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Body Clocks, Sleep Debt & Behavioral

Health

-Dr. Michael DeSanctis, PhD, LP, ABPP, DBSM, FAACoP

michael@drdesanctis.comOct 28, 2019

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DISCLOSURE STATEMENT

• Dr. DeSanctis discloses that he has neither financial agreements with nor endorsement from any commercial interest in relation to the topics of this presentation.

• This presentation is designed for educational purposes only and is not intended for self-assessment or self-treatment. Any concerns related to sleep or behavior should be addressed with the appropriate health care provider. Comments by presentor in regard to audience queries regarding clinical management of clients are not meant to substitute for supervision or direct consultation.

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Presentation Objectives

• 1. Describe basic circadian, homeostatic principles.• 2. Learn practical implications of circadian knowledge for client

assessments/treatments; how to screen for chronotypes.• 3. Identify typical circadian disorders and strategies for intervention.• 4. Discuss insufficient sleep as a behavioral risk factor related to

mood, neuro-cognitive and substance use status.• 5. Review of evidence-based solutions to remediate sleep debt and

identifying the need for further consultation.

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Types of Rhythms

• Natural Circadian-about 24 hours; Also involved in disease: Malaria, observed 24, 48 and 72-hour fever cycles; 24-hour cycle the deadliest

• Tides: ebb and flow: 2 high and 2 low tides q. 24 hours and 50 minutes;

• Ultradian-repeated periods throughout 24-hr day-• respiration• Infradian-periods >24 hours (e.g., menstrual cycle in humans)• Circannual –seasonal-ancient way of keeping track of the days, based

on light

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Circadian Processes

• Intrinsic to life forms, organizing principle of life

• Circa=about, Dies=day Kiser, K. (2005); Franz Halberg, U of MN;

• Hard-wired/DNA/clock genes/proteins

• Changes in circadian rhythms over the life span;Kiser, K. (2005). Father time. Minnesota Medicine, 88(1), 26-30.

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Specific Circadian Elements

• In humans, clock operates at a slightly greater length than a 24-hour period

• Linear time vs. circadian time Wright, K. (2012) Times of our lives. Scientific American, 21(1), 34-41.

• Suprachiasmatic Nucleus-SCN-master pacemaker, connected to periphery;

Duffy & Czeisler (2009). Effect of light on Human Circadian Physiology. Sleep Med. Clin, 4(2), 165-177 Doi: 10.1016/j.jsmc.2009.01.004;

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Circadian Drivers

• Entrainment/synchronization of SCN pacemaker and peripheral clocks by external light cues, social, eating, substance use activities-zeitgebers;

• Light, dopamine promote wakefulness

• Phase Response Curve-Delays and Advances/Chronobiotics-Melatonin

• Disconnect between what we do and think and status of our inner biological clock

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Creatures of Habit

• We are creatures of habit, entrained each and every day, intentionally and in a conditioned fashion; in Western culture forward propulsion;

• Deviations from our usual habits, such as eating large meals in middle of the night, traveling across many time zones puts us at cognitive and adaptive risk; insulin resistance and circadian disruption

• External and internal de-synchrony Wirz-Justice et al, (2009). Chronotherapeutics for Affective Disorders. Basel, Switzerland:S.Karger

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Insomnia/Circadian Disruption

• Fall/Accident risk

• Substance use risk

• Sleepy Driving/MV Crashes

• Impact on intimacy and communication in relationships (DeSanctis, M. J. Appl Behav Res, 2017; e12102.https://doi.org/10.1111/jabr.12102

• Mood Disturbance

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Circadian Neuro-functional Anatomy/Physiology

• Photic energy via optic nerve to SCN

• Pineal Gland/Melatonin-darkness signal; hormones signals peripheral clocks; circadian drive engaged by blue light wavelength;

• Orexin-wakefulness signal vs. adenosine (Liu & Gao, 2007-doi:10.1152/jn.00873.2006

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Circadian Inflection Points

• Wake Maintenance Zone (WMZ)

• Circadian Nadirs (Monk et al, 1996, Chronobiology International, 13, 123-133.

