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Personalized Medicine in Sleep Health

Ronald Grunstein

in Integrative Neuroscience and Personalized Medicine

Personalized sleep medicine is an emerging area of research and practice. Sleep disorders are common with appreciable morbidity and economic impact. Recent studies have identified clear ... More

Personalized sleep medicine is an emerging area of research and practice. Sleep disorders are common with appreciable morbidity and economic impact. Recent studies have identified clear inter-individual differences in performance vulnerability to sleep loss. Although clear biomarkers for this vulnerability are not known, new research indicates that genetic influences on sleep and circadian systems may be important. As well, recent work has shown a wide variation in clinical phenotypes and conventional disease severity metrics in sleep apnea. Similar phenotypic variation in insomnia exists. Currently, treatments in sleep disorders are not well individualized with typical “silo” approaches that do not reflect the value of targeting treatment to the individual patient. Development of a personalized medicine agenda in sleep health will depend on better research standardization and international collaboration to better understand phenotype-genotype influences on sleep disorders and their individualized treatments.Less

Ruth

Roza Yakubovitsh

in Scrolls of Love: Ruth and the Song of Songs

These poems present the story of Ruth in the form of a dialogue between Ruth and Boaz on the threshing floor of a barn that could as easily stand in the Polish countryside as on the ... More

These poems present the story of Ruth in the form of a dialogue between Ruth and Boaz on the threshing floor of a barn that could as easily stand in the Polish countryside as on the outskirts of ancient Bethlehem. The first poem allows Boaz indirect authority through Ruth's account of her response to him, but diminishes the authority of Naomi. The second poem is set in an Eastern European landscape, where, along with the biblical characters, the trees, the river, and the wind speak Yiddish. The poem's themes of restlessness, insomnia, indecision, and leave-taking show how the author avoids the certainty of the biblical Ruth, who successfully crosses over from her home in Moab to Naomi's in Bethlehem and from her Gentile origins to her adoptive religion and people. Instead, he focuses on Naomi, the displaced Jew, and Orpah, who returns to her Gentile home.Less

The epidemiology of sleep and depression

S. Weich

in Sleep, Health and Society: From Aetiology to Public Health

Sleep disturbances, and insomnia in particular, are extremely common in depression and vice versa. These conditions co-occur more often than each occurs on its own. Insomnia, hypersomnia, and fatigue ... More

Sleep disturbances, and insomnia in particular, are extremely common in depression and vice versa. These conditions co-occur more often than each occurs on its own. Insomnia, hypersomnia, and fatigue are also diagnostic criteria for depressive disorders. Longitudinal studies have demonstrated that sleep disturbances often begin before the onset of other depressive symptoms. Insomnia may (adversely) affect the response to treatment of depression and, if residual, predict depressive relapse. Early evidence suggests that persistent insomnia may increase the risk of suicide among people who are depressed. Even if not causally related to depression, better methods for recognizing sleep disturbance in populations might assist in the early detection of depression or in identifying those at high risk of suicide.Less

Misdiagnosis of sleep disorders in adults and children: implications for clinical practice and epidemiology

G. Stores

in Sleep, Health and Society: From Aetiology to Public Health

There is increasing concern about the apparently high rate of misdiagnosis of various clinical conditions despite the fact that they seem to be well taught in medical training. How much more likely ... More

There is increasing concern about the apparently high rate of misdiagnosis of various clinical conditions despite the fact that they seem to be well taught in medical training. How much more likely are mistakes in the recognition and diagnosis of sleep disorders, given their neglect in both public and professional training? Because of this neglect, help must often be denied those many people who suffer sleep disturbance and its potentially serious consequences. This chapter illustrates the ways in which the various causes of insomnia, excessive sleepiness, and disturbed behaviour at night (parasomnias) can be misconstrued in people of all ages. It suggests guidelines for the avoidance of such mistakes which, clearly, have important implications for patient care, use of clinical services, and also epidemiological studies of the many sleep disorders now officially acknowledged.Less

Old Age Psychiatry

Lena Palaniyappan and Rajeev Krishnadas

in Best of Five MCQs for MRCPsych Paper 3

Upper Limb—Shoulder, Humerus, and Elbow

Alex Trompeter and David Elliott (eds)

in Trauma for the FRCS (Tr + Orth) Examination

The Years of Silence

Ian Ker

in John Henry Newman: A Biography

In 1858, free of the university, John Henry Newman expressed his wish to go back to his old studies. In spite of all his accomplishments, he felt too weary and unfulfilled. He thought maybe time ... More

