Sleep in the Media
“Sleep with one eye open/ Gripping your pillow tight/ Exit light/ Enter night/ Take my hand/ We're off to never-never land”
What is Enter Sandman, Metallica?
(PGY2 only): An estimated 11% of adults experience this condition, and none of them ever pulled a pin
What is exploding head syndrome?
Female predominance. No pain or physical injury, perceive loud sound described as “explosion,” result in psychologic distress and difficult sleep, unknown pathology
(PGY2 only) - Probable REM sleep behavioral disorder involves history of vocalization and/or dream enactment. Definite RBD requires this test/finding.
What is polysomnogram of actions during REM sleep?
REM without atonia (RWA) is core finding – sustained tonic or transient phasic activity on EMG – sustained tonic or transient phasic chin or limb movement – more than one epoch, different duration cutoffs
In good tests, mostly see simple jerks (arms > legs); 1% of time violent acts (punching, kicking) even though these are common reasons for presentation
May not capture events at all – night to night variability, may see sleep disruptions from bad dreams, and alpha synucleinopathies can limit REM sleep
Polysomnogram is also helpful to evaluate for comorbid sleep disordered breathing (OSA can mimic RBD, found in ¼ patients with neurodegenerative condition), periodic limb movements (in ½ patients with RBD, more in those with neurodegenerative disease), other NREM events
(PGY2 only) You awaken from sleep but are unable to move, and you feel somewhat short of breath. You are likely experiencing this.
What is sleep paralysis?
Core feature = waking from sleep unable to move trunk or extremities, often feel weight on chest as paralysis spares diaphragm but not accessory respiratory muscles; lasts for seconds to minutes, spontaneous resolution or external stimulus; can have visual/ tactile/ auditory hallucinations
EEG shows normal sleep architecture with higher bifrontal beta activity during REM, then intrusion of alpha into REM sleep followed by arousal with persistence of REM atonia
This nucleus is involved in controlling the diurnal cycle in mammals
What is the suprachiasmatic nucleus?
Input from retinohypothalamic tract that receives light input (main zeitgeber, "time giver") via retinal ganglion cells with melanopsin
Output pathways to peripheral clocks– neural, neuroendocrine (liver, adipose tissue, muscle), hormonal; peripheral tissue clocks regulated by circadian gene expression with autoregulatory feedback loops (activators of transcription CLOCK, BMAL1; repressors PER1/2/3; cryptochrome circadian regulators CRY1/2)
“I'd like to make myself believe/ That planet Earth turns slowly/ It's hard to say that I'd rather stay awake when I'm asleep/ 'Cause everything is never as it seems (When I fall asleep)”
What is Fireflies, Owl City?
These are some examples of common actions that can occur with sleepwalking beyond walking (give 2)
What are urination, rearranging furniture, eating/ drinking, violent acts?
Leaving the bed = key diagnostic feature. Ambulation is the main activity, the above may or may not occur each time, never the predominant feature.
With eating, if patient sustains harm during this it becomes sleep related eating disorder.
NREM parasomnias tend to occur in this portion of the night and REM parasomnias tend to occur in that portion of the night
What is earlier half and later half
REM episodes tend to be later half of night. If narcolepsy, REM sleep intrusions may be anytime.
Awareness is also a clue - During REM events, patients have no awareness of environment. NREM parasomnias, patients may have some awareness but inappropriate responses
This is the most common cause of recurrent sleep paralysis episodes.
What is narcolepsy?
Other risk factors : sleep deprivation, jet lag, shift work, supine sleep, PTSD
Differential – sleep apnea, sleep related seizure, sleep terror, nightmare disorder, lucid dreaming, RBD, hypokalemic periodic paralysis
These are the two most common variations in preferences for falling asleep and waking up (chronotypes)
What is delayed and advanced chronotypes? (will accept night owl and morning person/lark)
Delayed = night owl; "disorder" more common in adolescents/ young adults; more likely to run in families; higher risk of depression, suicidality, poor academic performance, substance use, overweight, T2Dm
Advanced = morning lark; "disorder" more common in older adults
“‘I will split up my father's empire.’ Now, this is obviously an idea that Robert himself would choose to reject. Which is why we need to plant it deep in his subconscious. Subconscious is motivated by emotion, right? Not reason. We need to find a way to translate this into an emotional concept.”
