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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
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RBD is characterized by the dreamer acting out his or her dreams. These dreams often involve kicking, screaming, punching, grabbing, and even jumping out of bed. When awakened, people can usually recall the dream they were having, which will match the actions they were performing, but they will not be aware that they were moving. In a normal sleep cycle, REM sleep may be experienced at intervals of between 90 minutes and two hours every night, which means RBD episodes may occur up to four times a night. In a rare case, they may only happen once a week or once a month. Episodes occur more towards the morning hours because that is when REM sleep is more frequent. The actions in an episode can result in injuries to oneself or one's bed partner. People can also respond to other people while sleeping and not even know it. This causes them to be aware of things while they are sleeping, which can result in sleep deprivation.
Confusional arousal has a prevalence of 4% in adults, and is common in children. Infants and toddlers usually experience confusional arousals beginning with large amounts of movement and moaning, which can later progress to occasional thrashings or inconsolable crying. Confusional arousal is a condition when an individual awakens from sleep and remains in a confused state. It is characterized by the individual's partial awakening and sitting up to look around. They usually remain in bed and then return to sleep. These episodes last anywhere from seconds to minutes and may not be reactive to stimuli.
Confusional arousals are not considered dangerous. Another sleeping disorder may be present triggering these incomplete arousals.
NREM parasomnias are arousal disorders that occur during stage 3 (or 4 by the R&K standardization) of NREM sleep—also known as slow wave sleep (SWS). They are caused by a physiological activation in which the patient’s brain exits from SWS and is caught in between a sleeping and waking state. In particular, these disorders involve activation of the autonomic nervous system, motor system, or cognitive processes during sleep or sleep-wake transitions.
Some NREM parasomnias (sleep-walking, night-terrors, and confusional arousal) are common during childhood but decrease in frequency with increasing age. They can be triggered in certain individuals, by alcohol, sleep deprivation, physical activity, emotional stress, depression, medications, or a fevered illness. These disorders of arousal can range from confusional arousals, somnambulism, to night terrors. Other specific disorders include sleepeating, sleep sex, teeth grinding, rhythmic movement disorder, restless legs syndrome, and somniloquy.
Rapid eye movement behavior disorder (RBD) occurs when there is a loss of normal voluntary muscle atonia during REM sleep resulting in motor behavior in response to dream content. It can be caused by adverse reactions to certain drugs or during drug withdrawal; however, it is most often associated with the elderly and in those with neurodegenerative disorders such as Parkinson disease and other neurodegenerative diseases, for example multiple system atrophy and Lewy body dementia.
RBD is categorized as either idiopathic or symptomatic.
The most common sleep disorders include:
- Bruxism, involuntarily grinding or clenching of the teeth while sleeping.
- Catathrenia, nocturnal groaning during prolonged exhalation.
- Delayed sleep phase disorder (DSPD), inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. Other such disorders are advanced sleep phase disorder (ASPD), non-24-hour sleep–wake disorder (non-24) in the sighted or in the blind, and irregular sleep wake rhythm, all much less common than DSPD, as well as the situational shift work sleep disorder.
- Hypopnea syndrome, abnormally shallow breathing or slow respiratory rate while sleeping.
- Idiopathic hypersomnia, a primary, neurologic cause of long-sleeping, sharing many similarities with narcolepsy.
- Insomnia disorder (primary insomnia), chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms. Insomnia can also be comorbid with or secondary to other disorders.
- Kleine–Levin syndrome, a rare disorder characterized by persistent episodic hypersomnia and cognitive or mood changes.
- Narcolepsy, including excessive daytime sleepiness (EDS), often culminating in falling asleep spontaneously but unwillingly at inappropriate times. About 70% of those who have narcolepsy also have cataplexy, a sudden weakness in the motor muscles that can result in collapse to the floor while retaining full conscious awareness.
- Night terror, "Pavor nocturnus", sleep terror disorder, an abrupt awakening from sleep with behavior consistent with terror.
- Nocturia, a frequent need to get up and urinate at night. It differs from enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties.
- Parasomnias, disruptive sleep-related events involving inappropriate actions during sleep, for example sleep walking, night-terrors and catathrenia.
- Periodic limb movement disorder (PLMD), sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. See also Hypnic jerk, which is not a disorder.
- Rapid eye movement sleep behavior disorder (RBD), acting out violent or dramatic dreams while in REM sleep, sometimes injuring bed partner or self (REM sleep disorder or RSD).
- Restless legs syndrome (RLS), an irresistible urge to move legs. RLS sufferers often also have PLMD.
