Sleep Disorders in Psychiatric Patients

When addressing patients with comorbid sleep and psychiatric disorders, three sources of knowledge can be brought to light. I sincerely hope that this book will be useful to all clinicians who encounter sleep disorders and psychiatric disorders.

Foundations

Normal Sleep

Introduction—Definition of Sleep

Whatever the functions of sleep, it is very clear that sleep is essential for all animals, especially during periods of growth. A growing brain needs more sleep than a mature brain; daily sleep amount is highest during periods when the nervous system is developing.

Sleep Architecture

Stage Wake
Sleep Onset
Stage N1
Stage N2
Stage N3
Stage R

Stage R – REM sleep – is characterized by the presence of rapid eye movements (REMs), muscle atony and EEG desynchronization. The functions of REM sleep and dreaming have been the subject of much debate since Sigmund Freud's publication of 'The Interpretation of Dreams'.

The Two-Process Model of Sleep Regulation

The Homeostatic Process (Process S)
Circadian Rhythm (Process C)

REM sleep can help select brain networks that are restored during NREM sleep and ready for optimal functioning during the waking period. Melatonin is secreted by the pineal gland in the dark when the inhibitory signals from the SCN have been removed.

Sleep Across the Lifespan

The Infant
The Child
The Adolescent
The Adult
The Older Person
Conclusion

During the first part of the day, the homeostatic drive is low due to previous sleep. Sleep latency increases with age; this change is much more evident in the older person.

Neuroanatomical and Neurochemical Basis for Sleep Complex neurochemical circuitry is involved in the generation of wakefulness and

Historical Perspectives of the Neurobiology of Sleep
Hypothalamic Areas

The Lateral Hypothalamus
The Ventrolateral Preoptic Nucleus (VLPO)
The Tuberomammillary Nucleus (TMN)

Brainstem Regions

Clinical and Pharmacological Correlates

Reticular Formation
Dorsal Raphe Nucleus (DRN)

Locus Coeruleus (LC)

Basal Forebrain
Control of NREM Sleep
Control of REM Sleep
Muscle Atonia

There is a modest decrease in the percentage of REM sleep and REM sleep in adults. Anatomical sites important in the generation of REM sleep are the pons and caudal midbrain.

Range and Classification of Sleep Disorders

Why Develop a Classification System?
The Evolution of Sleep Disorder Classifications

The International Classification of Diseases (ICD)
The Diagnostic and Statistical Manual of Mental Disorders (DSM)
Diagnostic Classification of Sleep and Arousal Disorders Adding to the mix, in 1979 a third nosological framework entirely different than
The International Classification of Sleep Disorders (ICSD) Introduced in 1990 and revised in 1997, the International Classification of Sleep

Classification Systems Currently in Use

International Classification of Diseases (ICD-10)
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) 2013
International Classification of Sleep Disorders, 3rd Edition (ICSD-3) 2014

Technical Publications and Specifications for Recording and Scoring Sleep and Sleep Disorders
Summary

The first inclusion of sleep disorders occurred in 1977 in the International Classification of Diseases (ICD), published by the WHO. The “primary sleep disorders” were divided into dyssomnias (characterized by abnormalities in the quantity, quality, or timing of sleep) and parasomnias (characterized by abnormal behavioral or physiological events that occur in association with sleep, specific sleep stages, or sleep-wake transitions). ).

Taking a Sleep History

Introduction

Main Complaint

It is particularly useful to determine whether the concern was raised by a patient, a passenger, an employer or a doctor. For example, nightmares and night terrors are often confused, so it is imperative to ask the patient to describe their symptoms in more detail.

Timeline of Symptoms

Patients presenting with sleep disorders may present a very clear description of their problem, but this is not always the case. They may describe their problem in layman's terms, which are at odds with the terminology we use.

Typical Night

What time do they go to bed and what do they do when they go to bed ie. This information can be combined with nocturnal awakening times (see above) to estimate wakefulness after sleep onset (WASO).

