Sleep and Sleep Disorders

TERESITA A. HIDALGO-SISON, MD, DSBPP, DPCAM, FPSMS

Objectives
1. Discuss criteria under the three major categories of sleep
disorders.
2. Explain treatment options for each of the different sleep
disorders.
Outline
I. Normal Sleep
II. Sleep Disorders
III. Primary Sleep Disorders
IV. Sleep Disorders Related to Another Mental Disorder
V. Other Sleep Disorders
VI. Sleep and Aging
I. Normal sleep
Aproximately 8 hours of sleep at night
Sleep regulation complex
- dorsal raphe nucleus influences sleep through serotonergic
systems. Increase in serotonin promotes sleep
- locus ceruleus through norepinephrine mediated systems,
influences sleep systems, stimulation of this center disrupts
sleep patterns by decreasing rapid eye movement
Stages of sleep
1. wakefulness low voltage , fast waves
2. drowsiness alpha waves
3. non rapid eye movement ( NREM ) sleep
Stage 1 transition to sleep. Theta waves ( 3-7 cps ) . 5% of total
sleep time
Stage 2 light sleep. Sleep spindles ( 12-14 cps ) and triphasic
complexes 45% of total sleep time
Stages of sleep
Stage 3 slow wave sleep. Delta ( high amplitude, slow ) waves (
.5 -2.5 cps ) 12% of total sleep
Stage 4 slow wave sleep also. More than 50 % delta waves.
13% of total sleep time.
4. REM ( stage 5 )- low voltage , random fast waves that have
saw tooth ( alpha like ) wave pattern
Sleep Organization
Sleep latency 15-20 minutes
Sleep stages occur cyclically throughout the night; REM sleep
alternates with NREM sleep about every 90 minutes
NREM stage 3 and 4 occur during the first one third to one half of
the night and are absent during the last cycles of sleep.
REM sleep periods increase in duration toward the morning

Characteristics of REM sleep ( paradoxical sleep )

Autonomic instability increase HR, blood pressure, RR
Tonic inhibition of skeletal muscle tone leading to paralysis
Rapid eye movements
Dreaming, penile tumescence or vaginal lubrication
Reduced hypercapnic respiratory drive, no increase in tidal
volume as partial pressure of carbon dioxide decreases
Sleep Hygiene
1. Wake up at the same time daily.
2. Discontinue CNS acting drugs caffeine, nicotine, alcohol,
stimulants
3. Avoid daytime naps
4. Establish physical fitness
5.Avoid evening stimulation food, tv
6. Bath soaks before bedtime warm water
7. Eat regular meals
8. practice evening relaxation ; good bedtime conditions
DSM 5 classification
Insomnia Disorder
Hypersomnolence Disorder
Narcolepsy
DSM 5
Breathing related sleep Disorders :
1. Obstructive Sleep Apnea Hypopnea
2. Central Sleep Apnea
3. Sleep related hypoventilation
DSM 5
Circadian Rhythm Sleep-Wake Disorders
1. Delayed sleep phase type
2. Advanced sleep phase type
3. Irregular sleep wake type
4. non-24-hour sleep wake type
5. shift work type
DSM 5
Parasomnias
1. non- rapid eye movement sleep arousal disorders
2. nightmare disorder
3. rapid eye movement sleep behavior disorder
4. restless legs syndrome
DSM 5
Substance /Medication Induced Sleep Disorder
Insomnia Disorder

Most prevalent, 10-20 % primary settings

A.Predominant complaint of dissatisfaction with sleep quantity or
quality , associated with one or more of the following symptoms:
1. difficulty initiating sleep
2. difficulty maintaining sleep , with frequent awakenings or
problems returning to sleep after awakenings
3. early morning awakening with inability to return to sleep
Insomnia disorder
Sleep difficulty occurs at least 3 nights per week
Sleep difficulty is present for at least 3 months
Sleep difficulty occurs despite adequate opportunity for sleep
Not explained by another sleep wake disorder, substance or
medical condition
Insomnia disorder
Given as independent, co morbid with
another mental disorder or another sleep disorder
Sleep onset ( initial insomnia )
Sleep maintenance ( middle insomnia )
Early morning awakening (Late insomnia)
**Difficulty maintaining sleep is the most common single symptom ,
followed by difficulty falling asleep
With a lot of daytime and night time impairments
Definitions
Difficulty initiating sleep subjective sleep latency greater than
20-30 minutes
Difficulty maintaining sleep subjective time awake after sleep
onset greater than 20-30 minutes
no standard definition for early morning awakening but at least
30 minutes before scheduled time or less than 6.5 hours.
( consider bedtime )
Hypersomnolence Disorder
A. Self reported excessive sleepiness
( hypersomnolence) despite a main sleep period lasting at least 7
hours with at least 1 of the following :
1. Recurrent periods of sleep or lapses into sleep within the same
day
2. A prolonged main sleep episode of more than 9 hours per day
that is nonrestorative
3. Difficulty being fully awake after abrupt awakening
occurs at least 3 times /week for 3 months
Hypersomnolence
With distress and impairments
not explained by other substances, medical condition or does
not occur exclusively during the course of another sleep disorder
Fall asleep quickly with good sleep efficiency