- Shift work sleep disorder (SWSD), a situational circadian rhythm sleep disorder. (Jet lag was previously included as a situational circadian rhythm sleep disorder, but it doesn't appear in DSM-5 (see Diagnostic and Statistical Manual of Mental Disorders)).
- Sleep apnea, obstructive sleep apnea, obstruction of the airway during sleep, causing lack of sufficient deep sleep, often accompanied by snoring. Other forms of sleep apnea are less common. When air is blocked from entering into the lungs, the individual unconsciously gasps for air and sleep is disturbed. Stops of breathing of at least ten seconds, 30 times within seven hours of sleep, classifies as apnea. Other forms of sleep apnea include central sleep apnea and sleep-related hypoventilation.
- Sleep paralysis, characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of narcolepsy.
- Sleepwalking or "somnambulism", engaging in activities normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject.
- Somniphobia, one cause of sleep deprivation, a dread/ fear of falling asleep or going to bed. Signs of the illness include anxiety and panic attacks before and during attempts to sleep.
Patients with PLMD will complain of excessive daytime sleepiness (EDS), falling asleep during the day, trouble falling asleep at night, and difficulty staying asleep throughout the night. Patients also display involuntary limb movements that occur at periodic intervals anywhere from 20–40 seconds apart. They often only last the first half of the night during non-REM sleep stages. Movements do not occur during REM because of muscle atonia.
The universal feature of night terrors is inconsolability, very similar to that of a panic attack. During night terror bouts, people are usually described as "bolting upright" with their eyes wide open and a look of fear and panic on their faces. They will often scream. Furthermore, they will usually sweat, exhibit rapid breathing, and have a rapid heart rate (autonomic signs). In some cases, individuals are likely to have even more elaborate motor activity, such as a thrashing of limbs—which may include punching, swinging, or fleeing motions. There is a sense that the individuals are trying to protect themselves and/or escape from a possible threat of bodily injury. Although people may seem to be awake during a night terror, they will appear confused, be inconsolable and/or unresponsive to attempts to communicate with them, and may not recognize others familiar to them. Occasionally, when a person with a night terror is awakened, they will lash out at the one awakening them, which can be dangerous to that individual. Most people who experience this do not remember the incident the next day. Sleepwalking is also common during night terror bouts, as sleepwalking and night terrors are different manifestations of the same parasomnia.
During lab tests, subjects are known to have very high voltages of electroencephalography (EEG) delta activity, an increase in muscle tone, and a doubled increase in heart rate, if not more. Brain activities during a typical episode show theta and alpha activity when using an EEG. It is also common to see abrupt arousal from NREM sleep that does not progress into a full episode of a night terror. These episodes can include tachycardia. Night terrors are also associated with intense autonomic discharge of tachypnea, flushing, diaphoresis, and mydriasis – that is, unconscious or involuntary rapid breathing, reddening of the skin, profuse sweating, and dilation of the pupils.
In children with night terrors, there is no increased occurrence of psychiatric diagnoses. However, in adults who suffer from night terrors there is a close association with psychopathology or mental disorders. There may be an increased occurrence of night terrors—particularly among those suffering or having suffered from post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). It is also likely that some personality disorders may occur in individuals with night terrors, such as dependent, schizoid, and borderline personality disorders. There have been some symptoms of depression and anxiety that have increased in individuals that have suffered from frequent night terrors. Low blood sugar is associated with both pediatric and adult night terrors. A study of adults with thalamic lesions of the brain and brainstem have been occasionally associated with night terrors. Night terrors are closely linked to sleepwalking and frontal lobe epilepsy.
People with PLMD often do not know the cause of their excessive daytime sleepiness and their limb movements are reported by a spouse or sleep partner.
PLMD is diagnosed with the aid of a polysomnogram or PSG. PLMD is diagnosed by first finding PLMS (periodic limb movements of sleep) on a PSG, then integrating that information with a detailed history from the patient and/or bed partner. PLMS can range from a small amount of movement in the ankles and toes, to wild flailing of all four limbs. These movements, which are more common in the legs than arms, occur for between 0.5 and 5 seconds, recurring at intervals of 5 to 90 seconds. A formal diagnosis of PLMS requires three periods during the night, lasting from a few minutes to an hour or more, each containing at least 30 movements followed by partial arousal or awakening.
This sleep disorder frequently applies when patients report not feeling tired despite their subjective perception of not having slept. Generally, they may describe experiencing several years of no sleep, short sleep, or non-restorative sleep. Otherwise, patients appear healthy, both psychiatrically and medically. (That this condition is often asymptomatic could explain why it is relatively unreported.)
