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23.04.2015

Sleep disorders psychology, continuous ringing in ears - Review

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You won't see sleepwalkers shuffling around, arms outstretched; many navigate their rooms with ease and are capable of opening doors and moving furniture. Unlike nightmares, which arise during REM sleep, night terrors happen during non-REM sleep, usually early in the night. The cause of night terrors is a mystery, but fever, irregular sleep and stress can trigger them. During REM sleep, dream activity ramps up and the voluntary muscles of the body become immobile. Even today, some researchers suspect that tales of alien abduction may be explained by episodes of sleep paralysis. If sleep paralysis is an example of too much immobility, so-called REM behavior disorder is an example of too little.
REM behavior disorder occurs most often among older adults, and it can be a symptom of Parkinson's disease, a degenerative neurological disorder. If the previous nine conditions are making you rethink your once-positive stance on sleep, think again. In general, people with insomnia use more medical and psychiatric services than good sleepers.5,9,10 Simon and VonKorff5 reported a 10% prevalence of severe insomnia in primary care patients, and they found that insomnia was associated with significantly greater disability from medical disorders and with increased rates of healthcare utilization and depression.
In addition to their subjective sense of poorer health quality, insomniacs show increased rates of medical disorders.
Insomnia is most strongly associated with psychiatric disorders, particularly anxiety and depression. Chronic insomnia is also strongly associated with psychiatric symptomatology and psychiatric disorders. Epidemiologic studies of the general adult population have shown that one third to one half of people with chronic insomnia suffer from primary psychiatric disorders, predominantly anxiety and mood disorders.
The comorbidity between insomnia and psychiatric disorders may be even higher in clinical populations. Most psychiatric patients complain of sleep disturbance, not only during periods of acute illness but also during periods of remission.26 Virtually all psychiatric patient groups show changes in sleep architecture that are associated with insomnia. Sleep is generally most disturbed during acute episodes of depression, although certain sleep abnormalities tend to persist during periods of clinical remission. While bipolar patients in an episode of acute mania show the same sleep abnormalities as depressives,30,31 patients with dysthymia or subclinical depression seem to be indistinguishable from normal control subjects. There is increasing evidence supporting causal relationships between sleep and mood disorders.
Anxiety disorders, including generalized anxiety disorder, panic disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD), are commonly associated with insomnia.
Patients with generalized anxiety disorder experience chronic and persistent anxiety and, not surprisingly, most report problems with insomnia. Patients with OCD may have reduced sleep continuity, increased wake percent during sleep period, and decreased REM latency.42-44 Further, the obsessions and compulsions of OCD patients may directly disturb their sleep. Schizophrenic patients suffer significant sleep disruption, particularly during acute exacerbations of illness.21,45 They typically report increased nocturnal wakefulness, daytime fatigue and napping, and frightening dreams.
Patients with eating disorders may have a variety of sleep complaints and objective sleep abnormalities.51 Those with anorexia nervosa typically report excess energy and symptoms of insomnia, particularly during periods of weight loss, whereas those with bulimia nervosa may experience hypersomnia following eating binges. Binge eating in bulimics occurs in the evening or during the night, and some patients may binge-eat during sleep54; they typically get up sometime after sleep onset and consume large amounts of high-calorie foods.
Sleep is profoundly affected by age; not surprisingly, the prevalence of particular kinds of sleep problems clearly varies with age.
In the elderly, sleep is more shallow and disrupted, with reduction of total sleep, decreased sleep efficiency, prolonged sleep latency, increased arousals during sleep, loss of SWS, and increase in daytime napping.
Most psychotropic medications have significant effects on sleep patterns that may either improve or worsen sleep problems (Table 2).77 The newer antidepressants, including the selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline) and venlafaxine, may induce insomnia, which may lead to exacerbation of sleep difficulties in some patients.
