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Principles and Practice of Sleep Medicine - E-Book

Principles and Practice of Sleep Medicine - E-Book

Meir H. Kryger | Thomas Roth | William C. Dement

(2010)

Additional Information

Book Details

Abstract

Principles and Practice of Sleep Medicine, 5th Edition, by Meir H. Kryger, MD, FRCPC, Thomas Roth, PhD, and William C. Dement, MD, PhD, delivers the comprehensive, dependable guidance you need to effectively diagnose and manage even the most challenging sleep disorders. Updates to genetics and circadian rhythms, occupational health, sleep in older people, memory and sleep, physical examination of the patient, comorbid insomnias, and much more keep you current on the newest areas of the field. A greater emphasis on evidence-based approaches helps you make the most well-informed clinical decisions. And, a new more user-friendly, full-color format, both in print and online, lets you find the answers you need more quickly and easily. Whether you are preparing for the new sleep medicine fellowship examination, or simply want to offer your patients today's best care, this is the one resource to use!

  • Make optimal use of the newest scientific discoveries and clinical approaches that are advancing the diagnosis and management of sleep disorders.

Table of Contents

Section Title Page Action Price
Front cover cover
Principles and Practice of Sleep Medicine i
Copyright page iv
Dedication v
Poetry vii
Contributors ix
Foreword xxiii
Preface xxvii
Acknowledgments xxix
Abbreviations xxxi
Table of Contents xxxv
Video Contents xli
I Principles of Sleep Medicine 1
1 Normal Sleep and its Variations 3
1 History of Sleep Physiology and Medicine 3
Abstract 14
SLEEP AS A PASSIVE STATE 3
THE ELECTRICAL ACTIVITY OF THE BRAIN 4
THE ASCENDING RETICULAR SYSTEM 5
EARLY OBSERVATIONS OF SLEEP PATHOLOGY 5
SIGMUND FREUD AND THE INTERPRETATION OF DREAMS 6
CHRONOBIOLOGY 6
THE DISCOVERY OF REM SLEEP 6
ALL-NIGHT SLEEP RECORDINGS AND THE BASIC SLEEP CYCLE 7
REM SLEEP IN ANIMALS 8
THE DUALITY OF SLEEP 9
PREMONITIONS OF SLEEP MEDICINE 9
SLEEP-ONSET REM PERIODS AND CATAPLEXY 9
THE NARCOLEPSY CLINIC: A FALSE START 9
EUROPEAN INTEREST 9
BENZODIAZEPINES AND HYPNOTIC EFFICACY STUDIES 10
THE DISCOVERY OF SLEEP APNEA 10
ITALIAN SYMPOSIA 10
BIRTH PANGS 10
THE EARLY DEVELOPMENT OF SLEEP MEDICINE CLINICAL PRACTICE 11
CLINICAL SIGNIFICANCE OF EXCESSIVE DAYTIME SLEEPINESS 12
FURTHER DEVELOPMENT OF SLEEP MEDICINE 12
THE TURN OF THE CENTURY AND BEYOND 13
REFERENCES 14
2 Normal Human Sleep: 16
Abstract 25
SLEEP DEFINITIONS 16
SLEEP ONSET 17
Definition of Sleep Onset 17
Electromyogram 17
Electrooculogram 18
Electroencephalogram 18
Behavioral Concomitants of Sleep Onset 18
Simple Behavioral Task 18
Visual Response 19
Auditory Response 19
Olfactory Response 19
Response to Meaningful Stimuli 19
Hypnic Myoclonia 19
Memory Near Sleep Onset 19
Learning and Sleep 20
PROGRESSION OF SLEEP ACROSS THE NIGHT 20
Pattern of Sleep in a Normal Young Adult 20
First Sleep Cycle 20
NREM-REM Cycle 21
Distribution of Sleep Stages across the Night 21
Length of Sleep 21
Generalizations about Sleep in the Normal Young Adult 21
Factors Modifying Sleep Stage Distribution 22
Age 22
Prior Sleep History 22
Circadian Rhythms 23
Temperature 23
Drug Ingestion 23
Pathology 24
Narcolepsy 24
Sleep Apnea Syndromes 24
Sleep Fragmentation 24
Acknowledgments 25
REFERENCES 25
3 Normal Aging 27
Abstract 37
SLEEP ARCHITECTURE 27
Percentage of Time Spent in Each Sleep Stage 28
Arousals during Sleep 29
Comorbidities 29
Slow-Wave Sleep 29
CIRCADIAN RHYTHMS IN AGING 30
CAUSES AND CONSEQUENCES OF POOR SLEEP IN OLD AGE 32
Causes 32
Potential Consequences 33
RESTLESS LEGS SYNDROME AND PERIODIC LIMB MOVEMENTS IN SLEEP 33
SLEEP-DISORDERED BREATHING 34
Risk Factors 34
Outcomes 35
WHY DO OLDER PEOPLE NAP? 36
BASIC SCIENCE CONSIDERATIONS 36
SUMMARY 37
Acknowledgment 37
REFERENCES 37
4 Daytime Sleepiness and Alertness 42
Abstract 51
INTRODUCTION 42
EPIDEMIOLOGY OF SLEEPINESS 42
Sleepiness in Limited Populations or Populations of Convenience 42
Sleepiness in Representative Populations 42
Risk Factors for Sleepiness 43
NATURE OF SLEEPINESS 43
Physiological Need State 43
Neural Substrates of Sleepiness 44
ASSESSMENT OF SLEEPINESS 45
Quantifying Sleepiness 45
Relation of Sleepiness to Behavioral Functioning 46
Clinical Assessment of Sleepiness 47
DETERMINANTS OF SLEEPINESS 47
