Sleep-wake disorders

BY:
1. Nathnael Gebeyehu
2. Kirubel Ferehiwot
3. Rediet Andualem
4. Miraf Assefa
5. Tsedenia Solomon
6. Nathnael Sinilew

Submitted to – Dr. Fasil

Contents
Sleep............................................................................................................................................................2
Electrophysiology of sleep.......................................................................................................................2
Sleep disorders............................................................................................................................................3
I. Insomnia disorder.................................................................................................................................3
II. Hyper-somnolence disorder................................................................................................................4
III. Narcolepsy..........................................................................................................................................6
IV. Breathing-related sleep disorder........................................................................................................7
A. Obstructive sleep apnea syndrome.................................................................................................7
B. Central sleep apnea.........................................................................................................................8
C. Sleep- related hypoventilation........................................................................................................8
V. Circadian rhythm sleep-wake disorders..............................................................................................8
Delayed sleep-wake phase..................................................................................................................9
Advanced sleep-wake phase................................................................................................................9
Irregular sleep wake rhythm................................................................................................................9
Non-24-hour sleep wake rhythm.......................................................................................................10
Shift work type...................................................................................................................................10
Parasomnias..........................................................................................................................................10
VI. Non-rapid eye movement sleep arousal disorders.......................................................................10
VII. Nightmare disorder.....................................................................................................................11
VIII. Rapid eye movement sleep behavior disorder...........................................................................11
IX. Restlessness leg syndrome...............................................................................................................12
X. Substance /medication-induced sleep disorder................................................................................12
References.................................................................................................................................................13

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 Sleep
It is a state of partial or full unconsciousness from which the person can be aroused by sensory
or other stimuli.
Voluntary functions are suspended.
The body rests and restores itself.
The functions of sleep
 physical and psychological restoration and recovery
 energy conservation
 memory consolidation
 discharge of emotions
 biological functions including maintenance of immune systems
 satisfying metabolic needs

Electrophysiology of sleep
Sleep- wake rhythm also called circadian rhythm.
Is a natural, internal process that regulates the sleep-wake cycle and repeats roughly every 24
hours.
This rhythm is not present at birth but develop in the first 2 years of life.
This internal clock is controlled by an area of the brain called the superchiasmatic nucleus
which is located in the hypothalamus.
The optic nerve senses the morning light and send signal to SCN which triggers the release of
cortisol and other hormones to help wake up.
But when darkness comes at night, the SCN sends messages to the pineal gland which triggers
the release of the chemical melatonin.

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 Sleep disorders
I. Insomnia disorder
Most common sleep complaint.
Persons with insomnia primarily have difficulty falling asleep, difficulty staying asleep, or
trouble waking early with an inability to fall back to sleep, sufficient to impair their functioning.
Population-based estimates indicate that about one-third of adults’ report insomnia.
It is a more prevalent complaint among females than among males.
May be transient or persistent.
Episodic insomnia: - related to grief, loss, or almost any life change or stress.
- Sx last at least 1 month but less than 3 months.
Persistent: - most often difficulty falling asleep rather than remaining asleep.
-Sx lasts 3 month or longer.
Diagnostic criteria
A predominant complaint is dissatisfaction with sleep quantity or quality, associated with one
(or more) of the following symptoms:
Difficulty initiating sleep.
Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to
sleep after awakenings.
Early-morning awakening with inability to return to sleep.
The sleep difficulty occurs at least 3 nights per week for at least 3 months.
Occurs despite adequate opportunity for sleep and does not occur during the course of another
sleep-wake disorder.
Not attributable to the physiological effects of a substance.
Coexisting mental disorders and medical conditions do not adequately explain the predominant
complaint of insomnia.
Insomnia may be accompanied by a variety of daytime complaints and symptoms, including
fatigue, decreased energy, and mood disturbances.

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Symptoms of anxiety or depression that do not meet criteria for a specific mental disorder
Can have interpersonal, social and occupational problems, increased daytime irritability, poor
concentration, reduced productivity and quality of life.
long term consequences include increased risks of major depressive disorder, hypertension and
myocardial infraction.
Treatment
• Nonspecific Measures to Induce Sleep (Sleep Hygiene)
• Pharmacologic
– benzodiazepines, zolpidem, Alprazolam
– Long-acting sleep medications (e.g., flurazepam, quazepam)
– short-acting drugs (e.g., zolpidem, triazolam)
• dietary supplements-melatonin and L-tryptophan
• Reassurance

II. Hyper-somnolence disorder

Excessive amounts of sleep, excessive daytime sleepiness (somnolence), or sometimes both.
Deteriorated quality of wakefulness (i.e., difficulty awakening or inability to remain awake
when required), and
sleep inertia (i.e., a period of impaired performance and reduced alertness following awakening
from the regular sleep episode or from a nap)
Late adolescence or early adulthood, with a mean age at onset of 17-24 years.
It has progressive onset,
Can be: -
 Acute: less than 1 month
 subacute: 1-3 month
 persistent: more than 3 months