Although all mood stabilizers typically used in bipolar patients have sedative effects, they have few other effects on sleep architecture. Treatment of primary insomnia and sleep disturbance related to psychiatric illness should begin with a careful review of sleep-related habits and practices. Stimulus control therapy, developed by Bootzin and Nicassio,89 was primarily designed to reestablish a positive association between the bed and falling asleep; most chronic insomniacs actually become aroused in the sleeping environment after repeated experiences of insomnia. Sleep restriction therapy,90 like stimulus control, may also work in part by creating more consistent experiences of falling asleep quickly in bed.
This has raised the hope that melatonin may prove to be effective in the treatment of disrupted sleep, particularly in the elderly. When insomnia is related to a psychiatric disorder, primary treatment should be directed at the disorder itself.
In schizophrenic patients, most antipsychotic drugs have sleep-promoting effects, particularly the low-potency neuroleptics (eg, chlorpromazine) and clozapine, and hypersomnolence is a significant side effect of these medications.
The functional relationship between insomnia and the wide variety of associated medical and psychiatric disorders has been difficult to clarify.
Most of us drift from our waking lives into predictable cycles of deep, non-REM sleep, followed by dream-filled rapid-eye-movement (REM) sleep. When nightmares move beyond occasional annoyance to near-nightly terror, however, you might have nightmare disorder.
And while waking a sleepwalker won't do them any harm, sleepwalking itself can be dangerous.
This creatively-named disorder occurs during the onset of deep sleep, when the person is suddenly startled awake by a sharp, loud noise.
So-called hypnagogic hallucinations occur during the transition from wakefulness to sleep (just after our head hits the pillow).


So while the occasional phantasmic visitation is nothing to worry about, if the hallucinations are accompanied by daytime sleepiness and loss of muscle control when excited or surprised, Kline recommends you see a doctor.
In one 1999 study published in the Journal of Sleep Research, 75 percent of college students who'd experienced sleep paralysis reported simultaneous hallucinations. Doctors usually treat the disorder with medications that reduce REM sleep and relax the body. People with sleep-related eating disorder go on eating binges at night, only to wake the next morning with little to no memory of the event. First described in a 1996 case study of seven individuals, sleep sex can range from annoying (loud sexual moans) to dangerous (self-injurious masturbation) to criminal (sexual assault or rape). The largest study, an Internet survey of 219 people who said they experienced sleep sex, is limited because it relied on self-reports. She has a bachelor's degree in psychology from the University of South Carolina and a graduate certificate in science writing from the University of California, Santa Cruz.
Sleep disturbance is correlated with fatigue-related accidents, decreased productivity, poorer health, reduced quality of life, and medical and psychiatric disorders. Mellinger and colleagues2 reported that over half of individuals with serious insomnia had two or more health problems, in comparison to only about one quarter of those with no trouble sleeping. A recent meta-analysis by Schwartz and colleauges17 demonstrated that trouble falling asleep was associated with coronary events, independent of other risk factors for cardiac disease.17 Several studies of the associations between insomnia and medical illness have demonstrated that sleep disturbance tends to change in relation to health status. Psychiatric patients commonly report sleep difficulties, and polysomnographic studies show objective sleep abnormalities in association with all major psychiatric disorders (Table 1).20,21 Sleep complaints are a primary or associated diagnostic criteria for most psychiatric illnesses, which disrupt sleep through a variety of mechanisms, including the increased anxiety and arousal that accompany most acute episodes of illness and the secondary effects of psychotropic medications. Increased rates of psychological stress and poorer ability to cope with stress have been connected with insomnia in several surveys.6,12 Insomniacs also show more abnormalities on psychological testing.
These changes include reduced sleep efficiency, prolonged latency to sleep onset, increased time awake during the sleep period, and reduced amounts of total sleep.21 Thus, the increase in subjective complaints of insomnia among psychiatric patients is based on objective changes in sleep, and are not a consequence of a simple reporting bias or misperception of sleep state related to their psychiatric illness.
In general, sleep studies performed in patients with any of these disorders report prolonged latency to sleep onset, increased time awake during the sleep period, early morning awakening, reduced sleep efficiency, and decreased total sleep. In contrast to night terrors, which are characterized by incomplete arousal from sleep, in a sleep panic attack, patients are awake and alert immediately after the attack begins.
