SLEEP DISORDERS.

Sleep disorders or sleep-wake disorders, refers to problems involving with the quality, timing and amount of sleep which result in daytime distress and impairment in functioning (1,2). It can exist with other medical conditions or mental illnesses. DSM-5 point out 10 sleep disorders including insomnia, narcolepsy, breathing related sleeping disorders, restless leg syndrome and others. They occur when the body’s internal clock does not work properly or is out of synchronization with the surrounding environment (3).

1.?????Risk factors for sleep disorders.

Biologically, age beyond 60 years, chronic diseases with associated pain like in Neurodegenerative diseases like Parkinson’s disease, Alzheimer’s, Musculoskeletal Diseases like Osteoarthritis and Kidney diseases, use of some medications like levodopa, phenytoin and steroids, female gender and hormonal changes as in premenstrual Syndrome and Menopause, increases the chances of developing sleep disorders (1,4–6).

Chronic persistence stress in someone’s daily routines and other mental health diseases like Anxiety disorders, Bipolar disorders and depression are among psychological triggers for the development of Sleep disorders.

Socially, life style behaviors like smoking, drinking alcohol, caffeinated drinks, working or doing other mentally intense activities and exercising especially near sleeping time can increase the risk of getting sleep disorders on the long run. ?Night shift works, Long-range jet travel (crossing many time zones in a short period of time) and poor sleep environment may lead to sleep disorders (1).

2.?????Differences between hypersomnia and Narcolepsy.

Despite the fact that both hypersomnia and Narcolepsy are both disorders of excessive daytime sleepiness. Hypersomnia describes recurrent daytime sleepiness or prolonged sleep pattern but Narcolepsy is somehow severe and involve additional neurological functions beyond hypersomnia (1,2).?While there is periods of irresistible sleepiness and sleep attacks with most often auxiliary symptoms like cataplexy (loss of muscle control), REM sleep latency changes, sleep paralysis and hypnogogic hallucination in Narcolepsy sleep disorder, there is longer sleepiness and sleep attacks in hypersomnia that are more resistible than in narcolepsy and auxiliary symptoms are absent (7).

3.?????Mental disorders which can feature symptoms of insomnia.

A number of mental disorders can feature symptoms of insomnia (1,8,9). These includes Depression Disorders, Anxiety Disorders, Bipolar Disorder, Schizophrenia, Attention-deficit/ Hyperactive Disorder (ADHD), Autism Spectrum Disorders and Post-Traumatic Disorder (PTSD).

4.?????Which investigations are done for sleep disorders?

Different investigations have been done to diagnose and monitor different sleep disorders. Polysomnography is the sleep study follow up (used for investigation) which involves continuous and simultaneous recording of multiple physiological parameters (heart rate , respiration, muscle activity, blood pressure, brain activity, eye movement etc) ?so as to evaluate sleep and respiration (10).?Other investigations and tests which can be done to rule out the diagnosis includes Drug and alcohol toxicology screening, thyroid function tests, arterial blood gases test, Full blood Picture (to rule out anemia) and Beck (11). Also, other investigations and tests like Electrooculogram, Chin and leg alectromyogram and actigraphy can be used to rule in the disorders (11).

5.?????Which medications can be used to treat sleep disorders, what doses and why?

Pharmacological treatment of sleep disorders includes Benzodiazepines, Antidepressants, Antipsychotics and melatonin (12). Benzodiazepines which enhance the inhibitory effects of gamma-aminobutyric acid (GABA) which later induce sleepiness (13), are prescribed 10 mg nocte and are to be used for short term (up to two weeks) since long term increase the chance of developing dependency (13) and dementia (14–16).

Melatonin (short acting or long acting) can be used too. Long acting Melatonin most often is used at dose of 2mg once daily, one to two days before bedtime up to 13 weeks. Also SRRIs like Amitriptyline is most common used at a dosage of 10-50mg (low dose). Trazodone (100–150mg) and mirtazapine (15–30mg) are also prescribed, usually at doses lower than those that produce an antidepressant effect (12).

Neuropathic pain agents, such as Pregabalin, may also be prescribed off licence in practice to help sleep continuity, especially if pain or anxiety are factors in fueling insomnia. A dose of 75–150mg before bed can be helpful given the lack of contraindications and good side effect profile. Pregabalin has the advantage that it enhances the deeper non-rapid eye movement (NREM) stages of sleep (17). Other drugs like Dexamphetamine and Methylyphenidate can be used too depending on indication.

For children and adolescents, some recent studies (2020) have shown melatonin and trazodone (SSRI) to be the most effective drugs (18).

6. Mention 3 Psychotherapies that can help, and how?

CBT is recommended as the first line psychotherapy (19–23). The therapy enables the patient to recognize and change beliefs, thoughts and behaviors which affect his or ability to sleep. CBT might include Stimulus control therapy which helps to remove factors that condition the mind to resist, sleep restriction which needs a patient lying on the bed only when he/she is sleepy, sleep hygiene which involves changing basic lifestyle habits than influence sleep like drinking caffeinated drinks before sleeping, relaxation training which help calm the mind and the body and Biofeedback (24) which requires a patient to adjust to his or her biological heart rate and muscle tension.

REFERENCES.

1. ??????American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

2. ??????Sadock B, Ahmad S, Sadock V. Kaplan and Sadock’s pocket handbook of clinical psychiatry. 6th Editio. Teja CF, editor. Philadelphia: Wolters Kluwer; 2019.