Quantity of Sleep 47
Quality of Sleep 48
Circadian Rhythms 48
CNS Drugs 49
Sedating Drug Effects 49
Alerting Drug Effects 50
Influence of Basal Sleepiness 50
CNS Pathologies 50
CLINICAL AND PUBLIC HEALTH SIGNIFICANCE OF SLEEPINESS 50
REFERENCES 51
5 Acute Sleep Deprivation 54
Abstract 54
TOTAL SLEEP DEPRIVATION 54
Behavioral Effects 54
Sleep/Circadian Influences 54
Arousal Influences 55
Activity 55
Bright light 55
Noise 55
Temperature 55
Posture 56
Drugs 56
Motivation or Interest 56
Group Effects 57
Repeated Periods of Sleep Loss 57
Individual Characteristics 57
Age 57
Sensitivity to Sleep Loss 57
Personality and Psychopathology 57
Test Characteristics and Types 58
Length of Test 58
Knowledge of Results 58
Test Pacing 58
Proficiency Level 58
Difficulty or Complexity 58
Memory Requirement 58
Executive Function 58
Subjective (versus Objective) Measures 58
EEG Measures 58
Summary 59
PHYSIOLOGIC EFFECTS OF SLEEP DEPRIVATION 59
Neurologic Changes 59
Imaging Studies 59
Clinical EEG 59
Autonomic Changes 59
Biochemical Changes 60
Gene Studies 60
Clinical Changes 60
Immune Function 60
Pain 60
Weight Control and Insulin 61
Exercise 61
Summary 61
SLEEP FRAGMENTATION 61
Experimental Sleep Fragmentation 61
Sleep Disorders and Fragmentation 62
RECOVERY SLEEP 62
Performance Effects 62
EEG Effects 63
Relationship between EEG and Psychomotor Performance Recovery Effects 64
CONCLUSIONS 64
Acknowledgements 64
REFERENCES 64
6 Chronic Sleep Deprivation 67
Abstract 67
INCIDENCE OF CHRONIC SLEEP RESTRICTION 67
THEORETICAL PERSPECTIVES ON SLEEP NEED AND SLEEP DEBT 67
Basal Sleep Need 67
Core Sleep versus Optional Sleep 68
Adaptation to Sleep Restriction 68
Two-Process Model Predictions of Sleep Restriction 68
EFFECTS OF CHRONIC SLEEP RESTRICTION 69
Sleep Architecture 69
Sleep Propensity 69
Waking Electroencephalogram 70
Cognitive Effects 70
Driving Performance 72
Subjective Sleepiness and Mood 72
Individual Differences in Responses to Chronic Sleep Restriction 72
PHYSIOLOGIC EFFECTS 73
Endocrine and Metabolic Effects 73
Immune and Inflammatory Effects 73
Cardiovascular Effects 73
Acknowledgments 73
REFERENCES 73
2 Sleep Mechanisms and Phylogeny 76
7 Neural Control of Sleep in Mammals 76
Abstract 89
DIVERSE BRAIN REGIONS MODULATE WAKING AND NREM SLEEP 76
Isolated Forebrain 76
Diencephalon 77
Thalamus 77
Lower Brainstem 77
RETICULAR ACTIVATING SYSTEM AND DELINEATION OF AROUSAL SYSTEMS 77
WAKE-ON, REM-OFF AROUSAL SYSTEMS 78
Serotonin 78
Norepinephrine 79
Histamine 79
Orexin 79
WAKE-ON, REM-ON AROUSAL SYSTEMS 79
Acetylcholine 79
Dopamine 79
Glutamate 79
SLEEP-PROMOTING MECHANISMS 79
A POA Sleep-Promoting System 80
c-Fos Mapping 80
THE ORCHESTRATION OF SLEEP BY THE POA HYPNOGENIC SYSTEM 81
THALAMIC–CORTICAL INTERACTIONS AND THE GENERATION OF THE SLEEP EEG 82
Sleep Spindles 84
Delta Waves 84
Slow Oscillations 84
INTEGRATION OF CIRCADIAN RHYTHMS AND SLEEP 86
THE POA, THERMOREGULATION, AND CONTROL OF SLEEP 86
HIERARCHICAL CONTROL MODEL 86
SLEEP-PROMOTING NEUROCHEMICAL AGENTS 87
Adenosine 87
Proinflammatory Cytokines 88
Prostaglandin D2 88
Growth Hormone–Releasing Hormone 88
Sleep as Detoxification or Protection from Oxidative Stress 88
SUMMARY 89
Acknowledgments 89
REFERENCES 89
8 REM Sleep* 92
Abstract 108
CHARACTERISTICS OF REM SLEEP 92
REM GENERATION MECHANISMS 93
Technical Considerations 93
Inactivation of Neurons by Lesions, Inhibition, Antisense Administration, or Genetic Manipulation 93
Activation of Neurons by Electrical or Chemical Stimulation, Gene Activation, or Ion Channel Manipulation 94
Observation of Neuronal Activity 95
Summary 96
Transection Studies 96
Localized Lesion Studies 98
Stimulation Studies 99
Neuronal Activity, Transmitter Release 99
Medial Brainstem Reticular Formation 99
Cholinergic Cell Groups 100
Cells with Activity Selective for REM Sleep 100
Monoamine-Containing Cells 100
Other Cholinergic Cells in Lateral Pontine Regions 100
Fos Labeling 100
CONTROL OF MUSCLE TONE 101
NARCOLEPSY AND HYPOCRETIN 103
THE FUNCTIONS OF REM SLEEP 105
REFERENCES 108
9 Phylogeny of Sleep Regulation 112
Abstract 112
SLEEP REGULATION IN MAMMALS 112
The Origins and Definition of Sleep Homeostasis 112
Sleep Duration and Sleep Intensity 113
Daily Time Course of Slow-Wave Activity and Its Sleep-Wake Dependence 115
Is REM Sleep Homeostatically Regulated? 116
The Waking EEG Reflects Homeostatic Mechanisms 116
