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lOMoARcPSD|10070358 While You Were Sleeping (CAMS-UA 161) September 4th, 2018 Good sleep Fall asleep easily Sleep through the night Wake up rested Bad events: ● Exxon Valdez (oil spill) ● Challenger crash ● Chernobyl Nuclear meltdown ○ Lowest attention span = 1-2 am until 4-5 am ● Over 40 year period, Americans have reduced avg total sleep time by > hours Sleep metrics ● Behavioural observations ● Neurophysiological definitions ● Objective measures: ○ Polysomnography ○ Actigraphy ● Subjective measures: ○ Surveys ○ Rating scales ○ Self-reports Is someone sleeping? ● Physical quiescence (stillness) ● Posture ● Elevated threshold for arousal/reactivity ● Rapid awakening w/ moderate stimulation ● Rebound recovery (increased sleep following deprivation) *sleep = reversible behavioural state of perceptual disengagement from, + unresponsiveness to, the environment *EEG = Electroencephalogram; reflects summation of the synchronous activity, neuronal synchrony produces higher amplitude on the EEG Polysomnography ● Video-taped observation ● EEG - brain activity ● EMG (electromyogram) - muscle movement Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ● EOG (electrooculogram) - eye movement Vital signs Actigraphy ● Measure of human rest/activity cycles ● Continually records movements ○ E.g: apple watch BEARS ● Bedtime problems ● Excessive daytime sleepiness ● Awakenings during night ● Regularity ● Sleep-related breathing problems/Snoring Dreams ● main features: ○ “Conscious” ○ Accessible to recall ○ Occurs during sleep ● No universal definition Problems w/ Accuracy ● State change ● Time delay ● Visual imagery ● Censorship People who don’t dream: ● May be terrified of revealing themselves ● Sleep too deeply/too groggy to focus ● Sleep deprivation ● Medication/marijuana Assumptions Assume all dreams have meaning (stem from unconscious) Assume they have a unique language You are ultimate authority of the meaning of your dreams Your dreams are about your life + are on your side Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 September 11th, 2018 Sleep in Antiquity ● References appear in Bible, Veda, Koran ● Opium poppy or belladonna & alcohol known to induce sleep ● Premonitory qualities of dreams ● Early forms of hypnosis and lucid dreaming ● Sleep disturbances described in Egyptian, Greek, & Chinese medicine Early Theories of Sleep ● Alcmaeon ○ 6th century BC, first scientific theory of sleep ○ Sleep secondary to blood drainage from vessels on surface of body ● Aristotle ○ Wrote “On Sleep and Sleeplessness” ○ Vapors from food digesting in stomach rose to heart (brain) to cause sleep ● Galen ○ 2nd century AD ○ Used Hippocrates Humours Theory ○ Sleep necessary to rebalance the body’s humours: ■ phlegm ■ black bile ■ yellow bile ■ Blood 16th-17th Century ● Age of Discovery ● Descartes (1596-1650) ○ Hydraulic Model of Sleep ■ The pineal gland responsible for keeping the cerebral ventricles full to maintain alertness in the waking state 17th Century Thomas Willis ● The London Practice of Physick ○ Four chapters devoted to disorders producing sleepiness & insomnia ○ Coffee could prevent sleep ○ “Sleep”, not a disease but a symptom of underlying causes ○ Animal spirits undergo rest during sleep; those in the cerebellum become active during sleep to maintain control over physiology & cause dreaming ● Restless Legs Syndrome: first described as an escape of these animal humours into the nerves of the limbs ○ Noted treatment was powdered opium Sleep is a Passive State Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ● ● ● Before 1950s sleep was regarded as a passive state 18th century- blood flowing to the head put pressure on the brain which led to sleep 19th century- sleep occurred when brain “shut down” No clear distinction between sleep & other states with reduced awareness of surroundings, such as coma, stupor, intoxication, and hibernation Popular mid-19th century theories ● Stimulation ○ Sleep was an inactive state of the brain which occurred because of reduced sensory input (darkness, quiet) ○ Being awake occurred because of being in a loud, bright stimulating environment ● Hypnotoxin ○ Toxins and fatigue products accumulated during the day ultimately causing sleep ○ Toxins gradually eliminated during sleep Vascular Theory ● Sleep was related to the blood vessels caused by either an increase or decrease in brain blood pressure ● Supporting evidence was obtained from pathology and trauma Chemical theories ● Sleep caused by lack of oxygen or an accumulation of toxic substances such as: ○ Cholesterol ○ Carbon dioxide ○ “Urotoxins” ● Toxins built up during day and cause sleep ● As one slept, the toxins slowly drained away Evidence for Hypnotoxins ● 1909- Kuniomi Ishimori hypothesized evidence of “hypnotoxin” ○ (& in 1913 Legendre and Pieron) ● Suggested that hypnotoxin accumulates during wakefulness and dissipates during sleep ● Injected brain and blood extracts from sleep deprived dogs into awake dogs who fell asleep ● Great skepticism until it was replicated in 1960s with rabbits Nathaniel Kleitman ● 1920s- observed that sleep deprived subjects were less impaired and sleepy next morning than in the middle of night ● Kleitman argued that this observation is incompatible with hypnotoxin theory ● Lived for a month with “days” of 28 hours to study circadian rhythms ● In reality there are two systems that contribute to sleep, so they were both right (daily rhythm AND time spent awake) Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 EEG beginnings ● Richard Carton measures electrical activity in dogs’ brains after removing part of the skull using a galvanometer (1875) ● 1928- German psychiatrist Hans Berger r ecorded electrical activity of the human brain through the EEG ○ Clear differences when subjects were awake or asleep ○ Recordings of sleep were done for a few minutes per hour to save paper (no grants) ● He cut out/resected the nervous pathways that bring sensory stimulation to the brain ● This led Frederic Bremer to “isolate” cat brains ○ A Comatose after the resection of all sensorial info from the body (except olfactory & visual) ○ B Normal sleep and wake pattern; maintain face sensorial stimulation as resection is below cranial sensory centers (but above spinal centers) ○ Bremer concluded that the sleep is due to lack of stimulation of the cerebral cortex “demonstrating” that sleep is a passive phenomenon ■ Correct experiment, wrong conclusion Encephalitis Lethargica ● 1915-1926- epidemic spread around the world ○ No recurrence has since been reported, though isolated cases continue to occur ● Some patients affected had extreme somnolence, often leading to coma and death ● Others had hypokinetic form presenting with insomnia ● Don’t know what caused it Von Economo ● 1916 Austrian neurologist Konstantin Von Economo ○ Two different cerebral areas affected in the “sleepiness form” and “insomnia agitation” form ○ Excessive sleepiness: in patients with damage in central area of brain (junction of midbrain and posterior hypothalamus) ○ Insomnia: in parents with damage in preoptic area/basal forebrain (behind eyes) and in front of hypothalamus (anterior hypothalamus) Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● Diagonal hatching = hypersomnolence ○ Horizontal hatching = insomnia ○ Lesions at the arrow induce narcolepsy ■ These findings suggested that these two areas were the neural circuitry of sleep and wakefulness Bremer experiment ● Uncovered the existence of an “ascending arousal system” that was disconnected from the brain by upper transection of the cat brain resulting in coma ● Thought that transection A interrupted ascending sensory inputs Ascending Reticular Activating System ● Moruzzi and Magoun demonstrated that they could awaken sleeping cats by stimulating part of their brain ● Called this area the ARAS ● Implanted electrodes into the brains of the cats, anesthetized them, zapped them, leading to a desynchronized EEG (awake state pattern) Psychoanalysis ● Dreams were seen as guardians of sleep and to occur in response to disturbance ● Dreams would keep sleeper asleep ● Freud believed that dreams discharged instinctual drives ○ Dreaming became seen as a safety valve of the mind REM Sleep ● Kleitman and Eugene Aserinsky studying infant sleep noted a rhythm in eye movements ○ Same in adults as well ● Adopted electrooculography (EOG) and discovered periods of Rapid Eye Movement (REM) ● Woke people up during these phases ○ in REM they were reliably dreaming Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ● ● ● ○ rarely (and more confusedly) in NREM REM sleep EEG showed pattern close or identical to wakefulness Published in 1953 Sleep is passive no more Came up with sleep stages of NREM + REM REM Atonia ● Dement noted that when cats started REM sleep their muscle tone disappeared completely ● French researcher Michel Jouvet described the existence of REM in animals and reported that REM was associated with atonia (1959) ● 1960- Dement and Hodes made same observation with humans Medications to improve dream recall (& lucidity) Vitamin B6 (250 mg?) Galantamine (4-8 mg) Choline (250-500mg+?) Silene Capensis/African Dream Root (brewed into a tea) Mugwort (1 ounce dried herb to pint boiling water, 5-10 minutes) Calea Zacatechichi (tea or capsules) Writing Dreams Down ● Carl Jung created concept of “automatic handwriting” ○ Using non-dominant hand to write down dreams (dominant hand intrinsically bound to conscious mind) ● Three Adjective Rule ○ Choose person from your dream & spontaneously identify adjectives to describe that person ■ If a professor you view as harsh, critical, and dismissive shows up in your dream, then perhaps this represents an aspect of your critical character September 18th, 2018 ● Three states of being ○ Awake ○ NREM ○ REM ● Terms ○ Sleep latency = how long it takes to fall asleep once you are in bed with the intention of going to sleep ○ REM latency = time from sleep onset to first occurrence of REM sleep ○ REM density = how many rapid eye movements you have in 30 seconds ○ REM rebound = phenomenon after sleep deprivation where one enters REM sleep more quickly after sleep onset Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 Sleep onset REM period = the actual occurrence of entering REM sleep more quickly after sleep deprivation aves W ○ ● ○ ○ ○ ○ ○ ● ● Gamma ■ Awake and excited Beta ■ Awake or REM sleep ■ Open eyes and/or engaged intellectually Alpha ■ Awake, closed eyes, relaxed Theta ■ Awake or asleep ■ Often seen during light sleep or REM sleep or “trance” like states ■ Awake, N1, and REM Delta ■ Asleep ■ Characteristics of slow