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Sleep Disorders - Lecture notes 13

Clinical Psychology (Bournemouth University)

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 Sleep Disorders

Normal sleep:

Normal sleep is between 6 ½ to 8 hours a night

Our sleep is regulated by circadian rhythms – these are patterns the body goes through, a 24-hour cycle of
(internal) physiological processes – the physical, behavioural and mental changes we go through in a day.

- Knowing when to wake up/go to sleep, body temperature……

- Factors within our body produce circadian rhythms but environmental factors can affect them,
the main factor influencing them being daylight.
- During the day you go through dips in your energy – when you catch up on sleep that’s when
your circadian rhythm will normalise again.
- Your circadian rhythm works better when you have regular sleeping habits.
- When things get in the way of your normal sleeping pattern such as jetlag or shift patterns at work,
you disrupt your circadian rhythm which makes it harder for you to stay awake and pay full
attention to tasks.

Our sleep is also regulated by the wake-sleep routine we go through during the night and through using cues
from the environment such as ‘clocks and sunlight/darkness’ (Thase, 1998).

The body’s master clock or SCN (tiny region in the hypothalamus) respond to light and dark signals. Light hits
the optic nerve in the morning and sends signals to SCN, the SCN sends signals to raise our body
temperature and produce hormones like cortisol. The SCN also delays the release of the hormone
MELATONIN (associated with sleep onset, it makes you sleepy). We are then alerted that it is time to wake
up.

How we measure sleep:

Through EEG’s – it measures brain activity; the electrodes pick up tiny electrical signals when the brain’s
cells send messages to each other.

- It measures the presence and depth of sleep and can determine what stage of sleep a person is
in (deep sleep/REM sleep).
- Small electrodes are placed on the head and attached to wires which are connected to the
EEG machine
- It measures two aspects of waveforms – amplitude (height of wave) and the number of waves
that peak per second.

Sleep EEG – measured while your awake and then when your asleep. It enables the doctor / researcher to
see if there are any problems.

- There are two different types of sleep EEG – Sleep Deprived EEG (for this EEG you will need to
avoid sleep or have less sleep the night before) and Natural sleep EEG.

Polysomnography – is a type of sleep study (shows sleep activity). It shows the changes that occur during
sleep, including; brain activity (EEG), eye movement, muscle activity and heart rhythm (ECG).

- Brain activity during sleep is recorded on EEG machine, the activity is then visible
during polysomnographic recordings (the scale we see).

Sleep stages:

We have 4 stages of sleep (known as NON-REM sleep) and REM sleep – originally classified by Rechtschaffen
and Kales (1968).
We move through stages 1 to 4 and then through REM, then the cycle starts again. A sleep cycle is an average
of 90 – 110 minutes, with each stage lasting between 5 – 15 minutes. Typically, a person will go through 4-5
cycles a night.

As the night progresses and the sleep cycle continues the person will spend less time in deep sleep and more
time in REM sleep.

Your sleep cycle changes with age – infants spend around 50% in REM a night whereas adults spend half their
sleep in stage 2 and about 20% in REM.

Stage 1: light sleep

- Within minutes or even seconds after you fall asleep, your brain produces alpha and theta waves
and your eye movements slow down.
- This stage of sleep is relatively brief, lasting up to 7 minutes – because you are in such a light sleep
you drift in and out of sleep and can be woken up easily.
- During this stage people experience sudden muscle contractions (hypnic jerk) followed by a sense
of falling.
- Mixed frequency, low amplitude waves.

Stage 2: getting deeper

- Eye movements stop and brain waves become slower – with occasional rapid bursts of brain
activity (high amplitude) known as sleep spindles.
- The body begins to prepare for deep sleep – body temperature drops and heart rate slows down.
- A waveform known as K-complexes occurs during this stage – ‘they are the largest event in a
healthy human EEG’ (Cash et al, 2009). They are sharp high and low amplitudes – demonstrating a
deep decline in network activity. They have been linked to sleep preservation and memory
consolidation (Cash et al, 2009).
- If you want to have a ‘power nap’ you would want to wake up after this stage before sleep
becomes deeper because you will have reduced your need for sleep later on at night.
- This stage lasts about 20 minutes – we spend most of our night’s sleep in this stage (around 45%
of total sleep duration)

Stage 3 + 4: deeper sleep

- linked together because they are difficult to tell apart on a graph.