However, upon clinical observation, it is found that patients may severely overestimate the time they took to fall asleep—often reporting having slept half the amount of time indicated by polysomnogram or electroencephalography (EEG), which may record normal sleep. Observing such discrepancy between subjective and objective reports, clinicians may conclude that the perception of poor sleep is primarily illusionary.
Alternatively, some people may report excessive daytime sleepiness or chronic disabling sleepiness, while no sleep disorder has been found to exist. Methods of diagnosing sleepiness objectively, such as the Multiple Sleep Latency Test do not confirm the symptom"true" sleepiness is not observed despite the complaint. (It may be speculated that such reports of daytime sleepiness may be a result of the nocebo response —the reverse of the placebo effect—due to patient expectations of adverse effects from their subjective perception of poor sleep.)
Finally, on the opposite end of the spectrum, other patients may report feeling that they have slept much longer than is observed. It has been proposed that this experience be subclassified under sleep state misperception as "positive sleep state misperception", "reverse sleep state misperception", and "negative sleep state misperception".
The patient has a complaint of insomnia while sleep quality and duration are normal. Polysomnographic monitoring demonstrates normal sleep latency, a normal number of arousals and awakenings, and normal sleep duration with or without a multiple sleep latency test that demonstrates a mean sleep latency of greater than 10 minutes. No medical or mental disorder produces the complaint. Other sleep disorders producing insomnia are not present to a degree that would explain the patient’s complaint.
Night terrors typically occur in children between the ages of three and twelve years, with a peak onset in children aged three and a half years old.
An estimated 1–6% of children experience night terrors. Boys and girls of all ethnic backgrounds are affected equally. In children younger than three and a half years old, peak frequency of night terrors is at least one episode per week. Among older children, peak frequency of night terrors is one or two episodes per month. The children will most likely have no recollection of the episode the next day. Pediatric evaluation may be sought to exclude the possibility that the night terrors are caused by seizure disorders or breathing problems. Most children will outgrow sleep terrors.
A systematic review found that traumatic childhood experiences (such as family conflict or sexual trauma) significantly increases the risk for a number of sleep disorders in adulthood, including sleep apnea, narcolepsy, and insomnia. It is currently unclear whether or not moderate alcohol consumption increases the risk of obstructive sleep apnea.
In addition, an evidence-based synopses suggests that the sleep disorder, idiopathic REM sleep behavior disorder (iRBD), may have a hereditary component to it. A total of 632 participants, half with iRBD and half without, completed self-report questionnaires. The results of the study suggest that people with iRBD are more likely to report having a first-degree relative with the same sleep disorder than people of the same age and sex that do not have the disorder. More research needs to be conducted to gain further information about the hereditary nature of sleep disorders.
A population susceptible to the development of sleep disorders is people who have experienced a traumatic brain injury (TBI). Because many researchers have focused on this issue, a systematic review was conducted to synthesize their findings. According to their results, TBI individuals are most disproportionately at risk for developing narcolepsy, obstructive sleep apnea, excessive daytime sleepiness, and insomnia. The study's complete findings can be found in the table below:
Common symptoms of OSA include unexplained daytime sleepiness, restless sleep, and loud snoring (with periods of silence followed by gasps). Less common symptoms are morning headaches; insomnia; trouble concentrating; mood changes such as irritability, anxiety and depression; forgetfulness; increased heart rate and/or blood pressure; decreased sex drive; unexplained weight gain; increased urination and/or nocturia; frequent heartburn or gastroesophageal reflux disease; and heavy night sweats.
Parasomnia disorders are classified into the following categories:
- arousal disorders
- sleep-wake transition disorders
- parasomnias associated with REM sleep
The hallmark symptom of OSA syndrome in adults is excessive daytime sleepiness. Typically, an adult or adolescent with severe long-standing OSA will fall asleep for very brief periods in the course of usual daytime activities if given any opportunity to sit or rest. This behavior may be quite dramatic, sometimes occurring during conversations with others at social gatherings.
The hypoxia (absence of oxygen supply) related to OSA may cause changes in the neurons of the hippocampus and the right frontal cortex. Research using neuro-imaging revealed evidence of hippocampal atrophy in people suffering from OSA. They found that in more than 25% of the OSA cases, this problem results in irreversible problems in mentally manipulating non-verbal information and in executive functions and working memory, despite years of optimal continuous positive airway pressure (CPAP) treatment.
Diagnosis of obstructive sleep apnea is significantly more common among people in relationships, who are alerted to their condition by being informed by their sleeping partner since individuals with obstructive sleep apnea are often unaware of the condition. There is a stigma associated with loud snoring, and it is not considered a feminine trait. Consequently, females are less likely to be told by their partners that they snore, or to admit it to themselves or doctors. Furthermore, CPAP is also perceived negatively by females, and less likely to be utilized to its full extent in this group.