Circadian versus Homeostatic Aspects of Sleep Regulation 116
Special Features 118
Herbivores: Cows and Horses, Ruminants and Nonruminants 118
Sleep Regulation: Unihemispheric Sleep and Regional Aspects of Sleep 118
Sleep and Hibernation 118
Other Measures for Sleep Regulation: Sleep or Rest Consolidation 119
SLEEP REGULATION IN NONMAMMALIAN VERTEBRATES 119
Birds 119
Reptiles 120
Amphibians and Fish 120
SLEEP REGULATION IN INVERTEBRATES 120
OUTLOOK 122
REFERENCES 123
10 Sleep in Animals: 126
Abstract 126
ADAPTIVE INACTIVITY 126
QUANTITATIVE ANALYSES OF THE CORRELATES OF SLEEP DURATION 127
THE DIVERSITY OF SLEEP 129
SLEEP IN MONOTREMES 130
REINDEER 132
BIRDS 132
WALRUS 133
SLEEP IN CETACEANS (DOLPHINS AND WHALES) 133
SLEEP IN OTARIIDS (EARED SEALS) 135
SLEEP REBOUND 135
CONCLUSION 136
Acknowledgment 136
REFERENCES 136
3 Genetics of Sleep 139
11 Introduction 139
REFERENCES 140
12 Circadian Clock Genes 141
Abstract 141
THE MAMMALIAN CELLULAR CIRCADIAN CLOCK 141
CIRCADIAN CLOCK PROPERTIES AND CLOCK GENES 141
POSITIVE ELEMENTS 142
Clock 142
Bmal1 143
NEGATIVE ELEMENTS 143
Period Genes 143
Cryptochromes 144
MODULATORS OF Period 144
Timeless 144
Casein Kinase 1 145
MODULATORS OF Bmal1 145
Rev-erbα and ROR 145
MODULATORS OF Cry 145
Fbxl3 145
Other bHLH-PAS Family Members 146
Dec1 and Dec2 146
OUTPUT REGULATION 146
Clock 146
Prokineticin 2 146
Transforming Growth Factor α 146
VPAC2 146
Cardiomyotrophin-like Cytokine 146
INPUT REGULATION 146
Melanopsin 146
Rab3a 147
CONCLUSIONS 147
REMAINING QUESTION: CLOCK GENES AS SLEEP GENES? 147
Acknowledgements 148
REFERENCES 148
13 Genetics of Sleep in a Simple Model Organism: 151
Abstract 151
DROSOPHILA AS A MODEL SYSTEM FOR GENETICS 151
DROSOPHILA AS A MODEL FOR STUDIES OF SLEEP 152
DROSOPHILA CIRCADIAN BEHAVIOR REVEALS CONSERVED MECHANISMS BETWEEN FLIES AND HUMANS 153
CELLULAR AND MOLECULAR BASIS OF DROSOPHILA SLEEP 154
SPECIFIC NEURAL CIRCUITS ARE IMPORTANT FOR SLEEP–WAKE REGULATION 154
GENETICS AND PHARMACOLOGY OF SLEEP: WHICH MOLECULES REGULATE SLEEP? 155
Circadian Clock Pathway 155
Stress and Immune Pathways 156
Membrane Excitability 156
Growth Factors and Signal Transduction 156
Arousal Neurotransmitters: Monoaminergic Arousal Pathways 157
Sleep Neurotransmitters: GABA and Adenosine Sleep Pathways 157
WHICH GENES ARE REGULATED BY SLEEP–WAKE? 158
SUMMARY 158
REFERENCES 158
14 Genetic Basis of Sleep in Rodents 161
Abstract 171
GENE EXPRESSION, mRNAs, AND MICROARRAY STUDIES 161
IDENTIFICATION OF ALLELES THAT INFLUENCE SLEEP OR SLEEP-RELATED TRAITS 164
MUTAGENESIS AND KNOCKOUTS 168
High-Throughput Screening 169
Targeted Gene Deletion 169
Genetic Regulation of Homeostasis 170
Genetic Regulation of Circadian Rhythm 170
REFERENCES 171
15 Genetic Basis of Sleep in Healthy Humans 175
Abstract 182
EVIDENCE FOR GENOTYPE-DEPENDENT DIFFERENCES IN DIURNAL PREFERENCE, SLEEP TIMING, SLEEP DURATION, SLEEP ARCHITECTURE, AND SLEEP EEG 175
GENES CONTRIBUTING TO HUMAN MORNINGNESS–EVENINGNESS AND TIMING OF SLEEP 175
Candidate Genes 175
Genome-Wide Association Study 178
GENES CONTRIBUTING TO HABITUAL SLEEP DURATION 178
GENES CONTRIBUTING TO SLEEP ARCHITECTURE 178
Slow-Wave Sleep and REM Sleep 178
The Sleep EEG: Among the Most Heritable Traits in Humans 179
GENES CONTRIBUTING TO THE SLEEP EEG 180
GENETIC BASIS OF SLEEP–WAKE REGULATION: INTERACTION BETWEEN HOMEOSTATIC AND CIRCADIAN SYSTEMS 181
CONCLUDING REMARKS 181
Acknowledgements 181
REFERENCES 182
16 Genetics of Sleep and Sleep Disorders in Humans 184
Abstract 184
GENETIC STUDIES OF HUMAN SLEEP: METHODOLOGICAL LIMITATIONS 185
GENETIC FACTORS UNDERLYING THE CIRCADIAN CLOCK AND CIRCADIAN RHYTHM DISORDERS 187
GENETIC FACTORS REGULATING EEG AND THE SLEEP HOMEOSTAT 188
GENETICS OF NARCOLEPSY 188
Heritability 188
Human Leukocyte Antigen in Narcolepsy 189
Hypocretin Deficiency in Narcolepsy 189
Non-HLA, Non-Hypocretin Genes in Narcolepsy 189
GENETICS OF RESTLESS LEGS SYNDROME 190
Heritability 190
RLS Linkage Studies 190
Genome-Wide Associations 190
MEIS1 as a Candidate and Its Symptomatology 191
BTBD9 as a Candidate and Its Symptomatology 191
LBXCOR as a Candidate and Symptomatology 191
PTPRD and Nitric Oxide Synthase as Candidates in RLS 191
GENETICS OF OTHER HYPERSOMNIAS, INSOMNIA, AND PARASOMNIAS 192
AUTOSOMAL DOMINANT FRONTAL LOBE EPILEPSY 192
GENETICS OF OBSTRUCTIVE SLEEP APNEA 193
CONGENITAL CENTRAL HYPOVENTILATION SYNDROME 193
SLEEP DISORDERS IN ASSOCIATION WITH OTHER GENETIC DISORDERS 194
