Medical Journal of Dr. D.Y. Patil Vidyapeeth

GUEST EDITORIAL
Year
: 2019  |  Volume : 12  |  Issue : 3  |  Page : 189--192

Sleep assessment in psychiatry - To be awake to every possibility


Suprakash Chaudhury, Adnan Kadiani 
 Department of Psychiatry, Hospital and Research Center, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Hospital and Research Center, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
India




How to cite this article:
Chaudhury S, Kadiani A. Sleep assessment in psychiatry - To be awake to every possibility.Med J DY Patil Vidyapeeth 2019;12:189-192


How to cite this URL:
Chaudhury S, Kadiani A. Sleep assessment in psychiatry - To be awake to every possibility. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jul 19 ];12:189-192
Available from: http://www.mjdrdypv.org/text.asp?2019/12/3/189/258206


Full Text



Could you live without sleep? The answer would universally be NO by all human beings. If there was a way to ask this to all the 8.7 million species living on this planet, the reply would still be the same; even unicellular organisms have some sort of sleep mechanisms and pronounced circadian rhythms. It has always been clear that sleep is an essential part of life yet the WHY remains a mystery. Some say that sleep evolved to ensure that species are not active when they are most vulnerable to predator attacks and when their food supply is scarce; others say that it helps in conserving energy. Researchers have established that sleep helps to forge new neural connections and solidify memories; in fact, sleeping soon after learning improves retention of the learnt material. Physiologically, it is known that most of the body's systems are in an anabolic state during sleep. This helps to restore the immune, nervous, skeletal, and muscular systems of the body. As a result, sleep plays a vital role in maintaining mood, memory, and cognitive function. In addition, sleep also plays an important role in the normal functioning of the endocrine and immune systems.[1]

 Neurophysiology of Sleep



Our body needs to decide how much sleep it needs every day and what time should we sleep and wake up; the sleep-wake circadian rhythm helps regulate this. An interesting finding by researchers is that the sleep-wake cycle clock follows a 25-h schedule rather than the day and night 24-h clock. This is relevant and significant because we then depend on external cues to keep the diurnal cycle on time, and any external influence which leads to a change in its pattern by more than 1 hour a day can lead to sleep problems. Individual variability is also important in sleep pattern regulation, children and adolescents' sleep more than adults and young adults' sleep more than older ones.[2] A single-night sleep can be divided into stages based on the characteristic frequency, and waveforms seen on an electroencephalogram (EEG). Rapid eye movement (REM) sleep stage is where the brain is active, and nonrapid eye movement (NREM) sleep stage is where the brain is inactive. NREM sleep is further divided into stages from 1 to 4 based on increasingly slow EEG patterns. An average sleep cycle consisting of a REM and NREM stage is of 90 min; this means that a typical 7–8-h sleep probably includes 5–6 cycles, the middle two cycles tend to be longer, the NREM sleep stages of 3 and 4 are longer during the early part of sleep, and the REM stage is longer during the later part.[3]

 Normal Sleep Requirement



What is the optimum sleep required by adults? This question assumes importance as meta-analyses have reported increased mortality risk associated with both short and long sleep durations.[4],[5] However, the Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult mentions that the minimum duration of sleep to support optimum health in adults is 7 hours.[6]