• Central Clock: core body temperature, cortisol levels, behavior, hormones, metabolism; signals to and from peripheral clocks

• Cortisol peaks earlier in day, may be involved in entrainment of peripheral oscillators; external morning light amplifies signal

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• Persistent• Conscientious• Cooperative• Female>Male• Better Sleep

• Addiction Risk• Mood

Disturbance• Creativity• Novelty seeking• Volatility

Sharkey, 2014, Post-grad course Annual Mtg of AASM, Mpls, MN June 2014

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Homeostatic/Circadian Principles

• Homeostatic Sleep Pressure (H-drive) in a 24/7/365 business and personal culture, with less and less true darkness at night

• Homeostatic and Circadian Processes (S-drive) interact in the 24-hour period; the longer you are awake, the stronger the sleep pressure

Borbely, A.A. (1982). A two-process model of sleep regulation. Human Neurobiology, 1(3), 195-204.

• Rest-Activity Cycles, Light, Genes, Dopamine, Rewarding Behaviors (Parekh et al., 2015). Alcohol 2015 Jun 49(4), 341-349.

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Source: Wikipedia Commons

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Clinical Assessment of Circadian/Sleep Challenges

• Sleep habits, preferences, any hx of neurologic compromise, TBI/CHI/LOC; permeable sleep-wake boundary;

• Chronotypic evaluation Morningness-Eveningness Questionnaire-(MEQ)

Horne & Ostberg, 1976, International Journal of Chronobiology, 4, 97-110.

• Social Jet Lag (Wittmann et al, 2006 https://doi.org/10.1080/07420520500545979; Sleep Inertia (Santhi et al, 2013, PLOS ONE, 8(11), 1-13.

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MEQ

• Scale (19 items, 4-5 forced choices)

• Scoring (range from 16-86; 41 or < =evening; 59 and >=morning; lower scores mean later morning light exposure; higher values translate to earlier morning light exposure-algorithm developed

Cf. Wirz-Justice et al, 2009, Chronotherapeutics for Affective Disorders. Basel, Switzerland: S. Karger, AG. contains copies of the MEQ , Personal Inventory for Depression and SAD (PIDS), etc.

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MEQ continued

• Sample queries: what would be your preferred bedtime if you had total control over your schedule?

• Degree of alertness when first awakening

• How reliant are you on an alarm clock?

• Time interval during day for physical exercise and when you feel at peak(Breus, 2016)

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Morningness-Eveningness Questionnaire

• Morning vs. Evening Chronotypes Horne & Ostberg, 1976

• Self-Report, online version at www.cet.orgTerman et. al., 2014, Center for Environmental Therapeutics

• Other versions of chronotype screening for pediatric use

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Why Do Humans Need to Sleep?

• Homeostatic: restore tissue and regulate internal body temperature; conserve energy; sleep has been millions of years in the making;

• Protect from Predation; Sleep Patterns of Grazing vs. Predatory Animals

• REM sleep-remove, prune, consolidate daily experience from neural networks; hippocampus to cortex channeling

• Sleep needs studied across all biological kingdoms

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General Protocol for Sleep D/O Differential

• Diagnostic intake-include statement about sleep; R/O substance abuse, environment

• Epworth Sleepiness Scale Johns, 1991, Sleep, 14, 540-545

• Prospective Sleep Log Carney, http://drcolleencarney.com/wp-content/uploads/2016/Final-CSD-Morning-only-with-instructions.pdf

• Sleep Efficiency/Sleep Length/Quality• Referral to primary care/BSM/sleep clinic/Actigraphy, overnight

studies

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Epworth Sleepiness Scale (Johns, 1991)