Q- sleep inertia ( prolonged impairment of alertness at the sleep

wake transition) sleep drunkenness
Questions
Light sleep. Sleep spindles ( 12-14 cps ) and triphasic complexes
45% of total sleep time
Difficulty maintaining sleep is the most common single
symptom , followed by difficulty falling asleep
Avoid evening stimulation food, tv, or high attention situations
Average night time sleep episode > 9 hours, non-restorative
Narcolepsy
Recurrent periods of an irrepressible need to sleep , lapsing into
sleep or napping occurring within the same day
3 times over 3 months
1. episodes of cataplexy
A. individuals with long standing disease, brief episodes of
sudden bilateral loss of muscle tone with maintained
consciousness that are precipitated by laughter or joking
Narcolepsy
In children or individuals within 6 months of onset, spontaneous
grimaces or jaw opening episodes with tongue thrusting or global
hypotonia, without obvious emotional triggers
2. hypocretin deficiency using csf ( less than or equal to 110
pg/ml) without acute brain injury , inflammation or infection
Narcolepsy
Nocturnal sleep polysomnography with REM sleep latency less
than or equal to 15 minutes or a multiple sleep latency test
showing a mean sleep latency less than or equal to 8 minutes
and two or more sleep onset REM periods
Narcolepsy
4. Hypnagogic / hypnopompic hallucinations
Dreamlike experience during transitions from wakefulness to
sleep and vice versa
Vivid auditory or visual hallucinations or illusions
Narcolepsy
5. Sleep onset REM periods
( SOREMPS)
Appearance of REM within 15 minutes of sleep onset ( normal 90
minutes )
Narcolepsy can be distinguished from other mental disorders of
excessive daytime sleepiness
Multiple sleep latency test measures excessive sleepiness. MSLT
consists of 4 recorded naps at 2 hour intervals
Narcolepsy other findings
1. periodic leg movement

2. sleep apnea predominantly central

3. short leg latency
4. frequent night time arousals ; from REM sleep to stage 1 or
wakefulness , the patient usually is unaware of the awakenings
5. memory problems
6. ocular symptoms
7. Depression
8. automatic behavior no memory
Narcolepsy
Onset and clinical course
Full syndrome late adolescence or early 20s
Condition chronic without major remissions
Long delay between excessive somnolence to late appearance of
cataplexy
Narcolepsy
Causes abnormality of REM inhibiting mechanisms
Human leukocyte antigen ( HLA) DR2 and narcolepsy and HLADR2 , a type of human lymphocyte antigen
HLA-DR2 is also found in up to 30 % of unaffected person
Recent findings hypocretin
( neurotransmitter ) reduced in narcolepsy
Narcolepsy
Treatment :
Regular bedtime
Daytime naps scheduled at regular time of the day
Safety considerations caution while driving
Stimulants for daytime sleepiness ; high dose propranolol
( inderal ) may be effective
Tricyclics, SSRI for REM related symptoms
Narcolepsy
Drugs :
Treatment of excessive daytime somnolence
Stimulants
Methylphenidate
Pemoline
Modafinil
Amphetamine-dextroamphetamine
Dextroamphetamine
Narcolepsy
Treatment of cataplexy . Sleep paralysis and hypnogogic
hallucinations
Imipramine
Clomipramine