 Sleep in Medical Disorders



One way to study the effects of sleep is simply to observe what happens if the normal sleep pattern of a person is disturbed. The relationship between sleep disturbances and the different mental and physical disorders is well established. Various chronic debilitating medical conditions can alter the sleeping patterns which then, in turn, can alter the prognosis of those medical conditions. Difficulty in initiating sleep and maintaining sleep is seen in many debilitating conditions including but not limited to paraplegia, musculoskeletal disorders (rheumatic diseases and fibromyalgia), pulmonary disorders (chronic obstructive pulmonary disease [COPD] and asthma), gastrointestinal disorders (acid reflux), endocrine disorders (diabetes, hypothyroid, and acromegaly), cardiovascular disorders (myocardial infection), infectious diseases, multiple sclerosis, cancer, and patients on long-term dialysis. Pathology involving the thalamus (bilateral subcortical strokes and fatal familial insomnia) may sometimes cause intractable insomnia. Due to sleep difficulties, the quality of life of the person is impaired, and the subjective symptoms of the underlying disease seem worse to the patients. The psychological and social factors associated with a chronic debilitating illness seem to be an obvious contributing factor leading to sleep issues, yet it is not the only explanation. Chronic fatigue and pain associated with some conditions can prevent a person from getting a good night sleep; this is a vicious cycle as insufficient sleep itself causes fatigue and malaise.[7] COPD patients have some degree of nocturnal hypoxemia often leading to disrupted and fragmented sleep; similarly, patients with asthma have nocturnal awakening with dyspnea, cough, and wheeze. Patients on dialysis have a higher propensity of napping during treatment leading to disturbed sleep. Studies have shown that interleukin 1 and tumor necrosis factor alpha released during dialysis have sleep-inducing properties. A number of endocrine disorders, such as diabetes, hypothyroidism, and acromegaly, are associated with obstructive sleep apnea. Various medications used to treat chronic diseases are associated with sleep problems as follows: zidovudine causes insomnia, nevirapine, and efavirenz have been associated with vivid dreams and sleep disruption.[8] Researchers have found that many people suffer from insomnia before a surgery or an important procedure; this is related to the anticipated importance of the surgery/procedure. The deep sleep the person gets after the surgery/procedure is not just compensatory but it also helps in the healing process.[7],[9] Patients with critical illnesses admitted to intensive care units frequently have sleep disturbances that may persist up to 12 months after discharge. However, both subjective and objective studies indicate that sleep disturbance in these individuals improves over time.[7],[9]

 Primary Sleep Disorders



Primary sleep-related disorders are common and may adversely affect health and well-being. The most common of them all is insomnia which is transiently experienced by more than one-third of the adults sometimes in their life. However, insomnia can become chronic and persistent in 40% of these participants.[10] Chronic insomnia patients complain about difficulty in falling asleep. This may exist alone or in combination with difficulty in maintaining sleep or early-morning awakening. Insomniacs end up feeling low, fatigued, anxious, and irritable every morning. Both pharmacological and nonpharmacological therapies are available for insomnia. Education about good sleep practices and counseling is often sufficient to reduce insomnia symptoms. Cognitive behavioral therapy is often useful in chronic insomnia.[11] Other useful behavioral interventions included relaxation-based interventions and sleep restriction. A systemic review has shown that exercise improves sleep quality without major adverse effects.[12] Pharmacological therapy is recommended only for short periods (e.g., insomnia during stress) or in addition to behavioral treatments. Unfortunately, it is often the sole treatment prescribed for months together leading to habituation. Benzodiazepines are most frequently prescribed for insomnia as they are cheap and easily available, despite its adverse effects which include excessive sedation, high frequency of falls (due to nonselective gamma-aminobutyric acid effects), hypotension, tendency to lose efficacy after longer use, muscle relaxant effect, and significant cognitive effects. Other hypnotics include nonbenzodiazepines (zolpidem, zaleplon, and eszopiclone), melatonin and melatonin agonists (ramelteon and tasimelteon), orexin antagonist (suvorexant), sedating antidepressants (mirtazapine, trazodone, and amitriptyline), antihistamines, and other substances (herbal, etc.). However, all of them are associated with significant side effects.[13],[14]

Parasomnia's such as sleepwalking, nightmares, and night terrors are also very common. Sleepwalking (somnambulism) are episodes where the patients have a blank expression, behave as if indifferent to the environment, and exhibit low levels of awareness and reactivity. Night terror episodes are characterized by extreme vocalization, violent movement, and excessive autonomic reactivity. It is found that sleepwalking and night terrors fall along a spectrum and are very similar in their pathophysiology. Nightmares are nothing but bad dreams; they usually have recurring themes such as that of attack, falling, or death. A person is generally able to recall a nightmare but has no memory of a night terror. A little less common but a much more serious disorder is narcolepsy. It usually begins before the age of 25 and is characterized by excessive daytime sleepiness, irresistible sleep attacks, cataplexy, and sleep paralysis, along with hypnogogic and hypnopompic hallucinations. Breathing difficulties during sleep range from simple loud snoring to severe apnea with hypoxemia. This disorder affects men more than women and is often associated with obesity and hypertension. Another chronic condition is idiopathic hypersomnia, the symptoms consist of excessive sleepiness, daytime naps which are not refreshing, and difficulty with morning awakening and at times sleep drunkenness.[2]

