Our lives involve regular dramatic changes in the degree to which we are aware of our surroundings and our internal states. While awake, we feel alert and aware of the many important things going on around us. Our experiences change dramatically while we are in deep sleep and once again when we are dreaming. Some people also experience altered states of consciousness through meditation, hypnosis or alcohol and other drugs. This chapter will discuss states of consciousness with a particular emphasis on sleep. The different stages of sleep will be identified and sleep disorders will be described. The chapter will close with discussions of altered states of consciousness produced by psychoactive drugs, hypnosis and meditation. Learning objectives. By the end of this section, you will be able to understand what is meant by consciousness. Explain how circadian rhythms are involved in regulating the sleepwake cycle and how circadian cycles can be disrupted. Discuss the concept of sleep debt. Consciousness describes our awareness of internal and external stimuli. Awareness of internal stimuli includes feeling pain, hunger, thirst, sleepiness, and being aware of our thoughts and emotions. Awareness of external stimuli includes experiences such as seeing the light from the sun, feeling the warmth of a room, and hearing the voice of a friend. We experience different states of consciousness and different levels of awareness on a regular basis. We might even describe consciousness as a continuum that ranges from full awareness to a deep sleep. Sleep is a state marked by relatively low levels of physical activity and reduced sensory awareness that is distinct from periods of rest that occur during wakefulness. Wakefulness is characterized by high levels of sensory awareness, thought, and behavior. Beyond being awake or asleep, there are many other states of consciousness people experience. These include daydreaming, intoxication, and unconsciousness due to anesthesia. Often we are not completely aware of our surroundings even when we are fully awake. For instance, have you ever daydreamed while driving home from work or school without really thinking about the drive itself? You were capable of engaging in all of the complex tasks involved with operating a motor vehicle. Even though you were not aware of doing so, many of these processes, like much of psychological behavior, are rooted in our biology. Biological rhythms. Biological rhythms are internal rhythms of biological activity. A woman's menstrual cycle is an example of a biological rhythm, a recurring cyclical pattern of bodily changes. One complete menstrual cycle takes about 28 days, a lunar month, but many biological cycles are much shorter. For example, body temperature fluctuates cyclically over a 24-hour period. Figure 4.2. Alertness is associated with higher body temperatures and sleepiness with lower body temperatures. Figure 4.2. This chart illustrates the circadian change in body temperature over 28 hours in a group of eight young men. Body temperature rises throughout the waking day, peaking in the afternoon, and falls during sleep with the lowest point occurring during the very early morning hours. This pattern of temperature fluctuation which repeats every day is one example of a circadian rhythm. A circadian rhythm is a biological rhythm that takes place over a period of about 24 hours. Our sleepwake cycle which is linked to our environment's natural light dark cycle is perhaps the most obvious example of a circadian rhythm. But we also have daily fluctuations in heart rate, blood pressure, blood sugar, and body temperature. Some circadian rhythms play a role in changes in our state of consciousness. If we have biological rhythms, then is there some sort of biological clock? In the brain, the hypothalamus, which lies above the pituitary gland, is a main center of homeostasis. Homeostasis is the tendency to maintain a balance or optimal level within a biological system. The brain's clock mechanism is located in an area of the hypothalamus known as the supraismatic nucleus, SCN. The axons of light sensitive neurons in the retina provide information to the SCN based on the amount of light present allowing this internal clock to be synchronized with the outside world. Klene Moore and Reppert 1991 Welsh Takahashi and K2010. Figure 4.3 Figure 4.3. The super kaismatic nucleus SCN serves as the brain's clock mechanism. The clock sets itself with light information received through projections from the retina. Problems with circadian rhythms generally and for most people, our circadian cycles are aligned with the outside world. For example, most people sleep during the night and are awake during the day. One important regulator of sleepwake cycles is the hormone melatonin. The pineal gland, an endocrine structure located inside the brain that releases melatonin is thought to be involved in the regulation of various biological rhythms and of the immune system during sleep. Hardland Pandy Perumal and Cardali 2006. Melatonin release is stimulated by darkness and inhibited by light. There are individual differences in regard to our sleepwake cycle. For instance, some people would say they are morning people while others would consider themselves to be night owls. These individual differences in circadian patterns of activity are known as a person's chronoype. And research demonstrates that morning larks and night owls differ with regard to sleep regulation. Tyard Phillip Cost Sagaspe and Bulac 2003 Sleep regulation refers to the brain's control of switching between sleep and wakefulness as well as coordinating this cycle with the outside world. Disruptions of normal sleep whether lark owl or somewhere in between. There are situations in which a person's circadian clock gets out of synchrony with the external environment. One way that this happens involves traveling across multiple time zones. When we do this, we often experience jet lag. Jet lag is a collection of symptoms that results from the mismatch between our internal circadian cycles and our environment. These symptoms include fatigue, sluggishness, irritability, and insomnia, i.e. a consistent difficulty in falling or staying asleep for at least three nights a week over a month's time. Roth 2007. Individuals who do rotating shift work are also likely to experience disruptions in circadian cycles. Rotating shift work refers to a work schedule that changes from early to late on a daily or weekly basis. For example, a person may work from 7:00 a.m. to 3:00 p.m. on Monday, 3:00 a.m. to 11:00 a.m. on Tuesday, and 11:00 a.m. to 7:00 p.m. on Wednesday. In such instances, the individual schedule changes so frequently that it becomes difficult for a normal circadian rhythm to be maintained. This often results in sleeping problems and it can lead to signs of depression and anxiety. These kinds of schedules are common for individuals working in health care professions and service industries and they are associated with persistent feelings of exhaustion and agitation that can make someone more prone to making mistakes on the job. Gold at all 1992 presser 1995. Rotating shift work has pervasive effects on the lives and experiences of individuals engaged in that kind of work, which is clearly illustrated in stories reported in a qualitative study that researched the experiences of middle-aged nurses who worked rotating shifts, West, Bowen, and Burns, 2009. Several of the nurses interviewed commented that their work schedules affected their relationships with their family. One of the nurses said, "Hoig die. If you've had a partner who does work regular job, nineto-ive office hours, the ability to spend time, good time with them when you're not feeling absolutely exhausted, that would be one of the problems that I've encountered. West at all, 2009, page 114. While disruptions in circadian rhythms can have negative consequences, there are things we can do to help us realign our biological clocks with the external environment. Some of these approaches, such as using a bright light, as shown in figure 4.4, four have been shown to alleviate some of the problems experienced by individuals suffering from jet lag or from the consequences of rotating shift work. Because the biological clock is driven by light, exposure to bright light during working shifts and dark exposure when not working can help combat insomnia and symptoms of anxiety and depression. Hang Sai Chen and Shu 2013. Figure 4.4. Devices like this are designed to provide exposure to bright light to help people maintain a regular circadian cycle. They can be helpful for people working night shifts or for people affected by seasonal variations in light. Insufficient sleep. When people have difficulty getting sleep due to their work or the demands of day-to-day life, they accumulate a sleep debt. A person with a sleep debt does not get sufficient sleep on a chronic basis. The consequences of sleep debt include decreased levels of alertness and mental efficiency. Interestingly, since the advent of electric light, the amount of sleep that people get has declined. While we certainly welcome the convenience of having the darkness lit up, we also suffer the consequences of reduced amounts of sleep because we are more active during the nighttime hours than our ancestors were. As a result, many of us sleep less than 7 to 8 hours a night and acrew a sleep debt. While there is tremendous variation in any given individual sleep needs, the National Sleep Foundation ND cites research to estimate that newborns require the most sleep between 12 and 