- Slower delta waves occur, they are smaller and faster. – Also known as ‘Slow wave sleep’ (SWS)
- Typically starts around 35-45 minutes after falling asleep
- You will not experience any eye movement or muscle activity
- At this stage you sleep through most sleep disturbances (noise/movement) without waking
up because your body becomes less responsive to outside stimuli
- If you do wake up during this stage you are likely to feel very disoriented for a few minutes
- During this stage your body is repairing tissue and muscles, stimulating development and
growth, boosting your immune function and building up energy for the next day.
- It is during this stage that a person may experience sleep disturbances – sleep walking, nightmares,
sleep talking, bet wetting – these behaviours are known an PARASOMNIAS. They tend to occur in
the transition between NON-REM and REM sleep.

REM (Rapid Eye Movement) sleep:

- Short period of time where eye movement is very rapid – from side to side. It may be related
to intense dreams a person may be having (e.g. throwing a tomato).
 - This is a period of intense brain activity with frequent and intense eye movement – but lack of
muscle activity everywhere else
- Heart rate and blood pressure increase and breathing becomes faster
- Brain waves mimic the activity would occur when someone is awake – this is why REM sleep is
also known as ‘Paradoxical sleep’.
- Usually happens around 1-2 hours after sleep cycle starts. – the first REM sleep is very short
only lasting about 10 minutes.
- REM sleep periods get longer and denser through the night as you continuously go through the
sleep cycle
- This is when most dreams occur – if a person wakes up during REM sleep, this is when they
can remember their dreams. A person’s dreams normally reflect their mood and thinking
styles.
- REM sleep plays an important role in learning and memory function – this is when your brain
consolidates and processes information from the day before, so it can be stored into your long-
term memory.

Depression:

- Depression is seen to be associated with REM disruption (Benca, 2001) – depressed people
spend more time in REM sleep and do not get enough restorative sleep
- In REM you are more likely to dream. If the dream is negative then you are more likely to wake
up feeling sad and depressed (Beck, 1987).
- People who are depressed sleep less – they wake up a lot more during the night.
- Is it the poor sleep that causes depression or the depression that causes the poor sleep??? –
evidence has shown that if a person has insomnia they are 40% more likely to develop depression –
therefore, insomnia is a major factor in developing depression (Ford & Kamerow, 1989)
- Worrying about not getting enough sleep or about what time they should be asleep is also linked
to depression (sleep anxiety) – depression is linked to perceptions of sleep satisfaction (Mayers et
al, 2009).
- Evidence for sleep satisfaction in depressed people (Mayers et al, 2003): Depressed people reported
poorer sleep satisfaction even though their perceptions of sleep timing was no different to the
control group – showing, that sleep satisfaction was not about the amount of time they believed they
slept for.

Sleep Disorders:

There are many different sleep disorders, including; DYSSOMNIA (problems with sleep timings, stage
disruption and sleep quality) and PARASOMNIA (physical and behaviour abnormalities during sleep).

Dyssomnia:

- This is a sleep-wake disorder – the person has trouble trying to get to sleep or trying to stay asleep
for long periods of time
- They include intrinsic (caused by factors inside the body), extrinsic (caused by factors outside
the body) and circadian rhythm disorders
- Intrinsic – Insomnia, hypersomnia, narcolepsy, sleep apnoea
- Extrinsic – those induced by some other condition or behaviour
- Circadian rhythm disorders (the pattern of rhythm changes) – jetlag, shift work, sleep
phase syndromes
- When someone says they have sleeping problems dyssomnia is normally what people are referring to

Insomnia:
 - To be clinically diagnosed as having insomnia it must be affecting personal life, social life, been
happening for a long period of time (happening 3 times a week for at least 3 months), not due to
any substances or medications or because of another mental illness – DSM 5
- 3 stages of insomnia: difficulty getting to sleep (early insomnia) / difficulty staying asleep
(middle insomnia)/ waking up to early (late insomnia).
- Insomnia can be classified through two characteristics – ‘Sleep Onset Insomnia’ takes a long time
to sleep but will sleep for long periods once asleep / ‘Sleep-maintenance Insomnia’ wakes
frequently during the night.
- Symptoms include; sleepiness, fatigue, poor concentration, depression and muscle aches.
- New mums lose a lot of sleep when their baby is first born but cannot be classed as
insomnia. Insomnia is when sleep is there and available, but you just can’t fall asleep for new
mums the availability of sleep is not there.
- Katz and McHorney (2002) found that Chronic Insomnia can be so stressful that it can negatively
affect a person’s quality of life just as much as depression and heart failure.
- Insomnia is seen to be related to mental illness – a study found that if an adults insomnia was
not treated within a year the individual had a 34% chance of developing a psychiatric disorder
(TUCK, 2017). With over 40% of insomnia patients having a psychiatric condition (TUCK, 20170.
- Affects about 10% of the population – but studies vary on the intensity of the insomnia
(Ohayon, 2002) – 1/3rd of people report poor sleep but 6% fulfil DSM 5 criteria for having
insomnia.
- If affects more women than men.
- Types of insomnia – ‘Rebound Insomnia’ (you can’t sleep after coming off sleeping pills, your brain
has adjusted to the medication) / Insomnia related to substance misuse – alcohol or drugs /
Adjustment Sleep Disorder (insomnia caused by a change in life – stress or environment change)
- Insomnia has a big impact on a person’s life leading to negative outcomes (Leger 2010) – poor
quality of relationships, fatigue, irritability, memory problems, more likely to be in an accident
including car crashes (Horne & Baulk, 2004), strong relationship with depression, makes you more
susceptible to other illnesses.