CONCLUSION 194
REFERENCES 195
4 Physiology in Sleep 199
17 Relevance of Sleep Physiology for Sleep Medicine Clinicians 199
Abstract 199
REFERENCES 200
18 What Brain Imaging Reveals about Sleep Generation and Maintenance 201
Abstract 201
FUNCTIONAL SEGREGATION AND INTEGRATION DURING NORMAL HUMAN SLEEP 201
NON–RAPID EYE MOVEMENT SLEEP 201
PROCESSING OF EXTERNAL STIMULI DURING NREM SLEEP 204
RAPID EYE MOVEMENT SLEEP 205
Reorganization of Regional Brain Function during REM Sleep: Relation with Dream Characteristics 205
Brain Imaging and Other Characteristic Features of REM Sleep 206
Experience-Dependent Modifications of Regional Brain Function during NREM and REM Sleep 206
BRAIN IMAGING AND NEURAL CORRELATES OF SLEEP–WAKE CYCLE REGULATION 206
BRAIN IMAGING AND NEURAL CORRELATES OF HUMAN SLEEP DEPRIVATION 208
FUNCTIONAL NEUROIMAGING IN SLEEP DISORDERS 209
Insomnia and Brainstem and Hypothalamic Arousal Networks 209
Insomnia, Disorders of Emotion, and Limbic and Paralimbic Arousal Networks 210
Insomnia, Disorders of Emotion, and Neocortical Arousal Networks 211
REM Sleep in Depression 212
Fatal Familial Insomnia 212
SUMMARY 212
Acknowledgements 212
REFERENCES 212
19 Cardiovascular Physiology: 215
Abstract 223
SLEEP-STATE CONTROL OF CARDIOVASCULAR FUNCTION 215
CARDIORESPIRATORY INTERACTIONS 216
Central Mechanisms 216
Cardiorespiratory Homeostasis 217
SLEEP STATE–DEPENDENT CHANGES IN HEART RHYTHM 218
Heart Rate Surges 218
Heart Rhythm Pauses 219
CORONARY ARTERY BLOOD FLOW REGULATION DURING SLEEP 220
IMPACT OF SLEEP ON ARRHYTHMOGENESIS 220
Central Nervous System Sites Influencing Cardiac Electrical Stability 220
Autonomic Factors in Arrhythmogenesis during Sleep 222
SUMMARY 223
Acknowledgments 223
REFERENCES 223
20 Cardiovascular Physiology: 226
Abstract 226
INTRODUCTION 226
THE CARDIOVASCULAR AUTONOMIC NERVOUS SYSTEM: DEFINITION AND FUNCTIONS 226
Arterial Baroreflex 227
Cardiopulmonary Reflexes 227
The Chemoreflexes 227
MEASURES TO EXPLORE AUTONOMIC CHANGES DURING SLEEP AND THEIR PHYSIOLOGICAL SIGNIFICANCE 227
Heart Rate, Arterial Blood Pressure, and Their Variability 227
Baroreflex Sensitivity 229
Preejection Period 229
Microneurographic Recording of Sympathetic Nerve Activity 229
Peripheral Arterial Tone and Pulse Transit Time 230
Systemic Catecholamines 230
SLEEP RELATED CARDIOVASCULAR AUTONOMIC CHANGES 230
Day–Night Changes in Neural Circulatory Control 230
Physiologic Responses to NREM and REM Sleep 230
RR Variability and EEG Coupling 231
Autonomic Responses Associated with Arousal from Sleep and from Periodic Leg Movements 231
Arousals 231
Periodic Leg Movements during Sleep 231
IMPACT OF AGING ON NEURAL CIRCULATORY RESPONSE TO NORMAL SLEEP 232
EFFECTS OF DISORDERED SLEEP AND PRIMARY AUTONOMIC DYSFUNCTION ON DAY–NIGHT AUTONOMIC CHANGES 233
Effects of Sleep Loss and Sleep Disorders on Nighttime BP 233
Loss of Diurnal Variation in Autonomic Function in Diabetes Mellitus: What Comes First? 233
SYMPATHETIC ACTIVATION IN OBSTRUCTIVE SLEEP APNEA 234
SUMMARY 235
REFERENCES 235
21 Respiratory Physiology: 237
Abstract 237
RESPIRATORY NEUROBIOLOGY: BASIC OVERVIEW 237
Medullary Respiratory Neurons and Motoneurons 237
Pre-Bötzinger Complex 237
Neuronal Connections 238
SLEEP NEUROBIOLOGY: BASIC OVERVIEW 239
Wakefulness 239
NREM Sleep 240
REM Sleep 240
CONTROL OF RESPIRATORY MOTONEURONS 240
DETERMINANTS OF RESPIRATORY MOTONEURON ACTIVITY 241
Tonic and Respiratory-Related Inputs to Respiratory Motoneurons 241
Electrical Properties of Motoneurons 242
Presynaptic Modulation 242
Tonic and Respiratory-Related Activity in Respiratory Muscle 243
NEUROMODULATION OF RESPIRATORY MOTONEURONS ACROSS SLEEP–WAKE STATES 243
Excitatory Influences across Sleep–Wake States 244
Inhibitory Influences across Sleep–Wake States 245
CONTROL OF RESPIRATORY NEURONS 246
Respiratory Neurons Vary in the Strength of Their Relationship to Breathing 246
Respiratory Neuron Activity in NREM Sleep 246
Respiratory Neuron Activity in REM Sleep 246
Neuromodulation of Respiratory Neurons across Sleep–Wake States 247
Acknowledgments 248
REFERENCES 248
22 Respiratory Physiology: 250
Abstract 250
INTRODUCTION 250
Chemical Information 250
Mechanical Information 250
Information from Higher Central Nervous System Centers 250
PHYSIOLOGY OF VENTILATORY CONTROL DURING SLEEP 250
Hypoxic Ventilatory Response during Sleep 251
II Practice of Sleep Medicine 639