Typical Day

Effect on Daytime Functioning
Sleepiness and Fatigue
Occupation and Driving

The importance of this will be elaborated in the section on circadian rhythm disorders. In many countries, sleepiness due to a sleep disorder must be reported to the relevant licensing authority, and patients must be made aware of this.

Assessing Insomnia, Restless Legs and Circadian Rhythm Disorders

Insomnia
Restless Legs Syndrome (RLS)
Circadian Rhythm Disorders

In the absence of a sleep diary, one should inquire about the patient's usual bed and rise times and what times they fall asleep and wake up. Of course, in advanced sleep-wake phase disorder (ASWPD), the patient will be most awake in the early morning and most sleepy at night, and their sleep times will be advanced.

Assessing Parasomnias and Other Night-Time Events It is tempting to think that the diagnosis of parasomnias requires specialist investi-

Sleepwalking
REM Sleep Behaviour Disorder
Nocturnal Epilepsy
Confusional Arousals
Sleep Terrors
Nightmares
Panic Attacks
Hypnagogic and Hypnopompic Hallucinations
Sleep Paralysis

It is very rare for the patient to leave the bed during an episode of RBD. A common presentation, however, is when the patient strikes a blow in his sleep and in this connection throws himself out of bed.

Assessing Excessive Daytime Sleepiness

Insufficient Sleep Syndrome
Obstructive Sleep Apnoea (OSA)
Periodic Limb Movement Syndrome (PLMS)
Central Hypersomnolence

It should be noted that many OSA patients may not even be aware of any of these features. The patient is usually unaware of the leg movements and they can be so subtle that even the bed partner may not be aware of them.

Sleep Diaries

Using Scales
Epworth Sleepiness Scale (ESS) (See Appendix A)

This proves that there is a strong psychological element to insomnia, as they are able to fall asleep easily, except when they are actually trying to sleep. Another very useful aspect of the ESS is that it helps the patient (and doctor) distinguish between sleepiness and fatigue.

Assessing Sleep in a Psychiatric Inpatient Setting

Finally, although the staff can keep a log of the patient's sleep, there is no reason why the patient cannot keep a sleep diary for himself when he is on the ward. It also encourages the patient to be actively involved in managing their sleep and allows them to monitor their own progress as the therapeutic interventions take effect.

Taking a Brief Sleep History

Brief Sleep History Template Epworth sleepiness score: ________

What time do you wake up. this is the last awakening after which the patient does not fall back to sleep). When you fall asleep or wake up, do you ever find yourself completely paralyzed.

Sleep Investigations

Introduction

However, there is also a need for research that goes beyond a superficial understanding of a patient's sleep structure and tells us about the function and quality of an individual's sleep and the interplay between environment, neurobiology, chemistry and genetics. In patients with psychiatric disorders, the incidence of sleep disorders is believed to be very high; yet, examining these patients can be difficult.

In-Laboratory Polysomnography

Technique
Patterns of Disease
Advantages
Disadvantages
Reliability

The second part of the study allows CPAP to be introduced and titrated to control sleep apnea. Meals, alcohol and medications normally taken at home may vary in the sleep lab environment.

Multiple Sleep Latency Test

Technique
Reliability
Maintenance of Wakefulness Test

The patient's sleep architecture in the sleep laboratory may not be the same as at home. The PSG is also used to ensure that the patient has had 6 hours of sleep before the MSLT.

Portable Sleep Studies

Technique
Advantages
Disadvantages
Reliability

The main advantages of a portable sleep study are that it can be performed in the patient's home and has a lower cost. A portable sleep study can also be performed in a psychiatric hospital bed if the patient is unable to undergo a laboratory polysomnography.

Nocturnal Pulse Oximetry .1 Use

Technique
Advantages
Disadvantages
Reliability

The major advantage of pulse oximetry is ease of use, small size and low cost. Nocturnal pulse oximetry lacks sensitivity and specificity in detecting obstructive sleep apnea when compared with (gold standard) nocturnal PSG.

Actigraphy

Advantages
Disadvantages
Reliability

We recommend two consecutive nights of data collection to improve assessment of obstructive sleep apnea severity (Wallberg et al. 2010). Ankle actigraphy is also used to record periodic limb movements in sleep and may be useful in determining treatment response (Sforza et al. 2005).