Psychological and medical causes of insomnia – anxiety, stress or depression / medical problem or illness
such as asthma or chronic pain / medications such as antidepressants and high blood pressure medication /
insomnia can be a symptom of another sleep disorder such as sleep apnea.

Insomnia Treatment:

Medication:

- Benzodiazepines (e.g. Valium) – they reduce anxiety and promote calmness, relaxation and sleep.
These are an effective treatment but very short-term. They come with some significant problems to
– People can become addicted or dependant on them to get them to sleep / have withdrawal
problems / develop the ‘hangover effect’ (concentration problems, dizzy, fatigue, vomiting).
- Complimentary medication such as herbal remedies – these may only be useful for short-term.
– However, the NHS does not recommend herbal remedies.
- Melatonin – this is a hormone that is naturally produced by the pineal gland. Melatonin helps
control your sleep and wake cycles. – A drug called ‘Circadin’ is sometimes used as a short-term
treatment (about 3 weeks) in adults over 55 years. It contains melatonin.

Some antidepressants work very well, including tricyclics. However, some make it worse such as SSRI’s
(Selective Serotonin Re-Uptake Inhibitors)

- However, some antidepressants may affect people’s sleep more – clinicians must consider this
when giving the drugs to patients
 - Mayers and Baldwin (2005) carried out a literature review on antidepressant papers to see the
extant to which these medications (TCAs / MAOIs / SSRIs) were CAUSING insomnia NOT TREATING IT
- They found that TCA’s showed the greatest sedation properties, meaning they were the mostly likely
to get someone who was depressed of to sleep. However, it could also lead to the HANGOVER
EFFECT
– the drug can get the person to sleep but they wake up very drowsy – this can be very lethal if used a
lot.
- SSRI’s are the mostly commonly used antidepressant – they supress REM sleep (good) but it is
associated with insomnia. EEG studies showed greater fragmentation of sleep – there was a
reduction in time asleep. They noted this is NOT the best treatment for depressed people with sleep
problems.

Behavioural methods:

- These may be a lot better than medication

- sleep hygiene – temperature, not too hot or not too cold / it being dark/ quiet
- Having a regular bedtime – avoid taking daytime naps
- Sleep with the window open – temperature plays an important role in sleep / wake cycle
- Take some time (at least an hour) before bed to relax, put work away and focus on yourself
- Avoid too much alcohol, caffeine and nicotine in the evening
- Stimulus control – this helps build an association between the bedroom and sleep. If we are doing
everything in our bedroom such as eating, studying and watching tv then are body will not
associate the bedroom with sleeping.

Relaxation therapy:

- Racing minds is a problem for people with insomnia, relaxing before bed and being able to clear
your mind of the days thoughts may help people sleep better.
- Use mind relaxation therapy alongside progressive muscle relaxation therapy – this teaches a
person to tense and release muscles in different areas of the body. This helps to calm the body and
induce sleep (National Sleep Foundation).
- Some people also listen to audio recordings which can help them fall

asleep Cognitive-Behavioural Therapy (CBT):

- This is a talking therapy that enables you to manage your problems by helping you change the
way you think and behave.
- Based to the idea that ‘your thoughts, feelings, physical sensations and actions are
interconnected, and that negative thoughts and feelings can trap you in a vicious cycle’ (NHS, n.d.)
- CBT challenge thought processes to enable us to sleep better
- We can identify faulting sleep beliefs and bad behaviour – CBT will help someone change those
beliefs and introduce positive sleeping behaviours
- It may involve sleep restriction therapy – the amount of time spent in bed is limited, creating
mild sleep deprivation. Sleep time is then increased as your sleeping improves
- Research into CBT as a treatment for insomnia has shown rapid and long-lasting effects
- PROS – it can help when medication doesn’t / it can be completed in a short-period of time
compared to other talk therapies / it teaches useful and practical skills that can be used daily.
- CONS – it can be time-consuming between going to the CBT sessions and carrying out the extra
work afterwards / it involves controlling your anxiety and emotions, people may find that
uncomfortable