Desipramine
Protriptylline
SSRIs
Sertraline
Citalopram
Breathing Related Sleep Disorders
1. Obstructive sleep apnea hypopnea, central sleep apnea and
sleep related hypoventilation
Characterized by sleep disruption caused by sleep related
breathing disturbance , leading to excessive sleepiness,
insomnia, or hypersomnia.
Breathing disturbance include; apnea, hypoapneas, oxygen
desaturation
A. apnea three types, obstructive, central, mixed
Obstructive Sleep Apnea Hypopnea
Either 1 or 2
Evidence by polysomnography of at least five obstructive apneas
or hypopneas per hour of sleep and either of the following sleep
symptoms :
A. nocturnal breathing disturbances : snoring , snorting/gasping,
or breathing pauses during sleep
B. Daytime sleepiness, fatigue, or unrefreshing sleep despite
sufficient opportunities to sleep not explained by medical
condition or another mental disorder
Obstructive Sleep Apnea Hypopnea
Evidence by polysomnography of 15 or more obstructive apneas
and /or hypopneas per hour of sleep regardless of accompanying
symptoms
A. Apnea
1. Obstructive sleep apnea caused by cessation of air flow
through the nose or mouth in the presence of thoracic breathing
movements >> decrease in arterial oxygen saturation and
transient arousal respiration assumes normally
Occurs middle aged overweight men
( pickwickian syndrome )
Seen patients with smaller jaws , acromegaly, hypothyroidism
Loud snoring and intervals of apnea
Obstructive Sleep Apnea
Other symptoms :
Excessive daytime sleepiness , daytime sleep attacks , morning
headaches, morning confusion, depression, anxiety, may have
cardiac arrhythmia, systemic and pulmonary hypertension,
decreased sexual drive,

apneic events occur both REM and nonREM

10-20 seconds ; 5-10 events per hour of sleep
Patients unaware
Treatment
Nasal continuous positive airway pressure ( CPAP ) ,
uvulopharyngopalatoplasty, weight loss, SSRI, triccyclics
Sedatives and alcohol to be avoided exacerbate condition
Central sleep apnea cessation of air flow secondary to lack of
respiratory effort ; rare ; in elderly ; TX CPAP
Central Sleep Apnea DSM
Evidence by polysomnography of five or more central apneas per
hour of sleep .
The disorder is not better explained by another current sleep
disorder
A. idiopathic central sleep apnea repeated episodes of apneas
and hypopneas during sleep caused by variability in respiratory
effort but without evidence of airway obstruction
Central sleep apnea
Cheyne stokes breathing pattern of periodic crescendo
decrescendo variation in tidal volume that results in central
apneas and hypopneas at a frequency of at least 5 events per
hour , accompanied by frequent arousal
Central sleep apnea comorbid with opioid use
Breathing Related sleep disorder
B. Central alveolar hypoventilation- central apnea followed by an
obstructive phase
1. impaired ventilation that appears or greatly worsens only
during sleep and in which significant apneic episodes are absent
2. death may occur during sleep
( Ondines curse )
Hypoventilation treated with mechanical ventilation
Sleep related hypoventilation
Polysomnography demonstrates episodes of decreased
respiration associated with elevated CO2 levels
Disturbance not explained by another current sleep disorder
- idiopathic
-Congenital rare
-co-morbid sleep related hypoventilation
( due to medical conditions like pulmonary, neuromuscular,
medications )
Circadian Rhythm Sleep Wake Disorders
A. Persistent pattern of sleep disruption that is primarily due to
an alteration of the circadian system or to a misalignment
between the endogenous circadian rhythm and the sleep wake

schedule required by an individual s physical environment or

social or professional schedule
Circadian rhythm sleep wake disorders
The sleep disruption leads to excessive sleepiness or insomnia or
both
The sleep disturbance causes clinically significant distress or
impairment in social , occupational and other important areas of
functioning
Circadian
Delayed sleep phase type
History of a delay in the timing of the major sleep period
( usually more than 2 hours ) in the desired sleep and wake up
time , resulting in symptoms of insomnia, excessive sleepiness.
( usually with mental disorder )
Circadian
Advance sleep phase familial ,
Sleep wake times that are several hours earlier than desired or
conventional times . Diagnosis based on history of advance in
timing of major sleep period in relation to the desired sleep and
wake up time , with symptoms of early morning insomnia and
excessive daytime sleepiness.
Circadian

Irregular sleep wake-type history of symptoms of insomnia at

night ( during the usual sleep period ) and excessive sleepiness
( napping ) during the day.
Characterized by a lack of discernible sleep wake circadian
rhythm . No major sleep period and sleep is fragmented into at
least three periods during the 24 hour day
Non 24 hour sleep wake type
History of symptoms of insomnia or excessive sleepiness related
to abnormal synchronization between the 24 hour light dark
cycle and the endogenous circadian rhythm
( common among blind or visually impaired )
Shift work type
History of working outside of the normal daytime window ( 8-6)
particularly at night on regularly scheduled basis.
Symptoms of excessive sleepiness at work , impaired sleep at
home on a persistent basis
Circadian rhythm sleep- wake disorder- general
Misalignment between desired and actual sleep periods
Disturbance types :
Delayed sleep phase
Jet lag

