It was a dark and stormy night in Claire's mind. She felt very anxious about sleeping away from home.  

Her doctor had referred her to the sleep lab for obstructive sleep apnea testing. She complained of disturbed and restless sleep, and Claire's husband told her that she occasionally snored. Although the sleep lab bedroom appeared homey, the looming camera and male technologist made her feel uncomfortable. 

Pete, the sleep technologist, had two patients to hook up that shift. Claire was so jumpy that he had to reapply several of her electrodes. Later that night, when he noticed continued artifact in the EEG, he entered the bedroom with a flashlight and bent over Claire to try to fix the problem electrodes. In an instant, she awoke with a scream, her heart racing and arms flailing.  

Pete received a nasty scratch on his face and felt confused about what had occurred. Claire never returned to sleep that night and refused attempts to repeat the sleep study.  

Pete discussed the incident with his manager, and they reviewed department policies to ensure that a complete patient history would be available in the future. This way they could be better prepared if a patient has a history suggestive of a panic disorder or post-traumatic stress disorder (PTSD).  

Psychiatric disorders are common in sleep disorder patients, and disturbed sleep often afflicts patients with psychiatric disorders. A study of 8,000 people from around the country found that 40 percent of those with insomnia and 46.5 percent of those with hypersomnia met the criteria for mental illness.¹  

A sleep lab's employees should be trained and prepared to handle these patients' special needs. For example, staffing ratios may need to be adjusted so that a patient has a technologist's undivided attention. Also, the staff must recognize the likely effects of the disorders on sleep architecture and the medications used to treat them.  

Bipolar Disorder and Depression
Mood disorders and anxiety disorders, such as bipolar disorder, depression, panic disorder and PTSD, are some of the psychiatric conditions that sleep professionals need to be aware of.

Bipolar disorder is characterized by alternating phases of mania and depression. The phases may alternate within the same day or be months apart and aren't necessarily equal in length.

During the manic phase, people display expansive or irritable mood and reduced sleep. This often is perceived as a reduced need for sleep. There also may be substance abuse or excessive behavior, such as shopping sprees. In the depressed phase, hypersomnia is more common. Bipolar disorder affects more than 2 million Americans annually, with equal prevalence for men and women.²

The lifetime prevalence of depression is greater, at 5 percent to 12 percent for men and 10 percent to 25 percent for women.³ In one study, 66 percent of the patients presenting to a sleep disorders center reported one episode of major depression in the previous five years, while 26 percent described themselves as depressed on presentation.⁴

Depression is marked by a nearly constant depressed mood, which may be manifested as irritability in children and adolescents. Other symptoms include diminished interest or pleasure in activities and significant loss or gain in appetite and weight.

The depressed individual may complain of almost daily insomnia or hypersomnia, and fatigue or loss of energy. Insomnia may be experienced as sleep onset difficulty, increased awakenings and/or early morning awakenings. Patients may report less "deep" sleep and disturbed dreams.

Objective polysomnographic sleep findings confirm sleep continuity disturbances, seen as prolonged sleep latency, increased wake time and early morning awakening. NREM sleep may show decreased Stages 3 and 4, which may be displaced to later in the night.

Many with untreated depression show a shortened time from sleep onset to REM sleep (REM latency). While this is characteristic of depression, it's not diagnostic. Other factors, such as untreated OSA, narcolepsy or other psychiatric disorders, can produce an abnormally short REM latency.

The changes in architecture, particularly in REM sleep, become more pronounced with age. Measures of REM latency decrease with time, and elderly depressed patients may have REM sleep onset of less than 10 minutes.⁵ This is a far cry from the 90-minute to 120-minute REM latency that's often taught as the normal range. The scoring technologist may misinterpret these results as an indication of narcolepsy, circadian rhythm disorders and withdrawal of REM-suppressing medications, among other things.

The effective treatment of depression also affects sleep and sleep architecture. Sleep improves with recovery from depression, irrespective of the type of treatment.

However, most effective anti-depressants decrease REM sleep, and the sleep technologist must recognize some of the other side effects of anti-depressant medications. Some may produce a "hangover effect," resulting in complaints of excessive daytime sleepiness and/or difficulty awakening. Fluoxetine (Prozac^®, Eli Lilly and Co.) may result in NREM rapid eye movements. Tricyclics and selective serotonin reuptake inhibitors may precipitate or exacerbate restless legs syndrome or periodic limb movements in sleep.

