Sleep-Wake Disorders

Presentation Writeup
5/22/2025
BS Psychology (6TH B)
Written By:
Wania Ali Mirza 2057 (Insomnia)
Reha Adnan 2044 (Hypersomnlence)
Aqsa Bano 2050 (Narcolepsy)
Mishal Ayub 2051 (Circadian Rhythm Disrder)
Mahnoor Irfan 2048 (Non-Rapid Eye Movement Sleep Arousal Disorder)
Laiba Rubab 2043 (Nightmare Disorder)
Banafshi 2053 (Rapid Eye Movement Sleep Behavior Disorder)
Faria Shouqat 2051 (Restless Legs Syndrome)
Laiba Khan 2054 (Etiology)
Submitted To: Miss Kainat Waheed

International Islamic University

Islamabad, Pakistan
Department of Psychology
2022-2026
Insomnia Disorder:
Insomnia is a condition in which a person finds it hard to fall asleep, stay asleep, or wake up too
early and can’t fall back asleep. This happens even when a person has enough time and a
comfortable place to sleep. This disorder often causes issues with daytime activities such as
mood, energy, and focus.
According to Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), these sleep
troubles must occur at least 3 times a week and last for at least 3 months to be diagnosed as a
disorder.

Diagnostic Criteria:
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with
one or more of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep
without caregiver intervention)
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems
returning to sleep after awakenings.
3. Early morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course
of another sleep-wake disorder (e.g. narcolepsy, a breathing-related sleep disorder, a
parasomnia).
G. The insomnia is not attributable to the psychological effects of a substance (e.g., a drug of
abuse, a medication).
H. Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia.
Specify if:
With mental disorders, including substance use disorders
With mental conditions
With another sleep disorder
Episodic: Symptoms last at least 1 month but less than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.

Diagnostic Features:
Insomnia means having problems falling asleep, staying asleep, or waking up too early. It can
happen alone or with another mental or medical problem. People feel unhappy with their sleep,
and it affects their work, studies, or daily life.
It causes tiredness, poor focus, weak memory, and bad mood in the daytime. Some people, like
older adults, may sleep poorly but still feel fine in the day. The diagnosis depends on how the
person feels about their sleep and how it affects their daily life.

Case Study:

Background:
Mr. AB, a 21-year-old pharmacy student, visited his local pharmacy with a seven-day
prescription for diazepam 10 mg tablets, one to be taken at night. The medication was prescribed
by his general practitioner (GP) due to his recent sleep disturbances.

Presenting Complaint:
Approximately five weeks prior, Mr. AB began experiencing insomnia. Although he typically
needs to wake up at 7:00 am for lectures, he finds himself fully awake by 4:00 am. He does not
have difficulty falling asleep initially, nor does he wake up frequently during the night. However,
his early awakenings prevent him from achieving sufficient rest.
Daytime Symptoms:
During the day, Mr. AB reports feeling very tired, anxious, and tearful. These symptoms have
persisted despite taking the prescribed diazepam for three days.

Assessment:

 Sleep Pattern: Early morning awakenings without difficulty initiating sleep.

 Duration: Symptoms have been ongoing for over a month.
 Frequency: Occurs multiple times per week.
 Daytime Impairment: Fatigue, anxiety, and emotional distress.

Diagnosis:
Based on the DSM-5 criteria, Mr. AB meets the requirements for Insomnia Disorder,
characterized by:

 Difficulty maintaining sleep, (early morning awakenings).

 Sleep disturbance occurring at least three nights per week.
 Duration of sleep disturbance persisting for at least three months.
 Significant distress or impairment in social, occupational, or other important areas of
functioning.

Management:
The pharmacist advised Mr. AB on non-pharmacological interventions, including:

 Sleep Hygiene Education: Establishing a consistent sleep schedule, creating a restful

environment, and avoiding stimulants before bedtime.
 Cognitive Behavioral Therapy for Insomnia (CBT-I): Recommended as a first-line
treatment to address maladaptive sleep behaviors and thoughts.