• 0-3 ordinal scale, with 0=no chance of dozing to 3=high chance of dozing off

• 8 items, >10 considered abnormal

• items query one’s state of sleepiness in typical situations -as passenger in a vehicle; after lunch with no ETOH, resting or watching TV, etc.,

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The Challenges of Adolescence

• Delayed Sleep

• Hormone Flux

• Social Pressures

• E-Device Use

• School Start Times

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Hypothetical Case Study-DSPS

• Peter, Age 16, male, referred by parents in context of truancy and academic underachievement

• PHQ-9 T=10; GAD-7 T=5

• At 9am Intake: client irritable, tired, yawning; parents primary informants; client bored, detached;

• 3-year pattern of difficulty arising in morning

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Delayed Sleep-Wake Phase DisorderLater circadian melatonin phase

Alert in the eveningsleep onset insomnia

Morning sleepinessdifficulty awakening from sleep

Delayed sleep time and reduced sleep duration during the school week

Normal circadian melatonin phase

Normal sleep time

Restricted sleep with delayed phase

American Academy of Sleep Medicine; used with permission

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DSPS Case Study, continued

• MSE: no apparent neurocognitive compromise, MMSE 30/30; WNL intellect; no indication of any SLD; no CHI/LOC or seizure activity;

• Stays up late, till 2-3am every school night on his iPad, watching videos, keeps smartphone under his pillow; sleeps late on weekend mornings (11am-12noon)

• Client denies ETOH, caffeine, opioid, K2 use; Client smokes THC to take edge off school anxiety; no prescribed psychotropics

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DSPS Case Study, continued

• Sleep is restorative when not awakened on school mornings; no nocturnal or sleep period awakenings; simply unable to fall asleep at 10 or 11pm on school nights; considerable friction with parents over this issue; more and more academic concerns year over year;

• Report of solid peer friendship network, no prior trauma exposure; middle-class, stable family system; no IEP or 504 IAP

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DSPS Case Study Continued

• Dx Impressions? R/O Persistent Depressive Disorder, DSPS, compulsive e-device use;Treatment Plan:1. 2-week Sleep Log (BSM clinics may rely on actigraphy and log)2. referral to BSM clinic and to PCP; may benefit from early am bright

light, evening melatonin, counseling with client and parents around DSPS

3. Sleep Hygiene counseling; 4. Chemical Health Screening with CAGE-AID

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DSPS Case Study, continued

• 3. Secure ROIs, consultation with school, and/or juvenile court if truancy charges pressed by school/county attorney

• 4. Depression is not uncommon among adolescents with DSPS-may reflect frustration, not meeting expectations for attendance, sense of failure, circadian disruption; at risk for more self-medication;

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Advanced Phase Disorder

• Seen in elderly sub-populations; Sundowning, early evening drowsiness

• Weaker circadian signaling with advancing age; Flamer, 1996, Australian New Zealand Journal of Medicine, 26, 96-104.

• Treatable with environment/light/lifestyle modifications Ancoli-Israel et al., 2003, Behavioral Sleep Medicine, 1, 22-36.

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Practical Implications of Chronotype

• Differences in chronotype among humans living together or in committed relationships; MEQ as screening tool in couples assessment/conflict resolution

• When is a clinician at optimum and nadir points during the work day? Oxytocin and Testosterone levels higher in morning

• Times of day to prescribe skills training for clients such as meditation, mindfulness, Breus, 2016-The Power of When

• Personality traits, SOL, mood, substance use correlated with morning vs. evening types

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A Peek at Google Searches

• Porn searches reach maximum @ 1am

• Weather/News (5:24am/4:52am)

• Panic and loneliness searches peak at 3:24am

• Mental lapses reach maximum well after 12midnight-space out on PW at 2:44am

Source: Stephens-Davidowitz, 2015;

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Sleep/Circadian Issues in At-Risk Sub-populations• Fetal Depakote Syndrome

Garcia, 2010, Challenging and fascinating cases that arise in pediatric sleep medicine. Presentation to the MN Sleep Society, 1st Annual Meeting, St. Paul, MN

• Dementia (Lim et al, 2014): sleep disruption leads to increases in beta-amyloid and tau proteins);

• Sundowning

• Non-24 Circadian Rhythm Blind individuals; Lockley et al, 2007, Visual impairment and circadian rhythm disorders. Dialogues in Clinical Neuroscience, Sept 9(3), 301-314.