18 hours a night and that this amount declines to just 7 to 9 hours by the time we are adults. If you lie down to take a nap and fall asleep very easily, chances are you may have sleep debt. Given that college students are notorious for suffering from significant sleep debt. Hicks, Fernandez, and Pelleigrini 2001. Hicks, Johnson, and Pelleigrini 1992. Miller, Shadock, and Matt Sanongas 2010. Chances are you and your classmates deal with sleep debt related issues on a regular basis. In 2015, the National Sleep Foundation updated their sleep duration hours to better accommodate individual differences. Table 4.1 shows the new recommendations which describe sleep durations that are recommended, may be appropriate, and not recommended. Sleep dead and sleep deprivation have significant negative psychological and physiological consequences. Figure 4.5. As mentioned earlier, lack of sleep can result in decreased mental alertness and cognitive function. In addition, sleep deprivation often results in depression-like symptoms. These effects can occur as a function of accumulated sleep debt or in response to more acute periods of sleep deprivation. It may surprise you to know that sleep deprivation is associated with obesity, increased blood pressure, increased levels of stress hormones, and reduced immune functioning. Banks and Dings 2007. A sleep-deprived individual generally will fall asleep more quickly than if they were not sleepd deprived. Some sleep-deprived individuals have difficulty staying awake when they stop moving. Example, sitting and watching television or driving a car. That is why individuals suffering from sleep deprivation can also put themselves and others at risk when they put themselves behind the wheel of a car or work with dangerous machinery. Some research suggests that sleep deprivation affects cognitive and motor function as much as, if not more than alcohol intoxication. Williamson and Fire 2000. Research shows that the most severe effects of sleep deprivation occur when a person stays awake for more than 24 hours. Kilgore and Weber 2014. Kilgore at all 2007. Or following repeated nights with fewer than four hours in bed. Wiccans, Hutchkins, Lau, Seabbook 2015. For example, irritability, distractability, and impairments in cognitive and moral judgment can occur with fewer than four hours of sleep. If someone stays awake for 48 consecutive hours, they could start to hallucinate. Figure 4.5. This figure illustrates some of the negative consequences of sleep deprivation. While cognitive deficits may be the most obvious, many body systems are negatively impacted by lack of sleep. Ahan. The amount of sleep we get varies across the lifespan. When we are very young, we spend up to 16 hours a day sleeping. As we grow older, we sleep less. In fact, a metaanalysis, which is a study that combines the results of many related studies conducted within the last decade, indicates that by the time we are 65 years old, we average fewer than 7 hours of sleep per day. Oh, Carcadon, Gilmano, and Vitiello, 2004. Learning objectives. By the end of this section, you will be able to describe areas of the brain involved in sleep. Understand hormone secretions associated with sleep. Describe several theories aimed at explaining the function of sleep. Name and describe three theories about why we dream. We spend approximately one-third of our lives sleeping. Given the average life expectancy for US citizens falls between 73 and 79 years old, Singh and Sia push 2006. We can expect to spend approximately 25 years of our lives sleeping. Some animals never sleep, eg some fish and amphibian species. Other animals sleep very little without apparent negative consequences, eg giraffes. Yet some animals, eg rats, die after 2 weeks of sleep deprivation. Seagull 2008. Why do we devote so much time to sleeping? Is it absolutely essential that we sleep? This section will consider these questions and explore various explanations for why we sleep. What is sleep? You have read that sleep is distinguished by low levels of physical activity and reduced sensory awareness. As discussed by Seagull 2008, a definition of sleep must also include mention of the interplay of the circadian and homeostatic mechanisms that regulate sleep. Homeostatic regulation of sleep is evidenced by sleep rebound following sleep deprivation. Sleep rebound refers to the fact that a sleepd deprived individual will fall asleep more quickly during subsequent opportunities for sleep. Sleep is characterized by certain patterns of activity of the brain that can be visualized using electrophilography EEG and different phases of sleep can be differentiated using EEG as well. Sleepwake cycles seem to be controlled by multiple brain areas acting in conjunction with one another. Some of these areas include the phalamus, the hypothalamus and the pawns. As already mentioned, the hypothalamus contains the SCN, the biological clock of the body. In addition to other nuclei that in conjunction with the phalamus regulate slowwave sleep. The palms is important for regulating rapid eye movement. REM sleep. National Institutes of Health ND. Sleep is also associated with the secretion and regulation of a number of hormones from several endocrine glands including melatonin, follical stimulating hormone FSH, luteinizing hormone LH, and growth hormone. National Institutes of Health, ND. You have read that the pineal gland releases melatonin during sleep. Figure 4.6. Melatonin is thought to be involved in the regulation of various biological rhythms and the immune system. Hardland at all 2006. During sleep, the pituitary gland secretes both FSH and LH, which are important in regulating the reproductive system. Christensen atall 2012. Sophocitis atall 2008. The pituitary gland also secretes growth hormone during sleep which plays a role in physical growth and maturation as well as other metabolic processes. Bartkkey Sun and Longo 2013. Why do we sleep? Given the central role that sleep plays in our lives and the number of adverse consequences that have been associated with sleep deprivation, one would think that we would have a clear understanding of why it is that we sleep. Unfortunately, this is not the case. However, several hypotheses have been proposed to explain the function of sleep. Adaptive function of sleep. One popular hypothesis of sleep incorporates the perspective of evolutionary psychology. Evolutionary psychology is a discipline that studies how universal patterns of behavior and cognitive processes have evolved over time as a result of natural selection. Variations and adaptations in cognition and behavior make individuals more or less successful in reproducing and passing their genes to their offspring. One hypothesis from this perspective might argue that sleep is essential to restore resources that are expended during the day. Just as bears hibernate in the winter when resources are scarce, perhaps people sleep at night to reduce their energy expenditures. While this is an intuitive explanation of sleep, there is little research that supports this explanation. In fact, it has been suggested that there is no reason to think that energetic demands could not be addressed with periods of rest and inactivity. Frank 2006, real 2007 and some research has actually found a negative correlation between energetic demands and the amount of time spent sleeping. Capalini, Barton, McNamera, Preston and Nun 2008. Another evolutionary hypothesis of sleep holds that our sleep patterns evolved as an adaptive response to predatory risks which increase in darkness. Thus, we sleep in safe areas to reduce the chance of harm. Again, this is an intuitive and appealing explanation for why we sleep. Perhaps our ancestors spent extended periods of time asleep to reduce attention to themselves from potential predators. Comparative research indicates, however, that the relationship that exists between predatory risk and sleep is very complex and equivocal. Some research suggests that species that face higher predatory risks sleep fewer hours than other species. Kapalini at all 2008. While other researchers suggest there is no relationship between the amount of time a given species spends in deep sleep and its predation risk. Leu Roth Amlanner and Lima 2006. It is quite possible that sleep serves no single universally adaptive function and different species have evolved different patterns of sleep in response to their unique evolutionary pressures. While we have discussed the negative outcomes associated with sleep deprivation, it should be pointed out that there are many benefits that are associated with adequate amounts of sleep. A few such benefits listed by the National Sleep Foundation ND include maintaining health, lowering stress levels, improving mood, and increasing motor coordination. as well as a number of benefits related to cognition and memory formation. Cognitive function of sleep. Another theory regarding why we sleep involve sleep's importance for cognitive function and memory formation. Ratenborg, Lescu, Martinez Gonzalez, and Lima 2007. Indeed, we know sleep deprivation results in disruptions in cognition and memory deficits. Brown 2012 leading to impairments in our abilities to maintain attention, make decisions, and recall long-term memories. Moreover, these impairments become more severe as the amount of sleep deprivation increases. Alhola and Polo Cantala 2007. Furthermore, slowwave sleep after learning a new task can improve resultant performance on that task. Huber, Gillardi, Masamini, and Toni 2004. And seems essential for effective