Hyper somnolence disorder:

Hyper somnolence disorder is a sleep disorder that involves excessive daytime sleepiness,
despite a full night's sleep. Individuals with this condition tend to sleep for several hours at night,
usually in excess of 9 hours, and still wake up feeling tired or unrefreshed. They also take long
naps during the day that fail to refresh them. This continuous requirement for sleep can impact
daily functioning, such that it is hard to remain awake and alert during everyday activities such
as reading, working, or going to classes. In severe cases, drowsiness disrupts critical activities
and results in involuntary sleep attacks. Even though they sleep lots, people with
hypersomnolence typically have trouble with grogginess, slow thinking and low energy levels
during the day.
Diagnostic criteria
A. Self-reported excessive sleepiness (hypersomnolence) 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
non-restorative (i.e., un refreshing).
3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3
months.
C. The hypersomnolence is accompanied by significant distress or impairment in
cognitive, social, occupational, or other important areas of functioning.
D. The hypersomnolence is not better explained by and does not occur exclusively
during the course of another sleep disorder (e.g., narcolepsy, breathing-related
sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain the
predominant complaint of hypersomnolence.
Specify if:
With mental disorder, including substance use disorders
With medical condition
With another sleep disorder
Specify if:
Acute: Duration of less than 1 month.
Subacute: Duration of 1–3 months.
Persistent: Duration of more than 3 months.
Specify current severity:
Specify severity based on degree of difficulty maintaining daytime alertness
Mild: Difficulty maintaining daytime alertness 1–2 days/week.
Moderate: Difficulty maintaining daytime alertness 3–4 days/week.
Severe: Difficulty maintaining daytime alertness 5–7 days/week.
Diagnostic features
Hypersomnolence disorder is a situation where an individual experiences excessive daytime
sleepiness after receiving sufficient or even excess nighttime sleep. They sleep for more than 9
hours or even 20 hours in serious cases but still feel fatigued when they wake up. Long daytime
naps (more than an hour) are frequent but do not enhance alertness. Drowsiness sets in slowly
and tends to happen in a peaceful environment such as reading or television viewing, although in
advanced stages it may occur while at work or during conversations.

Upon waking, they can be confused, or disoriented—a condition referred to as "sleep inertia" or
"sleep drunkenness"—that may last from a few minutes up to hours. Others do tasks
automatically without being able to recall them. With ample sleep, rest is not refreshing, and they
tend to sleep in extra on weekends or holidays.
Case Study

Patient Profile:

 Age: 12 years
 Sex: Male
 Presenting Complaint: Episodes of excessive sleepiness and unresponsiveness
 Duration: Recurrent over 3 years
 Frequency: A few times per year
 Episode Length: 30 to 72 hours

Clinical History:

 The child was brought to the emergency department due to excessive sleepiness and lack
of response to verbal stimuli.
  The current episode was triggered by vomiting and numbness of the tongue following a
meal.
 During the episode, the child slept continuously for over 36 hours, waking only briefly to
eat or use the bathroom.
 Episodes often started with gastrointestinal symptoms (vomiting, tongue numbness).
 Between episodes, the child exhibited normal functioning with no mental, behavioral, or
neurological issues.

Medical Evaluation:

 Blood tests: Normal

 MRI (Brain scan): No abnormalities
 Polysomnography (Sleep study): Normal sleep architecture
 EEG: Showed slowed brain waves
 PET Scan: Revealed decreased activity in the thalamus and brainstem – areas responsible
for regulating wakefulness and sleep

Diagnosis:

 Hypersomnolence Disorder (Recurrent form)

 Other differentials such as epilepsy and behavioral issues were ruled out due to normal ne
urological function outside of episodes and consistent presentation.

Treatment & Outcome:

 Initial treatment: Modafinil (a wakefulness-promoting agent)

 Subsequent treatment: Switched to methylphenidate
 Response: Significant reduction in frequency and duration of episodes
 Outcome: Improved alertness, academic performance, and quality of life

This case shows how Hyper-somnolence Disorder can manifest differently in kids and be mistak
en for epilepsy on behavioral issues. Discovering potential causes, like impaired functioning in p
arts of the brain that govern sleep, can provide prompt diagnosis and proper treatment enhancing
the quality of life in the child and lessening misdiagnosis.

Narcolepsy Disorder:

A long-term neurological condition called narcolepsy interferes with the brain's capacity to
control sleep-wake cycles. Regardless of how much or how well they sleep at night, people with
narcolepsy frequently experience excessive daytime sleepiness (EDS) and unexpected,
uncontrollable episodes of falling asleep during the day. Usually, there are two primary
categories for the condition: Narcolepsy type 1 (accompanied by cataplexy): characterised by
EDS and cataplexy, or abrupt muscle paralysis brought on by intense emotions; this condition is
frequently linked to low levels of the brain chemical hypocretin. EDS without cataplexy is a
feature of type 2 narcolepsy, which typically has normal hypocretin levels. Diagnostic
Standards.

