Sleep in Schizophrenia

doi:10.1016/j.jsmc.2008.01.001

Sleep Medicine Clinics

Volume 3, Issue 2, June 2008, Pages 251-260

https://doi.org/10.1016/j.jsmc.2008.01.001 Get rights and content

Polysomnographic studies reveal sleep abnormalities or dyssomnias that are consistently characteristic of patients with schizophrenia. This article describes many of these dyssomnias and discusses their significance. It also discusses the relationship of these dyssomnias to some of the clinical and neuropathologic features of schizophrenia. Finally, it presents an overview of antipsychotic treatments; their effects on sleep; and their potential to facilitate or augment clinical sleep disorders, such as sleep-disordered breathing and restless legs syndrome.

Section snippets

Schizophrenia: a brief overview

Schizophrenia has been variously described as psychoticism, a gross impairment of reality testing, or a fundamental cognitive dysfunction known as “formal thought disorder.” Currently, the defining features and diagnostic criteria are best defined in the American Psychiatric Association's [5]Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The defining features include a mixture of both positive and negative symptoms. Positive symptoms reflect “an excess or distortion of

Subjective assessment

Although it is a common clinical experience that major depression and primary insomnia are associated with disturbed sleep, patients with schizophrenia describe the subjective quality of their sleep in very similar terms [6]. Their subjective assessment of poor sleep quality is predictive of self-assessed poor quality of life and impaired coping skills [7], [8]. Self-assessed poor sleep quality includes subjective reports bearing on measures of sleep maintenance (ie, loss of total sleep time

Clinical correlates

The relationship of the dyssomnias of schizophrenia to clinical symptoms, neurocognitive impairment, and prognosis has been extensively studied. Although some studies investigated global assessments of symptom severity, others examined the components of symptom severity, such as positive or negative symptoms and cognitive dysfunction.

Studies have documented a positive correlation between global symptom severity and increased waking, reduced REM sleep time, SWS deficits, and short REML [32], [33]

First- and second-generation antipsychotics: an overview

Most patients diagnosed with schizophrenia are exposed to AP medications. APs have signature effects on neurotransmitter receptors (eg, DA, 5-HT, α-adrenergic, cholinergic, and histaminic receptors) and their numerous subtypes; these unique receptor-binding profiles are associated with their therapeutic efficacy and a wide range of potentially adverse effects.

The first-generation AP medications are known as “traditional” or “typical” APs. Generally speaking, the typical APs have a strong

Summary

Patients diagnosed with schizophrenia may be comorbid for dyssomnias either induced by or exacerbated by their treatment with AP agents. These dyssomnias include somnambulism, sleep-related eating disorders, sleep-related breathing disorders, and sleep-related movement disorders. Every effort should be made to treat comorbid sleep disorders vigorously in patients with schizophrenia. A favorable prognosis or positive clinical outcome may require some normalization of sleep and its restorative

