigilance state regulation REM sleep

Aserinsky and Kleitman in the 1950s first documented the rapid eye movements indicative of REM sleep in humans, and coined the term REM sleep 113,114 . REM sleep mechanisms involve brain regions and systems that differ from those involved with NREM sleep induction and maintenance. Jouvet and colleagues, employing transections, determined that regions of the brain rostral to the midbrain and caudal to the medulla were not necessary for the brainstem activity seen during REM sleep 115,116 ....

REM sleep and the binding problem

One of the most remarkable aspects of waking consciousness is its unity. Consciousness integrates a vast panoply of information into what seems to us to be a simple and continuous flow of awareness. Strands of data from the outside world, from our bodies, and our very complex selves are woven together into a single piece. Our subjectivity may be conflicted but it is always unified. Such an effect can only be achieved by the binding of multiple neuronal representations into an integrated whole....

Sleep architecture

Sleep architecture refers to the organization of sleep across the recording period. Sleep recording is divided into 30-second epochs across the night, and each epoch is classified into a stage based on the predominant pattern (> 50 of the epoch). Sleep stage scoring is a standardized procedure established about 40 years ago 12 and is still routinely employed, with some recent modifications 13 , in clinical and research settings. Sleep scoring provides several measures of sleep quality and...

The reciprocal interaction model

McCarley and Hobson proposed the reciprocal interaction model to explain the transitions into and out of REM sleep states, described by the Lotka-Volterra equations, derived from population models of predator prey interaction 136 . The limit cycle model, an update of the reciprocal interaction model, incorporated circadian and local GABAergic influences on REM sleep regulation 118,137 . As reviewed in Figure 2.5, select cholinergic neurons of LDT PPT increase firing prior to and during REM...

Conclusions and recommendations

Insomnia, ES, and parasomnias are commonly encountered in psychiatric practice. They are the hallmark symptoms of a variety of sleep disorders, many of which will be discussed in greater detail in the ensuing chapters. This chapter has focused on the critical first steps in bridging symptom with disorder, namely the history and examination. These represent the cornerstones of the evaluation process. Below are some key recommendations that emerge from this chapter 1. Develop a systematic process...

Pontine sublaterodorsal nucleus activation during REM sleep

Excitatory cholinergic projections from LDT PPT to regions of the pontine RF may be responsible for some of the characteristic phenomena of REM sleep. One pontine RF region important for muscle atonia, just ventral to LC, was later defined as the perilocus coeruleus alpha in the cat (also termed the subcoer-uleus (SubC) or sublaterodorsal nucleus (SLD) in the rodent). Seminal investigations by Jouvet and colleagues revealed that lesions of the perilocus coeruleus alpha in the cat produced...

Evaluation of the patient with EDS

A detailed history and physical examination are of key importance in evaluating the patient complaining of EDS. Important points of the sleep history that the clinician should document include, but are not limited to, total daily 24-hour sleep time, nightly and daily sleep and nap patterns, time to initial sleep onset, and number and duration of nocturnal awakenings. A sleep log in either narrative or graphical form may be used to characterize a patient's sleep further. When reviewing a...

Summary and conclusions

Psychiatry was born when moral and medical forces combined to separate the mentally ill from common criminals and other social undesirables. In the beginning, the medical model prevailed but no bacteria, no viruses, and no malformations were found in the brains of the vast majority of the severely mentally ill. Frustration with the organic orientation of the field contributed to the uncritical acceptance of the psychoanalytic psychology of Sigmund Freud who based much of his speculation on the...

Somatic theories of sleep function

Sleep has historically been thought of as a time when our body reverses the wear and tear of wakefulness but is sleep fundamentally concerned with somatic functions As reviewed by Akerstedt and Nilsson, mortality rates in short and long sleepers do indicate a link between sleep and physical well-being 46 . Individuals who sleep much more or much less than average have higher mortality rates and greater incidences of myocardial infarction and type 2 diabetes 46 . Sleep also appears to be vital...

Treatment of SWST

The earliest pharmacological agents offered to individuals at serious risk of injury were diazepam 65 and imipramine 66 . Clonazepam has been reported to be effective in doses of 0.25-2.0 mg taken about 30-120 minutes before sleep. When given to 28 54 (51.9 ) patients with SW ST, it produced substantial benefit in over 80 19 . Other agents anecdotally effective include other benzodiazepines, carbamazepine, paroxetine, doxe-pin, trazodone 57 , and melatonin 67 . In cases with less imminent risk...

Epidemiology of restless legs syndrome and periodic limb movement disorder in children

RLS is often considered to be a disease ofmiddle to older age. However, the onset of RLS symptoms during childhood is commonly reported retrospectively by adult patients 4,18 . In fact, recent studies demonstrate that symptoms often start in childhood and early adolescence 22,23 . According to a recent large pediatric population-based study using consensus criteria developed at an NIH workshop 3 (Table 8.3), the prevalence of RLS was 1.9 of 8- to 11-year-olds and 2 of 12- to 17-year-olds,...

Conclusion

In this chapter we briefly reviewed the neurophysi-ology of normal human sleep, including the electro-physiological and neuroendocrine characteristics of the REM NREM sleep stages, and described the elec-trophysiological assessment of sleep disorders with polysomnography PSG . We also discussed the organization of sleep sleep architecture in young healthy adults, and reported the effects of age, psychiatric disorders, and psychoactive medications on sleep architecture. Finally, we presented...