8 Impact, Presentation, and Diagnosis 641
56 Approach to the Patient with Disordered Sleep 641
Abstract 641
CHIEF COMPLAINT AND HISTORY 641
Insomnia 643
Excessive Sleepiness 643
Nocturnal Movements, Behaviors, and Sensations 644
MEDICATION USE AND PAST MEDICAL HISTORY 644
FAMILY HISTORY 644
SOCIAL HISTORY 644
REVIEW OF SYSTEMS 645
PHYSICAL EXAMINATION 645
FORMULATION AND DIAGNOSTIC STUDIES 645
CONCLUSION 646
REFERENCES 646
57 Cardinal Manifestations of Sleep Disorders 647
Abstract 647
INSOMNIA 647
EXCESSIVE DAYTIME SLEEPINESS 650
FATIGUE 650
SNORING 650
SLEEP APNEA 651
MORNING HEADACHE 653
CATAPLEXY 653
SLEEP PARALYSIS 653
HYPNAGOGIC AND HYPNOPOMPIC HALLUCINATIONS 653
AUTOMATIC BEHAVIOR 654
EXCESSIVE MOVEMENT IN SLEEP OR PARASOMNIA 654
Sleeptalking 654
Sleepwalking 654
Sleep Terrors 654
Confusional Arousals and Sleep Drunkenness 655
Sleep-Related Groaning (Catathrenia) 655
Dream-Related Movement 655
Nightmares 655
Rhythmic Movement Disorder 655
Bruxism 655
RESTLESS LEGS SYNDROME AND PERIODIC MOVEMENTS OF SLEEP 656
SYSTEMIC FEATURES 656
PEDIATRIC CARDINAL MANIFESTATIONS 656
SUMMARY 657
REFERENCES 657
58 Physical Examination in Sleep Medicine 658
Abstract 658
SLEEP APNEA 658
Overall Inspection 658
Craniofacial Factors 658
Nasal Factors 658
Neck Circumference 658
Examination of the Pharynx 660
Examination of the Tonsils 660
Neurologic Examination 661
Cardiopulmonary Examination 662
NARCOLEPSY 662
RESTLESS LEGS SYNDROME 663
PARASOMNIAS 663
Nocturnal Eating Disorder and Sleep-Related Eating Disorder 663
REM Sleep Behavior Disorder 663
Sleep-Related Movement Disorders 663
Bruxism 663
Acknowledgment 664
REFERENCES 664
59 Use of Clinical Tools and Tests in Sleep Medicine 666
Abstract 666
EVALUATION FOR SLEEP-RELATED BREATHING DISORDERS 666
History and Questionnaires 666
Physical Examination 668
Nocturnal Polysomnography 671
Modified Forms of the Polysomnogram 672
Portable Recording 672
Studies of Airway Morphology 673
EVALUATION OF HYPERSOMNOLENCE 674
History and Questionnaires 674
Physical Examination 674
Nocturnal Polysomnography 674
Multiple Sleep Latency Test 674
Use of the MSLT in the Diagnosis of Narcolepsy 675
Variations of the Multiple Sleep Latency Test and Other Physiologic Tests 675
EVALUATION OF INSOMNIA 675
EVALUATION FOR SUSPECTED PARASOMNIAS 676
BEYOND SENSITIVITY, SPECIFICITY, AND PREDICTIVE VALUE: DECISION AND COST-EFFECTIVENESS ANALYSES 676
REFERENCES 677
60 Classification of Sleep Disorders 680
Abstract 680
INSOMNIAS 680
Primary Insomnia 680
Secondary Insomnia 683
SLEEP-RELATED BREATHING DISORDERS 683
Primary Sleep Apneas 684
Obstructive Sleep Apneas 684
Hypoventilation and Hypoxemia 684
HYPERSOMNIA OF CENTRAL ORIGIN 684
CIRCADIAN RHYTHM SLEEP DISORDERS 685
PARASOMNIAS 685
SLEEP-RELATED MOVEMENT DISORDERS 686
OTHER SLEEP DISORDERS 687
Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues 687
Other Organic Disorders Commonly Encountered in the Differential Diagnosis of Sleep Disorders 687
Other Psychiatric or Behavioral Disorders Commonly Encountered in the Differential Diagnosis of Sleep Disorders 687
CURRENT AND FUTURE CLASSIFICATION CONSIDERATIONS 687
Comorbid Insomnia and Insomnia Research Criteria 687
Hypersomnia 689
Parasomnia 689
REFERENCES 690
61 Epidemiology of Sleep Disorders 694
Abstract 694
SLEEP DURATION 694
INSOMNIA AND USE OF HYPNOTIC AGENTS 695
Use of Hypnotics 698
CIRCADIAN RHYTHMS AND THEIR DISORDERS 698
EXCESSIVE SLEEPINESS AND HYPERSOMNIA 698
NARCOLEPSY AND NARCOLEPSY-LIKE SYMPTOMS 701
SNORING, SLEEP-DISORDERED BREATHING, AND SLEEP APNEA SYNDROME 702
A Syndrome or a Disease? 702
Prevalence of Sleep Apnea 702
Role of Obesity as a Risk Factor for Snoring and Sleep Apnea 705
Other Risk Factors for Snoring and Sleep Apnea 705
Snoring and Sleep Apnea in Children 705
Sleep Apnea among Elderly People 705
Arterial Hypertension and Snoring 705
Snoring, Sleep Apnea, and Heart Disease 705
Snoring, Sleep Apnea, and Brain Infarction 706
Snoring and Sudden Death 706
Snoring and Dementia 706
Evolution of Obstructive Sleep Apnea Syndrome 706
RESTLESS LEGS SYNDROME 708
REM SLEEP BEHAVIOR DISORDER 708
PARASOMNIAS 708
REFERENCES 709
62 Sleep Medicine, Public Policy, and Public Health 716
Abstract 716
SLEEP IN MODERN SOCIETY 716
THE CHALLENGE 717
KEY AREAS FOR EDUCATION AND AWARENESS 717
Cardiovascular Disease 717
Metabolism, Obesity, and Diabetes 718
Transportation Safety 718