In 1858, free of the university, John Henry Newman expressed his wish to go back to his old studies. In spite of all his accomplishments, he felt too weary and unfulfilled. He thought maybe time alone would vanquish all his doubts about himself and his religion. The disappointments and sufferings of the last decade had taken their toll on Newman. 1859 proved to be one of the most critical and trying years of his life. His “general health” was better but he felt he was “fading out from the world”. Despite suffering from insomnia and strain, Newman left Birmingham by the end of July 1861 for a three-week holiday. He was accompanied by William Neville, whom he received into the Church and who joined the Oratory in 1851. Newman had been advised by a London specialist to rest for several months that eventually turned into years of silence.Less

Control of symptoms other than pain

CICELY SAUNDERS, MARY BAINES, and ROBERT DUNLOP

in Living with Dying: A Guide to Palliative Care

This chapter provides a brief account of the diagnosis and treatment of some of the common symptoms found in terminally ill patients. It discusses the causes and recommended treatment for these ... More

This chapter provides a brief account of the diagnosis and treatment of some of the common symptoms found in terminally ill patients. It discusses the causes and recommended treatment for these symptoms, which include anorexia, weight loss, insomnia, and dyspnoea. The chapter also provides a list of essential drugs often given until the last day of life, including morphine, anticonvulsants, and psychotropic drugs.Less

Sleep disorders

Bernard Lapointe

in Palliative Medicine: A case-based manual

This chapter provides a case study to show the desired skills, attitudes, and knowledge required to diagnose and manage sleep disorders in palliative patients. It addresses a number of questions such ... More

This chapter provides a case study to show the desired skills, attitudes, and knowledge required to diagnose and manage sleep disorders in palliative patients. It addresses a number of questions such as: How common are sleep disorders? Why should we pay close attention to the patient's disrupted sleep? How to diagnosis a patient's sleep disorder? What other medical conditions are associated with sleep disorders?Less

Sleep-disordered Breathing in Heart Failure

Lip Bun Tan, Thomas Köhnlein, and Mark W.Elliot

in Supportive Care in Heart Failure

This chapter discusses sleep-disordered breathing in heart failure (HF). The association between HF and sleep disturbance can be divided into two major categories: the symptoms of HF which result in ... More

This chapter discusses sleep-disordered breathing in heart failure (HF). The association between HF and sleep disturbance can be divided into two major categories: the symptoms of HF which result in direct disruption of sleep and insomnia; and sleep apnoea syndromes (central sleep apnoea syndrome (CSAS), which is usually a consequence of worsening HF; and obstructive sleep apnoea syndrome, which may be a precursor of cardiac diseases leading to the development of chronic HF). The diagnosis and treatment options for these categories are shown. The prognosis of patients with chronic HF seems to be significantly worse if CSAS is present. Treatment options include continuous positive airway pressure (CPAP) and supplemental oxygen. Adequately powered prospective randomized controlled trials with survival and health status as endpoints are needed to establish whether the correction of sleep-related abnormalities of breathing in patients with HF really does improve outcome.Less

The Work of Sleep: Insomnia and Discipline in Ford and Sassoon

Sarah Kingston

in War and the Mind: Ford Madox Ford's Parade's End, Modernism, and Psychology

This chapter explores the function of sleep habits and insomnia in Ford Madox Ford's Parade's End and Siegfried Sassoon's Memoirs of an Infantry Officer, arguing that insomnia is an embodiment of the ... More

This chapter explores the function of sleep habits and insomnia in Ford Madox Ford's Parade's End and Siegfried Sassoon's Memoirs of an Infantry Officer, arguing that insomnia is an embodiment of the individual's resistance to military discipline, loss of privacy, and the subjection of one's body to authoritative control. Insomnia, a liminal state between sleeping and waking, pits the body against the mind or mind against the body, and in doing so illustrates the failure of disciplinary mechanisms to completely regulate individual behaviours. Further, the phenomenology of insomnia is in many ways similar to the phenomenology of experience in the First World War, especially given the war's association with exhaustion and fatigue, nocturnal activity, a sense of endlessness, and idiosyncratic temporality, making it an apt device through which to express the anxieties associated with participation in the war.Less

