Stress, sleep disturbances

This model was developed after pioneering experiments carried out in the USA by Overmier and Seligman (1967) who reported profound behavioural changes in dogs after their exposure to inescapable, uncontrollable stress (footshock). Subsequent work has concentrated on rats and mice, which show a similar behavioural response. This is expressed as appetite and sleep disturbance, general passivity and, on re-exposure of subjects to the stress, a failure to attempt to escape ( escape deficits ), even when this is feasible. 

Pawlyk, A. C., Jha, S. K., Brennan, F. X., Morrison, A. R. Ross, R. J. (2005). A rodent model of sleep disturbances in posttraumatic stress disorder the role of context after fear conditioning. Biol. Psychiatry 57, 268-77. 

Although we are focusing on the primary sleep disorders, sleep disturbance quite often occurs as a symptom of another illness. Depression, anxiety, and substance abuse can impair the quality of sleep, though in the setting of chronic insomnia, other psychiatric disorders account for less than 50% of cases. Nightmares are a frequent complication of post-traumatic stress disorder (PTSD), and pain, endocrine conditions, and a host of medical illnesses can produce sleep problems. Thus, when discussing insomnia or hypersomnia, we are well advised to remember that these can be either a symptom of a psychiatric syndrome, a medical illness, or a sleep disorder. 

Identify Other Causes. As has already been stressed, the first step in developing a treatment plan is to identify and treat any underlying problem that may be triggering the sleep disturbance. 

Bruxism mainly occurs in stage 2 sleep and REM sleep (Bader et ah, 1977). A relationship to stress and anxiety has been suggested, but the disorder can be chronic without apparent association with stress (Faulkner, 1990 Pierce et ah, 1995). It has been suggested that the central dopaminergic system may be involved in the modulation of sleep bruxism (Lobbezoo et al., 1997). Case reports indicate that bruxism can be induced by the SSRI paroxetine (Romanelli et al., 1996). The mechanism remains unclear possibilities include sleep disturbance, serotonergic-mediated inhibition of dopamine manifesting as akathisia, and SSRI-induced anxiety. SSRI-induced bruxism may respond to therapy with buspirone (Ellison et al., 1993). 

Lancel M, MuUer-Preuss P, Wigger A, Landgraf R, Holsboer F (2002) The CRHl receptor antagonist R121919 attenuates stress-elicited sleep disturbances in rats, particularly in those with high innate anxiety. J Psychiatr Res 36 197-208... 

Insomnia includes a wide variety of sleep disturbances, such as difficulty in falling asleep, early or frequent awakenings, and remaining unrefreshed after sleep. Use of sedative-hypnotic drugs is one approach to the therapy of insomnia. Other measures include advice to avoid stimulants before retiring, maintenance of a proper diet, initiation of an exercise program, and avoidance of stressful or anxiety-provoking situations. 

Answer Zolpidem is the best choice. M. W. s inability to sleep well is probably the result of anxiety caused by several stresses in her life. She is a recent college graduate, has a new job, and has moved to a new town. These events constitute three stressors, which can induce anxiety and sleep loss. The sleep loss and anxiety are usually of relatively short duration. Zolpidem has a quick onset and a half-life of approximately 2.5 hours. If taken at bedtime, it should allow her to fall asleep quickly and sleep though most or all of the night. Its elimination is fast enough that it should not produce residual drowsiness during the day. A week-long trial of zolpidem should help M. W. overcome her sleep disturbance. 

Fisher BE, Rinehart S. Stress, arousal, psychopathology and temperament a multidimensional approach to sleep disturbance in children. Personal Individ Diff 1990 11(5) 431—438. 

Sleep and sleep disturbance in post-traumatic stress disorder... 

Ross RJ, Ball WA, Dinges DF, Kribbs NB, Morrison AR, Silver SM, Mulvaney FD (1994) Rapid eye movement sleep disturbance in posttraumatic stress disorder. Biol Psychiatry 35 195-202... 

Ross RJ, Ball WA, Sullivan KA, Caroff SN (1989) Sleep disturbance as the hallmark of posttraumatic stress disorder. Am J Psychiatry 146 697-707... 

To summarize, there is now strong evidence that sleep disturbances encountered in major depression are associated with an increase of wake-promoting mechanisms linked to a stress-related hyperarousal reaction implicating the CRH and the LC-AN systems. 

Although menopause is an important initiator for sleeping problems, sleep disturbances may just coincide with the menopausal period. Thus other explanatory factors behind should not be dismissed but evaluated with similar intensity at different periods around menopause. The most important reasons embrace depressive mood, stress, behavioral factors, as well as restless leg syndrome (RLS) and periodic limb movement syndrome (PLMS). 

Mental disorders, also called affective disorders, are multi-level, multi-scale and multiple-system diseases (Fig. 7.1). Mental disturbances generally go along with disturbances of autonomous functions. These essentially are (1) sleep disturbances, both sleep duration and sleep pattern, and (2) disturbances of the hypothalamic-pituitary-adrenal (HPA) axis, the so-called stress axis with elevated cortisol levels. It can be expected that disturbances of autonomous control systems as well as mood are caused by neuronal malfunctioning which may concern practically all neuronal levels systemic interactions, neuronal network connections, single neuron dynamics, synaptic transmitters and/or receptors, ion channels, second messengers, and gene expression (Fig. 7.1a). Nevertheless, despite a manifold of data, there are only vague ideas so far about the differences in neuronal dynamics in the brain of a chronically depressed person compared with a person with a sensitive but balanced mood. 

Clonazepam is widely used for the treatment of sleep disturbances related to post-traumatic stress disorder, despite very limited published data supporting its use for this indication. In a randomized, single-blind, placebo-controlled, crossover trial of clonazepam 1 mg at bedtime for 1 week followed by 2 mg at bedtime for 1 week in six patients with combat-related post-traumatic stress disorder there were no statistically significant differences between clonazepam and placebo (4). Adverse effects of clonazepam were generally mild and essentially indiscernible from those attributed to placebo. Only one patient elected to continue taking clonazepam at the end of the trial. The small sample size was a significant limitation of the study. 

Cates ME, Bishop MH, Davis LL, Lowe JS, Woolley TW. Clonazepam for treatment of sleep disturbances associated with combat-related posttraumatic stress disorder. Ann Pharmacother 2004 38 1395-9. 

The essential feature of this condition is chronic anxiety and worry. To the nonsufferer the focus of the worry often seems to be trivial, e.g. getting the housework done or being late for appointments, but to the patient it is insurmountable. The anxiety is often associated with other symptoms, which include restlessness, difficulty in concentrating, irritability, muscle tension and sleep disturbance. The course of the disorder is typically chronic with exacerbations at times of stress and is often associated with depression. Its chronic nature with worsening at times of stress helps to distinguish GAD from anxiety in the form of episodic panic attacks with associated anticipatory anxiety (panic disorder). Hyperthyroidism and caffeinism should also be excluded. 

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