Risk factors

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  Genetic and physiological: - may be familial with an autosomal dominant mode of
inheritance.
 Environmental: -
Stress and alcohol use.
Viral infections such as HIV, pneumonia, infectious mononucleosis.
Head trauma.
Diagnostic criteria
 Self-reported excessive sleepiness despite a main sleep period lasting at least 7 hours,
with at least one of the following symptoms:
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 (i.e.,
unrefreshing).
3. Difficulty being fully awake after abrupt awakening.
 The hypersomnolence occurs at least three times per week, for at least 3 months.
 The hypersomnolence is accompanied by significant distress or impairment in cognitive,
social, occupational, or other important areas of functioning.
Functional consequences of hypersomnolence disorder
Reduced efficiency
Diminished concentration
Poor memory
Significant distress and dysfunction in work and social relationships.
Unintentional daytime sleep episodes can be dangerous, (if for instance, the individual is
driving or operating machinery when the episode occurs)
Treatment
Stimulant drugs such as amphetamines and caffeins.
Non-sedating antidepressant drugs, such as SSRIs.

III. Narcolepsy
Is a chronic neurological disorder that affects the brain’s ability to regulate sleep-wake cycles.

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Due to death of hypocretin producing neurons.
It is a condition characterized by recurrent daytime naps or lapses into sleep.
Familial incidence.
Can occur at any age but frequently begins in adolescence or young adulthood, generally before
the age of 30 and progresses slowly and can maintain for life.
Sleep attacks: represent episodes of irresistible sleepiness, leading to perhaps 10—20 minutes
of sleep.
Can occur at inappropriate times (e.g., eating, talking, driving)
REM sleep include: -
 Hypnagogic and hypnopompic hallucinations
 Cataplexy and sleep paralysis.
 Cataplexy
 Sudden loss of muscle tone triggered by strong emotions.
 Patients often remain awake
 Sleep paralysis
 Most often occurring on awakening in the morning
 Patients are apparently awake and conscious but unable to move a muscle.
Diagnostic criteria
 Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping
occurring within the same day.
 These must have been occurring at least three times per week over the past 3 months.
Plus, the presence of at least one of the following:
1. Hypocretin deficiency, less than or equal to 110 pg/mL in CSF.
2. REM sleep latency less than or equal to 15 minutes.
3. Episodes of cataplexy.
Treatment
No cure but symptom management is possible.
Regimen of forced naps at a regular time of day.

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Drugs
Modafinil (stimulant): - reduce the number of sleep attacks and to improve psychomotor
performance.
TCA or SSRIs: -to reduce cataplexy.
-Imipramine, fluoxetine

IV. Breathing-related sleep disorder

Encompasses three relatively distinct disorders:
1. Obstructive sleep apnea/hypopnea
2. Central sleep apnea
3. Sleep related hypoventilation
A. Obstructive sleep apnea syndrome
Is the most common breathing-related sleep disorder.
It is characterized by repeated episodes of upper airway obstructions (apnea and hypopnea)
during sleep.
Apnea refers to total absence of airflow and hypopnea refers to a reduction in airflow for at
least 10 seconds in duration in adults or 2 missed breathes in children and is typically associated
with drops in oxygen saturation of 3% or greater.
The cardinal sxs of obstructive sleep apnea and hypopnea are snoring and daytime sleepiness.
Diagnostic criteria
Evidence 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.

Treatment
Nasal continuous positive airway pressure (NCPAP) is the treatment of choice for OSA.
Reduction of weight

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Nasal surgery
Tracheostomy
Patients must avoid the use of sedative medication, including alcohol.
B. Central sleep apnea
Characterized by inadequate tidal volume or respiratory rate during sleep.
Death may occur during sleep.
Diagnostic criteria
A. Evidence of five or more central apneas per hour of sleep.
B. The disorder is not better explained by another current sleep disorder.
Treated with some form of mechanical ventilation. (e.g., nasal ventilation)
C. Sleep- related hypoventilation
Episodes of decreased respiration associated with elevated CO2 levels.

V. Circadian rhythm sleep-wake disorders

Diagnostic criteria: -
A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of
the circadian system.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment in social,
occupational, and other important areas of functioning.
Subtypes
i. Delayed sleep-wake phase
ii. Advanced sleep –phase syndrome
iii. Irregular sleep- wake type
iv. Non-24-hour sleep-wake type
v. Shift work type
vi. unspecified type
Delayed sleep-wake phase
Sleep pattern that is delayed by two or more hours so that a person goes to sleep later at night
and awake later in the morning.