A Lyrical Digression

Maya Plisetskaya

in I, Maya Plisetskaya

In this chapter, Maya Plisetskaya reflects on her life, both personal and professional. Her entire bustling life has been characterized by premieres, struggles and conflicts, hassles, frustrations, ... More

In this chapter, Maya Plisetskaya reflects on her life, both personal and professional. Her entire bustling life has been characterized by premieres, struggles and conflicts, hassles, frustrations, impulses, meetings, suitcases, the daily grind. She has suffered from insomnia all her life, having swallowed kilograms of sleeping pills from Nembutal to Luminal, Tazepam, Roginal, and Valium. She was a creature of extremes and a fanatic soccer fan. Throughout her entire life, she adored and idolized Rodion Shchedrin, her husband. With regards to her ballet, she poured warm water into the heels of her ballet slippers (to make the foot sit more firmly) before every class and every performance. She and her fellow dancers bought all their food at Moscow markets and got some goodies from the buffets of the Bolshoi Ballet.Less

Disorders of arousal and sleep systems

Heather Ashton

in Brain Function and Psychotropic Drugs

Sleeping and waking mechanisms operate together as a homogeneous functional unit, the final output of which determines the level of arousal. Thus, disorders of one mechanism inevitably tend to affect ... More

Sleeping and waking mechanisms operate together as a homogeneous functional unit, the final output of which determines the level of arousal. Thus, disorders of one mechanism inevitably tend to affect others: anxiety is accompanied by insomnia; poor night-time sleep is associated with daytime sleepiness. However, for convenience the disorders are divided here into those which are mainly manifested in the waking state (for example anxiety syndromes) and those whose main characteristic is sleep disturbance (for example insomnia and hypersomnia).Less

Sleep disorders

Rebecca McKnight, Jonathan Price, and John Geddes

in Psychiatry

The term sleep disorder (somnipathy) simply means a disturbance of an individual’s normal sleep pat­tern. Doctors typically see patients in whom the ... More

The term sleep disorder (somnipathy) simply means a disturbance of an individual’s normal sleep pat­tern. Doctors typically see patients in whom the dis­turbance is having a negative effect upon physical, mental, or emotional functioning, but subclinical dis­turbances of sleep are common and something almost everyone will suffer at some point in their life. Sleep disorders are a heterogeneous group, ranging from the frequently experienced insomnia to the extremely rare hypersomnias such as Kleine– Levin syndrome. However, there are many shared characteristics and this chapter will concentrate mainly on providing a framework for assessment, diagnosis, and manage­ment in the generic sense, with some guidance on spe­cific disorders in the latter sections. A good working knowledge of basic sleep disorders is essential in all specialties of clinical medicine. As a general rule, sleep disorders within the general hos­pital environment tend to be poorly managed, with great detriment to the patient. There are a variety of reasons why it is important to be able to diagnose and treat sleep disorders: … ● Epidemiology: sleep disorders are very common and affect all ages. ● Co- morbidities: sleep disturbances may be a primary disorder or secondary to a mental or physical disorder. They are often prodromal symptoms of psychiatric conditions. ● Impact upon physical health: poor sleep is linked to increased mortality and morbidity from many pathologies (see ‘Consequences of inadequate sleep’, p. 405). ● Medications (not just psychotropics) often affect sleep. ● Sleep disturbance is an important part of many primary psychiatric conditions (e.g. mood disorders, psychosis, anxiety disorders); further information on these can be found in the chapter relating to each disorder. … Sleep is a natural state of bodily rest seen in humans and many animals and is essential for survival. It is different from wakefulness in that the organism has a decreased ability to react to stimuli, but this is more easily reversible than in hibernation or coma. Sleep is poorly understood, but it is likely that it has several functions relating to restoration of body equilibrium and energy stores. There are a variety of theories re­garding the function of sleep, which are outlined in Box 28.1. Less

Symptoms Associated with HIV and AIDS

Harold W. Goforth and Mary Ann Cohen

in Handbook of AIDS Psychiatry

Many persons with HIV and AIDS have symptoms that are unrelated to underlying psychiatric disorders but may masquerade as such. These symptoms may include insomnia, ... More