• “Early to bed, early to rise, makes [one] healthy, wealthy and wise.”

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Circadian/Sleep Disruption and General Health

• Shift work perils, industrial accidents, motor vehicle crashes, absenteeism

• Cardiovascular impacts; morbidity;

• Short Sleep and Diabetes risk, increase in hedonic food intake, role of endogenous cannibinoids

Van Cauter, 2018, Annual Mtg, MN Sleep Society, October 2018

• Immune system/Chronic pain

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Sleep, Circadian and Immune System Functions

• Spikes in adrenal activity correlated with presence of inflammatory cytokine (interleukin-6)

• Inflammatory cytokines and degenerative illnesses,-dementia of the Alzheimer’s type, tau and amyloid deposition in central neural networks

• Relationships between circadian de-synchrony, acute sleep deprivation, cortisol levels, CRP, IL-10, TNF;

Besedovsky et al, 2012 Pfluger Archiv. Jan 463(1), 121-137.

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Extrinsic Circadian Disorders

• Jet Lag versus Social Jet Lag Wittmann et al, 2006, Chronobiology International, 23 (1-2), 497-509. doi.org/10.1080/07420520500545979

• Misalignments-Perlis et al, 2016, Journal of Clinical Psychiatry, 66(11), 1148-1160. https://doi.org/10.4088/JCP.15m10131.

• Shift work Czeisler et al, 1986 Science, 233, 667-671.

• Effects of Surgery, Hospitalization on circadian rhythms Farr et al, 1984, Nursing Research, 33, 140-146.

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Facts about Sleeplessness

• Insomnia prevalent in the population; some estimates of 1 in 10 adults in US; more health care utilization, worker absences, marker for depression

• National Sleep Foundation, 2004: nocturnal awakenings typical in infants/children; impact on caregivers (primarily mothers and stepmothers)

• CDC, 2009: about 29% US adults sleep <7 hours per night; state-by-state estimates of 30 days of insufficient sleep varied from 7.4% in ND to 19.3% in WV-Hawaii actually has a problem with insufficient sleep

• Billions of prescriptions written for sleeping pills

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Sleep Hygiene Basics/Rationale (HANDOUT)

• Regularity of Schedule/Strategic Light and Dark Exposures

• Stimulus Control Bootzin, 1972, Proceedings of the American Psychological Association, 1972 395-396,

• Lifestyle Factors/Environmental home and office; DeAngelis, 2017, Monitor on Psychology, 48(5), 40-45.

• Lacks efficacy as single modality txPosner & Gehrman, in Perlis, Aloia & Kuhn, 2011, Behavioral Treatments for Sleep Disorders, Amsterdam: Elsevier.

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Sleep Hygiene and Sleep/Circadian Wisdom

• Social rhythm therapy, importance of daily routineFrank et al, 2007, Dialogues in Clinical Neuroscience 9(3), 325-332.

• Boundaries on e-device/LED exposure/Blue Wavelength Tosini et al. 2016

• Modifications to sleeping quarters

• Sleep Efficiency (overstaying your welcome in bed)

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Still counting Sheep?

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Insomnia

• Hyperarousal and weakened H-drive (primary); Intersection of Circadian and Homeostatic; overrides GABA

Gottesmann, 2002, Neuroscience, 111(2), 231-239.

• Association with Anxiety/Trauma/Physical Environment, insomnia is most common PTSD symptom

• Insomnia common in abstinence, early recovery, creates relapse riskHasler et al, 2012. Sleep Medicine Review, Feb 16(1), 67-81.

