Tag Archives: somatic

Sleep/Wake Disorders


Historically, sleep disorders have long been commonly recognized within the context of other psychopathological conditions, but they have been frequently minimized or otherwise ignored as distinct entities or stand-alone psychopathological situations.  Research supporting the current DSM-IV-TR classification system is extremely limited, despite the common sense approach (in my opinion) of grouping sleep disorders primarily on the basis of underlying constellation of symptoms.

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Primary insomnia is the hallmark diagnosis in this category.  It is “characterized by chronic difficulty initiating and/or maintaining sleep or persistent poor-quality sleep.”  (Blaney & Millon, 2009, p. 508)  Individually commonly suffer from mild anxiety, mood disturbances, concentration/memory dysfunction, somatic concerns, and general malaise… but these conditions are generally viewed as symptoms rather than causes.  Insomnia prevalence increases with age, in contrast with sleep onset difficulties are more common in young adults.  It has also been suggested that, generally speak, women are more susceptible than men.  Societal prevalence is between 1% and 2%.  (Blaney & Millon, 2009, p. 508)

I was intrigued by the statement that “the majority of insomnia sufferers tend to overestimate the time it takes them to fall asleep and to underestimate the time they actually sleep to some degree.”  (Blaney & Millon, 2009, p. 510)  This might give some basis to a cognitive-behavioral approach if we can reset those expectations.  A stated by the text, the main problem is that most clinicians don’t have access to the raw data to confirm or refute this subjective complaint.  My question… is it out of the realm of possibility for us to send a client home with a measurement device so we can accumulate that data?

Narcolepsy is characterized by recurrent, irresistible day time sleep episodes.  The “classic tetrad” indicative of narcolepsy includes excessive daytime sleepiness and unintended sleep episodes during situations where most persons could stay awake, abrupt and reversible decrease or loss of muscle tome (without loss of consciousness, also known as cataplexy), and/or awakening from nocturnal or diurnal sleep with an inability to move (sleep paralysis), and finally vivid images and dreams that are evoked just as sleep develops (hypnagogic hallucinations).  (Blaney & Millon, 2009, p. 510)  Narcolepsy generally first appears during adolescence or young adulthood, and is believed to be genetically predisposed.   Life events may precipitate the onsite of this disorder… although it is not clear to me whether they are causes or effects?

Breathing related sleep disorders encompass what is widely known as sleep apnea.  This condition manifests as loud snorting, pauses in breathing, gasping for breath during sleep, headaches on wake, and automatic behaviors during wakefulness or excessive daytime sleepiness.  The headaches on waking part turned my head because I get that all the time… although I haven’t really noticed any other signs or symptoms.  Odd…

Circadian Rhythm Sleep Disorders (CRSDs) represent a mismatch between natural sleep/wake rhythms and the schedule imposed by occupational or social demands.  (Blaney & Millon, 2009, p. 512)  Individuals typically report insomnia at certain times of the day (generally when they want to be sleeping) and excessive sleepiness at other times (generally when they should be awake).

Parasomnias encompass nightmares, night terrors, and sleepwalking.  Nightmare disorder is characterized by repeated awakenings by disturbing dreams.  Sleepwalking and Night Terrors both occur early in the sleep period and appear to represent incomplete arousals from the deepest states of sleep (states 3-4), known as slow wave sleep (SWS).  All of the above are more prevalent in children when compared with adults, and more common in males than in females. (I honestly would have expected it to be more common in females?)

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Reference

Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Differential Diagnosis – Delusional Disorders vs Schizophrenic Disorders


Schizophrenia is characterized by two or more of the following: Bizarre delusions, hallucinations (auditory or visual), disorganized speech, grossly disorganized or catatonic behavior, and/or negative symptoms like blunted affect (affective flattening) or a general lack of desire, drive, or motivation to pursue meaningful goals (avolition).  Subtypes include paranoid, disorganized, catatonic, undifferentiated, or residual types.  Compared with Delusional Disorder (DD), social and occupational dysfunction is clinically significant.  There must be continuous signs of the disturbance that persist for at least 6 months, including at least 1 month of bizarre delusions.  On the whole, schizophrenia is marked by delusions that are “not plausible,” where DD is characterized by delusions that are conceivably possible, even if unlikely.

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The essential feature of Delusional Disorder (DD) is the presence of one or more “nonbizarre” delusions that persist for at least 1 month, and which have never escalated to a constellation of symptoms that typify Schizophrenia.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 323)  Subtypes include ertomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified types.  DD can be distinguished from Schizophrenia by the absence active phase schizophrenia symptoms.  This would include prominent auditory or visual hallucinations, bizarre delusions, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 327)  In short, DD is comparatively mild in its symptoms when compared with schizophrenia.

In short, the primary differentiating factor between schizophrenia and DD is the word bizarre.  If the delusion is plausible, even if improbable, then the diagnosis is DD.  If the delusion is outlandish, or impossible, then the diagnosis is schizophrenia.  “If delusions are judged to be bizarre, only this single symptom is needed to satisfy Criterion A for Schizophrenia.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 299)

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Reference

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.