wave sleep or deep sleep N3 Scoring EEGs ○ Score sleep stages in 30 second sequential epochs commencing at start of study ○ Assign stage to each epoch ○ If or more stages coexist during a single epoch, assign the stage comprising the greatest portion of the epoch Wakefulness ○ Beta waves dominate ○ Gamma and theta also possible Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ○ Alpha waves appear most notably when eyes are shut (drowsy or not) ○ Wakefulness counts for less than 5% of the night in most adults ○ Anterograde amnesia for 1-3 minutes before sleep onset Sleep stages ○ Stage (N1) ■ Low voltage, mixed frequency EEG ■ Defined by exclusion (devoid of sleep spindles and K-complexes, minimal slow wave activity) ■ Cessation of blinking ■ Alpha activity of less than 50% of epoch ■ 4-7 cps, theta waves ■ Slow, pendular eye movements ■ 2-5% of total sleep ■ Perpetual Disengagement ● Experiment by Hoddes et al (1973) ○ Bright strobe lights flashed into eyes of adult volunteers whose eyelids are taped open ○ They are to press a small switch every time they see the light, brain waves are recorded ○ When volunteers entered NREM stage sleep, subjects failed to push the switch and deny seeing flash ○ Stage (N2) ■ Defined by presence of sleep spindles and/or K-complexes ■ Accounts for 45-55% of total adult sleep ● Sleep spindles = EEG waveforms in with a sinusoidal rhythm or 12-14 cps waxes and wanes for 1-2 seconds ○ Occur every 10-30 seconds ○ Occur in NREM stages & but are hard to see in stage (bc of high amplitude slow waves) ● K-complexes = EEG waveform with a well delineated negative sharp wave followed by a slower positive component ○ Can occur in response to a stimulus (external) but may be spontaneous as well (internal) ○ Stage (N3, slow wave) ■ High amplitude slow waves ■ Sleep spindles and K-complexes may or may not be seen (but often occur) ■ Delta (slow) waves occur at about cps with high voltage peaks (75 microvolts) ■ Accounts for 13-23% of total adult sleep ○ REM sleep ■ Saccadic eye movements ■ Low voltage, mixed frequency EEG Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ■ Very low level of below the brain EMG activity ■ Characterized by sawtooth waves Lucid dreaming ○ Dream in which the dreamer is aware he/she is dreaming ○ Term not used until 1913 ■ Dutch psychiatrist Willens Van Eden published book describing 352 dreams in which he knew he was dreaming ○ References to LD exist as far back as 415, the year in which St Augustine penned a letter recalling a LD experience ○ This phenomenon was subject of many 20th century books ■ Both personal accounts + tools for LD work ○ Stephen LaBerge ■ Brought LD study into scientific reading ○ Scientists still unsure what structure within brain causes LD ○ Tends to occur towards end of night ○ False awakening = dreamer thinks he/she is awake but is actually dreaming September 25th, 2018 ● Neurofeedback ○ Musicians and dancers use to attain relaxed theta state helps with creativity and performance ○ Binaural beats ● Point of NREM? ○ Sleep spindles ■ Originate in the thalamus ■ Thought to represent periods when the brain is inhibiting processing to keep the sleeper tranquil ○ K-complexes ■ Originate widely in cortex ■ Occur naturally in response to external stimuli ■ Aid in sleep based memory consolidation (usually followed by bursts of sleep spindles) ○ Delta waves ■ Originate in thalamus or cortex ■ Stimulate release of several hormones (GHRH/Prolactin) ■ Inhibit release of TSH ■ Important in declarative memory consolidation ● Point of REM? ○ Important for developing brain, especially during infancy & childhood ■ May provide a “workout” or stimulation for the developing brain, leads to more growth ○ Muscles most relaxed during REM ■ Cell repair Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● ● ● Same effect been observed in figure skating, rowing, golfing, baseball, swimming, and diving Core Body Temperature ○ Small window related to endogenous body temp rhythm during which time we may fall asleep and maintain sleep throughout night ○ Melatonin is thought to adjust CBT set-point thus allowing more blood flow to distal areas of the body and cooling of the core Jet Lag ○ Usually influenced by direction of travel ■ Slower adaptation when traveling east ■ Increases with number of time zones crossed ○ REM increases during the night following a phase advance resulting in a decreased REM latency ■ Likely due to REM Rebound ○ Melatonin taken in early evening advances the clock (as does early morning light exposure) ○ Jet lag associated with increase in sleep paralysis, brought on by an increase in REM Density ○ Induces initial increase in NREM, due to Process S, independent of Process C Fixing Jet Lag ○ Short trips ■ Keep to your home time zone schedule ■ Take sleeping pills for a few nights ○ Long trips ■ Give low doses of melatonin in the early evening to phase advance the clock (going east) or in the morning to delay the clock (going west) ■ Light boxes can be used Light & Melatonin ○ AM ■ Light advances the clock ■ Melatonin delays the clock ○ PM ■ Light delays the clock ■ Melatonin advances the clock The aging clock ○ Circadian rhythm naturally advances with age ○ Older adults may get sleepy earlier in the evening and awaken earlier in the morning than younger adults ○ It is unclear if the need to