Clinical classification and characteristics of common sleep disorders
1.Non-organic sleep disorders
It refers to the non-organic sleep and wakefulness disorders caused by various psychosocial factors. Including insomnia, narcolepsy and certain episodic sleep abnormalities (such as sleep walking disorder, night terrors, nightmares, etc.).
(1) Insomnia
It is a condition of unsatisfactory sleep quality mainly due to insomnia, with insomnia as the only symptom, including difficulty falling asleep, poor sleep, easy waking, dreaminess, early waking, difficulty in falling back to sleep after waking, discomfort after waking, fatigue, or daytime sleepiness. Has a dominant perception of insomnia and extreme preoccupation with the outcome of insomnia. Occurs 3 times a week for more than 1 month. Insomnia can cause anxiety, depression, or fear in the patient, and lead to a decrease in the efficiency of mental activities, impede social functioning, and cause significant distress. Insomnia is not diagnosed if it is the result of some physical disease or mental disorder (depression).
Insomnia is the most common of the sleep disorders. If insomnia lasts for 2 to 3 weeks or days, it is called short-term insomnia and is often caused by mental tension, emotional anxiety and so on. After the cause is removed, insomnia will be cured. Insomnia that lasts for more than 6 months is chronic insomnia, which affects the quality of life and physical and mental health. Antidepressants and anti-anxiety drugs can be taken, together with psychotherapy.
(2) Narcolepsy
Excessive daytime sleep or sleep episodes. There is no prolonged time from awakening to full wakefulness or apnea during sleep. Not due to sleep deprivation, drugs, alcohol, somatic diseases, or mental disorders. The patient is significantly distressed by it or it affects social functioning.
Occurs almost daily and lasts for more than 1 month.
(3) Sleep-wake rhythm disorder
The patient’s sleep-wake rhythm does not match what is required (i.e., what is socially required and followed by most people in the patient’s environment), and the patient has insomnia during the main sleep period and drowsiness during the time when he or she should be awake. This leads to a situation of persistent dissatisfaction with the quality of sleep, which occurs almost daily and lasts for more than a month. The patient is apprehensive or fearful about it and causes a decrease in the efficiency of mental activity, marked distress, and hinders social functioning. Sleep-wake rhythm disorder is not diagnosed if it is the result of some physical disease or mental disorder (e.g. depression).
(4) Sleep-walking disorder
Repeated episodes of getting up and walking during sleep, or doing some simple activities in a mixed state of sleep and wakefulness. It lasts for several minutes to half an hour. During the attack, the sleepwalker’s expression is blank and dull, and there is a relative lack of response to others’ greeting or interfering behavior. It is quite difficult to make the patient awake; after the attack, he/she automatically returns to bed and continues to sleep or lies on the floor and continues to sleep; it usually appears in the first one-third of the sleep period of deep sleep, and cannot be recalled when waking up in the next morning. Most often seen in children and adolescents. It can coexist with epilepsy, but should be differentiated from seizures. It usually does not significantly affect daily life and social function.
(5) Night terrors
Commonly seen in young children with sleep disorders. Recurrent episodes of awakening from sleep after a panic scream, inability to maintain appropriate contact with the environment, and accompanied by intense anxiety, somatic movements, and autonomic hyperactivity (such as tachycardia, shortness of breath, and sweating), lasting about 1-10 minutes, usually occurring in the first third of sleep; each episode lasts about 1-10 minutes. Amnesia afterwards. Exclude febrile convulsions and seizures.
(6) Nightmare
Sudden awakening from night sleep or naps by nightmares with clear and detailed recall of intensely frightening dreams that usually endanger survival, safety, or self-esteem. They usually occur in the second half of the night; once awakened from a frightening dream, the patient can quickly regain orientation and fully awaken; the patient is in great distress.
(7) Episodic narcolepsy
Irresistible sudden onset of sleep on any occasion such as eating, talking, working, walking, cannot be restrained, and is accompanied by sudden collapse disorder, sleep paralysis and hallucination of falling asleep. Monotonous work, quiet environment and after meals are more likely to attack. Sleep is similar to normal sleep with a normal EEG. The sleep is usually not deep, easy to wake up, but fall back to sleep after waking. The episodes can vary from several to dozens of times a day, and the duration is usually more than ten minutes.