Many persons with HIV and AIDS have symptoms that are unrelated to underlying psychiatric disorders but may masquerade as such. These symptoms may include insomnia, fatigue, nausea, or other troubling symptoms, and often result in suffering for patients, their families, and loved ones. The symptoms are common throughout the course of HIV and AIDS, from onset of infection to late-stage and end-stage AIDS. They need to be addressed whenever they occur and not only as part of end-of-life care. We present protocols to ameliorate or eliminate these symptoms and alleviate suffering. Fatigue is one of the most prevalent but underreported and undertreated aspects of HIV disease. The prevalence of fatigue in an HIV population has been estimated to affect at least 50% of seropositive individuals (Breitbart et al., 1998) and may affect up to 80% of the population. Darko and colleagues (1992) found that HIV-seropositive individuals were more fatigued, required more sleep and daytime naps, and showed less alert morning functioning than did persons who are HIV-seronegative. While the symptom of fatigue may fluctuate with increasing viral loads, there is no evidence base for a consistent correlation between fatigue and viral load. Fatigue is a pseudo-specific symptom common to a variety of disabilities found in an HIV population, and it has been linked to a variety of other AIDS-related disabilities including pain, anemia, impaired physical function, psychological distress, and depression. Hormonal alterations, such as those in testosterone and thyroxin, that occur in the context of HIV infection are also common in this group. While these findings are further discussed in Chapter 10, it is worth noting here that they can contribute substantially to tiredness and fatigue in this population. Other sources of fatigue include multimorbid chronic illnesses (opportunistic infections and cancers, chronic renal insufficiency, hepatitis C and other hepatic illnesses, and chronic obstructive pulmonary disease [COPD]) and some of their treatments (notably interferon/ribavirin for hepatitis C and cancer chemotherapy). Substances such as recreational drugs, nicotine, and caffeine are also factors in HIV-related fatigue. Less

‘I Don’t Want to Sweep Alone’: Paranoia and Anomalous Experiences

Daniel Freeman and Jason Freeman

in Paranoia: The 21st Century Fear

Thus George Costanza, nebbish anti-hero of hit sitcom Seinfeld. George is desperate to know why his girlfriend Gwen has dumped him. (‘It’s not you—it’s me’ is her ... More

Thus George Costanza, nebbish anti-hero of hit sitcom Seinfeld. George is desperate to know why his girlfriend Gwen has dumped him. (‘It’s not you—it’s me’ is her somewhat unhelpful—and utterly implausible—offering on the subject.) But all is not lost. Jerry, George’s best friend, has just started dating Laura, who is deaf. And what better way to discover what people are saying about you than have a friend read their lips? It’s a scheme that appeals to the paranoid in all of us. As George tells Jerry: ‘If we could just harness this power and use it for our own personal gain there’d be no stopping us.’ Well, Laura does indeed lip-read Gwen’s conversation with Todd, the host of the party, and she duly provides George with a running commentary in sign language. So far, so good. But George doesn’t understand sign language; it has to be translated for him by ‘hipster doofus’ Kramer: . . . KRAMER ‘Hi Gwen, hi tide.’ JERRY Hi tide? KRAMER Hi Todd. ‘You’ve got something between your teeth.’ GEORGE What? KRAMER No that’s what he said. That’s interesting. ‘I love carrots, but I hate carrot soup. And I hate peas, but I love pea soup.’ So do I. GWEN I don’t envy you, Todd. The place is going to be a mess. TODD Maybe you can stick around after everybody leaves and we can sweep together. KRAMER ‘Why don’t you stick around and we can sleep together.’ GEORGE What?!? KRAMER ‘You want me to sleep with you?’ TODD I don’t want to sweep alone. KRAMER He says ‘I don’t want to sleep alone.’ She says, oh boy, ‘love to.’ . . . You can guess the rest. This sad tale points up a crucial element in paranoia. Because, although by definition paranoid thoughts are unjustified and exaggerated, they aren’t completely irrational. Life is full of confusing or unsettling experiences and paranoid thoughts supply an explanation (albeit not an especially useful or accurate one) for these ambiguous experiences. They are acts of interpretation gone awry. Less

Advanced Trauma Life Support (ATLS), Polytrauma, Limb Salvage, and UK Trauma Guidelines

Alex Trompeter and David Elliott (eds)

in Trauma for the FRCS (Tr + Orth) Examination

Symptoms, Related Brain Regions, and Diagnosis

J. Eric Ahlskog

in Dementia with Lewy Body and Parkinson's Disease Patients: Patient, Family, and Clinician Working Together for Better Outcomes

As a prelude to the treatment chapters that follow, we need to define and describe the types of problems and symptoms encountered in DLB and PDD. The ... More