What is Inception, Leo DiCaprio?
These patient factors are predictors for confusional arousal, the most common NREM disorder in adults (give 2)
What are shift work, other sleep disorders, psychiatric comorbidities?
No terror, no walking, no action beyond sitting up and looking around. Common feature with other NREM disorders is little awareness/recall and early part of night. Prevalence 4% adults. Disrupted sleep from shift work, other sleep disorder. Bipolar disorder most common comorbid psych dx seen
Sleep pathophys - This nucleus is involved in producing both atonia and cortical activation during REM sleep
What is the sublateral dorsal nucleus?
REM-on nuclei:
Atonia: From sublateral dorsal nucleus or subcoeruleus, glutamatergic neurons descend to nucleus raphe raphe magnus and to ventromedial medulla (ventral alpha gigantocellular and lateral paragigantocellular reticular nuclei); from ventromedial medulla, GABA-ergic and glycinergic neurons descend to spinal motor neurons --> atonia
Cortical activation: From non/cholinergic neurons of sublateral dorsal nucleus, laterodorsal tegmentum, and pedunculopontine tegmentum AND glutamatergic neurons from reticular formation, all to hypo/thalamus --> cortical activation
REM-off nuclei:
Ventrolateral periaqueductal gray and lateral pontine tegmentum inhibit sublateral dorsal nucleus and subcoeruleus
Your host has recurrent nightmares of losing his teeth, making him among the 4% of adults with “frequent” nightmares. These are some of the criteria needed to diagnose him with a nightmare disorder (name 3)
What are mood disturbance, sleep resistance, affects family sleep, behavioral problems, daytime sleepiness, or impaired job/ school/ social function as a result of the nightmare?
Polysomnogram can be done, but not criteria to call it a disorder - would see increased awakenings, increased alpha rhythm, more NREM-REM transitions
In 2017, the International Agency for Research on Cancer categorized this pervasive phenomenon alongside UV radiation, benzro(a)pyrene, and acrylamide as a potential human carcinogen
What is shift work?
Work some/ all of nights; total sleep shortened by 1-4 hours, adaption varies by person
Shift Work Disorder = limited sleep subjectively unsatisfactory, resultant reduced daytime alertness and/or increased fatigue leads to poor job performance/ concentration, safety issues, irritability, headaches, impaired social functioning
Night shift work associated with breast cancer (night nurses 30+ year careers) and melanoma (exposure to light at night)
Cancers: daytime mitosis in mammals, circadian gene expression for DNA repair checkpoints
16% of adult workforce in non-daytime shift work, Black/ Hispanic patients 2x as likely as white to work night shift
“Don't wanna close my eyes/ I don't wanna to fall asleep/ 'Cause I'd miss you baby”
What is I Don’t Want to Miss a Thing, Aerosmith?
This will likely appear on EEG when a patient undergoing polysomnography for nighttime agitation is seen abruptly screaming and hiding behind their bed.
What is generalized delta with decreased frontal field activation? (would accept “N3 sleep pattern” for half credit)
Prompt is describing a sleep terror, which is an NREM disorder. All of these occur in N3 stage of sleep, thought to be higher threshold for waking fully i.e. more difficult to be aware of actions/surroundings.
Sleep terror involves no vivid imagery typically, frightened reaction along with autonomic changes, may flee or hide but not same as walking; if perseverative/ agitated walking suspect frontal lobe nocturnal epilepsy
Idiopathic RBD is now referred to as “isolated RBD” given the high likelihood of developing this type of neurologic disorder, and the 3 most common among them.