For example, infants and toddlers have more difficulty falling asleep compared with preadolescent school-age children.61,62 Younger children show increased incidence of parasomnias, such as sleepwalking, nightmares, bruxism, and enuresis, whereas adolescents and adults have more problems with insomnia and daytime sleepiness. Most antidepressants suppress REM sleep, prolong REM latency, and reduce total amounts of REM sleep.81 Monoamine oxidase inhibitors can lead to profound suppression of REM sleep,82,83 but tricyclics and SSRIs also reduce REM sleep amounts significantly. Medical illnesses, psychiatric disorders, and primary sleep disorders need to be addressed specifically. Insomnia patients frequently engage in activities that interfere with sleep, and the development of good sleep habits is an important first step in behavioral treatment. These may also be effective for many patients with chronic sleep disturbance from other causes.
Sleep restriction attempts to increase homeostatic pressure for sleep by limiting the hours spent in bed. Antihistamine constitutes the primary active ingredient in most over-the-counter sleeping aids.
However, there are no positive polysomnographic data to document that melatonin improves sleep maintenance insomnia comparable to the demonstrated efficacy of the short-acting benzodiazepines.105 Melatonin may be useful, however, as a chronobiotic to help with resetting or entraining circadian rhythms in shiftworkers or others with sleep schedule disorders. Benzodiazepines are often given to patients with anxiety disorders in a larger dose at bedtime, for sleep induction and maintenance. Behavioral disorganization is frequently a significant contributing factor to sleep disturbance in schizophrenics, and should be addressed through improved sleep hygiene. Studies have suggested that insomnia may precede or exacerbate medical and psychiatric disorders. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. Daytime consequences and correlates of insomnia in the United States: results of the 1991 National Sleep Foundation Survey.
Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Electroencephalographic sleep profiles before and after cognitive behavior therapy of depression. EEG sleep in outpatients with generalized anxiety: a preliminary comparison with depressed outpatients. Sleep in a community sample of elderly war veterans with and without posttraumatic stress disorder. Sleep polygraphic variables in anorexia nervosa and depression: a comparative study in adolescents. Sleep-related eating disorders: polysomnographic correlates of a heterogeneous syndrome distinct from daytime eating disorders. Increased pressure for rapid eye movement sleep at time of hospital admission predicts relapse in nondepressed patients with primary alcoholism at 3-month follow-up.
Prominent eye movements during NREM sleep and REM sleep behavior disorder associated with fluoxetine treatment of depression and obsessive-compulsive disorder. Lack of residual sedation following middle-of-the-night zaleplon administration in sleep maintenance insomnia. Sleep laboratory evaluation of the effects and efficacy of trazodone in depressed insomniac patients. The effects of exogenous melatonin on the total sleep time and daytime alertness of chronic insomniacs: a preliminary study.
But when the boundaries of these three phases of arousal get fuzzy, sleep can be downright scary.


People with nightmare disorder often wake in a cold sweat with vivid memories of horrible dreams. One study published in 2003 in the journal Molecular Psychiatry found that 19 percent of adult sleepwalkers had been hurt during their nocturnal forays.
And these hallucinations, when they occur with sleep paralysis, are no picnic; people commonly report sensing an evil presence, along with a feeling of being crushed or choked. Even so, that study, which was published in 2007 in the journal Social Psychiatry and Psychiatric Epidemiology, suggested that sleep deprivation, stress, alcohol, drugs and physical contact with a bed partner play a role. Lack of sleep has been associated with obesity, high blood pressure and heart attacks, among other nasty symptoms.
Not only do insomniacs have more medical problems, but medically ill patients also have more sleep complaints. Almost 80% show significant increases on one or more clinical scales on the Minnesota Multiphasic Personality Inventory (MMPI).22 These results may not have been due solely to an increase in psychiatric disorders, since even people whose insomnia was due to identified medical factors showed elevations on the MMPI, suggesting a direct effect of sleep disturbance on psychological symptomatology. Breslau23 found a strong correlation between lifetime prevalences of sleep problems and psychiatric disorders in a study of young adults.