Sudden collapse is the most common complication of the syndrome, accounting for about 50-70% of the episodes. The consciousness is clear during the episodes, and the trunk and muscle tone are suddenly hypotonic and collapse suddenly, usually lasting 1 to 2 minutes. It occurs mostly in adolescents and is more common in males. Seizures may decrease after middle age.
Sleep paralysis is seen in 20-30% of patients with episodic sleeping sickness and is characterized by clear consciousness and immobility and generalized flaccid paralysis. The seizure can be aborted by touching the patient’s body, and some patients have to shake hard to recover.
Sleep hallucinations account for about 25% of the disease, with audiovisual hallucinations being the most common, the content of which is mostly daily experience, and the patient is aware of the surroundings, but seems to be in a dream state.
2.Sleep disorders due to mental illness
Patients with mental illness often experience various forms of sleep disorders, with an incidence of up to 47%. breslau et al. reported that the lifetime prevalence of insomnia was 71% in psychiatric patients and 41% in normal subjects. Sleep disorders in psychiatric patients may be one of the symptoms of the disease itself. Common sleep disorders include difficulty falling asleep, decreased sleep, excessive sleep, and altered sleep patterns, with difficulty falling asleep and decreased sleep being the most common. According to the survey, the psychiatric disorders in which sleep disorders often occur include affective disorders, schizophrenia, neurosis, eating disorders, and drug dependence.
Most psychiatric disorders have sleep disorders as the first symptom, and psychiatric symptoms such as reduced sleep duration (insomnia), difficulty falling asleep and early awakening appear later. The frequency and severity of sleep disorders are closely related to the severity of the mental illness, i.e., the more severe the illness, the more chances of sleep disorders and their severity.
(1) Depression disorder
Sleep disorder is one of the most common clinical first symptoms of depressive disorder, including difficulty falling asleep, difficulty maintaining sleep, and a tendency to wake up early with a bad mood in the morning. A small number of patients present with excessive sleep due to psychomotor depression. Sleep disturbances can occur before, during, and after the onset of depression. Insomnia can be a risk factor for the onset of depression, or it can be an early precursor symptom. Survey data have found that insomnia can often coexist with depressed mood. Seventy-five percent of patients with chronic insomnia were previously depressed.
The main features of polysomnography are.
1. Impaired sleep maintenance: prolonged sleep latency, increased number and duration of mid-awakenings, and early awakenings.
2. NREMS abnormalities: Decrease in stage 3 and 4, slow wave sleep pushes from the first NREMS to the second half of the night.
3.REMS: shortened latency and increased REMS density, with the 1st REMS being the most significant, i.e., REMS is more frequent in the first half of the night.
Excessive activity of norepinephrine (NE) and adrenocorticotropin-releasing factor, etc., may be the pathogenesis of depression sleep disorder. The specificity of shortened REMS latency and significantly reduced slow-wave sleep in depression may often be related to reduced 5hydroxytryptamine (5HT)/NEergic neurotransmission or increased cholinergic transmission. The phenomenon of enhanced REMS activity such as shortened REMS latency, prolonged REMS time, and increased REMS density in depressed patients coincides with the etiological hypothesis of decreased 5HTergic and increased cholinergic in depressed patients. It also suggests that sleep disorders in depression are closely related to the pathogenesis of depression.
The effect of antidepressants on sleep is variable. Amitriptyline, promethazine, trazodone, mirtazapine, and others have the effect of increasing sleep persistence. Some drugs themselves cause pharmacogenic sleep disorders, including chlorpromazine, monoamine oxidase inhibitors, 5HT reuptake inhibitors, and vanafloxacin, which increase REMS latency, inhibit REMS, cause eye movements during NREMS, increase nocturnal awakening and nocturnal limb activity, reduce sleep efficiency, and shorten total sleep time.
(2) Mania
The main manifestation is difficulty in falling asleep, the sleep time is reduced, and the patient may sleep only 2~3 h per night, but the patient still feels energetic. the REMS latency period is shortened, and the NREMS stage 3 and 4 are also reduced. Compared with depressed patients, manic patients have shorter REMS latency; NEergic nerve abnormalities may be the cause of REMS changes and subjective energetic in manic patients, and the reduction of REMS in mania may be due to the enhancement of NEergic nerves in the brain.