sleep decreases with age ○ However, ability to sleep does decrease ■ Changes in rhythm and consolidation of sleep ■ Influence of medical and psychiatric illness ■ Influence of medications on sleep Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ■ Presence of specific sleep disorders November 13th, 2018 ● What is sleep hygiene? ○ Series of recommendations and practices designed to improve sleep quality, quantity, and daytime alertness including: ■ Environmental (temp, noise, light) ■ Scheduling (sleep/wake schedule) ■ Practices (bedtime routine) ■ Physiological (exercise, meal timing, caffeine) ○ Often advised by healthcare practitioners although evidence-base is not significant for most recommendations ● Sleep hygiene ○ Identify cause of poor sleep/other medical or psychiatric disorders and treat ○ Set a sleep/wake schedule ○ Exercise daily but not at light ○ Avoid napping, caffeine, cigarettes, alcohol, and drugs ○ Invent a relaxing bedtime ritual; bathing, reading, snacking, watching TV, etc ○ Use bed only for sleeping & sex ● Caffeine ○ 90% of Americans consume caffeine in one form or another every day ○ More than half of Americans consume more than 400 mg / day ○ Caffeine and Dopamine ■ Caffeine increases dopamine by slowing the rate of reabsorption ● Similarly to drugs such as heroin and cocaine ■ Could contribute to caffeine addiction ○ Half-life is hours in most people ■ Heavy cigarette smokers decrease half-life by 30 - 50% ■ Oral contraceptives and pregnancy can double it ● Xanthines ○ Adenosine ■ Inhibitory neurotransmitter in the CNS ■ Needed for RNA synthesis ■ Found in every cell in body ■ Builds up as a breakdown product of ATP ■ Binds to receptors that slow down nerve activity ○ To a nerve cell, caffeine looks like adenosine ○ Caffeine binds to the adenosine receptor & blocks it ○ Caffeine also causes brain’s blood vessels to constrict because they block adenosine’s ability to open them up ● Caffeine and mental health ○ Women who drank - cups of coffee / day had a 15% decreased risk for depression compared to those who drank cup / week Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ○ ● ● ● ● ● 20% decreased risk seen in those who drank cups of more per day Short term effects of coffee on mood may be due to altered serotonin and dopamine activity ○ Long term benefits may rest upon coffee’s antioxidant and anti-inflammatory properties Alcohol and sleep ○ Leads to a more rapid induction of sleep ○ Increases NREM and reduces REM and Stage in the first sleep cycles ○ Within a cycle or 2, the effects are wearing off and “withdrawal” symptoms then occur: ■ Shallow sleep with multiple awakenings (Stage rebound) ■ REM rebound (often associated with vivid dreams, sweating, and nightmares) ○ As a result, drinking more than drink before bed may result in excessive daytime sleepiness ○ Acts as a muscle relaxant and can exacerbate snoring and sleep apnea ○ Alcohol hours before bed still may fragment sleep ○ Inhibits Acetylcholine (why there is less REM) Napping ○ “Siesta” and southern cultures generally encourage napping or a rest ○ Northern cultures typically frown upon napping and view nappers as undisciplined ○ Numerous studies confirm that daytime naps are sufficient to induce performance improvements in declarative & procedural memory Regionally specific spindle activity ○ Motor skill task remembered better after hours among those who had a 60 - 90 minute nap (Nishida & Walker, 2006) ○ Enhanced spindle activation in right, contralateral motor cortex Strategic napping ○ Preventative (before an activity that will make you tired) ○ Operational (on the job) ○ Short naps (20 - 30 minutes) to avoid sleep inertia (grogginess) ■ “Power naps”, “Caffeine naps” ○ Long naps (30 - 180 minutes) are more rejuvenating but also more likely to interfere with sleep cycle ○ Take advantage of circadian “windows of opportunity” e.g when clock dependent alerting is low and melatonin is high ■ AM - 5AM (corresponds to lowest daily CBT) ■ PM - PM (corresponds to midday melatonin surge) Marijuana and sleep ○ THC known to decrease both SWS and REM ○ Regular users generally report fewer dreams than occasional or non-users Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● ● ● When a regular user stops using, they often report REM rebound effect and period of vivid dreaming Tobacco and sleep ○ Cigarette smokers have many sleep-related complaints ○ PSG study of 6400 subjects found increased sleep latency (5.4 min), less total sleep time (14 min), more Stage sleep, and less SWS ■ Less delta power and higher alpha power ○ Nicotine thought to have strongest effect on sleep architecture at beginning of sleep but then exert effects of withdrawal later in sleep epoch ■ Lower doses tend to stimulate REM, higher doses suppress ■ Rebound upon discontinuation increases wake time and decreases Stage sleep ■ Withdrawal begins - 12 hours after last use and can last weeks NSAIDs ○ Non-steroidal anti-inflammatory drugs ■ Aspirin, ibuprofen, naproxen, tylenol etc ○ Inhibit prostaglandin synthesis and suppress evening surges of melatonin, influencing body temp changes ○ One dose of aspirin at 11 PM can suppress melatonin by 75% within 75 minutes (Murphy et al 1993) Late night snacking ○ Small snack before bed has shown to promote sleep by keeping hunger at bay ○ Tryptophan ■ Combine with carb