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睡眠 Sleep

睡眠 Sleep. Professor Tung-Ping Su Department of Psychiatry National Yang-Ming University Taipei Veterans General Hospital Dec. 24, 2007 Lecture for the 4th class of Dept of Medicine National Yang-Ming University. Sleep disturbances. 正視失眠問題. 從流行病學角度來看，保守估計全台灣大約有 150~200 萬 的人飽受失眠之苦

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睡眠 Sleep

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  1. 睡眠Sleep Professor Tung-Ping Su Department of Psychiatry National Yang-Ming University Taipei Veterans General Hospital Dec. 24, 2007 Lecture for the 4th class of Dept of Medicine National Yang-Ming University

  2. Sleep disturbances

  3. 正視失眠問題 • 從流行病學角度來看，保守估計全台灣大約有150~200萬的人飽受失眠之苦 • 由於慢性失眠可能導致的社會問題 • 意外或交通事故 (高四倍) • 個人健康、家庭生活與人際關係的干擾 • 因為注意力及記憶力障礙造成的損失 (慢性失眠者比睡眠良好的人認知功能 表現降低大約20%)

  4. How Common Is Insomnia? • Overall prevalence • Symptomatic with consequences • Actually diagnosed • Insomnia symptoms • Overall prevalence 35% Insomnia symptoms with Daytime consequences10%-12% Insomnia diagnosis 6% Adapted from Buysse DJ et al. Primary Psychiatry. 2005;12:37-44.

  5. Prevalence of Insomnia 33% 10% Insomnia Symptoms With Daytime Symptoms Sleep Dissatisfaction 15% Insomnia Diagnosis 6 to 9% Ohayon MM. Sleep Med Rev. 2002;6:97-111.

  6. A Telephone Survey in 2006 Unit: % 30.0% 24.8% 25.0% 20.2% 20.0% 14.6% 13.5% 13.3% 15.0% 10.0% 5.0% 0.0% TOTAL Interrupted Sleep Difficulty in Initiation Nonrestorative Sleep Early Morning Awakening 【n=4,011】 Taiwan society of sleep medicine, 2006

  7. A Telephone Survey in 2006 P < 0.01 13.2% 11.5% 9.9% 【n=4,011】 Taiwan society of sleep medicine, 2006

  8. Effect of Sex on the Prevalence of Insomnia by Age 25% 20% 15% 10% 5% 0% Lifetime Prevalence Male Female 40-44 45-54 55-64 65-74 >=75 p < 0.1 6.60% 6.20% 6.90% 10.30% 6.60% 9.20% 9.90% 12.60% + 40-44 45-54 55-64 65-74 >=75 5.50% 5.30% 7% 8.65% 8.40% 5.20% 6.70% 12% 16% 16% 40-44 45-54 55-64 65-74 >=75 Years 30% 25% 20% 15% 10% 5% 0% One-month Prevalence Male Female p < 0.001 ** * * 40-44 45-54 55-64 65-74 >=75 Years

  9. Insomnia Is a 24-hour Problem • Daytime fatigue, lack of energy • Cognitive impairments (attention, memory, concentration) • Mood disturbances (irritability, dysphoria)

  10. DSM-IV Dyssomnia Primary insomnia Restless leg Syndrome (RLS), Periodic limb movement d/o (PLMS) Narcolepsy, Sleep apnea Circadian rhythm sleep d/o Insomnia mixed with hypersomnia Parasomnia Medical, psychiatric, & substance - induced sleep disorders Sleep walking, Sleep terrors Nightmares, REM behavior Bruxism, NPD, enuresis

  11. Figure 64-1. Narcoleptic Doberman pinschers in the middle of a cataplectic attack. Note that eyes are open. Autosomal recessive forms of canine narcolepsy are due to mutations in the hypocretin receptor type 2 gene.

  12. Sleep Switch: rapid transition From arousal to asleep & vice versa • VLPO: ventrolateral preoptic nuclei • - Inhibitory on arousal system and active during • sleep • - Damage on VLPO---chronic insomnia • - Suppress VLPO --- awakening • - receiving inputs from monoaminergic neurons • - LC, TMN & Raphe nuclei, inhibit VLPO, are • stabilized by orexin in the awake • - Sleep switch has mutually inhibitory elements • - In that, one side shut down the other side and • diminish its own actions and result in abrupt change • from awake to asleep • In the sleep state: • - VLPO inhibit orexin neurons • and LC, TMN & Raphe nuclei • Narcoolepsy • -a problem with such a switch: rapid unwanted • transitions from one state to the another can occur • when it is unstable • - Narcolepsy (2000) had few orexin neurons in the • hypothalamus • - Orexin neurons (hypocretin): active during wakeful- • ness and reinforce the arousal system • - Lost the stabilizing influence on the orexin neurons

  13. Neuronal degeneration of orexin neurons in lateral hypothalamus Of a pt with narcolepsy vs. control

  14. NarcolepsyThree - stage pathway for control of sleepGreater integration of multiple factors and greater flexibility in behavioral response 3rd system Dorsomedial nu. of hypothalamus (DMH) SCN many physiological Functions: eating, temp & Cortisol cycle are affected. Few direct projections VLPO Orexin neurons

  15. Obstructive Sleep Apneain Psychiatry

  16. EKG Airflow Thoracic effort Abd. effort SAO2 Obstructive Apnea: A complete blockage of the airway despite efforts to breath. Notice the effort gradually increasing ending in airway opening.

  17. Hypopnea: This is an 18 second hypopneic event. The airflow signal is reduced by approximately 50% during this event.

  18. Mixed Apnea

  19. Circadian rhythm sleep disorder

  20. Assessment

  21. Chronic Insomnia Clinical History Narcolepsy Sleep Apnea PSG MLST Primary Insomnia and Secondary Insomnia due to Mood Disorder PLMS

  22. Diagnosis in chronic insomniacs(N = 113) M : F = 21 : 20 M : F = 16 : 26 Primary Insomnia N=40 (36%) Secondary Insomnia N=41 (37%) Primary Insomnia with Scattered Affective disorders N=32 (27%) M : F = 11: 19

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