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Sleep problems and attenuated psychotic symptoms in youth at clinical high-risk for psychosis
2019, Psychiatry Research
There has been growing interest on the effect of sleep problems on psychotic and prodromal symptoms. The current study investigated cross-sectional relations between sleep problems and attenuated psychotic symptoms in a large sample of 740 youth at Clinical High Risk (CHR) for psychosis in an attempt to replicate previous findings and assess whether findings from general population samples and psychotic samples extend to this CHR sample. Sleep problems were found to be significantly positively associated with attenuated psychotic symptom severity. Sleep problems were also found to be more closely associated with certain specific prodromal symptoms (e.g., suspiciousness and perceptual abnormalities) than other attenuated psychotic symptoms. Further, we found that depression mediated the cross-sectional association between sleep problems and paranoid symptoms only. This adds to a growing body of evidence suggesting the mediation role of depression is more pronounced for paranoid-type psychotic symptoms as compared to other psychotic symptoms (e.g., hallucinations).
Sleep quality, psychological symptoms, and psychotic-like experiences
2018, Journal of Psychiatric Research
Citation Excerpt :
Poor sleep quality has been repeatedly linked to the entire psychosis continuum: in individuals with schizophrenia (Cohrs, 2008), in those at clinical high risk for developing psychotic disorders (Lunsford-Avery et al., 2013), and in individuals experiencing psychotic-like experiences (PLEs; subthreshold, attenuated versions of psychotic symptoms; Andorko et al., 2017; Lee et al., 2012; Oh et al., 2016). Sleep disturbances occur in 30–80% of people with schizophrenia, have been strongly associated with increases in both positive and negative symptom severity (Cohrs, 2008), and often precede relapse of psychotic episodes (Benson, 2008). People with schizophrenia demonstrate impairments in quality, continuity, efficacy, and duration of sleep, above and beyond the effects of medications (Chouinard et al., 2004).
Poor sleep quality has been repeatedly linked to the entire psychosis continuum, including psychotic-like experiences (PLEs); however, sleep dysfunction is a component of several other psychopathologies that have also been linked to increased risk for PLEs, including depression, anxiety, and post-traumatic stress disorder (PTSD). It has yet to be examined if PLEs are a significant risk factor for poor sleep quality or if this sleep dysfunction is better accounted for by comorbid psychopathology. In 2687 undergraduates, PLEs were evaluated using the positive items of the Prodromal Questionnaire. Symptoms of anxiety, depression, and PTSD were also assessed, as was sleep quality. Mediation analysis using PROCESS was conducted to determine if poor sleep quality associated with PLEs was in fact more associated with symptoms of other psychopathologies. Symptoms of depression and PTSD mediated the relationship between PLEs and sleep quality, though anxiety symptoms did not. These findings suggest that treating symptoms of depression and PTSD may improve multiple domains of psychotic illness.
Childhood trauma, depression, and sleep quality and their association with psychotic symptoms and suicidality in schizophrenia
2017, Psychiatry Research
Citation Excerpt :
Several polysomnographic abnormalities have been identified: sleep continuity disturbance, poor sleep efficiency, slow-wave sleep deficits, and short rapid eye movement (REM) sleep latencies (Wulff et al., 2012; Keshavan et al., 1998; Tandon et al., 1992; Wirz-Justice et al., 2001; Benson, 2008). In psychiatric disorders, not only is there a relationship between sleep disturbances and impaired function, problems with sleep also appear to affect the course of the disorder (Krystal et al., 2008).
This study involved the examination of the relationship between childhood trauma and both psychotic symptoms and suicidality in patients with schizophrenia after controlling for the possible confounding factors, such as clinical features, depression, and sleep quality. The Childhood Trauma Questionnaire-Short Form, Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), Pittsburgh Sleep Quality Index (PSQI), and the suicidality subscale of Mini-International Neuropsychiatric Interview (MINI) were administered to 199 patients with schizophrenia. We used sequential multiple stepwise regression analyses in which positive symptoms, negative symptoms, overall psychopathology, total symptoms of schizophrenia, and suicidality were dependent variables.
Depressive symptomatology and childhood physical abuse significantly contributed to positive, negative, general psychopathology, and global schizophrenia symptomatology. Interestingly, general psychopathology scores were negatively associated with childhood physical neglect. Also, subjective sleep quality significantly contributed to positive schizophrenia symptoms. Although prior suicide attempts and depression were significant antecedents of suicidal ideation, no association between suicidality and both childhood trauma and sleep was found. Childhood physical abuse could have an impact on psychopathology in schizophrenia. In addition to childhood trauma, depression, sleep disturbances, and clinical features should be considered and inquired about in the course of clinical care of schizophrenia patients.
Sleep disorders in schizophrenia: A review
2017, Psiquiatria Biologica
La esquizofrenia se acompaña hasta en un 80% de los pacientes de trastornos del sueño, que son normalmente infradiagnosticados e infratratados debido a su falta de consideración en el manejo de esta enfermedad. Los principales trastornos son el insomnio, el síndrome de piernas inquietas, el síndrome de apnea obstructiva del sueño, la hipersomnia, las parasomnias y los trastornos del ritmo circadiano. Destaca en su importancia el insomnio, ya que puede ser un signo prodrómico de la enfermedad, así como un signo de alarma temprano de una descompensación psicótica incipiente. En pacientes con esquizofrenia se han encontrado alteraciones polisomnográficas en la arquitectura del sueño que se correlacionan tanto con la clínica subjetiva de insomnio como con las manifestaciones clínicas predominantes de la esquizofrenia.