3. ??????Muth CC. Sleep-Wake Disorders. JAMA [Internet]. 2016 Dec 6 [cited 2022 Mar 15];316(21):2322–2322. Available from: https://jamanetwork.com/journals/jama/fullarticle/2589344

4. ??????Demicheli V, Barale A, Rivetti A. Vaccines for women for preventing neonatal tetanus. Cochrane Database of Systematic Reviews. 2015.

5. ??????Smagula SF, Stone KL, Fabio A, Cauley JA. Risk factors for sleep disturbances in older adults: Evidence from prospective studies. Sleep Med Rev [Internet]. 2016 Feb 1 [cited 2022 Mar 15];25:21–30. Available from: https://pubmed.ncbi.nlm.nih.gov/26140867/

6. ??????Donskoy I, Loghmanee D. Insomnia in Adolescence. Med Sci [Internet]. 2018 Sep 1 [cited 2022 Mar 15];6(3):72. Available from: /pmc/articles/PMC6164454/

7. ??????Manfredi RL, Brennan RW, Cadieux RJ. Disorders of excessive sleepiness: narcolepsy and hypersomnia. Semin Neurol [Internet]. 1987 [cited 2022 Mar 15];7(3):250–8. Available from: https://pubmed.ncbi.nlm.nih.gov/3332460/

8. ??????Mental Health and Sleep | Sleep Foundation [Internet]. [cited 2022 Mar 15]. Available from: https://www.sleepfoundation.org/mental-health

9. ??????Soehner AM, Kaplan KA, Harvey AG. Insomnia comorbid to severe psychiatric illness. Sleep Med Clin [Internet]. 2013 Sep [cited 2022 Mar 15];8(3):361. Available from: /pmc/articles/PMC4187404/

10. ????Davey MJ. Investigation of sleep disorders. J Paediatr Child Health [Internet]. 2005 Jan [cited 2022 Mar 15];41(1–2):16–20. Available from: https://pubmed.ncbi.nlm.nih.gov/15670217/

11. ????Overview of Tests and Procedures for Sleep Disorders | University Hospitals [Internet]. [cited 2022 Mar 15]. Available from: https://www.uhhospitals.org/health-information/health-and-wellness-library/article/adult-diseases-and-conditions-v1/overview-of-tests-and-procedures-for-sleep-disorders

12. ????Sleep disorders: treatment - The Pharmaceutical Journal [Internet]. [cited 2022 Mar 15]. Available from: https://pharmaceutical-journal.com/article/ld/sleep-disorders-treatment

13. ????Wilson SJ, Nutt DJ, Alford C, Argyropoulos S V., Baldwin DS, Bateson AN, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010 Nov;24(11):1577–600.

14. ????De Gage SB, Moride Y, Ducruet T, Kurth T, Verdoux H, Tournier M, et al. Benzodiazepine use and risk of Alzheimer’s disease: Case-control study. BMJ. 2014;349.

15. ????Zhong GC, Wang Y, Zhang Y, Zhao Y. Association between benzodiazepine use and dementia: A meta-analysis. PLoS One. 2015 May 1;10(5).

16. ????Benzodiazepine Use and the Risk of Dementia [Internet]. [cited 2022 Mar 15]. Available from: https://www.psychiatrictimes.com/view/benzodiazepine-use-risk-dementia

17. ????Trenkwalder C, Winkelmann J, Inoue Y, Paulus W. Restless legs syndrome - Current therapies and management of augmentation. Nat Rev Neurol. 2015 Aug 8;11(8):434–45.

18. ????Boafo A, Greenham S, Sullivan M, Bazaid K, Suntharalingam S, Silbernagel L, et al. Medications for sleep disturbance in children and adolescents with depression: a survey of Canadian child and adolescent psychiatrists. Child Adolesc Psychiatry Ment Health [Internet]. 2020 Mar 10 [cited 2022 Mar 15];14(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32175006/

19. ????Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD, Barry MJ, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med [Internet]. 2016 Jul 19 [cited 2022 Mar 15];165(2):125–33. Available from: https://pubmed.ncbi.nlm.nih.gov/27136449/

20. ????Trauer JM, Qian MY, Doyle JS, Rajaratnam SMW, Cunnington D. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med [Internet]. 2015 Aug 4 [cited 2022 Mar 15];163(3):191–204. Available from: https://pubmed.ncbi.nlm.nih.gov/26054060/

21. ????Parsons CE, Zachariae R, Landberger C, Young KS. How does cognitive behavioural therapy for insomnia work? A systematic review and meta-analysis of mediators of change. Clin Psychol Rev. 2021 Jun 1;86:102027.

22. ????Bootzin RR, Epstein DR. Understanding and Treating Insomnia. https://dx.doi.org/101146/annurev.clinpsy3022806091516 [Internet]. 2011 Mar 28 [cited 2022 Mar 15];7:435–58. Available from: https://www.annualreviews.org/doi/abs/10.1146/annurev.clinpsy.3.022806.091516

23. ????Sharma MP, Andrade C. Behavioral interventions for insomnia: Theory and practice. Indian J Psychiatry [Internet]. 2012 Oct [cited 2022 Mar 15];54(4):359. Available from: /pmc/articles/PMC3554970/

24. ????Melo DLM, Carvalho LBC, Prado LBF, Prado GF. Biofeedback Therapies for Chronic Insomnia: A Systematic Review. Appl Psychophysiol Biofeedback [Internet]. 2019 Dec 1 [cited 2022 Mar 15];44(4):259–69. Available from: https://pubmed.ncbi.nlm.nih.gov/31123938/