rich foods to help it cross the blood brain barrier ■ Carbs cause body to release insulin, which diverts other amino acids away from the brain allowing tryptophan less competition to cross BBB ■ Foods high in tryptophan include ● Beans ● Grains and rice ● Lentils ● Chickpeas ● Hazelnuts Exercise ○ Exercise later in day may increase depth of sleep, demonstrated by increase in SWS and total sleep time ■ But exercise just before bed may increase sleep latency ○ Research suggests that core body temp may be what matters, not exercise Sleep and temperature ○ In general sleep is best in humans at night when CBT is low and melatonin is high ■ Sleep onset latency is minimized if sleep is initiated about hours before minimum CBT Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ■ ■ Electric blankets that increase CBT slightly cause increased nocturnal awakenings Spicy meals may increase CBT by 0.2 C and lead to decrease in SWS November 20th, 2018 ● Function of sleep ○ Restorative/homeostatic ○ Thermoregulation/energy conservation ○ Consolidation of learning and memory ○ Brain growth in infancy ○ Programming of species-specific behaviours ● Physiology ○ Healthy men always have an erection during REM ○ Women experience increased vaginal blood flow and clitoral engorgement ○ These effects are due to ANS activity ■ Not muscle activity but blood flow ■ Generally nothing to with sexual interest or erotic dream content ■ Even newborn males have erections in REM ● Negative emotion in REM ○ The amygdala (aka “fear hub”) is highly activated in REM ■ Area of the brain that is engaged when unpleasant emotions like fear or aggression are felt ○ May help to explain the preponderance of negative emotions in dreams ○ Note: people with MDD experience a greater amount of REM and sooner in the sleep cycle, which may increase the proportion of negative emotion in sleep and contribute to their depression ● Nightmares ○ Some suggest that nightmares and bad dreams are necessary rehearsals left over from evolution to help us prepare for threats that may come our way ■ Wild animals, fire, etc ■ These “primitive” dreams still occur in children ○ In adults, the modern vision of these events is losing your wallet or having an auto accident ● Dream reports ○ Entirely subjective ○ Recall is the limiting factor ○ Some people say they don’t dream, but when this 6% is awoken during REM, they most often report dreams ○ Dreams are subject to “secondary revision” upon awakening ○ The estimated time of dream reports generally correlates well to the time elapsed in REM sleep before awakening (for the first 10-15 mins) ● NREM sleep reports Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● ● ● Reports obtained upon awakening from NREM (esp deep sleep) are hard to evaluate because of disorientation assoc w/ sleep inertia ○ Now believed that mental activity occurs throughout sleep ○ Much of NREM “dreaming”is considered sleep mentation ■ Abstract thoughts, fragmentary images, and isolated feelings Dream consciousness in NREM ○ Evidence suggests that dreams can occur in NREM and not simply reflect recall of earlier REM sleep dreams: ■ Possible to influence dream content by sounds delivered in NREM (e.g phone calls, discussions, etc.) ■ Some NREM parasomnias (sleep talking & sleep terrors) correspond to a reported dream experiences ■ Full dreams are sometimes reported upon awakening from NREM only (before the first REM period or after NREM naps) Sleep Transition Imagery ○ Thought to result from abstract thoughts before a sleep transition and include: ■ Hypnic Jerks or Sleep Starts ● A vivid startle in response to the feeling of falling ● Often unpleasant and very disturbing ■ Hypnagogic Hallucination ● Vivid imagery associated w/ the onset of sleep ■ Hypnopompic Hallucination ● Vivid imagery associated with awakening Dream Senses ○ Unless blind, all dreams are visual ○ 2/3 of dreams contain sounds ○ 8% of dreams contain touch ○ All other sense occur in only 4% of dreams ○ Pain is extremely rare in dreams ○ One’s own death almost never occurs in dreams Visual dreams ○ Dreams are largely visual & in color ○ Those who become color blind later in life can still see colors in their dreams; those who are color blind from birth are limited in the colors they can see in their dreams as they are when awake ○ Individuals who become blind before y/o tend to experience auditory dreams ○ Those who lose their sight after y/o continue to experience some other visual content ■ Clarity and frequency of dreams diminishes Freud’s Psychoanalytic dream terms ○ Condensation = connection between the manifest dream content and latent content Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 Displacement = a latent dream thought is “displaced” upon a manifest image without any obvious relation ○ Symbolism = symbols have a similar form to that which is symbolized ○ Secondary Revision = process of dream work Carl Gustav Jung ○ Disciple of Freud from 1907 - 1913 ○ Disagreed with Freud’s idea that every dream was a facade behind which psychological meaning lay hidden ○ Held fast to the dream “script” ○ Jung worked with “amplification”, not free association ■ Amplification = gathering all info on each item in a dream; amplifying the actual dream itself ○ Dreams are seen as facts, as real experiences and feelings Collective unconscious ○ Jung