Primary and secondary Insomnia

1. Primary and secondary Insomnia Aims To know a variety of sleep disorders To understand the causes of sleep disorders (Primary, secondary insomnia with Sleep apnoea) To be able to explain if personality has an effect on the amount of sleep we have

2. Insomnia Key concepts • Possible explanations range from: • Genetics vulnerability (predisposing factors) 50% (Watson) • Diathesis Stress model (precipitating factors) • Age and gender • Hyper arousal • Personality (Individual differences) • Neuroticism • Internalisation • Cognitive factors: attention bias and sleep difficulty expectation • Poor sleep hygiene • Staying up late • Sleeping with bright lights on • Alternatively, • Sleep Apnoea • Learning theory • Increased levels of Cortisol– Stress hormone Synoptic IDA

3. Insomnia • Insomnia can be defined as problems with sleep patterns: • Initial insomnia: problems falling asleep • Middle insomnia: problems remaining asleep • Terminal insomnia: waking up too early • There are problems with the quality and quantity of sleep, leading to daytime sleepiness. • If insomnia has no obvious cause then it is known as Primary. When it is caused by something else (stress) it is secondary insomnia. • A diagnosis of insomnia is given on the basis of how the person operates the following day. • Napoleon slept for 4-5 hours as did Margaret Thatcher and could function normally. However, Einstein slept for 10 hours. This shows how sleep varies from person to person. This is an example of how research is affected by individual differences; making generalisations difficult.

4. Use as commentary after you have described AO1! Sleep Disorders • Insomnia is a common sleep disorder. It affects 10% of the adult population, who suffer chronic insomnia; and 25% of the population suffer insomnia intermittently. • Sleep deficits associated with insomnia create serious health risks such as falling asleep while driving and accidents in the workplace. • Therefore research into the disorder and its treatment has huge RWA!!!!!!!

5. RWA: Real World Application • With 25% of the population suffering from intermitted Insomnia, and10% chronic, this research has great real world application. • If sufferers know the possible causes and some of the effective treatments then the well being of a nation can be enhanced. • For example, Morin et al (2005) found that the herb combination valerian and hops had a greater impact on initiation and maintenance of sleep than a placebo or sleeping pill.

6. The closer the genetic relatedness the greater the risk Discussing Genetic risk factors • One possible explanation for the development of insomnia is the role of predisposing factors. One predisposing factor is a genetic vulnerability. • This means that the closer genetically related you are to a sufferer, the greater your predisposed risk. Evidence from twin studies by Watson et al (2006) found 50% of the variance in the risk for insomnia could be attributed to genetic factors. • However, from the twin studies, it is clear that genes do not contribute 100% to insomnia; therefore environmental factors are also important. The diathesis stress model helps to explain how a genetic predisposition manifests into a disorder. This model can explain how nature and nurture interact; that a genetic predisposition is triggered by an environmental event (for example, ...... stress or poor sleep hygiene). Nature nurture debate? Diathesis Stress model of abnormality? Freewill and Determinism debate important for treatment

7. Individual differences; generalise; questions Restorative nature of REM Brain injury • Lavie (1996) reports the case study of a man with a piece of shrapnel in his head who slept for 15 minutes a night and experienced virtually no REM, just a few minutes a week. But he had no cognitive problems. • The shrapnel was located in his Pons. This area is involved in the control of sleep, especially REM. • Therefore, damage to this area or an imbalance of neurotransmitters may cause insomnia in some people.

8. Other factors: hyper-arousal • Furthermore, physical factors may predispose someone to developing insomnia. • Insomniacs are more likely to experience hyper-arousal both awake and asleep. • Hyper-arousal will make it more difficult to initiate and maintain sleep.

9. Perpetuating factors • Espie (2002) suggests that perpetuating factors are key to ongoing insomnia. • Perpetuating factors are factors which maintain insomnia after the initial cause (stress) has disappeared. • For example being tense when going to bed because of previously experienced sleep problems. • Relate to hyper arousal; emotional arousal; anxiety; cognitive expectancy

10. Primary Insomnia • DSM definition of Primary Insomnia is that it occurs without any known cause and for more than a month. • It is a long term condition

11. Types of Primary Insomnia • Idiopathic insomnia starts in childhood and is life long. • It is extremely rare and runs in families ICSD 2005 • There are no clear explanations for this disorder • Psycho-physiologic insomnia. This is characterised by arousal, persistence with behaviours that are incompatible with sleep and a preoccupation with sleeping. • Task: Handout • Read McMahon et al (2006) attentional bias for sleep related stimuli in Primary and delayed sleep phase syndrome using the dot probe task.