Hypersomnia:

- To be diagnosed with this disorder you must experience excessive sleepiness despite sleeping
normally, difficulty being fully awake after abrupt awakening, occurs at least 3 times a week for
at
 least 3 months, cause significant distress, not better explained by another sleeping disorder or by
substance misuse or mental illness.
- Even after waking up you still don’t feel refreshed.

Narcolepsy: (NOT AS LIKELY TO COME UP IN THE EXAM)

- A rare long-term neurological condition which affects the brains ability to regulate a normal
sleep- wake cycle. Affects about 1 in every 2000
- It causes people to suddenly have a tempting urge to fall asleep – people just suddenly collapse
- Very light sleeping – people fall immediately into REM sleep (dreaming) without experiencing
Non- REM (stages 1-4).
- It can lead to: excessive sleeping during the day / cataplexy / sleep paralysis (temporary unable
to speak or move just as you fall asleep or wake up) / sleep attacks (suddenly falling asleep
without warning).
- It can also cause excessive dreaming just as you fall asleep or just before you wake up -
hypnogogic hallucinations – these are very vivid dreams that can often be upsetting or disturbing, they
are usually visual but can be auditory – however, these can also occur in people who don’t have
narcolepsy.

Sleep paralysis: I the temporary inability to speak or move when first waking up or just falling asleep. The
person knows what is going on but cannot move or open their eyes. – Can be associated with sleep apnea

To be clinically diagnosed (DSM 5) you must have –

- Uncontrollable sleeping/napping occurring at least 3 times a week for at least 3 months.

- May have episodes of cataplexy – a sudden and brief loss of muscle control triggered by a
strong emotion such as laughter.
- Have a Hypocretin deficiency – but not because of a brain injury/ brain inflammation or infection-
Hypocretin are small protein-like molecules that regulate arousal, wakefulness and appetite. Cells
that contain hypocretin are found in the lateral hypothalamus. Ebrahim et al, (2003) - detected low
levels of hypocretin in those with narcolepsy.

Biological cause:

The exact cause of narcolepsy is unknown but there is evidence to show that those with narcolepsy have
low levels of the chemical hypocretin (above).

- The immune system may attack the production of hypocretin, it is not known why this happens,
but experts say it is due to an autoimmune disease.

There may be a genetic explanation – some people are born with a genetic predisposition to narcolepsy.

- It has been seen that narcolepsy can run in the family – however research suggests that this is very
unlikely, in normally occurs in people who have no history of the disorder in the family. However, if a
parent or sibling has narcolepsy there is a 40 times increased risk of you developing it compared to
the general population (Genetics Home Reference).

It may be caused by an infection.

- In early childhood a disease or infection may trigger the onset of narcolepsy. Instead of the
immune system fighting off the infection it begins to attack the specialised cells in the brain that
produce hypocretin. This infection may trick the immune system into attacking the cells that
produce hypocretin by mistaking those cells for attacking the body.
- One infection seen to be linked to the onset of narcolepsy is the H1N1 virus (swine flu).
 It may be caused by a vaccination to prevent an infection.

- The CDC (Centre for Disease Control) has provided evidence to show that children in Finland
(Partinen et al, 2012) and children in England who were given the vaccination Pandemrix for the virus
have shown there is a link between the vaccination and narcolepsy. However, it suggests
environmental factors may also have played a role in increasing the children’s susceptibility.
- However, a study by Duffy et al (2014) found that there was no association between the vaccination
Pandemrix and the onset of narcolepsy. They suggested that vaccination itself does not appear to
be enough on its own to cause the onset of narcolepsy – there must be other factors that are
involved too. MAYBE this does suggest that there is a genetic predisposition to narcolepsy and the
vaccination just triggered the deficiency quicker.
- Researchers (NHS) suggest that the likelihood of a person developing narcolepsy after receiving the
vaccination is 1 in 52,000 in the UK. However, the drug is no longer given to anyone under that age
of
20. – This may also show that there is a link between the onset of narcolepsy and puberty.

It may be due to another underlying condition which damages the area of the brain where hypocretin is
produced. This type of narcolepsy is known as ‘Secondary Narcolepsy’.