Los antipsicóticos pueden alterar la estructura del sueño, pero también tienen un papel importante en el tratamiento de las alteraciones del sueño en la esquizofrenia. Han demostrado una mejoría clínica del insomnio y la corrección polisomnográfica de las alteraciones de la arquitectura del sueño, mejorando la calidad de vida y la capacidad funcional de los pacientes. Sin embargo, pueden también exacerbar otros trastornos comórbidos del sueño, como el síndrome de piernas inquietas o el síndrome de apnea obstructiva del sueño, o provocar hipersomnia u obesidad.
Existe evidencia de que los trastornos del sueño en esquizofrenia afectan de forma relevante la calidad de vida y de que influyen en la sintomatología de los pacientes con esquizofrenia, por lo que es muy importante reconocerlos y tratarlos de forma adecuada.
Up to 80% of patients with schizophrenia suffer from sleep disorders, and are usually under-diagnosed and under-treated due to a lack of being taken into account in the management of this illness. The main disorders are insomnia, restless legs syndrome, obstructive sleep apnoea syndrome, hypersomnia, the parasomnias, and circadian rhythm disorders. The importance of insomnia is highlighted, as it can be a prodromic sign of the illness, as well as an early alarm sign of an incipient psychotic decompensation. Polysomnographic changes that correlate with subjective clinical insomnia and with the predominant clinical manifestations of schizophrenia.
Antipsychotic drugs can alter the structure of sleep, but they also have an important role in the treatment of sleep alterations in schizophrenia. They have demonstrated a clinical improvement of the insomnia and the polysomnographic correction of the changes in sleep architecture, with an improvement in the quality of life and functional capacity of the patients. However, they can also exacerbate other comorbid sleep disorders such as restless legs syndrome and obstructive sleep apnoea syndrome, or trigger hypersomnia or obesity.
There is evidence that sleep disorders in schizophrenia has a significant effect on the quality of life and has an influence on the symptoms of patients with schizophrenia, thus it is very important to recognise them and treat them accordingly.
The role of sleep dysfunction in the occurrence of delusions and hallucinations: A systematic review
2015, Clinical Psychology Review
Sleep dysfunction is extremely common in patients with schizophrenia. Recent research indicates that sleep dysfunction may contribute to psychotic experiences such as delusions and hallucinations.
The review aims to evaluate the evidence for a relationship between sleep dysfunction and individual psychotic experiences, make links between the theoretical understanding of each, and highlight areas for future research.
A systematic search was conducted to identify studies investigating sleep and psychotic experiences across clinical and non-clinical populations.
66 papers were identified. This literature robustly supports the co-occurrence of sleep dysfunction and psychotic experiences, particularly insomnia with paranoia. Sleep dysfunction predicting subsequent psychotic experiences receives support from epidemiological surveys, research on the transition to psychosis, and relapse studies. There is also evidence that reducing sleep elicits psychotic experiences in non-clinical individuals, and that improving sleep in individuals with psychosis may lessen psychotic experiences. Anxiety and depression consistently arise as (partial) mediators of the sleep and psychosis relationship.
Studies are needed that: determine the types of sleep dysfunction linked to individual psychotic experiences; establish a causal connection between sleep and psychotic experiences; and assess treatments for sleep dysfunction in patients with non-affective psychotic disorders such as schizophrenia.
Actigraphic-measured sleep disturbance predicts increased positive symptoms in adolescents at ultra high-risk for psychosis: A longitudinal study
2015, Schizophrenia Research
Sleep disturbance is prevalent among patients with psychosis, yet little is known about sleep health during the ultra high-risk (UHR) period. This study used actigraphy to evaluate sleep in healthy control (HC) and UHR adolescents to examine the relationship between sleep disturbance and psychosis symptoms at baseline and 12-month follow-up, as well as comparisons between objective and subjective measurements of sleep functioning in UHR youth.
Thirty-six UHR and 31 HC youth participated in a baseline evaluation including 5 nights of actigraphy, subjective measurement of sleep health (Pittsburgh Sleep Quality Index; PSQI), and clinical interviews. Clinical measures were repeated with UHR youth (N = 23) at a 12-month follow-up.
The actigraphy data indicated that UHR youth displayed increased wake time after onset (WASO), increased movements during sleep, and decreased efficiency compared to HC, and several markers of sleep disturbance including decreased efficiency, increased WASO, number of awakenings, and increased movements were associated with symptomatology in the UHR group. Interestingly, there were associations between actigraph and self-report indices of sleep duration and efficiency (at the trend level) but not awakenings. Several objective measures of sleep disturbance and one self-reported measure (disrupted continuity) predicted the longitudinal course of symptoms over 12 months in the UHR group.
Taken together, the results suggest a potential role for sleep problems in the etiology of schizophrenia, and highlight sleep health as a possible target for prevention/intervention efforts. Additionally, actigraphy represents an inexpensive, sensitive measurement providing unique information not captured by self-report, and may be an informative adjunct to UHR assessments.

