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1 Assessment and Treatment of Sleep Disturbances Associated With Dr. William Brim, Deputy Director, Center for Deployment Psychology Assessment and Treatment of Sleep Sleep and Insomnia Basics Disturbances Associated with Deployment Dr. William Brim “I’ll sleep when I’m dead Deputy DIrector ‐Warren Zevon 1 2 Why do we sleep? How is sleep regulated? Inactivity Theory • Also called an adaptive or evolutionary theory • Early scientists believed that gases rising • Sleep serves a survival function and has developed through natural selection • Animals that were able to stay out of harm’s way by being still and quiet during times of vulnerability, from the stomach during digestion brought usually at night…survived Energy Conservation on the transition to sleep. • Related to inactivity theory • Suggests primary function of sleep is to reduce energy demand and expenditure • Research has shown that energy metabolism is significantly reduced during sleep Restorative Aristotle (c350 B.C.) “We awaken when the • Sleep provides an opportunity for the body to repair and rejuvenate • Major restorative functions such as muscle growth, tissue repair, protein synthesis and growth hormone digestive process is complete” release occur mostly or exclusively during sleep Brain Plasticity • One of the most recent theories is based on findings that sleep is correlated to changes in the structure and organization of the brain. • Sleep plays a critical role in brain development with infants and children spending 12‐14 hours a day sleep and a link to adult brain plasticity is becoming clear as well 3 4 14-15 October 2014 1 How is sleep regulated? • Homeostatic sleep drive (Process S) – During wakefulness a drive for sleep builds up that is discharged primarily during sleep “Sleep is a dynamic behavior. Not simply the – As sleep drive increases, so do subjective absence of waking, sleep is a special activity feelings of sleepiness of the brain controlled by elaborate and precise mechanisms.” • Circadian rhythms (Process C) – Varying strength alerting signal increases over the course of the day and decreases across the night until early morning J. Allan Hobson, Sleep, 1989 5 6 How is sleep regulated? Sleep architecture • N1 or Stage 1 (5%) – 5 mins; transitional phase – Low arousal threshold • N2 or Stage 2 (50-55%) – 10-15 mins; • N3 or Stage 3 & 4 (20%) – Lasts 20-40 mins; “delta” “slow-wave sleep” • REM (20%) – Tonic (hypotonic muscles) and Phasic Kilduff TS, Kushida CA. 1999. (eye movement) stages 7 8 2 Harvard University Terms & Abbreviations Sleep Lab Website http://healthysleep.med.harvard.edu/ • SOL = Sleep Onset Latency • WASO = Wake After Sleep Onset • EMA = Early Morning Awakening •TWT = Total Wake Time • TST = Total Sleep Time • TIB = Time in Bed • FNA = Frequency of Night-time Awakenings • SE = Sleep Efficiency = TST / TIB //healthysleep.med.harvard.edu/interactive/sleep_lab 9 10 Disorder Taxonomies - ICSD The International Sleep‐Wake Disorders Classification of Sleep Disorders‐2 (ICSD‐2) lists more than 80 distinct sleep disorders in 8 categories 11 12 3 Disorder Taxonomies – DSM-5 Substance Insomnia Disorder /Medication Hyper ‐ induced somnolence sleep Disorder • Organized for easier differential diagnosis and disorder to clarify when a referral to a sleep specialist is Restless Leg Narcolepsy warranted Syndrome SLEEP • Geared towards general mental health and WAKE medical clinicians vs sleep medicine specialists REM sleep Breathing‐ behavior DISORDERS related sleep • Mandated concurrent specification of medical disorder disorders and mental disorders Circadian Nightmare Rhythm • Lumping (e.g., insomnia disorder) vs Splitting disorder Non‐REM sleep‐wake sleep arousal disorders (e.g., narcolepsy) disorders 13 Disorders Common in the Military • The most common complaint of military members returning from deployment is about Sleep disturbance during sleep deployment • There has been a rise in the number of service members receiving treatment for; – Obstructive Sleep Apnea – Circadian Rhythm Sleep Disorders – Nightmares – Insomnia 15 16 4 Sleep Disturbance War and Sleep and PTSD • Sleep disturbance and nightmares are part of a normal “I observed disorientation, overwhelming sleepiness, and and typical acute response to trauma (Pillar, Malhotra, & an inability to give and receive orders due to Lavie, 2000) and are usually transient (Lavie, 2001). uncontrollable lapses in attention and poor memory.” Gen George Marshall observations during Operation Overlord at Normandy, June 1944 • Combat exposure has been strongly correlated with the frequency of nightmares, moderately correlated with problems falling asleep and weakly correlated with problems staying asleep (Neylan et al., 1998) in Vietnam On some nights, he has nowhere to sleep, on others he Veterans in objective tests suffers from insomnia. "That's just how it is," thinks the warrior. "I was the one who chose to walk this path." • Sleep disturbance is a core feature of PTSD not a consequence of the disorder (Spoormaker et al 2008) Paulo Coelho from The Warrior of the Light 17 18 Residual Insomnia Residual