memory formation. Stick Gold 2005. Understanding the impact of sleep on cognitive function should help you understand that cramming all night for a test may not be effective and can even prove counterproductive. Getting the optimal amount of sleep has also been associated with other cognitive benefits. Research indicates that included among these possible benefits are increased capacities for creative thinking. Kai, Mednik, Harrison, Kennady, and Mednik 2009. Vagner, Gase, Hater, Verleagger, and Bourne, 2004. Language learning, Fen, Nusbomb, and Margolash, 2003. Gomez, Bootsen, and Nadell, 2006. An inferential judgments, Ellen Bogen, Hugh, Payne, Titon, and Walker, 2000. It is possible that even the processing of emotional information is influenced by certain aspects of sleep. Walker 2009 learning objectives. By the end of this section, you will be able to differentiate between REM and nonREM sleep. Describe the differences between the three stages of non-REM sleep. Understand the role that REM and non-REM sleep play in learning and memory. Sleep is not a uniform state of being. Instead, sleep is composed of several different stages that can be differentiated from one another by the patterns of brain wave activity that occur during each stage. While awake, our brain wave activity is dominated by beta waves as compared to the brain wave patterns while asleep. Beta waves have the highest frequency 13 to 30 hertz and lowest amplitude and they tend to show more variability. As we begin to fall asleep, our brain wave activity changes. These changes can be visualized using an EEG and are distinguished from one another by both the frequency and amplitude of the brain wave. The frequency of a brain wave is how many brain waves occur in a second and frequency is measured in hertz. Hz. Amplitude is the height of the brain wave. Figure 4.7. Sleep can be divided into two different general phases. REM sleep and nonrem nrem sleep. Rapid eye movement sleep is characterized by darting movements of the eyes under closed eyelids. Brain waves during REM sleep appear very similar to brain waves during wakefulness. In contrast, nonrem nrem sleep is subdivided into three stages distinguished from each other and from wakefulness by characteristic patterns of brain waves. The first three stages of sleep are nrem sleep typically followed by REM sleep. In this section, we will discuss each of these stages of sleep and their associated patterns of brain wave activity. Figure 4.7 brain wave activity changes dramatically across the different stages of sleep. NRM stages of sleep. As we begin to fall asleep, we enter NRM sleep and brain wave patterns decrease in frequency and increase in amplitude. The first stage of NRM sleep is known as stage one sleep. Stage one sleep is a transitional phase that occurs between wakefulness and sleep. The period during which we drift off to sleep. During this time, there is a slowdown in both the rates of respiration and heartbeat. In addition, stage one sleep involves a marked decrease in both overall muscle tension and core body temperature. In terms of brain wave activity, stage one sleep is associated with both alpha and theta waves. The early portion of stage one sleep produces alpha waves. These patterns of electrical activity, waves, resemble that of someone who is very relaxed yet awake, but they have less variability, are more synchronized, and are relatively lower in frequency, 8 to 12 hertz, and higher in amplitude than beta waves. Figure 4.8. As an individual continues through stage 1 sleep, there is an increase in theta wave activity. Theta waves are even lower frequency four to seven hertz and higher in amplitude than the alpha wave patterns. It is relatively easy to wake someone from stage 1 sleep. In fact, people often report that they have not been asleep if they are awoken during stage one sleep. Figure 4.8 brain wave activity changes dramatically across the different stages of sleep. As we move into stage two sleep, the body goes into a state of deep relaxation. Theta waves still dominate the activity of the brain, but they are interrupted by brief bursts of activity known as sleep spindles. Figure 4.9. A sleep spindle is a rapid burst of higher frequency brain waves that may be important for learning and memory. Fogle and Smith 2011. Po Walsh and Bjornis 2010. In addition, the appearance of K complexes is often associated with stage 2 sleep. A K complex is a very high amplitude pattern of brain activity that may in some cases occur in response to environmental stimuli. Thus, K complexes might serve as a bridge to higher levels of arousal in response to what is going on in our environments. Halaz 1993, Stereot and Empica 1998. Figure 4.9 stage 2 sleep is characterized by the appearance of both sleep spindles and K complexes. NRM stage three sleep is often referred to as deep sleep or slowwave sleep because this stage is characterized by low frequency less than three hertz high amplitude delta waves. Figure 4.10. These delta waves have the lowest frequency and highest amplitude of our sleeping brain wave patterns. During this time, an individual's heart rate and respiration slow dramatically and it is much more difficult to awaken someone from sleep during stage three than during earlier stages. Interestingly, individuals who have increased levels of alpha brain wave activity, more often associated with wakefulness and transition into stage one sleep during stage three, often report that they do not feel refreshed upon waking regardless of how long they slept. Stone, Taylor, McCrae, Calicar, and Licksteen 2008. Figure 4.10A 10A delta waves which are low frequency and high amplitude characterize B slowwave stage three and REM sleep R a AAA sleep as mentioned earlier REM sleep is marked by rapid movements of the eyes the brain waves associated with this stage of sleep are very similar to those observed when a person is awake as shown in figure 4.11 and this is the period of sleep in which dreaming occurs. It is also associated with paralysis of muscle systems in the body with the exception of those that make circulation and respiration possible. Therefore, no movement of voluntary muscles occurs during rim sleep in a normal individual. Rim sleep is often referred to as paradoxical sleep because of this combination of high brain activity and lack of muscle tone. Like NRM sleep, REM has been implicated in various aspects of learning and memory. Vagner Gase and Bourne 2001. Seagull 2001. Figure 4.11A a period of rapid eye movement is marked by the short red line segment. The brain waves associated with REM sleep outlined in the red box in A look very similar to those seen B during wakefulness. If people are deprived of REM sleep and then allowed to sleep without disturbance, they will spend more time in REM sleep in what would appear to be an effort to recoup the lost time in REM. This is known as the REM rebound and it suggests that REM sleep is also homeostatically regulated. Aside from the role that REM sleep may play in processes related to learning and memory, REM sleep may also be involved in emotional processing and regulation. In such instances, REM rebound may actually represent an adaptive response to stress in non-depressed individuals by suppressing the emotional salience of aversive events that occurred in wakefulness. Suchi ta and machado 2012 sleep deprivation in general is associated with a number of negative consequences. Brown 2012 The hypnogog below figure 4.12 shows a person's passage through the stages of sleep. Figure 4.12. A hypnoggram is a diagram of the stages of sleep as they occur during a period of sleep. This hypnogog illustrates how an individual moves through the various stages of sleep. Dreams. Dreams and their associated meanings vary across different cultures and periods of time. By the late 19th century, Austrian psychiatrist Sigman Freud had become convinced that dreams represented an opportunity to gain access to the unconscious. By analyzing dreams, Freud thought people could increase self-awareness and gain valuable insight to help them deal with the problems they faced in their lives. Freud made distinctions between the manifest content and the latent content of dreams. Manifest content is the actual content or storyline of a dream. Latent content on the other hand refers to the hidden meaning of a dream. For instance, if a woman dreams about being chased by a snake, Freud might have argued that this represents the woman's fear of sexual intimacy with the snake serving as a symbol of a man's penis. Freud was not the only theorist to focus on the content of dreams. The 20th century Swiss psychiatrist Carl Young believed that dreams allowed us to tap into the collective unconscious. The collective unconscious as described by Yung is a theoretical repository of information he believed to be shared by everyone. According to Yung, certain symbols in dreams reflected universal archetypes with meanings that are similar for all people regardless of culture or location. The sleep and dreaming researcher Rosalyn Cartwright, however, believes that dreams simply reflect life events that are important to the dreamer. Unlike Freud and Jung, Cartwright's ideas about dreaming have found empirical support. For example, she and her colleagues published a study in which women going through divorce were asked several times over a 5-month period to report the degree to which their former spouses were on their minds. These same women were awakened during REM sleep in order to provide a detailed account of their dream content. There was a