believed that dreams arise from both the personal unconscious and from the collective unconscious ■ Collective unconscious underlies and links all humans and is expressed through myth, fairytale, etc ■ Developed this idea after travelling to Africa and finding that his rich Swiss patients had many of the same dreams as the tribal Africans ● Swiss were chased by bankers or assailants, and the Africans were chased by lions ○ CU represents the whole of our genetic history ○ Realm of experience shared by all humans (and maybe all animals) ○ We know of its existence through the commonality of experiences during dreams and the presence of recurrent themes across cultures Little vs Big dreams ○ Little = deal with individual dreamer’s life ○ Big = tap into a larger, universal world expressed via archetypes ■ Archteypes → universally understood symbols or images ■ “Animus” = male element in female unconscious ■ “Anima” = female element in male unconscious Archetypes ○ “Energies” or symbols existed in the universe far before humans existed ○ As the human race developed, we incorporated these energies into our stories and myths as “ideal forms” ■ E.g Marilyn Monroe may well be Aphrodite, modern-day athletes may as well be Hercules ○ Archetypal character will not be someone you know in a dream ○ The archetypal character will have a singular, specific persona (not volatile, changing, and unpredictable as many dream characters are) ■ Ex King, queen, wise old man, witch, magician, warrior, etc ○ Most dreams are frenetic and chaotic, archetypal dreams are more static ○ ● ● ● ● Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● ● Presence of an archetype is theorized to indicate a moment in life when a major integration is occuring deep within the psyche ■ As we are “evolving” toward a higher level as a human being ■ It’s because of this more “spiritual” and “energy” type of interpretation that Jung is sometimes regarded as mystical or unscientific Shadow ○ The Shadow is an archetype where we hide what we hate or cannot accept about ourselves ○ Jung might say that a quiet person who hates strongly opinionated others has a loud, overbearing character aspect hidden below the surface (their Shadow) ○ Others might consider this to be Projective Identification ■ That which we hate most about ourselves but cannot admit to ourselves is what we find distasteful in others ○ Getting to know the Shadow may teach us about ourselves ○ Any imagery that is overtly dark in nature such as dreams that take place at night or gloomy settings or dangerous places, may represent the Shadow ○ A character who is unmistakably contrary to our physical appearance (e.g a dark haired character if we are blonde suggests the Shadow) Freud vs Jung ○ Freud ■ Dream is a symbolic representation of some other meaning ■ Free Association used to uncover hidden meaning ■ Repression ● Sex primary drive underlying dream content ■ Dreams are a representation of unconscious conflict that psychoanalysis can resolve ○ Jung ■ Dream itself may be factual ■ Amplification is used to identify the facts within the dream ■ Creative approach to interpretation ● What is this dream telling me? ■ Dreams reveal key aspects of our defended selves that must be integrated to make us whole Modern dynamic interpretation ○ Dreaming is driven by the “wanting” dopaminergic system ○ Per Freud, dreams preserve sleep in the face of unconscious needs for excitement ○ Per Solms, the biological function of dreaming remains unknown ○ Dreams are “top down” ■ Brain creates perception ■ Day residue and consciousness influence dream content AIM Model (Hobson) ○ Consciousness is determined by: Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ■ Activation → total and regional brain activity levels ■ Input → activation generated internally and externally ■ Modulation → ratio of aminergic to cholinergic neuromodulation ○ Dreams are “bottom up” → auto-generated perceptions (hallucinations) which are interpreted by the brain ■ PGO waves = activation of the sensory cortex by the brainstem, “interpreted/organized” by higher order brain structures as images and finally dreams ■ Ponto-geniculo-occipital waves ■ Originate in the pons, thalamus, end up in primary visual cortex of the occipital lobe ■ Appearance of these waves are most prominent in the period right before REM sleep ■ Perceptions → interpreted as dreams ○ Dreaming is the brain’s attempt at interpreting activation signals in a coherent manner ○ With cholinergic activity on in REM, the limbic system is activated without the prefrontal cortex turned on to work out logical associations ○ Contents of individual dreams are nearly random ○ In REM activated brain areas include areas for ■ Awareness, eye movements, instincts, vestibular sensation (body in space), memory consolidation, and emotions ■ Production of motor movements ■ Processing of sensory information ○ Not active: ■ Primary reception of sensory info areas (no breeze on my face) ■ Dorsolateral prefrontal cortex areas ○ Thus the difference between dreaming and wakefulness is where the “activation” comes from: ■ External when awake, internal when in REM Neurocognitive Model ○ Dreams are “top down” ○ Dreams probably have no function but have coherence and meaning ○ Based upon stored memory representations ○ Due to a complex neurochemical mixture