12. The role of cognitive factors: McMahon et al (2006) attention bias for sleep related stimuli • McMahon et al (2006) tested the idea that insomniacs pay more attention to sleep related stimuli. They used 3 groups of 20 (IGd) • GS-good sleepers, • DSPS • Primary insomnia. • They were tested on the dot probe task with sleep related and neutral words. • It was found that the primary insomnia group paid greater attention to the sleep related stimuli as they responded faster to them. • Thus suggesting that cognitive factors are important.

13. Primary Insomnia Risk factors • Age and Gender: it appears that older women suffer from Primary insomnia. In older people, with increasing physical problems (arthritis) sleep may be disrupted. Also, an increase in insomnia may be related to hormonal fluctuations which are age related (menopause).

14. Innate Personality trait: Neuroticism • Another possible explanation for the development of insomnia is the innate personality trait Neuroticism. This personality trait is characterised by high levels of emotional arousal and anxiety. • Twin study evidence suggests that insomnia is associated with high levels of neuroticism (anxiety and bodily arousal). It is clear that high levels of arousal and anxiety can prevent the initiation and maintenance of sleep. • However, ... (100%, NN, DSM) ..... • Therefore, by looking for one single explanation we are at risk of making reductionist statements/conclusions)

15. Furthermore ..... • Kales et al (1976) explain that Personality is another risk factor for the onset of insomnia. For example, insomniacs are more likely to internalise psychological disturbance rather than acting out problems. • It is proposed that this high level of internalisation that leads to higherlevels of emotional arousal and anxiety, thus becoming a risk factor.

16. Secondary Insomnia • Insomnia resulting in problems with the quality and quantity of sleep leading to day time sleepiness, which is caused by a pre-existing condition such as narcolepsy or depression. • Other explanations include: • Too much noise • Circadian phase disorder • Stress • Food intolerance • Family conflict • Bereavement • Stimulants • However if this goes untreated it can become chronic. This occurs when the individual learns a new (maladaptive) sleep pattern.

17. There is some debate over the labelling of secondary insomnia. Is secondary Insomnia a symptom of another disorder? Well Maybe not! • Is has been claimed that secondary insomnia is caused by other disorders. However, recent research by Ohayon and Roth (2003) on 15,000 Europeans, found that insomnia more often preceded rather than followed mood disorders. • This means that it may be helpful to treat insomnia regardless of whether it is primary of secondary. • If secondary insomnia goes untreated, it can develop into chronic insomnia. This occurs when the individual learns a new (maladaptive) sleep pattern.

18. Treatments (AO2/3) • Treatments focus on factors that perpetuate or maintain insomnia. • For example: • Relaxation techniques • Improving sleep hygiene – reducing caffeine, darkened rooms, exercise • Paradoxically it is the things that people do to cope with their insomnia block recovery. • Phototherapy can be used for circadian disruption. Sedatives, anti-anxiety drugs and melatonin can be used in the short term. • Attribution therapy, sleep restriction therapy (reducing night time sleep and slowly increasing it) and reconditioning (associating their bed with sleep and only go to bed when very sleepy).

19. CBT – addressing anxiety and cognitive elements of the disorder • People who suffer from insomnia report being very anxious before bed time. They know they need to sleep and the more they think about it the harder it becomes. • CBT is aimed at correcting these faulty cognitions. • Causes of the insomnia are discussed and elements of stimulus control therapy are introduced. • Assumptions such as needing 7 or 8 hours sleep are challenged thus reducing anxiety. The success of this technique supports a cognitive and anxiety role in insomnia.