(3) Schizophrenia
Sleep disturbance is a common clinical symptom in schizophrenia, with an incidence of up to 72%, and difficulty sleeping is an important complaint in schizophrenic patients. In addition to sleep disorders, there are obvious cognitive, emotional and behavioral symptoms.
Abnormal indicators on polysomnography include.
Prolonged sleep latency.
Shortening of NREMS stage 4, or even lack thereof.
Decreased slow-wave sleep.
Disorders of sleep persistence.
Shortening of total sleep duration.
Shortened REMS latency in schizophrenia is associated with cholinergic hypersensitivity. Many antipsychotics have sedative effects, especially traditional antipsychotics, which improve sleep onset and sleep persistence, but also cause excessive daytime sedation. Clozapine and olanzapine, atypical antipsychotics, also have strong sedative effects and cause excessive sleepiness in patients. Abrupt withdrawal can cause a brief reduction in sleep duration that can last 2 to 4 weeks. The insomnia rebound caused by withdrawal may be due to cholinergic hypersensitivity. The effect of different antipsychotics on sleep EEG is different, and most antipsychotics increase slow-wave sleep. Olanzapine increases stage 2 sleep, increases slow-wave sleep, and is present on the 1st night of medication. Sulpiride increases slow-wave sleep, decreases the number of awakenings, increases the total duration of sleep, and is present on the 1st night of medication. Increased NREMS, especially stage 2 sleep. Antipsychotic-induced sedation cannot be associated with sleep and behaves like restless legs syndrome, and both conditions are associated with altered dopamine and iron ion metabolism. The main difference between sedentary inability and restless legs syndrome is that the former feels fidgety and has no significant fluctuation in 1 d; while the latter is mainly caused by abnormal sensations in the legs, often occurring during sleep and rest, leading to sleep disruption.
The treatment of mental illness sleep disorder has certain specificity, mental illness itself is the main cause of sleep disorder, to improve sleep disorder must pay attention to the treatment of mental illness, only when the mental illness condition improves, sleep can be improved. Appropriate treatment with sleeping pills is necessary. Patients with depression should be treated with antidepressants in order to achieve good results.
(4) Anxiety disorders
The treatment strategies for sleep disorders are: (1) to solve the difficulty of falling asleep, maintain mid-sleep, and prevent early awakening; (2) to maintain the original sleep physiology as much as possible; and (3) to improve the quality of life of patients.
In many cases, nonpharmacological treatment should be the first choice for the treatment of sleep disorders. Transient or acute sleep disorders can be treated very well with non-pharmacological treatment alone. Even for long-term sleep disorders, non-pharmacological treatment is one of the effective methods. There are many clinical reports on the treatment of sleep disorders, but there are still no clear treatment guidelines for clinical use.
1.Physical therapy
(1) Comfortable sleeping space, comfortable bed, sealed doors and windows, reduce noise. Adjust the appropriate room temperature.
(2) Do not take coffee, strong tea, chocolate and other foods before bedtime. Avoid alcohol, alcohol will make the quality of sleep decline.
(3) Develop good sleep hygiene habits, develop suitable rest and rest time, get up and move during the day, participate in physical work or sports exercise within your ability to prevent sleepiness during the day and sleeplessness at night. Sleep regularly and on time.
(4) Other: eliminate somatic discomfort, appropriate massage before sleep.
(5) Transcranial microcurrent stimulation therapy, this physical therapy is to stimulate the brain through microcurrent, which can directly regulate the brain to secrete a series of neurotransmitters and hormones that can help improve depression, such as 5-hydroxytryptamine, acylcholine, these hormones are involved in regulating a number of physiological and psychological activities of the human body, which can improve the overall insomnia patients with excessive dreaming, early awakening, difficulty in falling asleep, etc. In addition, it can also relieve the patient’s dizziness in the daytime due to insomnia. In addition, it can also alleviate the symptoms of dizziness, decreased concentration and emotional irritability that occur during the daytime the next day due to insomnia.
(6) Sound therapy: mainly used in music therapy.