- Conditions include – head injury / brain tumour / multiple sclerosis (MS)

Treatment:

- There is no specific cure for narcolepsy, but you can manage the symptoms to minimise the impact
on everyday life.

Medications:

- Ritalin can be used to treat excessive daytime sleeping and sleep attacks (Billiard, 2008). These
mediations stimulate your CNS and keep you more awake during the day. They have shown
some success however side effects include irritability, palpitations and insomnia.
- Antidepressants can be used to treat sleep paralysis, cataplexy and hypnogogic hallucinations.
MAOI’s such as Selegiline are effective – ‘increase REM sleep, reduce cataplexy attacks by 89% and
reduce daytime sleeping by 36%’ (Hublin et al, 1994). However, dietary restrictions apply when
taking these drugs.

While these other treatments to improve a person’s life by reducing the cataplexy and excessive daytime
sleeping. They do not treat the sleep deficits that lead to the daytime sleeping. A new drug known as
‘sodium oxybate’ has been seen to effectively reduce narcolepsy (Billiard,2008). While it is a very
controversial drug, patients have said they fall asleep quicker and experience improved sleep duration
and quality (Kranh, 2003).

- Another name for this drug is GHB also known as the ‘date rape drug’. This drug administration has
to be strictly controlled due to the dangers associated with it, if over used it may lead to a person
becoming sedated.

Breathing related sleep disorders:

These include Sleep apnea, Obstructive sleep apnea (OSA) and Central sleep apnea (CSA).

- Sleep apnea is a common disorder where you have one or more pauses in breathing or
shallowing breathing while you sleep.
- This causes you to move out of deep sleep and into a lighter sleep. Which means you to have a
poorer quality of sleep, it is a leading cause of excessive daytime sleeping (EDS).
 - The pauses can last for a few seconds or minutes and can happen as much as 30 times in an
hour (National Information for the Public).
- When normal breathing starts again it usually causes a load snort or choking sound.
- Central sleep apnea (CSA) is less common. It is due to brain dysfunction where the area of your
brain that controls breathing doesn’t send signals to your breathing muscles.

The most common form of sleep apnea is OSA – airflow is prevented during sleep due to an obstruction in
the upper airway, this means air does not get to the lungs because the airways become blocked or collapse
during sleep due to a lack of muscle tone in your upper airway.

- When trying to breathe, air is pushed past the obstruction causing very loud snoring, snorting
and gasping noises.
- Leads to poor sleep – becoming very tired during the day and can increase the risk of having
an accident such as a car crash.
- When you stop breathing this has an impact on the heart as it must work harder. OSA can lead to
high blood pressure – which can be seen in around 30-50% of people with OSA (American College of
Cardio, 2015). The combination of OSA and high bloody pressure can increase a person’s risk of
having a heart attack or stroke.
- It can last for around 10 seconds and can happen at least 5 times an hour. It affects around 5% of
the population.
- It is usually associated with bigger people, due to the increased body fat it puts a stain on the
soft tissue and muscle in the throat. More common in males due to the distribution of fat in the
body compared to females. Or if young children have enlarged tonsils.

Treatment for OSA: OSA is a chronic (ongoing) condition which requires long-term management. This
includes:

- lifestyle changes such as limiting alcohol intake and losing weight – lowing your weight by 10%
can decrease OSA by 25%.
- Changing sleeping position, lie on your side not on your back.
- Surgery - changing the inner neck structure
- Wearing a device when you go to sleep – CPAP device (Continuous positive airway pressure)
prevents your airway from collapsing but placing a pipe down your throat / MAD is a shield that fits
around your teeth to increase the space in your throat by holding your jaw and tongue forward.

Parasomnia:

- This refers to sleeping disorders when ‘abnormal’ things happen during sleep, behaviours,
emotions, movements or dreams – they include: sleep walking / sleep paralysis / nightmares /

Sleep terrors or night terrors are a type of parasomnia. The person will probably have no recollection
about what happened in their dream, they look like there awake, could be sitting up but there still asleep

- This is a Non-REM sleep arousal disorder, happens when someone is not in REM (dreaming) sleep.
- The person can wake up screaming and panicking, it can be very difficult for a person
- Can be a result if a mental disorder – or usually stress in adults.
- It can be common in children between 4 and 12 years (Pagel, 2000) due to brain
immaturity. Treatment is not normally given because they can grow out of it.
- Treatment in adults may be needed: antidepressant can be useful / Benzodiazepines are good in
the short-term / therapy may tackle and treat the persons fears and stressors.
- Pharmacological interventions should not be used because they can lead to further sleep
disruption (Wise, 1997).