Hypersomnia is more common in those with bipolar disorder or winter depression,27 often characterized by symptoms of prolonged nocturnal sleep and daytime napping. Patients with recurrent sleep panic attacks may become fearful of going to sleep, which can contribute further to their insomnia.
REM sleep rebound consisting of increases in REM sleep amounts, reduced REM sleep latency, and sleep disruption, may occur following discontinuation of REM sleep-suppressing antidepressants. The principles of sleep hygiene, outlined in Table 3, include establishment of a regular sleep-waking schedule to reinforce the circadian or daily sleep-waking rhythm, avoidance of sleep-disrupting activities, elimination of stimulants, and maintenance of a sleep-conducive environment. Patients are instructed to go to bed only when they are sleepy and not to engage in activities other than sleep or sexual activity in bed. Although studies have shown that antihistamines increase sleepiness in healthy normal individuals, no studies have clearly established the dose range over which hypnotic effects in people with insomnia might be found.99 They are also associated with potentially significant side effects, such as daytime sedation, orthostatic hypotension, and other anticholinergic effects. Patients should be educated in principles of sleep hygiene and comorbid psychiatric disorders should be treated.
For example, a recent meta-analysis of the effects of benzodiazepines in the treatment of insomnia found that they increased both sleep duration and daytime drowsiness and light-headedness.91 Other studies have reported increased impairment in cognitive function with benzodiazepine use, particularly with longer-acting compounds.
So is genetics: Close relatives of sleepwalkers are 10 times more likely to sleepwalk than the general population. Falling is the biggest danger, so if you've got a sleepwalker in your house, experts recommend you move the electrical cords and steer your somnambulist away from stairs. Chronic insomnia affects up to 40% of adults over the course of a year, and 10% of adults complain of moderate to severe sleep problems.1-6 Insomnia is more prevalent with aging and in women. Since most individuals do not discuss their sleep problems with a physician, and only a minority of patients receives treatment, the potential costs of treating insomnia may be even higher. A survey of patients in primary care clinics in Hawaii and California found a total prevalence of insomnia of 69%, with 19% reporting chronic insomnia.11 In a study of medical outpatients, Katz and McHorney16 found that half complained of sleep disturbance, with severe insomnia reported by 16%. Anxiety, depression, and substance abuse were the most common disorders in this population. A prospective study of community-dwelling, elderly over a 2-year period, found that sleep disturbance was the best predictor for development of depression.32 Another study assessed the sleep habits of over 1,000 men while they were medical students and followed them for a median of 34 years. Several effective antidepressants, including nefazodone,84 trimipramine, iprindole, and amineptine,81 appear to have no REM sleep-suppressing properties.
Sleep hygiene is particularly important for psychiatric patients, many of whom may lack daily structure due to their illness. If they do not fall asleep in about 10 minutes, or find themselves becoming aroused or anxious, they are to get out of bed, go to another room, and engage in quiet or relaxing activities until they feel sleepy, at which point they may return to bed. If sleep efficiency increases to an average of 90% or more for 5 days, the patient increases the time in bed by 15 minutes. Sedating antidepressants may be helpful for those who continue to suffer from significant sleep disruption. Bugs or animals crawling on the walls are a common vision, said Neil Kline, a sleep physician and representative of the ASA. Sleep disturbance is also strongly associated with medical, and particularly, psychiatric illnesses, with up to half of adults with insomnia having concomitant psychiatric disorders. Sleep problems were associated with a variety of medical conditions, including cardiopulmonary disease, musculoskeletal conditions, prostate problems, and depression. Manic patients may have severe insomnia during episodes of acute illness, accompanied by the sense of a decreased need for sleep. Conversely, if sleep efficiency decreases below 85%, time in bed is reduced to the average sleep time from the previous 5 days. After 10 or 15 minutes, the person usually settles back into sleep, according to the National Institutes of Health.
The relationship between sleep loss and mania is one of the most robust associations between sleep disturbance and resulting illness.
These data suggest that sleep disturbance is an important risk factor and possibly a precipitant for depression.



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