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Tips for Zeroing in on Insomnia• Bed partner/parent/caregiver input, possible delayed circadian phase

• Predisposing factors: cognitive ruminative styles; circadian de-synchrony, lifestyle, personality traits

• Precipitating: acute grief or loss, trauma;

• Perpetuating: anxiety/mood/substances/e-device overuseSpielman et al, 1987, Sleep, 10, 45-56.

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SLEEP PROBLEMS ARE ENDEMIC • Nearly everyone experiences some transient sleeplessness

• People with insomnia have perfected the art of not sleeping

• Mechanical view of sleep (viewed as a necessary evil by some)

• Family sleep attitudes/Insomnia is a cross-cultural issue Kalmbach et al, 2016, Sleep Dec 1, 39(12), 2101-2111. doi: 10.5665/sleep.6306.

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Sleep Hygiene-Learning How to Sleep

• Behavioral (clock watching, regularity of sleep-wake schedule, scheduling of heavy meals, social activity, cell-phone/laptop use in or just before bedtime)

• Environmental: temperature, ambient light in bedroom, noise levels, air circulation, humidity, allergens, mattresses, etc.

• Avoid caffeine, nicotine, ETOH anywhere near late evening/bedtime

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More about insomnia as a learned problem

• People copy others and use caffeine to stay awake, ETOH or Cannabis/THC, but do not learn enough about the dose-response relationships

• People try hard to sleep, very hard!

• Learning to live without distractions

• Positive and Negative Sleep Thoughts Jacobs, 1998. Say Goodnight to Insomnia. New York, N.Y.: Henry Holt and Company, LLC

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New & Existing Sleep Tracking Technologies

• Growing consumer awareness/interest, part of the digital universe

• Pillows/Mattresses; Apps

• Motion/Movement Detectors/Actigraphy

• Search for holy grail of technology to improve sleep

• Limitations in understanding sleep quality/impact of measurement

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Insomnia and Primary Care

• Insomnia still not snuffed out in primary care to the extent needed;

• Insomnia may be missed or not reported in the record even though surveyed providers may view it as an important issue, perhaps equal to other non-behavioral sleep issues (e.g., apnea)

• Reliance on Rx as expedient; not behavioral health interventions especially for transient and acute insomnia;

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Medications/Substances that cause insomnia

• Steroids, theophylline, decongestants, pseudoephedrine, stimulants

• Beta blockers (impact melatonin), diuretics

• Antidepressants, such as Prozac, Effexor, Zoloft

• Alcohol, Nicotine, Caffeine, Thyroid meds

• Opioid withdrawal

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CBT-I

• Evidence-based practice for managing insomnia (Pigeon, 2010)

• Online programs/manualsBlom et al, 2016, Sleep, June 39(6), 1267-1274), need for external coaching/support;

• Readily adapted from standard CBT

• Imagery Rehearsal Training (IRT) for nightmares Aurora, et al, 2010, Journal of Clinical Sleep Medicine, 6(4), 389-401.

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Co-morbid Medical Issues Impacting Sleep

• Respiratory illnesses, Apnea, Snoring

• Nocturia/GI problems; indigestion, heartburn

• Chronic pain, fibromyalgia/Obesity/RLS/PLM (one indication for PSG)

• Dementia; mild TBI, decreased REM sleep

Mantua et al., 2017, Sleep, Jun 1, 40(6). Doi:10.1093/sleep/zsx062.

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Periodic Limb Movement Disorder

• Unlike RLS, these are involuntary movements that occur while asleep; Hauri & Linde, 1996, No More Sleepless Nights. New York: John Wiley & Sons, Inc.

• Baffling to person affected, as they awaken in morning tired despite “sleeping all night”

• Similar pharmacologic remedies as with RLS-elevate Dopamine

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Melatonin Facts

• Neuro-hormone produced by pineal gland, not a sleeping pill!