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Sleep in Schizophrenia

Section snippets

Schizophrenia: a brief overview

Subjective assessment

Clinical correlates

First- and second-generation antipsychotics: an overview

Summary

Psychiatry Res

Psychiatry Res

Psychiatry Res

Compr Psychiatry

Psychiatr Clin North Am

Schizophr Res

J Psychiatr Res

Neuropsychopharmacology

J Psychiatr Res

Biol Psychiatry

Biol Psychiatry

Psychiatry Res

Compr Psychiatry

Biol Psychiatry

Psychiatry Res

J Psychiatr Res

Schizophr Res

Biol Psychiatry

Schizophr Res

Schizophr Res

Biol Psychiatry

Psychiatry Res

J Psychiatr Res

Psychiatry Res

Psychiatry Res

J Psychiatr Res

Psychiatry Res

Biol Psychiatry

Biol Psychiatry

Psychiatry Res

J Psychiatr Res

Biol Psychiatry

Psychiatry Res

Biol Psychiatry

Psychiatry Res

Biol Psychiatry

Prog Neuropsychopharmacol Biol Psychiatry

Regularly occurring periods of eye motility, and concomitant phenomena, during sleep

Science

Dream recall and eye movements during sleep in schizophrenics and normals

J Nerv Ment Dis

Schizophrenia and physiological indices of dreaming

Arch Gen Psychiatry

Diagnostic and statistical manual of mental disorders

Perceived quality of life in schizophrenia: relationships to sleep quality

Qual Life Res

Quality of sleep in patients with schizophrenia is associated with quality of life and coping

BMC Psychiatry

Sleep disturbance in schizophrenia

Br J Psychiatry

Sleep and daily activity preferences in schizophrenia: associations with neurocognition and symptoms

J Nerv Ment Dis

Relapse in schizophrenia

Am J Psychiatry

Coping with symptoms of relapse in schizophrenia

Eur Arch Psychiatry Neurol Sci

CSF MHPG, sleep and psychosis in schizophrenia

Clin Neuropharmacol

Schizophrenic relapse after drug withdrawal is predictable

Acta Psychiatr Scand