significant positive correlation between the degree to which women thought about their former spouses during waking hours and the number of times their former spouses appeared as characters in their dreams. Cartwright, Aggerun, Kirkby, and Freriedman 2006. Recent research Horawa, Tamaki, Miyawaki, and Kamatani 2013 has uncovered new techniques by which researchers may effectively detect and classify the visual images that occur during dreaming by using fMRI for neural measurement of brain activity patterns, opening the way for additional research in this area. Alan Hobson, a neuroscientist, is credited for developing activation synthesis theory of dreaming. Early versions of this theory proposed that dreams were not the meaning-filled representations of angst proposed by Freud and others, but were rather the result of our brain attempting to make sense of synthesize the neural activity activation that was happening during REM sleep. Recent adaptations, eg Hobson 2002, continue to update the theory based on accumulating evidence. For example, Hobson 2009 suggests that dreaming may represent a state of protoconsciousness. In other words, dreaming involves constructing a virtual reality in our heads that we might use to help us during wakefulness. Among a variety of neurobiological evidence, John Hobson cites research on lucid dreams as an opportunity to better understand dreaming. In general, lucid dreams are dreams in which certain aspects of wakefulness are maintained during a dream state. In a lucid dream, a person becomes aware of the fact that they are dreaming and as such they can control the dream's content. Leurge 1990 learning objectives. By the end of this section, you will be able to describe the symptoms and treatments of insomnia. Recognize the symptoms of several parasomnas. Describe the symptoms and treatments for sleep apnea. Recognize risk factors associated with sudden infant death syndrome asalids and steps to prevent it. Describe the symptoms and treatments for narcolepsy. Many people experience disturbances in their sleep at some point in their lives. Depending on the population and sleep disorder being studied, between 30% and 50% of the population suffers from a sleep disorder at some point in their lives. Bixler, Kales, Soldos, Kales, and Healey 1979. Hussein and Shapiro 2002. Ohon 1997 2002. Ohon and Roth 2002. This section will describe several sleep disorders as well as some of their treatment options. Insomnia. Insomnia, a consistent difficulty in falling or staying asleep, is the most common of the sleep disorders. Individuals with insomnia often experience long delays between the times that they go to bed and actually fall asleep. In addition, these individuals may wake up several times during the night only to find that they have difficulty getting back to sleep. As mentioned earlier, one of the criteria for insomnia involves experiencing these symptoms for at least three nights a week for at least one month's time. Roth 2007. It is not uncommon for people suffering from insomnia to experience increased levels of anxiety about their inability to fall asleep. This becomes a self-perpetuating cycle because increased anxiety leads to increased arousal and higher levels of arousal make the prospect of falling asleep even more unlikely. Chronic insomnia is almost always associated with feeling overt tired and may be associated with symptoms of depression. There may be many factors that contribute to insomnia including age, drug use, exercise, mental status, and bedtime routines. Not surprisingly, insomnia treatment may take one of several different approaches. People who suffer from insomnia might limit their use of stimulant drugs such as caffeine or increase their amount of physical exercise during the day. Some people might turn to over-the-counter OTC or prescribed sleep medications to help them sleep. But this should be done sparingly because many sleep medications result in dependence and alter the nature of the sleep cycle and they can increase insomnia over time. Those who continue to have insomnia, particularly if it affects their quality of life, should seek professional treatment. Some forms of psychotherapy, such as cognitive behavioral therapy, can help sufferers of insomnia. Cognitive behavioral therapy is a type of psychotherapy that focuses on cognitive processes and problem behaviors. The treatment of insomnia likely would include stress management techniques and changes in problematic behaviors that could contribute to insomnia, eg spending more waking time in bed. Cognitive behavioral therapy has been demonstrated to be quite effective in treating insomnia. Savard Simard Ivers and Morin 2005. Williams Roth Vattow and McCrae 2013. Everyday connection solutions to support healthy sleep. Has something like this ever happened to you? My sophomore college housemate got so stressed out during finals sophomore year, he drank almost a whole bottle of Nyquil to try to fall asleep when he told me I made him go see the college therapist. Many college students struggle getting the recommended 7 to 9 hours of sleep each night. However, for some, it's not because of all night partying or late night study sessions. It's simply that they feel so overwhelmed and stressed that they cannot fall asleep or stay asleep. One or two nights of sleep difficulty is not unusual, but if you experience anything more than that, you should seek a doctor's advice. Here are some tips to maintain healthy sleep. Stick to a sleep schedule, even on the weekends. Try going to bed and waking up at the same time every day to keep your biological clock in sync so your body gets in the habit of sleeping every night. Avoid anything stimulating for an hour before bed. That includes exercise and bright light from devices. Exercise daily. Avoid naps. Keep your bedroom temperature between 60 and 67°. People sleep better in cooler temperatures. Avoid alcohol, cigarettes, caffeine, and heavy meals before bed. It may feel like alcohol helps you sleep, but it actually disrupts REM sleep and leads to frequent awakenings. Heavy meals may make you sleepy, but they can also lead to frequent awakenings due to gastric distress. If you cannot fall asleep, leave your bed and do something else until you feel tired again. Train your body to associate the bed with sleeping rather than other activities like studying, eating, or watching television shows. Parisomnias. A parisomnia is one of a group of sleep disorders in which unwanted disruptive motor activity and/or experiences during sleep play a role. Parisomnas can occur in either REMM or NREM phases of sleep. Sleepwalking, restless leg syndrome and night terrors are all examples of parasomnas. Mahawald and Shank 2000. Sleepwalking. In sleepwalking or some nambulism, the sleeper engages in relatively complex behaviors ranging from wandering about to driving an automobile. During periods of sleepwalking, sleepers often have their eyes open, but they are not responsive to attempts to communicate with them. Sleepwalking most often occurs during slowwave sleep, but it can occur at any time during a sleep period in some affected individuals. Mahawald and Shank 2000. Historically, some nambulism has been treated with a variety of phicotherapies ranging from bzzoazipines to anti-depressants. However, the success rate of such treatments is questionable. Gimmano Adal 2005 found that sleepwalking was not alleviated with the use of bzzoazipines. However, all of their sambulistic patients who also suffered from sleep-related breathing problems showed a marked decrease in sleepwalking when their breathing problems were effectively treated. Dig deeper. A sleepwalking defense. On January 16th, 1997, Scott Fowler sat down to dinner with his wife and children and told them about difficulties he was experiencing on a project at work. After dinner, he prepared some materials to use in leading a church youth group the following morning. And then he attempted to repair the family swimming pool pump before retiring to bed. The following morning, he awoke to barking dogs and unfamiliar voices from downstairs. As he went to investigate what was going on, he was met by a group of police officers who arrested him for the murder of his wife. Cartwright, 2004. CNN, 1999. Yarma Fader's body was found in the family's pool with 44 stab wounds. A neighbor called the police after witnessing Fallader standing over his wife's body before dragging her into the pool. Upon a search of the premises, police found bloodstained clothes and a bloody knife in the trunk of Fader's car, and he had blood stains on his neck. Remarkably, Fader insisted that he had no recollection of hurting his wife in any way. His children and his wife's parents all agreed that Fader had an excellent relationship with his wife, and they couldn't think of a reason that would provide any sort of motive to murder her. Cartwright 2004. Scott Fallader had a history of regular episodes of sleepwalking as a child, and he had even behaved violently toward his sister once when she tried to prevent him from leaving their home in his pajamas during a sleep-walking episode. He suffered from no apparent anatomical brain anomalies or psychological disorders. It appeared that Scott Fader had killed his wife in his sleep, or at least that is the defense he used when he was tried for his wife's murder. Cartwright, 2004, CNN, 1999. In Fader's case, a jury found him guilty of first-degree murder in June of 1999. CNN 1999. However, there are other murder cases where the sleepwalking defense has been used successfully. As