• Responsive to circadian clock, light and ambient temperature; Internal melatonin levels decline with age;

• Dietary supplement (US Dietary Supplement Health and Education Act, 1994; Rx not required; most people are dosing too high, >3mg

• Mixed findings re: efficacy in insomnia (National Sleep Foundation, 2004), be aware of potential interactions with other meds

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Pharmacologic Interventions for Insomnia

• Sedating Tricyclics (Trazodone)

• Benzodiazepines Receptor Agonists (e.g., Lunesta, Ambien)

• Over-the-Counter Remedies (anti-histaminic)-Unisom

• Melatonin Agonists (e.g., Ramelteon)

• Orexin Antagonists (Suvorexant)

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Caveats with Rx

• Benzodiazepines such as Ativan should be used for short-term anxiety reduction, up to 8 weeks duration but less than a fortnight when treating insomnia

• Long-term use of sedative-hypnotics creates risk of falls, dependence, drowsiness, erosion of coping skills, amnestic periods, complex sleep behaviors; need to emphasize non-pharmacologic approaches

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Potential Complementary Approaches• B-vitamins: Deficiencies in thiamine (B1), folic acid, riboflavin (B2), Niacin and

Pyridoxine (B6) Hauri & Linde, 1996;

• Aromatherapy for depression, anxiety and pain relief;

• CBD oil-legal status in flux; lack of high quality human research

• Yoga

• Contraindications: kava (liver toxicity), Sleeping Buddha herb associated with fetal damage

Barnett et al. 2014, Complementary and Alternative Medicine for Psychologists, Washington, D.C.: American Psychological Association

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Bright Light/Dawn Simulation

• Dawn Simulation studies Avery et al, 2001, Biological Psychiatry 50(3), 205-216.

• Bright Light Interventions for winter SAD Rosenthal, 2006 Winter Blues. New York: The Guilford Press.

• Bright Light for Re-setting circadian rhythm (Czeisler et al, 1986)

• Chronotherapeutics for depression (Wirz-Justice, Terman & Benedetti, 2009)

• Chronotherapy using behavioral scheduling

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Sleep Requirements for Adults

• Young Adults lose deep sleep in their 20s

• Middle-agers lose sleep consolidation

• Adults and Seniors: average 7-8 hours of sleep requirement; less stage 1 and REM in aging males and females

• SWS declines more in males as opposed to females over timeColten & Altevogt, Eds; 2006, Institute of Medicine, Committee on Sleep Medicine and Research, Washington, D.C.: National Academies Press, 2006.

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Sleep Architecture (Carkasdon & Dement, 2005, Principles and Practice of Sleep Medicine. Philadelphia: Elsevier Saunders

• N1: from wakefulness to sleep: 5 minute period); alpha to theta at 4-7Hz; tonic muscle activity decreases

• N 2: first stage of true sleep; irregular brain wave activity; sleep spindles (.5 sec acceleration of brain waves, 12-14Hz); theta; K-complexes, high amplitude; eye movements rare

• N 3: Delta, large, slow brain waves .5 to 3Hz; 50% Delta; blood pressure falls/muscle repair

• REM: longer intervals toward end of night’s sleep

• SWS and sleep spindles-move info from hippocampus to prefrontal cortex for LT storage Andrillon et al, 2011, Journal of Neuroscience, Dec 7 31(49), 17821-17834.

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E-Devices

• Blue wavelength Tosini et al, 2016

• f.lux software for changing screen illumination; “night light” option on device

• Social media utilization among adolescents and sleep disruption Levenson et al, 2017, Sleep, Sep 1, 40(9), doi: 10.1093/sleep/zsx113.

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Sleep Deprivation• Working memory and attention; pre-frontal impacts

Alhola & Kantola, 2007, Neuropsychiatric Disease and Treatment, Oct 3(5), 553-567.

Goldstein et al, (2007) Personality and Individual Differences, 42(3), 431-440.