Under DSM-5 criteria, there are 11 diagnostic groups that comprise sleep-wake disorders. These include, Insomnia disorder, Hypersomnolence disorder, Narcolepsy, Obstructive sleep apnea hypopnea, Central sleep apnea, Sleep-related hypoventilation, Circadian rhythm sleep-wake disorders, Non–rapid eye movement (NREM) sleep arousal disorders, Nightmare disorder, Rapid eye movement (REM) sleep behavior disorder, Restless legs syndrome, and substance-medication-induced sleep disorder. Sexsomnia is classified under NREM arousal parasomnia.
Symptoms of UARS are similar to those of obstructive sleep apnea, but are usually less severe. Fatigue, daytime sleepiness, unrefreshing sleep, and frequent awakenings during sleep are the most common symptoms.
Many patients experience chronic insomnia that creates both a difficulty falling asleep and staying asleep. As a result, patients typically experience frequent sleep disruptions. Loud snoring also serves as a possible indicator of the syndrome, but is not a symptom required for diagnosis.
Some patients experience hypotension, which may cause lightheadedness, and patients with UARS are also more likely to experience headaches and irritable bowel syndrome.
Because of the abnormal writhing movements, often patients’ sleep patterns are disrupted. This may be due to RMD’s comorbidity with sleep apnea, which has been observed in some patients
. Many find that their sleep is not refreshing and are tired or stressed the following day, despite getting a full nights rest. However, other patients report that their sleep patterns are infrequently interrupted due to RMD episodes and do not report being excessively sleepy during the next day as scored on the Epworth Sleepiness Scale. Thus, as can be seen, the effects and severity of RMD vary from person to person.
Upper airway resistance syndrome is caused when the upper airway narrows without closing. Consequently, airflow is either reduced or compensated for through an increase in inspiratory efforts. This increased activity in inspiratory muscles leads to the arousals during sleep which patients may or may not be aware of.
A typical UARS patient is not obese and possesses a triangular face and misaligned jaw, which can result in a smaller amount of space behind the base of the tongue. Patients may have other anatomical abnormalities that can cause UARS such as deviated septum or nasal valve collapse. UARS affects equal numbers of males and females. It is unclear as to whether UARS is merely a phase that occurs between simple snoring and sleep apneas, or whether UARS is a syndrome that describes a deviation from normal upper airway physiology.
Children with UARS may experience symptoms due to minor anomalies of the facial bones or due to enlarged tonsils or adenoids.
Episodes of RMD are short, lasting between 3 and 130 seconds. Rare cases of constant RMD can last for hours. The majority of RMD episodes usually occur just before or during sleep. Some cases have been reported on rhythmic movements during wakeful activities like driving. When occurring in sleep, RMD episodes are more likely to onset during non-REM, stage 2 sleep. Roughly 46% of sleep-RMD episodes occur only in non-REM sleep; 30% in non-REM and REM; and only 24% strictly in REM sleep. Most patients are unresponsive during an episode and are unlikely to remember the movements occurring upon awakening. In some patients who also experience sleep apnea, episodes of apnea can be followed immediately by RMD-like symptoms, suggesting that the apnea episodes may trigger an RMD episode. Similarly, current studies suggest that external stimuli are not the cause of RMD episodes.
Somniloquy or sleep-talking is a parasomnia that refers to talking aloud while asleep. It can be quite loud, ranging from simple mumbling sounds to loud shouts and long, frequently inarticulate speeches, and can occur many times during a sleep cycle. As with sleepwalking and night terrors, sleeptalking usually occurs during delta-wave NREM sleep stages or during temporary arousals therefrom.
It can also occur during the REM sleep stage, at which time it represents what sleep therapists call a "motor breakthrough" (see sleep paralysis) of dream speech: words spoken in a dream are spoken out loud. Depending on its frequency, this may or may not be considered pathological. All motor functions are typically disabled during REM sleep thus, motoric, i.e., verbal elaboration of dream content, could be considered an REM behavior disorder (see below).