Insomnia Intrusive Memories Nightmares Flashbacks Emotional Reactivity Physiological Reactivity Avoidance Reminders Avoidance Thoughts Poor Recall Diminished Interest Pre Tx Detachemnt Post Tx Restricted Affect Foreshortened Future Insomnia Anger Difficulty concentrating Hypervigilence Exaggerated Startle 0 5 10 15 20 25 30 Zayfert & Devira, 2004 19 Zayfert & Devira, 2004 20 5 Predictive power Sleep Disturbance of sleep disturbance and PTSD • Moderate probability of PTSD if sleep symptoms • 35 veterans w/ PTSD and 37 patients with insomnia were present soon after the trauma but High but no PTSD probability of no PTSD if no sleep disturbance • No difference in average sleep per night (2.7 hrs vs. within 1 month after trauma (Harvey and Bryant, 2.8 hrs) • PTSD group reported more sleep-related anxiety 1998) - NPP symptoms including – Fear of going to sleep, waking up with covers torn apart, fear of the dark, having thoughts of the trauma whilst lying • MVA survivors – Insomnia at 1 week not in bed, having disturbing thoughts while lying in bed, talking during sleep, yelling/shouting during sleep, waking predictive of PTSD but sleep complaints at 1 up confused and disoriented fear of the dark and waking up from a frightening dream and finding it hard to return to month post trauma were a significant predictor sleep. or PTSD at 12 months post trauma. (Koren, Arnon, Lavie and Klein, 2002) - PPP Inman, Silver, and Doghramji (1990) 21 22 Sleep Disturbance and PTSD SOL & Sleep Maintenance • SOL – 44% of VV w/PTSD reported SOL • 35 veterans w/ PTSD and 37 patients with insomnia sometimes or very frequently vs 6% of VV w/o but no PTSD PTSD (Neylan et al. 1998) • No difference in average sleep per night (2.7 hrs vs. 2.8 hrs) • PTSD group reported more sleep-related anxiety • Sleep maintenance – 91% of VV w/PTSD rated symptoms including sometimes or very frequent difficulty maintaining – Fear of going to sleep, waking up with covers torn apart, sleep vs. 63% w/o PTSD and 53% of civilians fear of the dark, having thoughts of the trauma whilst lying in bed, having disturbing thoughts while lying in bed, talking during sleep, yelling/shouting during sleep, waking up confused and disoriented fear of the dark and waking • PTSD community sample more disrupted sleep up from a frightening dream and finding it hard to return to (47% vs 18%) and wake too early (43% vs sleep. 13%). Inman, Silver, and Doghramji (1990) 23 24 6 Nightmares - Prevalence Nightmares - Content • 52% VV w/ PTSD sometimes or very frequently compared to 5% VV w/o PTSD • Only VV w/PTSD reported dreams related to wartime experiences but both VV w and w/o PTSD reported disturbing dreams along themes other than war (Mellman, Kulick-Bell, Ashlock, & Nolan, 1995) • Community sample 19% vs 4% (Ohayon and Shapiro 2000) • VV w/PTSD 50% combat themes, 85% mod to highly threatening, 53% set in present, 79% distorted elements • Patients who reported distressing dreams were also more likely to • Female sexual or physical assault survivors have more severe PTSD symptoms (Mellman, 2001) w/PTSD reported nightmares on avg. 5 nights a week (Krakow, Schrader, et al., 2002). • In general, appears that content is more exact reenactment trending towards more distorted over time. 25 26 Sleep Disturbances Are Common and Harmful to Patients with TBI . 50% of patients with TBI have some form of sleep disturbance (Mathias & Alvaro, 2012) . In a study of veterans with TBI, PTSD, or chronic pain Sleep and TBI (Lew et al., 2010): • 93.5% of the entire study population had a sleep disorder • 65% of the population screened positive for mTBI . Sleep disturbances may cause harmful consequences on memory function in patients with TBI and/or exacerbate comorbid symptoms (Bloomfield, Espie, & Evans, 2010; Castriotta et al., 2007) • May prolong concussion recovery • Potentially a risk factor for suicide 27 2828 7 Influence of Severity of Injury Prevalence of Sleep Disorders on Sleep Disturbance Insomnia* Sleep Apnea* CRSD •Patients with less severe brain injuries have more severe General • 10% of U.S. • 24%–28% of men and • Prevalence is sleep disturbances Population population (Roth, 2005; 9%–28% of women (Young, unknown Roth & Roehrs, 2003) Peppard & Gottlieb, 2002) • Insomnia higher in mTBI (38%) than moderate (35%) or severe (25%) injuries (Ouellet et al., 2006) TBI • Ranges from • 47% of TBI patients • 36% of mTBI Population • Insomnia linked to milder injury severity, severe 24.6–87% within three months of patients diagnosed depressive symptoms, higher pain and fatigue depending on injury (Webster et al., 2001) with CRSD (Ayalon et al., (Ouellet et al., 2004) study population 2007) (Ouellet et al., 2006; Castriotta & • 53.1% in blunt trauma Murthy, 2011; Fichtenberg et al., • mTBI patients had poorer sleep quality and duration and 2002; Parcell et al., 2008; patients vs. 30.8% in Fichtenberg et al., 2000; Mayer more sleep disturbances than moderate/severe TBI et al., 2011) blast injury patients (Collen et al., 2011) (Mahmood et al., 2004) *These studies included mixed TBI populations (mild, moderate, and severe).
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