scary as it sounds, many sleep researchers believe that homicidal sleepwalking is possible in individuals suffering from the types of sleep disorders described below. Broenol 1994, Cartwright 2004, Mahawald, Shank, and Kramer Bourneman 2005, Pressman 2007. REM sleep behavior disorder RBD. REM sleep behavior disorder, RBD, occurs when the muscle paralysis associated with the REM sleep phase does not occur. Individuals who suffer from RBD have high levels of physical activity during REM sleep, especially during disturbing dreams. These behaviors vary widely, but they can include kicking, punching, scratching, yelling, and behaving like an animal that has been frightened or attacked. People who suffer from this disorder can injure themselves or their sleeping partners when engaging in these behaviors. Furthermore, these types of behaviors ultimately disrupt sleep, although affected individuals have no memories that these behaviors have occurred. Arnold 2012. This disorder is associated with a number of neurodeenerative diseases such as Parkinson's disease. In fact, this relationship is so robust that some view the presence of RBD as a potential aid in the diagnosis and treatment of a number of neurodeenerative diseases. Fini Strombi 2011. Clinazipam, an anti-anxiety medication with seditive properties, is most often used to treat RBD. It is administered alone or in conjunction with doses of melatonin, the hormone secreted by the pineal gland. As part of treatment, the sleeping environment is often modified to make it a safer place for those suffering from RBD, Zenini, Kandra Bonora, Grimmaldi, and Cortelli. 2011. Other parisomias. A person with restless leg syndrome has uncomfortable sensations in the legs during periods of inactivity or when trying to fall asleep. This discomfort is relieved by deliberately moving the legs which not surprisingly contributes to difficulty in falling or staying asleep. Restless leg syndrome is quite common and has been associated with a number of other medical diagnoses such as chronic kidney disease and diabetes. Mahawald and Shank 2000. There are a variety of drugs that treat restless leg syndrome, benzoazipines, opiates and anti-convulsants. Restless leg syndrome Foundation ND Night terrors result in a sense of panic in the sufferer and are often accompanied by screams and attempts to escape from the immediate environment. Mahawald and Shank 2000. Although individuals suffering from night terrors appear to be awake, they generally have no memories of the events that occurred and attempts to console them are ineffective. Typically, individuals suffering from night terrors will fall back asleep again within a short time. Night terrors apparently occur during the NRM phase of sleep. Provini, Tiniper, Bulli, and Lagari 2011. Generally, treatment for night terrors is unnecessary unless there is some underlying medical or psychological condition that is contributing to the night terrors. Mayo Clinic ND. Sleep apnea. Sleep apnea is defined by episodes during which a sleeper's breathing stops. These episodes can last 10 to 20 seconds or longer and often are associated with brief periods of arousal. While individuals suffering from sleep apnea may not be aware of these repeated disruptions in sleep, they do experience increased levels of fatigue. Many individuals diagnosed with sleep apnea first seek treatment because their sleeping partners indicate that they snore loudly and/or stop breathing for extended periods of time while sleeping. Henry and Rosenthal, 2013. Sleep apneoa is much more common in overweight people and is often associated with loud snoring. Surprisingly, sleep apnea may exacerbate cardiovascular disease. Sanchez deator Campos Rodriguez and Barbet 2012. Anyone, regardless of their weight, who snores loudly or gasps for air while sleeping should be checked for sleep apnea. While people are often unaware of their sleep apnea, they are keenly aware of some of the adverse consequences of insufficient sleep. Consider a patient who believed that as a result of his sleep apnea. He quote, "Had three car accidents in 6 weeks. They were all my fault. Two of them I didn't even know I was involved in until afterwards." Henry and Rosenthal, 2013, page 52. It is not uncommon for people suffering from undiagnosed or untreated sleep apnea to fear that their careers will be affected by the lack of sleep. Illustrated by this statement from another patient. I'm in a job where there's a premium on being mentally alert. I was really sleepy and having trouble concentrating. It was getting to the point where it was kind of scary. Henry and Rosenthal 2013 page 52. There are two types of sleep apnea. Obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea occurs when an individual's airway becomes blocked during sleep and air is prevented from entering the lungs. In central sleep apnea, disruption in signals sent from the brain that regulate breathing cause periods of interrupted breathing. White 2005. One of the most common treatments for sleep apnea involves the use of a special device during sleep. A continuous positive airway pressure CPAP device includes a mask that fits over the sleeper's nose and mouth, which is connected to a pump that pumps air into the person's airways, forcing them to remain open, as shown in figure 4.13. Some newer CPAP masks are smaller and cover only the nose. This treatment option is proven to be effective for people suffering from mild to severe cases of sleep apnea. McDade at all 2009. However, alternative treatment options are being explored because consistent compliance by users of CPAP devices is a problem. Recently, a new EPAP expiratory positive air pressure device has shown promise in double blind trials as one such alternative. Barry, Kriger, and Massie 2011. Figure 4.13. A typical CPAP device used in the treatment of sleep apnea is B. affixed to the head with straps and a mask that covers the nose and mouth. SIDS. In sudden infant death syndrome, SIDS, an infant stops breathing during sleep and dies. Infants younger than 12 months appear to be at the highest risk for SIDS, and boys have a greater risk than girls. A number of risk factors have been associated with SIDS, including premature birth, smoking within the home, and hyperothermia. There may also be differences in both brain structure and function in infants that die from SIDS. Burkowitz 2012, Mage and Donner 2006. Thatch 2005. The substantial amount of research on SIDS has led to a number of recommendations to parents to protect their children. Figure 4.14. For one, research suggests that infants should be placed on their backs when put down to sleep, and their crib should not contain any items which pose suffocation threats, such as blankets, pillows, or padded crib bumpers, cushions that cover the bars of a crib. Infants should not have caps placed on their heads when put down to sleep in order to prevent overheating, and people in the child's household should abstain from smoking in the home. Recommendations like these have helped to decrease the number of infant deaths from SIDS in recent years. Mitchell 2009 task force on sudden infant death syndrome 2011 figure 4.14 the safe to sleep campaign educates the public about how to minimize risk factors associated with SIDS this campaign is sponsored in part by the national institute of child health and human development narcolepsy unlike the other sleep disorders described in this section a person with narcolepsy cannot resist falling asleep at inopportune times these sleep episodes are often associated with catyplexi which is a lack of muscle tone or muscle weakness and in some cases involves complete paralysis of the voluntary muscles. This is similar to the kind of paralysis experienced by healthy individuals during REM sleep. Burgess and Scaml 2012, Hishikawa and Shimizu 1995, Lupy at all 2011. Narcoleptic episodes take on other features of REM sleep. For example, around onethird of individuals diagnosed with narcolepsy experience vivid dreamlike hallucinations during narcoleptic attacks. Chakravery 2010. Surprisingly, narcoleptic episodes are often triggered by states of heightened arousal or stress. The typical episode can last from a minute or two to half an hour. Once awakened from a narcoleptic attack, people report that they feel refreshed. Chuck Rivery 2010. Obviously, regular narcoleptic episodes could interfere with the ability to perform one's job or complete school work. And in some situations, narcolepsy can result in significant harm and injury, eg driving a car or operating machinery or other potentially dangerous equipment. Generally, narcolepsy is treated using psychoot stimulant drugs such as amphetamines, mno 2012. These drugs promote increased levels of neural activity. Narcolepsy is associated with reduced levels of the signaling molecule hypocritin in some areas of the brain. De laaharonorita and drugercol 2012 Han 2012 and the traditional stimulant drugs do not have direct effects on this system. Therefore, it is quite likely that new medications that are developed to treat narcolepsy will be designed to target the hypocritin system. There is a tremendous amount of variability among sufferers, both in terms of how symptoms of narcopsy manifest and the effectiveness of currently available treatment options. This is illustrated by McCarti's 2010 case study of a 50-year-old woman who sought help for the excessive sleepiness during normal waking hours that she had experienced for several years. She indicated that she had fallen asleep at inappropriate or dangerous times, including while eating, while socializing with friends, and while driving her car. During periods of emotional arousal, the woman complained that she felt some weakness in the right side of her body. Although she did not experience any dreamlike hallucinations, she was diagnosed with narcolepsy as a result of sleep testing. In her case, the fact that her cataplexi was confined to the right side of her body was quite unusual. Early attempts to treat her condition with a stimulant drug alone were unsuccessful. However, when a stimulant drug was used in conjunction with a popular anti-depressant, her condition improved dramatically. Learning objectives. By the end of this section, you will be able to describe the diagnostic criteria for substance use disorders. Identify the neurotransmitter systems impacted by various categories of drugs. Describe how different categories of drugs affect behavior and experience. While we all experience altered states of consciousness in the form of sleep on a regular basis, some people use drugs and other substances that result in altered states of consciousness as well. This section will present information relating to the use of various psychoactive drugs and problems associated with such use. This will be followed by brief descriptions of the effects of some of the more well-known drugs commonly used today. Substance use disorders. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, DSM5, is used by clinicians to diagnose individuals suffering from various psychological disorders. Drug use disorders are addictive disorders, and the criteria for specific substance drug use disorders are described in DSM5. A person who has a substance use disorder often uses more of the substance than they originally intended to and continues to use that substance despite experiencing significant adverse consequences. In individuals diagnosed with a substance use disorder, there is a compulsive pattern of drug use that is often associated with both physical and psychological dependence. Physical dependence involves changes in normal bodily functions. The user will experience withdrawal from the drug upon sessation of use. In contrast, a person who has psychological dependence has an emotional rather than physical need for the drug and may use the drug to relieve psychological distress. Tolerance is linked to physiological dependence and it occurs when a person requires more and more drug to achieve effects previously experienced at lower doses. Tolerance can cause the user to increase the amount of drug used to a dangerous level, even to the point of overdose and death. Drug withdrawal includes a variety of negative symptoms experienced when drug use is discontinued. These symptoms usually are opposite of the effects of the drug. For example, withdrawal from seditive drugs often produces unpleasant arousal and agitation. In addition to withdrawal, many individuals who are diagnosed with substance use disorders will also develop tolerance to these substances. Psychological dependence or drug craving is a recent addition to the diagnostic criteria for substance use disorder in DSM5. This is an important factor because we can develop tolerance and experience withdrawal from any number of drugs that we do not abuse. In other words, physical dependence in and of itself is of limited utility in determining whether or not someone has a substance use disorder. Drug categories. The effects of all psychoactive drugs occur through their interactions with our endogenous neurotransmitter systems. Many of these drugs and their relationships are shown in table 4.2. As you have learned, drugs can act as agonists or antagonists of a given neurotransmitter system. An agonist facilitates the activity of a neurotransmitter system and antagonists impede neurotransmitter activity. Alcohol and other depressants. Ethanol, which we commonly refer to as alcohol, is in a class of psychoactive drugs known as depressants. Figure 4.15. A depressant is a drug that tends to suppress central nervous system activity. Other depressants include barbbiterates and bzzoazipines. These drugs share in common their ability to serve as agonists of the gamma aminobuteric acid GABA neurotransmitter system. Because GABA has a quieting effect on the brain, GABA agonists also have a quieting effect. These types of drugs are often prescribed to treat both anxiety and insomnia. Figure 4.15. The gabagated chloride CL minus channel is embedded in the cell membrane of certain neurons. The channel has multiple receptor sites where alcohol barbbiterates and benzoazipines bind to exert their effects. The binding of these molecules opens the chloride channel allowing negatively charged chloride ions Cl minus into the neuron cell body. Changing its charge in a negative direction pushes the neuron away from firing. Thus, activating a GABA neuron has a quieting effect on the brain. Acute alcohol administration results in a variety of changes to consciousness. At rather low doses, alcohol use is associated with feelings of euphoria. As the dose increases, people report feeling sedated. Generally, alcohol is associated with decreases in reaction time and visual acuity, lowered levels of alertness, and reduction in behavioral control. With excessive alcohol use, a person might experience a complete loss of consciousness and/or difficulty remembering events that occurred during a period of intoxication. McKim and Hancock 2013. In addition, if a pregnant person consumes alcohol, their infant may be born with a cluster of birth defects and symptoms collectively called fetal alcohol spectrum disorder, FASD, or fetal alcohol syndrome, FAS. With repeated use of many central nervous system depressants such as alcohol, a person becomes physically dependent upon the substance and will exhibit signs of both tolerance and withdrawal. Psychological dependence on these drugs is also possible. Therefore, the abuse potential of central nervous system depressants is relatively high. Drug withdrawal is usually an aversive experience and it can be a life-threatening process in individuals who have a long history of very high doses of alcohol and/or barbiterates. This is of such concern that people who are trying to overcome addiction to these substances should only do so under medical supervision. Stimulants. Stimulants are drugs that tend to increase overall levels of neural activity. Many of these drugs act as agonists of the dopamine neurotransmitter system. Dopamine activity is often associated with reward and craving. Therefore, drugs that affect dopamine neurotransmission often have abuse liability. Drugs in this category include cocaine, empetamines including methamphetamine, cathones, i.e. bath salts, MDMA ecstasy, nicotine, and caffeine. Cocaine can be taken in multiple ways. While many users snort cocaine, intravenous injection and inhalation, smoking are also common. The freebase version of cocaine known as crack is a potent smokable version of the drug. Like many other stimulants, cocaine agonizes the dopamine neurotransmitter system by blocking the re-uptake of dopamine in the neuronal synapse. Dig deeper. Methamphetamine. Methamphetamine in its smokable form, often called crystal meth due to its resemblance to rock crystal formations, is highly addictive. The smokable form reaches the brain very quickly to produce an intense euphoria that dissipates almost as fast as it arrives, prompting users to continuing taking the drug. Users often consume the drug every few hours across days long binges called runs in which the user foregoes food and sleep. The availability of potent and inexpensive forms of methamphetamine coupled with a lower risk of overdose than with opiate drugs is making crystal meth a popular choice among drug users today. Naida 2019. Using crystal meth poses a number of serious long-term health issues, including dental problems, often called meth mouth, skin abrasions caused by excessive scratching, memory loss, sleep problems, violent behavior, paranoia, and hallucinations. Methamphetamine addiction produces an intense craving that is difficult to treat. Amphetamines have a mechanism of action quite similar to cocaine in that they block the re-uptake of dopamine in addition to stimulating its release. Figure 4.16. While empmphetamines are often abused, they are also commonly prescribed to people diagnosed with attention deficit hyperactivity disorder, ADHD. It may seem counterintuitive that stimulant medications are prescribed to treat a disorder that involves hyperactivity, but the therapeutic effect comes from increases in neurotransmitter activity within certain areas of the brain associated with impulse control. These brain areas include the prefrontal cortex and basil ganglia. Figure 4.16. As one of their mechanisms of action, cocaine and empetamines block the re-uptake of dopamine from the syninnapse into the presinaptic cell. In recent years, methamphetamine, meth use, has become increasingly widespread. Methamphetamine is a type of amphetamine that can be made from ingredients that are readily available. Eg. medications containing pseudoephedrin, a compound found in many over-the-counter cold and flu remedies. Despite recent changes in laws designed to make obtaining pseudo ephedrin more difficult, methamphetamine continues to be an easily accessible and relatively inexpensive drug option. Shukla, Crump, and Krisco 2012. Stimulant users seek a euphoric high feelings of intensilation and pleasure, especially in those users who take the drug via introvenous injection or smoking. MDMA 3.4 methylindoxymethamphetamine