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Symptoms of sleep-onset insomnia, difficulty waking in the morning, and excessive early day
sleepiness are prominent.
Treatment
changing one’s internal circadian rhythms
Melatonin is a hormone that is widely available in supplement form.
CBT helps you change actions or thoughts that hurt your ability to sleep well. It helps you
develop habits that promote a healthy pattern of sleep.
Advanced sleep-wake phase
Causes people to fall asleep several hours before a normal bedtime and wake up hours earlier
than most people wake in the morning.
Diagnosis is based primarily on a history of an advance in the timing (usually more than 2hours),
with symptoms of early morning insomnia and excessive daytime sleepiness.
Treatment
CBT
Bright light therapy during the early evening hours
Irregular sleep wake rhythm
Circadian rhythms are so disorganized that there is no clear sleep or wake pattern.
People with this have a weak body clock.
This may happen in neurological conditions like: Dementia, Brain damage, Mental retardation
This can also happen in people with bad sleep habits & lack of proper exposure to daily light.
Treatment
Light treatment
Melatonin in children and teens
Education and behavioral counseling can be helpful.
Following the rules of good sleep hygiene.

Non-24-hour sleep wake rhythm

Common condition in totally blind person.
Causes a person's sleep time to shift a little later every day.

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Bad sleep habits & lack of proper exposure to daily light may allow this condition to occur in
people who have weaker clocks & neurological comorbidity.
Shift work type
Occurs when you have difficulties adjusting to a work schedule that takes place during a time
which most people sleep.
Is a conflict between your body’s circadian rhythms and your work schedule.

Parasomnias
Parasomnias are disorders characterized by abnormal behavioral, experiential, or physiological
events occurring in association with sleep.
The most common parasomnias:
 Non-rapid eye movement (NREM) sleep arousal disorders
 Nightmare disorder and
 Rapid eye movement (REM) sleep behavior disorder
VI. Non-rapid eye movement sleep arousal disorders
Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third
of the major sleep episode, accompanied by either one of the following:
1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While
sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of
others to communicate with him or her; and can be awakened only with great difficulty.
2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning
with a panicky scream. There is intense fear and signs of autonomic arousal. There is relative
unresponsiveness to efforts of others to comfort the individual during the episodes.
Amnesia for the episodes is present.
The episodes cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.

VII. Nightmare disorder

Dream that seems real and that incite anxiety, fear or other dysphoric emotions.
Nightmares occurring after traumatic experiences may replicate the threating situation
(‘’replicative nightmares”)

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On awakening nightmares are well remembered and can be described in detail.
Almost exclusively during rapid eye movement (REM) sleep.
Diagnostic criteria
A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams.
B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and
alert.
C. The sleep disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
VIII. Rapid eye movement sleep behavior disorder
Repeated episodes of arousal, often associated with vocalizations and/or complex motor
behaviors arising from REM sleep.
Involves a failure if the patient to have atonia (Sleep paralysis) during the REM stage sleep.
These behaviors may be termed as dream enacting behaviors. The eyes typically remain closed
during these events.
Diagnostic criteria
A. Repeated episodes of arousal during sleep associated with vocalization and/or complex
motor behaviors.
B. These 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 daytime naps.
C. Upon awakening from these episodes, the individual is completely awake, alert, and not
confused or disoriented.
Treatment
Treatment using behavioral techniques can be helpful
Desensitization and exposure therapy
Cognitive therapy can help address nightmare disorders
Pharmacotherapy: - prazosin, nitrazepam and triazolam

IX. Restlessness leg syndrome

Characterized by a desire to move the legs or arms, usually associated with uncomfortable
sensations typically described as creeping, crawling, tingling, burning, or itching.

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The symptoms of RLS can delay sleep onset and awaken the individual from sleep and are
associated with significant sleep fragmentation.
Diagnostic criteria
A. An urge to move the legs, usually accompanied by or in response to uncomfortable and
unpleasant sensations in the legs, characterized by all of the following:
1. The urge to move the legs begins or worsens during periods of rest or inactivity.
2. The urge to move the legs is partially or totally relieved by movement.
3. The urge to move the legs is worse in the evening or at night than during the day.
B. The symptoms in Criterion A occur at least three times per week and have persisted for at
least 3 months.

X. Substance /medication-induced sleep disorder

A. A prominent and severe disturbance in sleep.
B. There is evidence from the history, physical examination, or laboratory findings of both (1)
and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or after
withdrawal from or exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.

References
Diagnostic and statistical manual of mental disorders, 5th edition DSM-V by American Psychiatric
Association

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Kaplan and sadock’s synopsis of psychiatry by Robert Boland, Marcia Verdiun, Pedro Ruiz 12 th
edition
National institute of neurological disorders and stoke.gov
www.hopkinsmedicine.org

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