As a prelude to the treatment chapters that follow, we need to define and describe the types of problems and symptoms encountered in DLB and PDD. The clinical picture can be quite varied: problems encountered by one person may be quite different from those encountered by another person, and symptoms that are problematic in one individual may be minimal in another. In these disorders, the Lewy neurodegenerative process potentially affects certain nervous system regions but spares others. Affected areas include thinking and memory circuits, as well as movement (motor) function and the autonomic nervous system, which regulates primary functions such as bladder, bowel, and blood pressure control. Many other brain regions, by contrast, are spared or minimally involved, such as vision and sensation. The brain and spinal cord constitute the central nervous system. The interface between the brain and spinal cord is by way of the brain stem, as shown in Figure 4.1. Thought, memory, and reasoning are primarily organized in the thick layers of cortex overlying lower brain levels. Volitional movements, such as writing, throwing, or kicking, also emanate from the cortex and integrate with circuits just below, including those in the basal ganglia, shown in Figure 4.2. The basal ganglia includes the striatum, globus pallidus, subthalamic nucleus, and substantia nigra, as illustrated in Figure 4.2. Movement information is integrated and modulated in these basal ganglia nuclei and then transmitted down the brain stem to the spinal cord. At spinal cord levels the correct sequence of muscle activation that has been programmed is accomplished. Activated nerves from appropriate regions of the spinal cord relay the signals to the proper muscles. Sensory information from the periphery (limbs) travels in the opposite direction. How are these signals transmitted? Brain cells called neurons have long, wire-like extensions that interface with other neurons, effectively making up circuits that are slightly similar to computer circuits; this is illustrated in Figure 4.3. At the end of these wire-like extensions are tiny enlargements (terminals) that contain specific biological chemicals called neurotransmitters. Neurotransmitters are released when the electrical signal travels down that neuron to the end of that wire-like process. Less

Psychiatry

Stevan R. Emmett, Nicola Hill, and Federico Dajas-Bailador

in Clinical Pharmacology for Prescribing

Anxiety disorders fall mainly into the category of neurotic, stress, or somatoform disorders, as defined by the inter­national classification of disease system (ICD- ... More

Anxiety disorders fall mainly into the category of neurotic, stress, or somatoform disorders, as defined by the inter­national classification of disease system (ICD- 11, WHO, 2018). They refer to several disorders that include gener­alized anxiety disorder (GAD), phobic anxiety disorders, panic disorder (± agoraphobia), obsessive compul­sive disorder (OCD) and post- traumatic stress disorder (PTSD). Collectively, anxiety disorders affect almost 30% of people in the western world during their lifetime, with PTSD and GAD amongst the most prevalent. In general, anxiety disorders are associated with neurotransmitter dysregulation and amygdala hyperactivity. Insomnia is the unsatisfactory quantity and/ or quality of sleep, which persists for sufficient time to affect quality of life. It is often associated with other mental health (e.g. depression, anxiety, alcohol dependence) and physical (e.g. pain, neoplasms) pathologies, or iatrogenic effects (e.g. diuretic, β- blockers, statins, levodopa). It may require treatment if symptoms are troublesome. Chronic insomnia can last for years, and affects almost 10% of the popula­tion. Around 30% have symptoms that are occasionally worse, with higher prevalence in older age. Many factors interplay to generate a state of anxiety, but from a biological perspective one of the key central brain pathways involved in this process is the limbic system, which regulates an array of functions, including emo­tion, fear, behaviour, and memory. One vital brain area that processes fear reactions from the thalamus and cortex is the amygdala, with connections to the hypothal­amus, which can activate sympathetic reactions and the hypothalamic– pituitary axis (HPA). Activation/ inhibition within this pathway leads to altered neurotransmitter activity. Corticotrophin- releasing factor (CRF) is known to be released from the hypothalamus in response to stress, under the regulation of the amygdala. CRF acts to drive the HPA, promoting the release of ACTH from the pituitary and then cortisol from the adrenal gland. In effect, sus­tained CRF exposure may lead to limbic system up- regu­lation and the heightening of anxiety states. Moreover, dysregulation in this system and changes in central cor­tisol sensing systems (e.g. decreased receptor expression) may cause chronic anxiety. The locus coeruleus (LC), is another brain region partly responsible for regulating the sympathetic effects of stress, again under the control of CRF. Less