commonly known as ecstasy or molly is a mild stimulant with perception altering effects. It is typically consumed in pill form. Users experience increased energy, feelings of pleasure, and emotional warmth. Repeated use of these stimulants can have significant adverse consequences. Users can experience physical symptoms that include nausea, elevated blood pressure, and increased heart rate. In addition, these drugs can cause feelings of anxiety, hallucinations, and paranoia. Furinadol 2011. Normal brain functioning is altered after repeated use of these drugs. For example, repeated use can lead to overall depletion among the monoamine neurotransmitters, dopamine, norepinephrine and serotonin. Depletion of certain neurotransmitters can lead to mood dysphoria, cognitive problems, and other factors. This can lead to people compulsively using stimulants such as cocaine and amphetamines in part to try to reestablish the person's physical and psychological preuse baseline. Gianth and Ramomorphy 2005. Rothman, Blau, and Bowman 2007. Caffeine is another stimulant drug. While it is probably the most commonly used drug in the world, the potency of this particular drug pales in comparison to the other stimulant drugs described in this section. Generally, people use caffeine to maintain increased levels of alertness and arousal. Caffeine is found in many common medicines such as weight loss drugs, beverages, foods, and even cosmetics. Herman and Herman 2013. While caffeine may have some indirect effects on dopamine neurotransmission, its primary mechanism of action involves antagonizing adenosine activity. Porcaiskin 2011. Adenosine is a neurotransmitter that promotes sleep. Caffeine is an adenosine antagonist. So, caffeine inhibits the adenosine receptors, thus decreasing sleepiness and promoting wakefulness. While caffeine is generally considered a relatively safe drug, high blood levels of caffeine can result in insomnia, agitation, muscle twitching, nausea, irregular heartbeat, and even death. Riceig strain and griffiths 2009, Walt, Ganetski, and Babu 2012. In 2012, Croman and Neielen reported on a case study of a 40-year-old woman who suffered significant ill effects from her use of caffeine. The woman used caffeine in the past to boost her mood and to provide energy. But over the course of several years, she increased her caffeine consumption to the point that she was consuming three lers of soda each day. Although she had been taking a prescription anti-depressant, her symptoms of depression continued to worsen and she began to suffer physically, displaying significant warning signs of cardiovascular disease and diabetes. Upon admission to an outpatient clinic for treatment of mood disorders, she met all of the diagnostic criteria for substance dependence and was advised to dramatically limit her caffeine intake. Once she was able to limit her use to less than 12 ounces of soda a day, both her mental and physical health gradually improved. Despite the prevalence of caffeine use and the large number of people who confessed to suffering from caffeine addiction, this was the first published description of soda dependence appearing in scientific literature. Nicotine is highly addictive and the use of tobacco products is associated with increased risks of heart disease, stroke, and a variety of cancers. Nicotine exerts its effects through its interaction with acetylcholine receptors. Acetylcholine functions as a neurotransmitter in motor neurons. In the central nervous system, it plays a role in arousal and reward mechanisms. Nicotine is most commonly used in the form of tobacco products like cigarettes or chewing tobacco. Therefore, there is a tremendous interest in developing effective smoking sessation techniques. To date, people have used a variety of nicotine replacement therapies in addition to various psychotherrapeutic options in an attempt to discontinue their use of tobacco products. In general, smoking sessation programs may be effective in the short term, but it is unclear whether these effects persist. Cropley, Theatum, Pravatoni, and Web 2008. Levit, Shaw, Wong, and Katarowski 2007. Smedzland, Fiser, BS, and Likenstein, 2004. Vaping as a means to deliver nicotine is becoming increasingly popular, especially among teens and young adults. Vaping uses battery powered devices, sometimes called ecigarettes, that deliver liquid nicotine and flavorings as a vapor. Originally reported as a safe alternative to the known cancer-causing agents found in cigarettes, vaping is now known to be very dangerous and has led to serious lung disease and death in users. Schmurling 2019. Opioids. An opioid is one of a category of drugs that includes heroin, morphine, methadone, and codin. Opioids have analesic properties, that is, they decrease pain. Humans have an indogenous opioid neurotransmitter system. The body makes small quantities of opioid compounds that bind to opioid receptors, reducing pain and producing euphoria. Thus, opioid drugs which mimic this indogenous painkilling mechanism have an extremely high potential for abuse. Natural opioids called opiates are derivatives of opium which is a naturally occurring compound found in the poppy plant. There are now several synthetic versions of opiate drugs correctly called opioids that have very potent painkilling effects and they are often abused. For example, the National Institutes of Drug Abuse has sponsored research that suggests the misuse and abuse of the prescription painkillers hydrocodone and oxycodone are significant public health concerns. Maxwell 2006. In 2013, the US Food and Drug Administration recommended tighter controls on their medical use. Historically, heroin has been a major opioid drug of abuse. Figure 4.17. Heroin can be snorted, smoked, or injected intravenously. Heroin produces intense feelings of euphoria and pleasure which are amplified when the heroin is injected introvenously. Following the initial rush, users experience four to six hours of going on the nod, alternating between conscious and semic-conscious states. Heroin users often shoot the drug directly into their veins. Some people who have injected many times into their arms will show track marks, while other users will inject into areas between their fingers or between their toes so as not to show obvious track marks. And like all abusers of introvenous drugs have an increased risk for contraction of both tuberculosis and HIV. Figure 4.17A. Common paraphernalia for heroin preparation and use are shown here in a needle exchange kit. B heroin is cooked on a spoon over a candle. Credit A modification of work by Todd Huffman. Aside from their utility as analesic drugs, opioid-like compounds are often found in cough suppressants, anti-nausea, and anti-diarrhea medications. Given that withdrawal from a drug often involves an experience opposite to the effect of the drug, it should be no surprise that opioid withdrawal resembles a severe case of the flu. While opioid withdrawal can be extremely unpleasant, it is not life-threatening. Julenne, 2005. Still, people experiencing opioid withdrawal may be given methadone to make withdrawal from the drug less difficult. Methadone is a synthetic opioid that is less euphoric than heroin and similar drugs. Methadone clinics help people who previously struggled with opioid addiction manage withdrawal symptoms through the use of methadone. Other drugs, including the opioid buprenorphine, have also been used to alleviate symptoms of opiate withdrawal. Codin is an opioid with relatively low potency. It is often prescribed for minor pain and it is available over-the-counter in some other countries. Like all opioids, codine does have abuse potential. In fact, abuse of prescription opioid medications is becoming a major concern worldwide. Aquina, Marques, Baptista, Bridgemond, and Merlin 2009. Casadi, Sedif, and Fifer Gershel 2012. Everyday connection, the opioid crisis. Few people in the United States remain untouched by the recent opioid epidemic. It seems like everyone knows a friend, family member, or neighbor who has died of an overdose. Opioid addiction reached crisis levels in the United States such that by 2019, an average of 130 people died each day of an opioid overdose. Naida 2019. The crisis actually began in the 1990s when pharmaceutical companies began mass marketing pain- relieving opioid drugs like Oxycontton with the promise now known to be false that they were non-addictive. Increased prescriptions led to greater rates of misuse along with greater incidence of addiction even among patients who used these drugs as prescribed. Physiologically, the body can become addicted to opiate drugs in less than a week, including when taken as prescribed. Withdrawal from opioids includes pain, which patients often misinterpret as pain caused by the problem that led to the original prescription and which motivates patients to continue using the drugs. The FDA's 2013 recommendation for tighter controls on opiate prescriptions left many patients addicted to prescription drugs like Oxycontton, unable to obtain legitimate prescriptions. This created a black market for the drug where prices soared to $80 or more for a single pill. To prevent withdrawal, many people turned to cheaper heroin, which could be bought for $5 a dose or less. To keep heroin affordable, many dealers began adding more potent synthetic opioids, including fentinol and carfentinyl, to increase the effects of heroin. These synthetic drugs are so potent that even small doses can cause overdose and death. Large-scale public health campaigns by the