What are neurodegenerative disorders, DLB/ PD/ MSA (will also accept alpha synucleinopathies
Most common neurodegenerative = alpha synucleinopathy (DLB, PD, MSA) – diagnose RBD in 30-50% in PD (often onset after PD sxs) and 70+% in MSA/ DLB patients
RBD symptoms can change – dream enactment may decrease, RWA increases with PD/DLB
RBD predicts worse motor and cognitive outcomes
Also association with Huntington’s, SCA 2/3, ALS, Alzheimer’s, PSP, FTD, CBD, neurodegeneration with brain iron accumulation, prion disease
These are risk factors for nightmare disorder (name 4)
What are anxiety/ depression (37% of pts with these have nightmares), PTSD (67% of these have nightmares), migraines, bronchitis, asthma, beta blocker or SSRI use, alcohol withdrawal, female gender, children more than adults (19% of children have 1+ nightmare per week)
Over 50% of blind people (and some sighted people, less commonly) are affected by this sleep disorder likely due to damage/absence of inner retina photosensitive ganglion cells and retinohypothalamic pathway.
What is non-24-hour sleep disorder?
Diurnal cycle consistently more than 25 hours; patient alternating between nighttime insomnia and daytime drowsiness
Treat with scheduled melatonin/ tasimelteon; if perceive light can trial timed light therapy or find other non-photic zeitgeber
“But Jack... Jack gave me the perfect gift: a stamp in my passport. He took me to Florence for our honeymoon. I guess you might say he gave me the world. Peter once asked me when it was that I fell in love with Jack. And I told him, 'It was--’ ”
What is While You Were Sleeping, Sandra Bullock
These medications are associated with increased NREM parasomnias (name 4)
What are oxybate salts (eg Xywav), zaleplon, zolpidem, zopiclone, eszopiclone? (also accept any sedative-hypnotics)
These affect amount of sleepiness and/or occurrence of arousals
Patient factors include other sleep deprivation, narcolepsy, OSA, RLS/ periodic limb movements.
Sedative/hypnotics are not specific for NREM parasomnias, can impact REM parasomnias as well
(Daily double - teams all submit 5) These are some of the less-common causes of secondary RBD
Narcolepsy – 10-15% of RBD; 41% of narcolepsy type 1 and 13% of narcolepsy type 2
Focal or diffuse brain lesions – MS, stroke, pontine tumor/ischemia, autoimmune (IgLON5, CASPR2, LGI1, NMDA, Ma1/2), Wilson, TBI
Other neuro dxs: ET, myotonic dystrophy, Tourette, autosomal dominant leukodystrophy
Drug induced
--antidepressants (SSRI, SNRI, TCA > MAOIs – RWA in 12%) – can switch to bupropion to see if RBD sxs persist
--Beta blockers (propranolol) – may bind 5HT or melatonin receptors
Psych – PTSD (RBD in 15% of veterans with PTSD; uncertain pathophysiology)
Pediatric – autism, Chiari, 22q11, epilepsy, ADHD, Smith-Magenis, Mobius
This form of cognitive behavioral therapy for nightmare disorder involves the patient thinking about their nightmare throughout the day and repeatedly imagining alternative positive outcomes
What is image rehearsal therapy?
Akin to exposure therapy, patient makes a more positive “script” for the nightmare
A variant image rehearsal with sleep hygiene education + progressive muscle relaxation
Can also do lucid dreaming, sleep dynamic therapy, systematic desensitization
A patient with a relatively short nighttime sleep phase and 2 or more naps randomly during the day may have this sleep disorder.
What is irregular sleep wake rhythm disorder?
No clearly defined sleep-wake periods; 3 discrete sleep episodes at variable times in 24 hours (rather than main nighttime sleep and midday lull)
Risk factors: poor sleep hygiene, lack of light exposure (photic zeitgeber), irregular/ atypical nonphotic zeitgebers (e.g. exercise, meal timing, social interactions)
Risk groups: children with developmental delay (Angelman, Williams, Smith-Magenis syndromes), adults with neurodegenerative disorders (dementia, Alzheimer, PD, HD)