Other Tests

Nocturnal oximetry for the diagnosis of sleep apnea hypopnea syndrome: a method to reduce the number of polysomnographies. Practice parameters for the use of actigraphy in the evaluation of sleep and sleep disorders: a 2007 update.

Pharmacology of Psychiatric Drugs and Their Effects on Sleep

Introduction
Drugs for Depression
Serotonin Reuptake Inhibitors and Dual Reuptake Inhibitors
Older Dual Reuptake Inhibitors
Monoamine Oxidase Inhibitors (MAOIs)

Rebound Effects of REM-Suppressing Antidepressants

Other Antidepressants

Daytime Sedation

Drugs for Psychosis
Wake-Promoting Drugs
Drugs for Bipolar Disorder
Drugs for Anxiety Disorders
Drugs for Dementia
Other Drugs .1 Sodium Oxybate

Alcohol
Opiates
Ecstasy (3,4-Methylenedioxy-N-methylamphetamine, MDMA)
Cannabis

Impact of These Psychotropic Medications on Sleep Disorders

It is reported to improve subjective sleep in depressed patients, although it has little effect on sleep architecture (Sharpley et al. 2011). Its effects on sleep are shortening sleep latency, reducing arousal, and significantly increasing slow-wave sleep (Moldofsky et al. 2010).

Insomnia

Insomnia: Epidemiology, Subtypes, and Relationship to Psychiatric

Epidemiology
Insomnia Subtypes
Relationship to Psychiatric Disorders
Major Depressive Disorder
Bipolar Affective Disorder
Schizophrenia
Anxiety Disorders
Personality Disorders

The incidence of insomnia is higher in individuals with lower education (Bixler et al. 1979; Ancoli-Israel and Roth 1999; Interestingly, sleep complaints in this study were not objectively supported by actigraphy (Klein et al. 2003).

Insomnia Assessment

Introduction
Taking an Insomnia History

Main Complaint
Typical Night
Daytime Symptoms

Other Sleep Disorders

Circadian Rhythm Disorders
Restless Leg Syndrome
Medical Disorders
Psychiatric Disorders
Medications
Habits

Physical Examination and Investigations
Formulation of the Insomnia

Homeostatic Factors
Circadian Factors
Physical Factors
Mental Factors
Environmental Factors
Medication

In depression in particular, insomnia often precedes depression (Baglioni et al. 2011). The examination is also useful if we suspect that the patient has a circadian rhythm disorder.

The Science and Art of Prescribing for Insomnia

Introduction

Division of Brain Sciences, Center for Psychiatry, Imperial College London, London, UK e-mail: [email protected].

Neurotransmitters of the Sleep-Wake Systems

In addition, the orexin system with cell bodies in the hypothalamus promotes wakefulness by regulating the arousal (and sedative) 'pathway' (Samuels and Szabadi 2008). Sleep is also regulated by a number of neurotransmitters that reduce arousal (see Table 8.1). ; primary among them is gamma -aminobutyric acid (GABA), the most prolific inhibitory neurotransmitter in the brain.

Drugs Which Increase Function of Sleep-Promoting Neurotransmitters

Benzodiazepine-Receptor Agonists (GABA-A-Positive Allosteric Modulators)
Tolerance, Dependence and Withdrawal Considerations with GABA-Acting Drugs
Melatonin
Adenosine

They all work in the same way, but differ in the speed of onset and duration of action. The circadian pacemaker in the suprachiasmatic nucleus (SCN) of the hypothalamus directs the synthesis and secretion of melatonin from the pineal gland.

Drugs Which Decrease Function of Wakefulness- Promoting Neurotransmitters

Histamine (H1 Receptor Antagonists)
Orexin
Drugs for Depression Used in Insomnia

A controlled trial (Riemann et al. 2002) in insomnia at doses of 50-200 mg for 4 weeks found a significant improvement in sleep efficiency, as measured by polysomnography, in parallel with subjective improvements. Paroxetine, a serotonin reuptake inhibitor, was studied in insomnia patients aged over 55 years, at a mean dose of 20 mg for 6 weeks (Reynolds et al. 2006), with improved subjective sleep quality and daytime well-being .