National Institutes of Health and the National Institute of Drug Abuse have led to recent declines in the opioid crisis. These initiatives include increasing access to treatment and recovery services, increasing access to overdose reversal drugs like Nlloxxone, and implementing better public health monitoring systems. NAIDIA 2019. Hallucinogens. A hallucinogen is one of a class of drugs that results in profound alterations in sensory and perceptual experiences. Figure 4.18. In some cases, users experience vivid visual hallucinations. It is also common for these types of drugs to cause hallucinations of body sensations, eg feeling as if you are a giant and a skewed perception of the passage of time. Figure 4.18. Psychedelic images like this are often associated with hallucinogenic compounds. Credit modification of work by new one Illuminati/ flicker. As a group, hallucinogens are incredibly varied in terms of the neurotransmitter systems they affect. Measculine and LSD are serotonin agonists in PCP angel dust in ketamine in animal anesthetic act as antagonists of the NMDA glutamate receptor. In general, these drugs are not thought to possess the same sort of abuse potential as other classes of drugs discussed in this section. Dig deeper. Medical marijuana. The decade from 2010 to 2019 brought many changes in laws regarding marijuana. While the possession and use of marijuana remains illegal in many states, it is now legal to possess limited quantities of marijuana for recreational use in 11 states: Alaska, California, Colorado, Illinois, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont, and Washington. Medical marijuana is legal in over half of the United States and in the District of Columbia. Figure 4.19. Medical marijuana is marijuana that is prescribed by a doctor for the treatment of a health condition. For example, people who undergo chemotherapy will often be prescribed marijuana to stimulate their appetites and prevent excessive weight loss resulting from the side effects of chemotherapy treatment. Marijuana may also have some promise in the treatment of a variety of medical conditions. Mather Rowendall Moxom Hall and Wodak 2013 Robson 2014 Shicho and Store 2014 Figure 4.19 Medical marijuana shops are becoming more and more common in the United States credit Lori Avocado. While medical marijuana laws have been passed on a state-by-state basis, federal laws still classify this as an illicit substance, making conducting research on the potentially beneficial medicinal uses of marijuana problematic. There is quite a bit of controversy within the scientific community as to the extent to which marijuana might have medicinal benefits due to a lack of large-scale controlled research. Bastwick 2012. As a result, many scientists have urged the federal government to allow for relaxation of current marijuana laws and classifications in order to facilitate a more widespread study of the drugs effects. Agarwal at all 2009, Bastwick 2012, Kogan and Machulum 2007. Until recently, the United States Department of Justice routinely arrested people involved and seized marijuana used in medicinal settings. In the latter part of 2013, however, the United States Department of Justice issued statements indicating that they would not continue to challenge state medical marijuana laws. This shift in policy may be in response to the scientific community's recommendations and/or reflect changing public opinion regarding marijuana. Learning objectives. By the end of this section, you'll be able to define hypnosis and meditation. Understand the similarities and differences of hypnosis and meditation. Our states of consciousness change as we move from wakefulness to sleep. We also alter our consciousness through the use of various psychoactive drugs. This final section will consider hypnotic and meditative states as additional examples of altered states of consciousness experienced by some individuals. Hypnosis. Hypnosis is a state of extreme self-focus and attention in which minimal attention is given to external stimuli. In the therapeutic setting, a clinician may use relaxation and suggestion in an attempt to alter the thoughts and perceptions of a patient. For individuals who are especially open to the power of suggestion, hypnosis can prove to be a very effective technique and brain imaging studies have demonstrated that hypnotic states are associated with global changes in brain functioning. Delasale at all 2012 Golden Vanhadeniza Bolley Loris and Sodu 2012. Historically, hypnosis has been viewed with some suspicion because of its portrayal in popular media and entertainment. Figure 4.20. Therefore, it is important to make a distinction between hypnosis as an empirically based therapeutic approach versus as a form of entertainment. Hypnosis is conducted by trained professionals with consenting clients, often in the context of ongoing therapy. While hypnosis may be useful in enhancing memory or a skill, such enhancements are very modest in nature. Raz 2011 figure 4.20. Popular portrayals of hypnosis have led to some widely held misconceptions. How exactly does a hypnotist bring a participant to a state of hypnosis? While there are variations, there are four parts that appear consistent in bringing people into the state of suggestability associated with hypnosis. National Research Council 1994. These components include the participant is guided to focus on one thing such as the hypnotist's words or a ticking watch. The participant is made comfortable and is directed to be relaxed and sleepy. The participant is told to be open to the process of hypnosis, trust the hypnotist, and let go. The participant is encouraged to use their imagination. These steps are conducive to being open to the heightened suggestability of hypnosis. People vary in terms of their ability to be hypnotized, but a review of available research suggests that most people are at least moderately hypnotizable. Kilstrom 2013. Hypnosis in conjunction with other techniques is used for a variety of therapeutic purposes and has shown to be at least somewhat effective for pain management, treatment of depression and anxiety, smoking sessation, and weight loss. Aladdin 2012, Elkins Johnson and Fiser 2012. Golden 2012, Montgomery, Schneer and Kravitz 2012. How does hypnosis work? Two theories attempt to answer this question. One theory views hypnosis as dissociation and the other theory views it as the performance of a social role. According to the dissociation view, hypnosis is effectively a dissociated state of consciousness. Much like our earlier example where you may drive to work, but you are only minimally aware of the process of driving because your attention is focused elsewhere. This theory is supported by Ernest Hillgard's research into hypnosis and pain. In Hillgard's experiments, he induced participants into a state of hypnosis and placed their arms into ice water. Participants were told they would not feel pain, but they could press a button if they did. While they reported not feeling pain, they did in fact press the button, suggesting a dissociation of consciousness while in the hypnotic state. Hillgard and Hillgard 1994. Taking a different approach to explain hypnosis, the social cognitive theory of hypnosis sees people in hypnotic states as performing the social role of a hypnotized person. As you will learn when you study social roles, people's behavior can be shaped by their expectations of how they should act in a given situation. Some view a hypnotized person's behavior not as an altered or dissociated state of consciousness but as their fulfillment of the social expectations for that role. Co 2009 co and Sarban 1966. Meditation. Meditation is the act of focusing on a single target such as the breath or a repeated sound to increase awareness of the moment. While hypnosis is generally achieved through the interaction of a therapist and the person being treated, an individual can perform meditation alone. Often, however, people wishing to learn to meditate receive some training and techniques to achieve a meditative state. Although there are a number of different techniques in use, the central feature of all meditation is clearing the mind in order to achieve a state of relaxed awareness and focus. Chen at all 2013, Lang at all 2012. Mindfulness meditation has recently become popular. In the variation of mindful meditation, the meditator's attention is focused on some internal process or an external object. Ziden, Grant, Brown, Macaffy, and Cogill, 2012. Meditative techniques have their roots in religious practices. Figure 4.21. But their use has grown in popularity among practitioners of alternative medicine. Research indicates that meditation may help reduce blood pressure. And the American Heart Association suggests that meditation might be used in conjunction with more traditional treatments as a way to manage hypertension. Although there is not sufficient data for a recommendation to be made. Brooke atall 2013. Like hypnosis, meditation also shows promise in stress management, sleep quality. Caldwell Harrison Adams Quinn and Greon 2010. Treatment of mood and anxiety disorders. Chen at all 2013. Freeman at all 2010. Volistad Neielson and Neielen 2012 and pain management riner Tibby and Lipits 2013. Figure 4.21A. This is a statue of a meditating Buddha representing one of the many religious traditions of which meditation plays a part. B. People practicing meditation may experience an alternate state of consciousness. Credit A. Modification of work by Jim Eper. Credit B. Modification of work by Caleb Ronic.