Relieving Sleepiness with Naps: Aviation as a Case Study 720
Health Care Workers 720
Hazardous Workplaces 721
Adolescents and Young Adults 721
MAKING SLEEP A MATTER OF PUBLIC HEALTH AND PUBLIC POLICY 721
CONCLUSION 722
REFERENCES 723
63 Sleep Forensics 725
EVOLUTION OF LEGAL THOUGHT 725
General 725
Sleep 725
EVOLUTION OF CONSCIOUSNESS THOUGHT 726
Waking Consciousness 726
Dreaming Consciousness 727
COMPLEX BEHAVIOR ARISING FROM SLEEP 728
Consciousness as a Continuum 728
Fixed Action Patterns and Central Pattern Generators: A Neuroethologic Approach to Behavior 729
THE DEVELOPMENT OF SLEEP FORENSICS 730
CLINICAL GUIDELINES TO ASSIST IN DETERMINING PURPORTED VIOLENCE ARISING FROM SLEEP 730
THE ROLE OF THE SLEEP MEDICINE SPECIALIST 731
Expert Witness Qualifications 731
Guidelines for Expert Testimony 731
CONCLUSION 731
REFERENCES 732
9 Occupational Sleep Medicine 734
64 Introduction 734
Abstract 734
FATIGUE AS A FUNCTION OF SLEEP–WAKE HISTORY, CIRCADIAN RHYTHM, AND WORK LOAD 734
MANAGING SLEEP AND CIRCADIAN RHYTHM–RELATED FATIGUE RISK 735
DROWSY DRIVING 735
MONITORING SLEEP AND WORKPLACE PERFORMANCE 736
SHIFT WORK, SHIFT-WORK SLEEP DISORDER, AND JET LAG 736
POLICE, FIRST RESPONDERS, AND THE MILITARY 736
PHARMACOLOGIC MANAGEMENT OF SLEEP AND FATIGUE 736
SLEEP, STRESS, AND BURNOUT 736
THE SCIENCE AND ART OF OCCUPATIONAL SLEEP MEDICINE 737
REFERENCES 737
65 Performance Deficits during Sleep Loss: 738
Abstract 738
THE NATURE OF SLEEPINESS-INDUCED PERFORMANCE DEFICITS 738
FUNCTIONAL BRAIN IMAGING STUDIES OF SLEEPINESS AND PERFORMANCE 739
INFLUENCE OF THE CIRCADIAN RHYTHM OF ALERTNESS ON PERFORMANCE 740
TIME ON TASK (FATIGUE) EFFECTS 740
THE NONSPECIFICITY OF SLEEP LOSS–INDUCED PERFORMANCE DEFICITS 742
PERFORMANCE PREDICTION MODELING 742
CONCLUSION 743
Disclaimer 743
REFERENCES 743
66 Fatigue and Performance Modeling 745
Abstract 745
COMPONENTS OF A FATIGUE MODEL 745
Circadian Oscillators 745
Sleep–Wake Homeostatic Regulation 746
Sleep Inertia 746
MODULATION OF PERFORMANCE 746
RECUPERATION DURING SLEEP 746
SLEEP ESTIMATION 748
ADAPTATION OF CIRCADIAN PHASE 748
PREDICTING PERFORMANCE 748
FATIGUE MODELING APPLIED TO OPERATIONAL SETTINGS 749
LIMITATIONS AND ENHANCEMENTS OF FATIGUE MODELS 750
REFERENCES 751
67 Fatigue, Performance, Errors, and Accidents 753
Abstract 753
SLEEP, CIRCADIAN, AND TIME-ON-TASK FACTORS MODULATING RISK OF ERRORS AND ACCIDENTS 753
FATIGUE, PERFORMANCE IMPAIRMENT, AND WAKE- STATE INSTABILITY 754
PREDICTING ACCIDENTS 755
MODELING SLEEP–WAKE–WORK AND ACCIDENT RISK 756
CONCLUSION 758
REFERENCES 758
68 Fatigue Risk Management 760
Abstract 760
A THEORETICAL FRAMEWORK 760
DYNAMICS OF SLEEP LOSS AND RECOVERY 761
Effects of Total Sleep Deprivation and Sleep Restriction 761
Influence of Task Type 762
Individual Differences in Sensitivity to Sleep Loss 762
Restorative Value of Sleep 762
Role of the Circadian Pacemaker 763
MANAGING FATIGUE RISK 763
Safety Management Systems 764
The Role of Regulation 764
CHALLENGES 765
Scientific Knowledge Gaps 765
Knowledge Transfer 765
Changing Roles and Competing Interests 765
Cost 766
Evaluation 766
CONCLUSIONS 766
Acknowledgement 766
REFERENCES 766
69 Drowsy Driving 769
Abstract 769
PREVALENCE AND ASSOCIATED RISKS 769
Rest/Activity Patterns 769
Sleep Disorders 770
Drugs 771
EVALUATION OF RISK IN PATIENTS WITH SLEEPINESS WHILE DRIVING 771
IMPACT OF TREATMENT AND COUNTERMEASURES ON ACCIDENT RISK 771
DRIVING LICENSE REGULATIONS 771
FUTURE CONSIDERATIONS 772
REFERENCES 773
70 Sleep and Performance Monitoring in the Workplace: 775
Abstract 775
SLEEP, CIRCADIAN RHYTHM, WORKLOAD, AND OPERATIONAL PERFORMANCE 775
Sleep and Sleep Loss 775
Circadian Rhythm 776
Workload and Operational Environment 776
TECHNIQUES FOR MEASURING SLEEP AND PERFORMANCE IN THE OPERATIONAL ENVIRONMENT 777
Historical Perspective 777
Measuring Sleep 777
Performance and Total Sleep Time in 24 Hours 777
Performance and Napping 777
Added, Simulator-Derived, and Embedded Performance Metrics 777
A REVIEW OF FIELD SLEEP AND PERFORMANCE STUDIES 778
METHODOLOGICAL FACTORS IN FIELD STUDIES OF SLEEP AND PERFORMANCE 778
Studies in Military Field Training Exercises 778
Studies of Physicians in Training 778
Effect of Sleep on Task Performance 779
Effect of Sleep on Cognitive Performance 779
A Series of Field Studies in Other Industries 779
Driving Home after the Night Shift 780
More Studies in Train Drivers 780
USEFULNESS OF FIELD STUDIES OF SLEEP AND PERFORMANCE 781