In addition, at least half of the severe mental illness sufferers (including bipolar disorder) "self medicate" with drugs or alcohol, according to the Alcohol, Drug Abuse and Mental Health Administration. These other forms of "treatment" can disrupt sleep as well.

Most patients with insomnia complaints aren't referred to a sleep lab. Yet, polysomnography may have a role in the diagnosis and treatment of the psychiatric patient with insomnia.

It could reveal a concomitant diagnosis, such as depression in patients with anxiety disorder or dementia. Also, it may show a primary sleep disorder and can be used to evaluate the efficacy or side effects of medication.

Panic Disorder
Panic disorder is characterized by discrete periods (seconds to minutes) of intense fear associated with anxiety symptoms, such as shortness of breath, chest pains, sweating, tachycardia, shaking, dizziness and fear of dying.

There's a progressive pattern to panic disorder. First, people have unexpected, spontaneous panic attacks, followed by apprehension about future attacks. Secondary fears may develop.

Patients may present at various stages or levels of frequency and severity, with the average age of onset at 22 years old. Females are two times to three times more likely to experience panic attacks.

Sleep complaints of patients with panic disorder include insomnia and restless or fitful sleep. Panic attacks can arise directly from sleep. An estimated 18 percent of panic attacks occur during sleep hours, and 33 percent to 71 percent of panic disorder populations report sleep-related panic attacks.^6,7 Most patients report chronic intermittent sleep deprivation.

If a person has a panic attack while in the sleep lab, the recording should continue. The technologist must go immediately into the bedroom to ensure patient safety and to explain to the patient that he's in a safe environment. After the patient has returned to a less agitated state, the technologist should repair or replace any electrodes or sensors loosened or damaged and encourage the patient to return to sleep.

Polysomnographic data in panic disorder show surprisingly normal sleep parameters, but there are some with increased sleep latency and poor sleep continuity resulting in decreased sleep efficiency and total sleep time.

Most sleep-related panic attacks occur within three hours of sleep onset during the transition from Stage 2 to Stage 3. Most are short-lived, ending within two minutes to eight minutes, and they tend not to be associated with dreams.

Sleep laboratory evaluation may be indicated. Symptoms similar to those associated with sleep panic attacks could be reported by patients with arrhythmias, gastroesophageal reflux, sleep apnea, sleep terrors and REM behavior disorder.

Post-traumatic stress disorder
PTSD often is characterized by recurrent nightmares that replicate the traumatic event. Patients with PTSD often report sleep-onset and sleep-maintenance insomnia.

Polysomnographic findings may include excessive motor activity and increased awakenings with anxiety symptoms. Polysomnographic studies with male veterans have been contradictory, as some research shows decreased total sleep time and sleep efficiency. Researchers also have found that sleep-disordered breathing is common in this patient population.⁸

Sleep laboratory preparations are important for all patients with these psychiatric disorders but especially for patients with PTSD.

"They need to feel safe, and the study is much more successful from their perspective and ours if they are made to feel safe and comfortable in any way possible," said Cynthia Dorsey, PhD, clinical director of the Sleep Health Center and the Sleep Research Program, McLean Hospital, Boston.

"It's important that patients be informed ahead of time about what they will experience during a sleep study," she said. "Movements by the technologist should be slow and steady because often these patients have a heightened startle response and may dislike being touched."

If at all possible, a female technologist should be paired to work with female PTSD patients. And patients may be encouraged to bring with them things that make them feel safe and comfortable (a favorite pillow, etc.).

Generally, the technologist should be trained to have a greater sensitivity and awareness in terms of electrode and sensor application, how the room is entered, how the patient is awakened, and how to deal with a patient in distress.

When all of these concerns are met, patients will feel more at ease, and the lab will have a better chance at solving their sleep problems.

Malloy is the lead instructor at the Atlanta School of Sleep Medicine and Technology.

For a list of references, visit www.Respiratory-care-sleep-medicine.advanceweb.com/Editorial/Content/editorial.aspx?CC=21581.