• Cumulative effects, drowsy driving, accident ratesLuyster et al, 2012, Sleep, Jun 1, 35(6) 727-734. doi: 10.5665/sleep.1846

• “Nothing good happens after midnight” suicide rates in 24-hour period

Perlis et al, 2016

• Health consequences of chronic, partial sleep debt, Van Cauter, (2011)

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More on sleep deficit

• Medication errors/critical thinking of interns on call, extended duty hours

• Impaired learning of new tasks (loss of REM on first night after learning impacts memory of cognitive procedural tasks but not declarative or fact retrieval; loss of stage 2 sleep impairs learning of motor procedural tasks;

Dotto, 1996, Canadian Medical Association Journal, Apr 15 154(8), 1193-1196.

“SLEEP ON IT”-retrieval better when sleep period intervenes before recall as opposed to learning early in day and recall later that day;

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Sleep Deficit-General Points

Factors to consider:-type of task-visual-motor vs. auditory vs decision-time of day (circadian), chronotype-acute sleep deprivation (SD) vs. partial SD vs. chronic -effects of situational fatigue, boredom, motivation-simple reaction time vs. complex tasks-impact of age and gender (little data on latter variable)-total SD in research paradigm studied more but does not mimic life

Cf. Valdez et al, 2008. Mind, Brain and Education, 2(1), 7-16.

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Pregnancy, Gender and Sleep

• Females at slightly greater risk of insomnia than males, across geographic regions, progressive with age

Zhang & Wing, meta-analysis, 2006, Sleep, Jan 29(1), 85-93; (Li et al, 2002, Journal of Psychosomatic Research, 53(1), 601-609.

• Pregnancy and clearly post-partum period are risk factors for sleep initiation and maintenance

• >2x greater risk of insomnia in 3rd as opposed to the 1st and 2nd trimesters; 52.2% prevalence of insomnia in random sample N=486

Kizilirmak et al, 2012, Scientific World Journal, online, doi: 10.1100/2012/197093

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Psychological Disorders and Sleep

• Bipolar Disorder: evening chronotype Baek et al, 2016, Behavioral Sleep Medicine, 14, 155-168. doi: 10.1080/15402002.2014.974179.

• Generalized Anxiety, Trauma and Stress (nightmares, flashbacks)

• Sleep Disordered Breathing

• Insomnia can raise risk of Major Depression; depression and sleep problems bi-directional impact;

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Depression and Sleep, (Riemann et al, 2001)

• Interval from sleep onset to first REM period is abbreviated; Less time in N3 deep sleep (SWS)

• More fragmentation, arousals, Stage 1

• Reduced latency to first REM, increased REM density

• Early am insomnia (terminal insomnia)

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Generalized Anxiety Disorder and Sleep

• Decreased efficiency of sleep: more time awake in bed

• More awakenings during the night, sleep architecture disrupted

• Nocturnal Panic episodes

Cf. Staner, 2003, Dialogues in Clinical Neuroscience, Sep 5(3), 249-258.

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Schizophrenic Spectrum and Sleep Kaskie et al, 2017

• Significant delays in sleep onset

• less SWS, rapid entry into REM phase; more fractionated sleep, possible marker for relapse

• Nocturnal VH/AH alone do not = psychosis

• Impact of Medications for Psychosis: diurnal sedation, movement disorders

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Sleep and ASD (Cf. Williams et al, 2004)

• Adult ASD-frequent complaints of insomnia; sensory sensitivities/poor insight/perseveration; intolerant of transitions/change in environments

• ASD have indicated shorter periods of sleep and decreased TST, possibly related to e-device use, obsessional anxiety, sensory disruptions

• ASD with co-morbid Social or Generalized Anxiety

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Sleep and ADHD (Owens, 2009)

• ADHD, hyperactive, delayed sleep onset, RLS, OSA ; circularity of causation, impact on diurnal functioning in school setting