Sleep-talking can occur by itself or as a feature of another sleep disorder such as:
- Rapid eye movement behavior disorder (RBD) – loud, emotional or profane sleep talking
- Sleepwalking
- Night terrors – intense fear, screaming, shouting
- Sleep-related eating disorder (SRED)
Sleep-talking is very common and is reported in 50% of young children, with most of them outgrowing it by puberty, although in rare cases it may persist into adulthood (about 4% of adults are reported to talk in their sleep). It appears to run in families. In 1966, researchers worked to find links between heredity and somniloquy. Their research suggests the following:
- Sleep-talking parents are more likely to have children who sleep-talk
- Sleep talking can still occur, though much less commonly, when neither parent has a history of sleep talking
- A large portion of parents begin to sleep-talk later in life without any prior history of sleep-talking during childhood or adolescence
Sleep-talking by itself is typically harmless; however, it can wake others and cause them consternation—especially when misinterpreted as conscious speech by an observer. If the sleep-talking is dramatic, emotional, or profane it may be a sign of another sleep disorder (see above). Sleep-talking can be monitored by a partner or by using an audio recording device; devices which remain idle until detecting a sound wave are ideal for this purpose. Polysomnography (sleep recording) shows episodes of sleep talking that can occur in any stage of sleep.
Poor sleep quality can occur as a result of, for example, restless legs, sleep apnea or major depression. Poor sleep quality is caused by the individual not reaching stage 3 or delta sleep which has restorative properties.
Major depression leads to alterations in the function of the hypothalamic-pituitary-adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.
Symptoms of insomnia:
- difficulty falling asleep, including difficulty finding a comfortable sleeping position
- waking during the night and being unable to return to sleep
- feeling unrefreshed upon waking
- daytime sleepiness, irritability or anxiety
Sleep-onset insomnia is difficulty falling asleep at the beginning of the night, often a symptom of anxiety disorders. Delayed sleep phase disorder can be misdiagnosed as insomnia, as sleep onset is delayed to much later than normal while awakening spills over into daylight hours.
It is common for patients who have difficulty falling asleep to also have nocturnal awakenings with difficulty returning to sleep. Two-thirds of these patients wake up in the middle of the night, with more than half having trouble falling back to sleep after a middle-of-the-night awakening.
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of depression.
In the study "sleepwalking and sleep terrors in prepubera children", it was found that, if a child had another sleep disorder such as restless leg syndrome (RLS) or sleep-disorder breathing (SDB), there was a greater chance of sleepwalking. The study found that children with chronic parasomnias may often also present SDB or, to a lesser extent, RLS. Furthermore, the disappearance of the parasomnias after the treatment of the SDB or RLS periodic limb movement syndrome suggests that the latter may trigger the former. The high frequency of SDB in family members of children with parasomnia provided additional evidence that SDB may manifest as parasomnias in children. Children with parasomnias are not systematically monitored during sleep, although past studies have suggested that patients with sleep terrors or sleepwalking have an elevated level of brief EEG arousals. When children receive polysomnographies, discrete patterns (e.g., nasal flow limitation, abnormal respiratory effort, bursts of high or slow EEG frequencies) should be sought; apneas are rarely found in children. Children's respiration during sleep should be monitored with nasal cannula/pressure transducer system and/or esophageal manometry, which are more sensitive than the thermistors or thermocouples currently used in many laboratories. The clear, prompt improvement of severe parasomnia in children who are treated for SDB, as defined here, provides important evidence that subtle SDB can have substantial health-related significance. Also noteworthy is the report of familial presence of parasomnia. Studies of twin cohorts and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias. RLS and SDB have been shown to have familial recurrence. RLS has been shown to have genetic involvement.
In some cases, sleepwalking in adults may be a symptom of a psychological disorder. One study suggests higher levels of dissociation in adult sleepwalkers, since test subjects scored unusually high on the hysteria portion of the "Crown-Crisp Experiential Index". Another suggested that "A higher incidence [of sleepwalking events] has been reported in patients with schizophrenia, hysteria and anxiety neuroses". Also, patients with migraine headaches or Tourette Syndrome are 4–6 times more likely to sleepwalk.
There are two subcategories of sleepwalking: sleepwalking with sleep-related eating, and sleepwalking with sleep-related sexual behavior (sexsomnia).
Sleep eating involves consuming food while asleep. These sleep eating disorders are more often than not induced for stress related reasons. Another major cause of this sleep eating subtype of sleepwalking is sleep medication, such as Ambien for example (Mayo Clinic). There are a few others, but Ambien is a more widely used sleep aid. Because many sleep eaters prepare the food they consume, there are risks involving burns and such with ovens and other appliances. As expected, weight gain is also a common outcome of this disorder, because a food that is frequently consumed contains high carbohydrates. As with sleepwalking, there are ways that sleep eating disorders can be maintained. There are some medications that calm the sleeper so they can get longer and better-quality rest, but activities such as yoga can also be introduced to reduce the stress and anxiety causing the action.