SLEEP AND PERFORMANCE STUDIES AND THE MANAGEMENT OF FATIGUE-ASSOCIATED RISK OF ERROR, INCIDENT, AND ACCIDENT 781
THE FUTURE OF SLEEP AND PERFORMANCE MONITORING IN THE WORKPLACE 781
REFERENCES 781
71 Shift Work, Shift-Work Disorder, and Jet Lag 784
Abstract 784
SHIFT WORK 784
Prevalence 784
Types 784
Night-Shift Workers 784
Early Morning-Shift Workers 785
Evening/Afternoon-Shift Workers 785
Rotating-Shift Workers 785
Circadian Misalignment and Effects of Light Exposure 785
Morbidity Associated with Shift Work 786
Sleepiness and Insomnia 786
Reduced Alertness and Accidents 786
Work Productivity and Quality of Life 786
Health Effects of Shift Work 787
SHIFT-WORK DISORDER 787
Prevalence 787
Morbidity 788
Clinical Evaluation 788
Treatment 789
Circadian Interventions 789
Improving Diurnal (and Nocturnal) Sleep 790
Pharmacologically Enhancing Alertness 791
Enhancing Alertness with Combined Treatments 791
Management Guidelines for Shift-Work Sleep Disorder 791
JET LAG 791
Treatment 792
Promoting Sleep during Flight and in the New Time Zone 793
Promoting Wakefulness during Flight in the New Time Zone 793
Circadian Adaptation 793
Partial Preflight Circadian Adaptation 793
CONCLUSIONS 794
Acknowledgments 795
REFERENCES 795
72 Sleep Problems in First Responders and the Military 799
Abstract 799
PREVALENCE OF SLEEP LOSS, MORTALITY, AND MORBIDITY 799
IMPLICATIONS FOR OTHER FIRST RESPONDERS AND THE MILITARY 800
Performance Challenges and Sleep Loss 800
Decision-Making 802
SYSTEMATICALLY MANAGING, PREVENTING, AND TREATING SLEEP-DEPRIVED POLICE 802
Shift Work: Interaction between the Organization and the Individual 802
Shift Work: The Individual 804
Shift Work: The Organization 804
Exemplary Unified Approach 806
REFERENCES 807
73 Pharmacologic Management of Performance Deficits Resulting from Sleep Loss and Circadian Desynchrony 809
Abstract 809
PHARMACOLOGIC STRATEGIES FOR IMPROVING COGNITIVE PERFORMANCE 810
Caffeine 810
Modafinil 810
Dextroamphetamine 811
Summary and Future Directions 811
PHARMACOLOGIC STRATEGIES FOR IMPROVING SLEEP 811
Prescription Sleep-Inducing Agents 811
Melatonin 812
Summary and Future Directions 812
CONCLUSION 812
Disclaimer 812
REFERENCES 812
74 Sleep, Stress, and Burnout 814
Abstract 814
THE CROSS-SECTIONAL CONNECTION BETWEEN STRESS AND SLEEP 814
THE PROSPECTIVE CONNECTION BETWEEN STRESS AND SLEEP 815
RUMINATION AND ANTICIPATION 816
POSTTRAUMATIC STRESS 816
SLEEP PHYSIOLOGY THAT SEEMS TO LINK SLEEP WITH STRESS 816
SIMILARITY OF MORBIDITY DUE TO STRESS AND SLEEP LOSS 817
BURNOUT AND SLEEP 817
MEASURING STRESS 818
CONCLUSION 818
REFERENCES 818
10 Insomnia 822
75 Insomnia: 822
EPIDEMIOLOGY 822
DIAGNOSIS AND ASSESSMENT 822
PATHOPHYSIOLOGY AND BIOLOGICAL FINDINGS 823
TREATMENT 824
Behavioral Treatment 824
Pharmacologic Treatment 824
DEVELOPMENT OF TREATMENT GUIDELINES 825
FUTURE DIRECTIONS 825
Acknowledgments 825
REFERENCES 825
76 Insomnia: 827
Abstract 827
EPIDEMIOLOGY 827
Definition of Insomnia 827
Evaluation 828
Prevalence 828
Comorbidities 829
Demographics 830
Aging 830
Gender 831
Ethnicity 832
Education and Socioeconomic Status 832
RISK FACTORS 833
Static Risk Factors for Insomnia 833
Gender 833
Age 833
Ethnicity 833
Genetics 833
Modifiable Risk Factors for Insomnia 833
Hyperarousal 833
Stress and Life Events 834
Transient Insomnia 834
Medical Comorbidities 834
Psychological Comorbidities 834
Hypotheses for How Risk Factors Result in Chronic Insomnia 834
Insomnia as a Risk Factor 834
Evidence 834
Hypotheses for Why Insomnia Is a Risk for Other Disorders 835
CONCLUSIONS 835
REFERENCES 835
77 Insomnia: 838
Abstract 838
DIAGNOSING INSOMNIA 838
CLINICAL ASSESSMENT 838
Theoretical Guide 841
Developmental, Social, and Cultural Context 842
Clinical Interview 842
Focusing on the Night 842
Sleep History 842
Current Sleep 842
Questionnaire Measures 843
Sleep Diary 843
Focusing on the Day 844
Comorbid Disorders 844
Comorbid Psychiatric Disorders 844
Comorbid Sleep Disorders 845
Comorbid Medical Disorders 845
Perpetuating Factors 846
Testing 846
Polysomnography 846
Actigraphy 846
TREATMENT OUTCOME 847
SUMMARY 847
REFERENCES 847
78 Models of Insomnia 850
THE DEFINITION OF INSOMNIA 850
THE STIMULUS CONTROL MODEL 850
Basic Description 850
Strengths and Weaknesses 850
Implications for Current and Future Research and Therapeutics 851
THE 3P MODEL 851
Basic Description 851
Strengths and Weaknesses 852