20. RWA: Food and supplements • Morin et al (2005) compared the effects of the herb combination valerian and hops with a placebo and sleeping pill containing the drug diphenhydramine. The participants all suffered from insomnia and were recruited from sleep disorder centres. Although the effects were small and mainly non-significant, they found that after 28 days the valerian hop supplement group fell asleep faster and stayed asleep longer than the placebo group.

21. Real world application • Sometimes it is the belief that they are going to have sleep difficulty that causes insomnia. This can become self-fulfilling because of becoming tense. According to attribution theory, the insomniac has learned to attribute their sleep difficulties to insomnia. Convincing them that the difficulty lies elsewhere, will end their maladaptive attribution. In one study Insomniacs were given a pill and told it would stimulate/sedate them. Those who expected arousal went to sleep faster because they attributed their arousal to the pill and therefore relaxed.

22. Looking for one cause is reductionist

23. See Dog book

24. Teenage insomnia goes unreported or investigated • Teenagers suffer Circadian shift phase disorder resulting in insomnia (Kalb et al 2008). • Roberts et al (2008) used 4,000 adolescents, 11-17 and found 25% symptoms of insomnia, 5% reported poor functioning as a consequence. And 41% were found to be still suffering one year later.

25. Fatal familial insomnia: Genetic Sleep normal until middle age then can not sleep, leading to death in 2 years. Autopsies have revealed a degeneration of the Thalamus, which may be the cause of the onset of insomnia. During SWS sleep, sensory information is inhibited from entering conscious awareness by the thalamus. This may also serve to maintain sleep by stopping distractions. These are rare and the clear brain damage makes causality very difficult and also generalisation is difficult.

27. Possible explanation: EP-EZ desynchronisation • It is possible that there is some form of problem with the SCN (EP); or maybe a problem with sleep brain areas may be the reason for the onset of insomnia. As EP’s are genetically inherited, sleep problems may also be inherited.

28. IDA: huge application in the real world • Research into sleep disorders • Immediate impact on society • Real world application of research • Development of treatments • Non-drug therapy effectiveness • Therefore any CBA would result in any animal research being justified

29. What other conditions may effect insomnia? • Sleep apnea is a common related condition and is defined by the sufferer not breathing/decreased breathing whilst asleep. • There are two types of apnea: • *Sleep apnea (most common) • Common central sleep apnea (least common) • *Although cases are usually diagnosed on the basis of a patients history there are several tests that can be carried out to formally diagnose the condition.

30. Sleep Apnoea (SA) • Sleep Apnoea is the inability to breath during sleep (a few seconds to a few minutes). Obesity can cause sleep Apnoea due to the narrowing of the airways, but also in older people due to impairment in the function of the brain mechanisms for respiration. • During SA CO2 builds up in the blood stream to a point where Chemoreceptors are stimulated (specialised neurones that detect specific chemicals in the blood) and these cause the sufferer to wake up. • In chronic cases the sufferer may use a machine that provides continuous positive airway pressure (CPAP) that pumps air under pressure into the nose and/or mouth cavity in order to keep the air passages open.

31. What does apnea look like? • An apnea event has 4 components. • First, the airway collapses. • Second, an effort is made to take a breath, but is unsuccessful. • Third, the oxygen level in the blood drops. • Finally, when the amount of oxygen reaching the brain decreases, the brain signals the body to wake up and take a breath. (This is what the bed partner hears as a silence followed by a gasp for air.)

32. How common is obstructive sleep apnea? • Obstructive sleep apnea (OSA) is estimated to affect about 4% of men and 2% of women. • In one study of people over 18 years of age, obstructive sleep apnea was estimated to develop in 1.5 % of people per year over the 5 year study. • (It is probably more common than either of these numbers because the population is becoming more obese, and obesity worsens obstructive sleep apnea).

33. Some more facts! • Men are more likely to have obstructive sleep apnoea than women before age 50. • After age 50, the risk is the same in men and women. • Among obese patients, 70% have obstructive sleep apnoea. Obstructive sleep apnea worsens in severity and prevalence with increasing obesity. • Among cardiac patients, 30-50% have obstructive sleep apnoea, and among patients with strokes, 60% have obstructive sleep apnoea. • Cause and effect?

34. Essays • Outline explanations of insomnia (8marks) • Evaluate two or more explanations of insomnia (8marks)