When to Prescribe Drugs for Insomnia

Does the Patient Need a Hypnotic?
Selecting a Medication for Insomnia
Hypnotics and Sleep Apnoea
How to Initiate, Titrate and Monitor Hypnotics
When and How to Discontinue Hypnotics

If taken in the middle of the night, driving is adversely affected (Verster and van de Loo 2017). If sleep significantly worsens, the rate of reduction should be reduced to reduce distress to the patient.

Managing Dependence

Prescribing Medication for Insomnia in Psychiatric Disorders
Schizophrenia
Bipolar Disorder
Anxiety Disorders and Post-traumatic Stress Disorder
Major Depressive Disorder
Dementia
Substance Misuse Disorders
Learning Disability

Similarly, there is low-level evidence that clonidine can reduce nightmares and sleep complaints (Lipinska et al. 2016). In fact, alprazolam and clonazepam have not been shown to be superior to placebo (Lipinska et al. 2016).

Cognitive Behaviour Therapy for Insomnia in Co-morbid

Introduction

Insomnia as a Co-morbid, Rather Than
Evidence for CBT in the Management of Insomnia with Co-morbid Psychiatric Disorders
An Outline of CBT for the Treatment of Chronic Insomnia A plethora of behavioural and cognitive techniques have been validated for the
CBT for Insomnia Associated with Depressive Disorders It is very common for patients presenting with depression to also report difficulty initiat-

CBT for Insomnia Associated with Bipolar Affective Disorder

CBT for Insomnia Associated with PTSD
CBT for Insomnia Associated with Alcohol Dependence
CBT for Insomnia Associated with Psychosis

7Individual sleep diary, ISI, actigraphy, HRSD17 DepressionWatanabe et al. 2011)Po STAUSE Sleep education, sleep hygiene, sleep reprogramming, stimulus control, relapse prevention. However, as in Currie et al.'s investigation, CBT-I had little effect on alcohol consumption.

Practical Considerations for the Implementation of CBT for Insomnia

Accessing Therapy
Anatomy of CBT-I
Who Is Appropriate for CBT-I in Co-morbid Insomnia?
Special Considerations for Conducting CBT-I in Co-morbid Psychiatric Disorders

Depression
Bipolar-Affective Disorder
Anxiety
PTSD
Alcohol Dependence
Psychosis

CBT for Insomnia with Older Adults
Combined CBT-I and Pharmacotherapy
Is There a Role for CBT-I in Co-morbid Paradoxical Insomnia?

In their pilot study, Myers et al. 2011) report using a simplified model of CBT-I focused on stimulus control as the primary therapeutic intervention.

Other Sleep Disorders

Restless Legs Syndrome

Introduction
Clinical Features
Differential Diagnosis
Impact of RLS on Health
Epidemiology
Pathophysiology
Substances and Medications Exacerbating or Triggering RLS
Management

Furthermore, D2 receptor density in the basal ganglia is inversely correlated with the severity of RLS (Connor et al. 2009). Several therapeutic options exist (Winkelman et al. 2016), but in the UK only three agents are licensed for the indication of RLS.

Circadian Rhythm Sleep-Wake Disorders

Introduction

In humans, the regulation of sleep-wake cycles depends on the precise interaction and counterbalance between the circadian system and the homeostatic sleep process (Borbely 1982). Thus, the adaptation and opposing interactions of these two independent processes affect wakefulness and the timing, amount and architecture of sleep (Dijk and Czeisler 1994;.

Delayed Sleep-Wake Phase Disorder .1 Description

Risk Factors
History
Investigations
Treatment

This suggests that DSWPD may be associated with the severity of psychopathology (Shahid et al. 2012). Furthermore, the long-term effectiveness of chronotherapy is variable, including common reports of relapse (Ito et al. 1993).

Advanced Sleep-Wake Phase Disorder .1 Description

Risk Factors
History