of acetylcholine and dopamine (and serotonin, norepinephrine, and histamine are absent) November 27th, 2018 ● Insomnia ○ Classified by subjective complaints about dissatisfaction with sleep quality or duration, difficulty falling asleep at bedtime, waking up in the middle of the night or too early in the morning or non-restorative or poor quality sleep ● Subjective findings Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● EDS, fatigue, low energy, mood disturbance, or cognitive impairment (e.g inattention, memory) ○ Most patients perceive their global functioning to be greatly impaired ○ Diagnosis of insomnia is based upon subjective symptoms: ■ Distress ■ Daytime consequences ○ Rather than objective laboratory findings ○ Average reported sleep latency or > 30 mins ○ Wakefulness after sleep onset of > 30 mins ○ Sleep efficiency of less than 85% ○ Total sleep time of less than 6.5 hours Objective findings ○ Typical polysomnography findings: ■ Nothing ■ But can include increased sleep latency and reduced total sleep time, although severity commonly does not match patient’s subjective complaint ○ Cerebral cortex commonly more active during sleep in those with insomnia at sleep onset and during REM, indicating a general state of hyperarousal (excessive alertness) Insomnia (DSM-5) vs Delayed Sleep Phase ○ Insomnia ■ Difficulties initiating sleep (in children without caregiver intervention) ■ Difficulties maintaining sleep characterized by frequent awakening or problems returning to sleep (in children w/o caregiver intervention) ■ At least nights per week, for at least months ■ Coexisting mental disorders and medical conditions not adequately explain the complaint of insomnia ■ 24 hour condition ○ Delayed Sleep Phase ■ Sleep disruption due to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required ■ Leads to excessive sleepiness or insomnia, or both ■ Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time Evaluation of insomnia ○ History ■ symptoms/frequency/habits ■ Sleep schedule & environment ■ Sleep disordered breathing ■ Symptoms of EDS/daytime consequences ■ Comorbidities (medical & psychiatric) Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ● ● ● ● ● ● Physical exam ■ Tonsils ■ Obesity ■ Reflux ○ Labs ■ Blood (anemia) ■ Sleep logs/rating scales/polysomnogram? Economic impact of insomnia ○ Total annual cost = $30-107 billion ○ Direct cost ■ Workers: $63 billion (8-11 lost work days/year and a cost of $2280 per worker in lost capital value) MVAs & sleep disorders ○ 10,780 drivers evaluated ○ Epworth scale overall baseline score was 7.4 for drivers with no accidents ○ Ranged to 12.7 for drivers with > accidents Comorbidity ○ Adults with insomnia ■ >5x comorbid anxiety or depression ■ >2x comorbid congestive heart failure ■ >3x comorbid anxiety, mood, impulse-control or substance use ■ Strong correlation between chronic pain and insomnia Which came first? ○ Young adults with insomnia ■ 4x more likely to develop major depressive disorder within 3.5 years ■ 2x more likely to develop anxiety disorder ■ 7x more likely to develop substance use disorder Natural history of insomnia ○ Insomnia can be a situational, recurrent or persistent ○ Acute insomnia is often associated with life events or sleep schedule changes ○ Nearly 70% of individuals with insomnia at baseline continue to report insomnia a year later, 50% still have insomnia up to years later ○ Outcome of untreated insomnia is not well documented Pathophysiology of insomnia ○ No clear mechanism ○ Positive family history is common among those with insomnia ■ Suggests genetic vulnerability, common environmental factors, or a learned component ○ Neurobiological abnormalities ■ Increased activation of Autonomic Nervous System (elevations in heart rate, metabolic rate, temperature, NA secretion, HPA axis) ■ Nighttime BP higher in one study Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ■ ● ● ● ● PET studies show elevations in brain glucose metabolism in sleep & wake, and smaller sleep-related reductions in brain glucose metabolism in wake-promoting regions ■ SWS generally decreases and increases in faster frequencies (e.g beta and gamma) are observed Rat experiment ○ Rats placed in cage that was dirty and previously inhabited by a male rat ○ Inactivation of limbic system and arousal regions allowed recovery of specific sleep components ○ Decreasing activation of arousal systems likely better than increasing activity of sleep promoting systems Sleeping pills ○ Americans filled 60 million Rx for sleeping pills in 2012, up from 47 million in 2006 ○ By 2010, about in adults in America had an Rx for sleeping pills ○ Most sleeping pills are benzodiazepines or benzodiazepine-like ■ Bond directly to the GABA receptor or to a nearby receptor ■ Open the GABA receptor and allow an influx of chlorine ions, which relaxes the neurons BZRA prescription guidelines ○ Bedtime dozing ○ Avoid hazardous activities after dose ○ Allow sufficient time in bed ○ Dose adjustments ■ WOMEN ● Half the dose of men (different metabolic rate) ■ Elderly and debilitated patients ■ Hepatic impairment ○ Nightly versus as needed (PRN) dosing ○ Middle of the night dosing? ○ Taper dose on discontinuation? Side effects ○ Dizziness ○ Headache ○ Somnolence ○ Blurred vision ○ Depression ○ Addiction ○ Paradoxical reaction ○ Nausea/diarrhea ○ Fatigue ○ Difficulty with balance ○ Anterograde amnesia Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ● ● ● ● ○ Somnambulism/complex sleep behaviour Discontinuation effects ○ Recrudescence ■ Return of original symptoms ■ At baseline level of severity ○ Rebound insomnia ■ Exacerbation relative to baseline ■ 1-2 night duration, resolves on its own ○ Withdrawal Acute vs chronic use ○ Few long term, randomized controlled trials have been done ○ Eszopiclone (Luneta) showed continued efficacy with no rebound insomnia ○ Extended-release z olpidem for 24-week study show continued efficacy, without significant tolerance or rebound insomnia ○ Ramelteon reduced latency to sleep onset in a month trial in adults with chronic insomnia Antihistamines ○ Half-life = hours ○ Blocks action of the histamine and Acetylcholine receptors ○ Product in most OTC sleep aids ○ Rapid tolerance to sedating effects ○ Pill strengths )mg): 25, 37.5, 50 ○ Potential adverse effects: ■ Residual effects ■ Confusion ■ Dry mouth ■ Constipation ■ Blurred vision ■ Difficulties urinating Suvorexant ○ Brand name Belsomra ○ Antagonist for Orexin ○ Half life = 15 hours ○ For initial and maintenance insomnia (waking up in middle of night) stays in body for as long as possible Ramelton ○ Acts on the suprachiasmatic nucleus ■ Melatonin receptor agonist ○ Acts on melatonin receptor responsible for sleep induction rather than circadian rhythm ○ No abuse liability, not a DEA controlled substance ○ FDA approved for sleep onset insomnia ○ No limitation on duration of use Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ● ● ● ● ● ● ○ Single dose is mg ○ Take about 30 mins prior to bedtime ○ Half-life = - 2.6 hours Cognitive Behavioural Therapy (CBT) ○ Brief intervention that includes psychological and behavioural procedures ○ Addresses factors that perpetuate insomnia ■ Behavioural factors (poor sleep habits, irregular sleep schedules) ■ Psychological factors (unrealistic expectations, worry, unhelpful beliefs) ■ Physiological factors (mental and somatic tension, hyperarousal) ○ Works for all types of insomnia ○ Typically 4-6 sessions (once a week) Indications for CBT ○ Primary insomnia ■ Psychophysiological insomnia ■ Inadequate sleep hygiene ○ Comorbid insomnia ■ ○ All ages Efficacy of CBT ○ Benefits for sleep onset latency, sleep quality, number of awakenings, duration of awakenings, and total sleep time ○ 70 - 80% therapeutic response ○ 40% achieve clinical remission ○ Subjective sleep latency and time awake after sleep onset are reduced ○ Improvements are sustained over time Components of CBT for insomnia ○ Education ■ Circadian rhythm, sleep hygiene, sleep cycle ○ Cognitive distortions ○ Stimulus control ■ Reduce stimulation → reduce hyperarousal ○ Sleep restriction ○ Arousal reduction (relaxation techniques) Beginning of CBT-I ○ Start with their sleep goals ■ E.g reducing amount of time awake in bed (as opposed to the number of hours asleep) ○ Validate that the behavioural changes they’re about to start aren’t easy and will be difficult ○ Roll with resistance (e.g people don’t understand how much you’re suffering) ○ Provide sleep education and start sleep logs ○ Photograph the sleep environment; identify pros and cons CBT-I: Stimulus Control Therapy Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) lOMoARcPSD|10070358 ○ ○ ● ● ● ● Assumes there is a learned association between wakefulness and the bedroom To break cycle, patient must not spend time while awake in the bedroom ■ Go to bed only when sleepy ■ Do not use bedroom for sleep-incompatible activities ■ Leave the bedroom if awake for more than 20 mins ■ Return to bed only when sleepy ■ Do not nap during the day ■ Arise at same time every morning ■ Relaxing bedtime routine CBT: Relaxation Training ○ Deep breathing ○ Progressive muscle relaxation ○ Guided imagery ○ Biofeedback ○ Self-hypnosis/meditation Pediatric Insomnia ○ Can be diagnosed at months ○ No clear definition existed until 2007 ○ DSM-5 has same criteria for adults & children ○ Prevalence at - 6% in general pediatric population ○ Higher on children with neurodevelopmental delay and chronic med/psych conditions ○ Adolescents up to 10% Positive bedtime routines ○ Same every night ○ Last portion in sleeping environment ○ Short and sweet, heading in one direction (30 mins recommended) ○ Consistent bedtime environment Behavioural insomnia ○ Diagnostic category that emphasizes the sleep difficulties resulting from: ■ Inadequate limit setting ■ Sleep associations: ● Rocking ● Watching TV ● Falling asleep every night in the parents’ bed ● Child unable to fall asleep in the absence of these conditions at both bedtime and following nocturnal awakenings Downloaded by Plants vs Zombiesss TV (tranphuzap2@gmail.com) ... neurotransmitter ● Neurotransmission ○ Can be described: ■ Anatomically pathways ■ Chemically neurotransmitters ■ Electrically ○ Agonists & antagonists ■ Agonists mimic neurotransmitter,... skating, rowing, golfing, baseball, swimming, and diving Core Body Temperature ○ Small window related to endogenous body temp rhythm during which time we may fall asleep and maintain sleep throughout... response to the feeling of falling ● Often unpleasant and very disturbing ■ Hypnagogic Hallucination ● Vivid imagery associated w/ the onset of sleep ■ Hypnopompic Hallucination ● Vivid imagery