Implications for Current and Future Research and Therapeutics 852
THE NEUROCOGNITIVE MODEL 853
Basic Description 853
Strengths and Weaknesses 854
Strengths 854
Weaknesses 855
Implications for Current and Future Research and Therapeutics 855
THE PSYCHOBIOLOGICAL INHIBITION MODEL 855
Basic Description 855
Psychobiological Framework for Normal Sleep 856
Insomnia as the Failure to Inhibit Wakefulness 856
Cognitive Factors Trigger the Failure to Inhibit Wakefulness 856
Strengths and Weaknesses 856
Strengths 856
Limitations 857
Implications for Current and Future Research and Therapeutics 857
THE DROSOPHILA MODEL 858
Basic Description 858
Strengths and Weaknesses 859
Implications for Current and Future Research and Therapeutics 860
THE CAGE EXCHANGE MODEL OF ACUTE INSOMNIA 860
Basic Description 860
Strengths and Weaknesses 861
Implications for Current and Future Research and Therapeutics 862
CONCLUSION 862
Acknowledgement 863
REFERENCES 863
79 Psychological and Behavioral Treatments for Insomnia I: 866
Abstract 866
CURRENT TREATMENT PRACTICES 866
TREATMENTS 866
Rationale and Indications 866
Sleep Restriction 867
Stimulus Control Therapy 867
Relaxation-Based Interventions 868
Cognitive Therapy 868
Sleep Hygiene Education 869
Multifaceted Cognitive Behavior Therapy 869
Complementary and Alternative Therapies 869
TREATMENT OUTCOME EVIDENCE 869
Evidence for Efficacy 869
Generalizability of Treatment Effects to Comorbid Insomnia 870
Treatment of Insomnia in Older Adults 879
Initial Treatment Response versus Long-Term Outcome 879
Clinical Significance 880
Comparative Efficacy of Single Therapies 880
Treatment Specificity and Mechanisms of Changes 880
Combined Cognitive Behavior Therapy and Medication 880
Efficacy versus Effectiveness 881
Clinical and Practical Considerations 881
SUMMARY AND CONCLUSION 881
Acknowledgment 882
REFERENCES 882
80 Psychological and Behavioral Treatments for Insomnia II: 884
Abstract 884
INTERVENTION TOOLS 884
Sleep Diaries 884
Actigraphy 884
Written Behavioral Prescriptions and Instruments for Home Use 885
Sleep Restriction 886
Stimulus Control 888
Sleep Hygiene 888
Sleep Education 889
Additional Educational Resources 889
Cognitive Therapy Tools 889
Structured Problem-Solving 889
Thought Records 889
METHODS OF DELIVERING TREATMENT 890
Individualized Treatment 890
Group Treatment Protocols 890
Delivery by Nontraditional Providers 892
Delivering Treatment Outside of the Office 892
Summary 893
TREATMENT DOSING 893
TREATMENT ACCEPTABILITY AND ADHERENCE ISSUES 894
Treatment Acceptability 895
Treatment Adherence 895
APPLICATIONS TO PATIENTS WITH COMORBID PSYCHIATRIC CONDITIONS 896
APPLICATIONS TO PATIENTS WITH COMORBID MEDICAL CONDITIONS 897
The Impact of Disease-Specific Symptoms on Insomnia 897
Addressing Pain and Fatigue with Psychological and Behavioral Strategies 898
Increasing Activities 898
Scheduling Short Naps 898
Other Considerations for Patients with Chronic Pain 898
Cognitive Issues in Insomnia Related to Medical Treatment 898
Excessive Concern about Sleep 898
Unhelpful Sleep-Related Beliefs 898
Alterations in Standard Behavioral Instructions 899
Addressing Psychological Reactions to the Comorbid Medical Disease 899
USE WITH YOUNGER AND OLDER ADULTS 899
Young Children 899
Adolescents 899
Older Adults 900
SUMMARY AND CONCLUSIONS 900
REFERENCES 900
81 Pharmacologic Treatment of Insomnia: 905
Abstract 905
EFFICACY AND EFFECTIVENESS 905
Primary Insomnia 906
Comorbid Insomnia 907
Effectiveness Studies 908
Impact on Daytime Symptoms of Insomnia and Comorbid Conditions 909
SAFETY 910
Residual Effects 910
Amnestic Effects 910
Discontinuation Effects 910
Abuse Potential 911
Falls, Cognitive Effects, and Other Considerations for Older Adults 911
Complex Behavior in Sleep 912
Mortality 912
CONSIDERATIONS FOR PHARMACOTHERAPY 912
CONCLUSION 913
REFERENCES 913
82 Pharmacologic Treatment: 916
Abstract 916
MELATONIN AND MELATONIN RECEPTOR AGONISTS 916
Melatonin 916
Overview 916
Index 1697
A 1697
B 1700
C 1700
D 1703
E 1705
F 1706
G 1707
H 1708
I 1709
J 1711
K 1711
L 1711
M 1711
N 1713
O 1714
P 1715
Q 1717
R 1717
S 1719
T 1721
U 1722
V 1722
W 1723
Y 1723
Z 1723
Kryger’s Atlas of Clinical Sleep Medicine: e1
Cardiac Rhythm Abnormalities e1
Neurologic Diseases e1
Movement Disorders e4
Seizure e4
Artifacts in Sleep Recordings e7
New Web-Only Sections e8
Sleep Staging e9
Rapid Review of Polysomnographs e9