 Sleep in Psychiatric Disorders



Psychiatric disorders have a very complex relationship with sleep. Sleep problems can be a trigger for psychiatric disorders, sleep issues can be a symptom of psychiatric conditions, various psychiatric medications can lead to a change in the sleeping pattern, and sleep pattern regulation can be a part of treatment for psychiatric disorders. Insomnia or hypersomnia increases the risk of having an episode of major depression. What is not known is whether the treatment of insomnia may prevent the development of depression. Chronic insomnia can also be a trigger for anxiety disorders such as panic and generalized anxiety disorder. People who have a problem in initiating sleep are more likely to self-medicate themselves with alcohol or sleeping pills and thus are more likely to suffer from substance use disorders. Schizophrenia is known to sometimes have an episodic course with acute exacerbation of positive symptoms and consequent violent and aggressive behavior from time to time, sleep pattern disturbance is sometimes seen at the start of such an episode; however, it can be difficult to distinguish if the sleep disturbance is a precipitant or merely the part of prodrome.[15]

Sleep problems are a part of the diagnostic criteria for mood disorders in both International Classification of Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders-5. Early-morning awakening is a criterion for melancholic depression and decreased need for sleep is an important indicator for an episode of mania. People with generalized anxiety disorders typically have worrying thoughts more during the night time and thus have a problem in mostly the initiation of sleep, while those suffering from posttraumatic stress disorder have disturbing dreams resulting in mostly a difficulty in maintaining sleep. Though alcohol intake decreases sleep-onset time, it leads to the disruption of the sleep-wake cycle and rebound wakefulness. This problem in patients suffering from alcohol dependence syndrome is not just restricted to periods of alcohol ingestion.[15]

One of the mechanisms of action of antidepressant is to suppress the frequency and duration of REM sleep, though most resolve sleep disturbance, some tend to disturb sleep, and some have a propensity to cause or exacerbate periodic leg movements of sleep and restless legs syndrome. Lithium which is used to treat bipolar mood disorder also has a very similar effect on sleep as antidepressants.[3] Antipsychotic medications block D2 receptors in the brain which leads to the decrease in the positive symptoms of schizophrenia. Most antipsychotics also, however, block other receptors such as histamine and muscarinic receptors.[16] This may lead to increased sedation in patients on those antipsychotics. These medications may also increase the risks of developing sleep-disordered breathing. Interpersonal and social rhythm therapy combines a behavioral approach to increasing the regularity of social and biological routines or social rhythms (such as regular sleep pattern) with an interpersonal approach to coping with interpersonal stress and social role problems. This is a well-researched effective form of psychotherapy for bipolar mood disorder patients.[17] Some researchers have found that a night of sleep deprivation can reduce the severity of depression. One possible explanation is that the patient does not go into REM sleep which is implicated in the causation of depression.[18]

 Conclusions



Sleep-related disorders when classified into primary (without other psychiatric disorder) or secondary (as a symptom of other disorders) seem rather simplistic. A much more nuanced view needs to be taken to correctly understand and as a result attempt to treat the problems related to sleep. It could be concluded that no medical consultation (more specifically chronic medical or psychiatric) be it a new patient assessment or a follow-up evaluation can be complete without a detailed workup of the sleeping habits of the individual. Treatment should stress on nonpharmacological therapies before initiating pharmacotherapy. It is imperative for a busy physician who does not have time for a detailed evaluation of primary sleep disorders to refer these patients to a sleep specialist/psychiatrist. Sleep disorders are too serious a problem to be dismissed with the prescription of a hypnotic.

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