• Evening chronotypic preference

• Sleep hygiene problematic in ADHD compared to normal developing children

• Psychstimulants and insomnia

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Sleep and Alcohol• 2-3 drinks before bed can promote sleep, but less impact after 3 days of

same behavior

• REM inhibition at high doses within 1 hour of sleep, but chronic ETOH leads to less REM suppression; with cessation, REM rebound occurs

• SWS increases following moderate use at bedtime but effects diminish with chronic use

• Dose dependent stimulating or sedating effect, and interval from use to bedtime

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Sleep and Alcohol, Part 2

• Partial sleep deprivation (insomnia) leads to more sedation with ETOH than those without sleep deficiency

• Moderate ETOH in chronically sleep deprived individuals increases risk of accidents-drowsy driving impact & BAC comparisons

• Persistent sleep disturbance in recovery

Review of literature: Stein & Friedmann, 2005, Substance Abuse, Mar 26(1), 1-13.

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Sleep and Illicit/Recreational Substances

• Sleep disturbance/Circadian disturbance- substance abuse bidirectional impacts;

Hasler et al, 2012, Sleep Medicine Review, Feb 16(1), 67-81; chronic THC use may entrain the circadian rhythm; DA, genes and reward circuitry

• THC chronic use can reduce REM and increase SWS sleep; sleep problems raise risk of relapse into use;

• Opioid use: cravings, sleep disruption, parasomnias, diurnal sleepiness; chronic use with withdrawal leads to REM rebound, more nocturnal arousals, respiratory depression, apneas

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Sleep and Aging

• Sleep architectural changes/sleep debt Lim et al, 2014, Neurodegenerative Disease Management, 4(5), 351-362; doi.org/10.2217/nmt14.33

• Older drivers, reaction time, accidents and sleepiness

• Advanced Circadian Phase / Co-morbid Anxiety/Depression

• Cardiovascular stress for even healthy seniors, less than 5 hours per night

Nagai et al, 2010, Current Cardiology Review, Feb 6(1), 54-61; doi: 10.2174/157340310790231635

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Sleep Wellness Resources

• National Sleep Foundation www.sleepfoundation.org

• Lighting Science www.lsgc.com

American Academy of Sleep Medicine www.aasmnet.org

• Sweet Dreamzzz, Inc. www.SweetDreamzzz.org

• iSideSleep www.iSideSleep.com; www.justgetflux.com

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Professional Training/Research Resources

• CBT-I Training-Michael Perlis, PhD, U of Penn Behavior Sleep Medicine

• www.apa.org/monitor/2016/10/insomnia.aspx

• Society for Behavior Sleep Medicine www.behavioralsleep.org

• www.sleepresearchsociety.org

• Society for Light Treatment and Biological Rhythms www.sltbr.org

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Clinician Resources• Ehrnstrom, C. & Brosse, A. (2016). End the Insomnia Struggle. Oakland:

New Harbinger.

• Meltzer, L.J. & Crabtree. V.M. (2015). Pediatric Sleep Problems.Washington, D.C. American Psychological Association

• Perlis, M., Aloia, M. & Kuhn, B. (Eds). 2011. Behavioral Treatments for Sleep Disorders. Amsterdam: Elsevier.

• Behavioral Sleep Medicine; International Journal of Chronobiology; Sleep; Journal of Clinical Sleep Medicine;

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Insomnia/Circadian Aids Online

• David Ackerman podcasts

• www.sleepwithmepodcasts.com

• Online CBT-I

• Meditation apps

• American Academy of Sleep Medicine-sleep calculators, info kits for school start times, etc; www.aasmnet.org

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10/18/19

29

SLEEP GUIDES

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New Horizons for Clinical Practice• Integrated Health Care/Sleep Behaviors/Blending of Western/Eastern

• Transferability of skills (Acceptance/Commitment, CBT, CT, PMR, exposure therapies, IRT, systematic desensitization, hypnotherapy, etc)

• Public Awareness/Safety/Athletic Performance

• Future Healing: genomic, environmental, specialized, more precision around circadian rhythm biomarkers (Mullington, et al, 2016)

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