Shift work
Unspecified advance sleep phase, non 24 hour , irregular or
disorganized sleep wake pattern
Quality of sleep normal
Treatment bright light therapy ; uncertain but melatonin is
suggested
Parasomnias
Non rapid eye movement sleep arousal disorders
- Recurrent episodes of incomplete awakening from sleep ,
usually occurring during the first third of major the major sleep
episode , accompanied by either one of the following :
1. sleepwalking
2. sleep terrors
Continuation
No or little dream imagery is recalled
Amnesia for the episodes is present
Episodes cause clinically significant distress or impairment
B. Parasomnias
unusual or undesirable phenomena during sleep or on the threshold of
wakefulness
1. nightmare disorder vivid dreams in which one awakens
frightened
Occurs during REM sleep
TX: benzodiazepines, tricyclics, SSRIs
Parasomnias
Sleep terrors
Occurs during deep, NREM sleep , stage III or IV sleep
Occurs during adolescence or later may be the first symptom of
temporal lobe epilepsy
Treatment rarely needed; diazepam as needed
Parasomnias
Sleep walking type somnambulism
Brief episodes of leaving bed and walking about without full
consciousness
Begins between 4-8 years with peak at age 12 ; disappears
spontaneously
Treatment : reassurance and education
Precaution include window guards and other measures to prevent
injury
Benzodiazepines can be used to suppress stage IV sleep
Rapid Eye Movement Sleep Behavior Disorder
Repeated episodes of arousal during sleep asociated with
vocalization and /or complex motor beahviors

Behaviors arise during rapid eye movement ( REM ) sleep and

therefore usually occur more than 90 minutes after sleep onset,
are more frequent during the later portions of the sleep period ,
and uncommonly occur during the daytime naps
Upon awakening from these episodes, the individual is
completely awake, alert, and not confused or disoriented
Either of the following :
1. REM sleep without atonia on polysomnographic recording
2. history suggestive of REM sleep behavior disorder and
synucleinopathy diagnosis ( parkinsons disease, multiple system
atrophy )
Impairment in functioning , not due to substances or medical
condition
Sleep Bruxism throughout the night , stage I and II sleep or
during partial arousals or transitions
Bite plates to prevent dental damage
REM sleep behavior disorder- loss of atonia during REM sleep
with complex, often violent behaviors
( acting out dreams ) ; in the elderly ; may occur as rebound to
sleep deprivation ; may occur in patients with stimulants and
SSRIs
TX : clonazepam
Parasomnia NOS
C. Sleep talking ( somniloquy ) ; with night terrors and
sleepwalking
Found in all stages of sleep ; no need for treatment
D. Rhythmic movement disorder
( jactatio capitis nocturna ) rhythmic head and body rocking just
before or during sleep
Limited to childhood
no treatment required
IV. Other Sleep Disorders
A. Sleep disorders Due to General Medical Condition
A. sleep related epileptic seizures
B. Sleep related cluster headaches
C. Chronic paroxysmal hemicrania
D. Sleep related abnormal swallowing syndrome
E. Sleep related asthma
Due to general medical condition
F. Sleep related cardiovascular symptoms
G. Sleep related gastro esophageal reflux
H. Sleep related hemolysis
Tx: underlying medical condition
B. Substance/ Medication- Induced Sleep Disorder

Prominent and severe disturbance in sleep

May be due to substances or exposure to medication
1. Use of medication or intoxication or withdrawal
Somnolence can be related to tolerance or withdrawal from a
CNS stimulant or sustained use of CNS depressants
Insomnia associated with tolerance or withdrawal from sedative
hypnotics , CNS stimulants, with long term alcohol consumption
As side effects of drugs anticonvulsants, antidepressants,
thyroid preparations , etc. )
V. Sleep and Aging
A. Subjective Reports by Elderly- time in bed increases ; total
sleep time at night decreases
Dissatisfaction with sleep
Sleep latency increases
Tired and sleepy during daytime
More frequent napping
V. Sleep and Aging
B. Objective evidence of age related changes in sleep cycle
Reduced total REM sleep
Reduced stage III and IV
Frequent awakenings
Reduced duration of nocturnal sleep
Need for daytime naps
Propensity for phase changes
Sleep and Aging
C. Certain sleep disorders are more common in the elderlynocturnal myoclonus, restless legs syndrome
REM sleep behavior disturbance
SUNDOWNING
( confusion from sedation )
D. Medications and medical disorders contribute to the problem