2.Psychotherapy
(1) Stimulus control therapy: Invented by Richard Bootzin in 1972, it is now recommended by the American Academy of Sleep Medicine as the “standard” non-pharmacological treatment for difficulty falling asleep and maintaining sleep. The core idea is to de-condition pre-sleep arousal and reconnect the bed and bedroom with rapid sleep onset and sustained sleep. The main points of operation:
1) Lie down to sleep only when you want to sleep. 2) Use the bed only for sleeping and sex, not for reading, watching TV, eating, thinking, etc. 3) If you feel that you cannot fall asleep in bed, get up immediately and go to another room. 4) If you do not feel sleepy after 30 minutes in bed, get up immediately. The purpose of getting up immediately when you can’t sleep is to establish a connection between the person and the bed for sleeping conditions. 5) If you can’t fall asleep immediately, repeat the second rule again. 6) Regardless of how much sleep you get each night, set your alarm clock and get up on time each day. No napping or snoozing during the day will help your body establish a lasting and continuous sleep rhythm.
(2) Sleep hygiene education: Help patients understand the physiological process of sleep, and help them rebuild good sleep hygiene habits. Sleep hygiene education must be individualized.
(3) Relaxation training: Commonly used methods include deep breathing training to slow down the breathing and make it deeper; progressive muscle relaxation, allowing oneself to experience the whole process of muscle groups from tension to gradual relaxation, helping patients to enter a relaxed state of mind and body; imagination can help patients to relieve the worries and tensions associated with sleep disorders.
(4) Cognitive behavioral therapy (CBT), cognitive and behavioral therapy synthesis, CBT has become one of the most used psychological treatment methods, cognitive therapy is mainly to correct the misconceptions about sleep and sleep deprivation, and reduce anxiety, improve sleep. CBT treatment can shorten the time to fall asleep and maintain sleep.
(5) Myoelectric biofeedback therapy, firstly, introduce the role of myoelectric biofeedback for sleep disorders to patients. The electrode is placed on the frontal area, and the recorded instruction is played to guide the patient to relax gradually, once a day for 30 min each time, to understand the patient’s feelings and experience after each treatment, to provide timely guidance and assign homework, home training once a night; EMG biofeedback therapy can make the patient enter the relaxation state quickly through the guidance of the tape, eliminate the patient’s anxiety and tension, and regulate the function of the vegetative nerves to achieve the therapeutic purpose;
3.Medication
(1) over-the-counter drugs: the most commonly used are antihistamines. These drugs have a certain degree of help to sleep, but the efficacy of the lack of systematic observation, adverse reactions must be worth noting.
(2) Prescription drugs: Phenobarbital, due to its high addictive properties and poor safety, is no longer used to treat sleep disorders. Benzodiazepines, as non-selective GABA receptor complex agonists, pharmacologically have anxiolytic, muscle relaxant and anticonvulsant effects. It can shorten the sleep latency and prolong the total sleep time, but also affects the normal sleep physiology. Obvious side effects include daytime sleepiness, impaired cognitive and psychomotor function, rebound and withdrawal symptoms. Long-term heavy use can produce dependence. Long half-life drugs have more significant effects on psychomotor and cognitive function the day after the drug is taken. Short half-life drugs have more severe rebound and withdrawal symptoms upon discontinuation and should be avoided, such as triazolam. Benzodiazepines are not used as the drug of choice, but are more appropriate for patients with significant anxiety. The dosage should be tapered when discontinuing the drug. Non-benzodiazepines, because of their safety and effectiveness, have become the drugs of choice for the treatment of sleep disorders. They include zolpidem, zopiclone, and zaleplon. They have a short half-life, which means they are easily cleared from the body. They do not cause daytime sleepiness. Also, these drugs are selective in their action, acting directly on specific receptors associated with sleep. Non-benzodiazepines are selective agonists of the GABA receptor complex, but do not have anxiolytic, muscle relaxant, or anticonvulsant effects. They generally do not affect the normal sleep physiology of healthy individuals and may even improve the sleep physiology of patients with sleep disorders. Zolpidem is administered as one tablet (10 mg) daily at bedtime for patients under 65 years of age and 1/2 tablet (5 mg) daily at bedtime for patients over 65 years of age. Antidepressants, whose use is gradually increasing, can significantly improve all sleep with stable efficacy. It is especially suitable for patients with depressive symptoms of sleep disorders.
(3) Chinese patent medicine treatment: including Sweet Dreams capsule, Ningxin Anshin and other Chinese patent medicines.