Diagnostic Criteria:

A. 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.
B. The presence of at least one of the following:

1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per
month:

a. In individuals with long-standing disease, brief (seconds to minutes) episodes of

sudden bilateral loss of muscle tone with maintained consciousness that are precipitated
by laughter or joking.

b. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-

opening episodes with tongue thrusting or a global hypotonia, without any obvious
emotional triggers.

2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1

immunoreactivity values (less than or equal to one-third of values obtained in healthy
subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF
levels of hypocretin-1 must not be observed in the context of acute brain injury,
inflammation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye movement (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.

Specify whether:
G47.411 Narcolepsy with cataplexy or hypocretin deficiency (type 1): Criterion B1 (episodes of
cataplexy) or Criterion B2 (low CSF hypocretin-1levels) is met.

G47.419 Narcolepsy without cataplexy and either without hypocretin deficiency or hypocretin
unmeasured (type 2): Criterion B3 (positive polysomnography/multiple sleep latency test) is met,
but Criterion B1 is not met(i.e., no cataplexy is present) and Criterion B2 is not met (i.e., CSF
hypocretin-1levels are not low or have not been measured).

G47.421 Narcolepsy with cataplexy or hypocretin deficiency due to a medical condition

G47.429 Narcolepsy without cataplexy and without hypocretin deficiency due to a medical
condition.

Diagnostic Features

 Criterion A: Daytime sleep episodes ≥3 times/week for ≥3 months.

 Criterion B: At least one of:Cataplexy ,Hypocretin deficiency ,Abnormal sleep studies
(Polysomnogram/MSLT
 Narcolepsy involves excessive daytime sleepiness (≥3 times/week for ≥3 months).
 NT1 includes cataplexy, often triggered by emotions, and is usually caused by low
hypocretin
 NT2 lacks cataplexy and usually has normal hypocretin diagnosis is based on sleep
studies.
 Cataplexy: Sudden, brief muscle weakness; person stays conscious.
 In children, cataplexy may appear as continuous muscle weakness (e.g., slack jaw).
 MSLT confirms diagnosis: sleep latency ≤8 min + ≥2 SOREMPs (REM in naps).
 False positives an occur due to sleep loss, shift work, or meds.
 NT1 tests are reliable; NT2 tests are less so (<50% reliable).

Case Study:

Patient: Ali 17 years old

Background: Ali is a high school student who began to struggle with extreme daytime sleepiness
and sudden episodes of muscle weakness, especially when laughing or excited.

Symptoms:

Frequent daytime sleep attacks, even after a full night's sleep

Cataplexy: sudden loss of muscle tone triggered by emotions

Difficulty staying awake in class

Sleep paralysis and vivid hallucinations when falling asleep

Diagnosis:

Ali visited a sleep specialist and underwent a polysomnography and Multiple Sleep Latency Test
(MSLT). The tests confirmed narcolepsy with cataplexy, likely caused by a deficiency in the
brain chemical hypocretin (orexin).

Treatment Plan:

Prescribed modafinil to promote wakefulness Low-dose antidepressants to help manage

cataplexy Educated on the importance of scheduled naps and consistent sleep habits.

Outcome:

Ali showed significant improvement in daytime alertness and school performance with treatment
and lifestyle changes.

Circadian Rhythm Sleep-Wake Disorders

Circadian Rhythm Sleep-Wake Disorder is a sleep disorder in which a person’s internal body
clock (circadian rhythm) is not aligned with the external environment or daily schedule. This
misalignment causes difficulty in falling asleep, staying asleep, or waking up at socially
acceptable times. Although the person’s total sleep time may be normal if allowed to follow their
natural rhythm, the mismatch with required routines (like work or school) leads to insomnia,
excessive daytime sleepiness, and impaired functioning in daily life. This disorder includes
several subtypes, such as delayed sleep phase, advanced sleep phase, shift work type, and others.

Diagnostic criteria

A. A persistent or recurrent 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.
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.

Specify whether:

G47.21 Delayed sleep phase type: A pattern of delayed sleep onset and Awakening times,
with an inability to fall asleep and awaken at a desired or Conventionally acceptable earlier
time.

Specify if:

Familial: A family history of delayed sleep phase is present.

Specify if:

Overlapping with non-24-hour sleep-wake type: Delayed sleep Phase type may overlap
with another circadian rhythm sleep-wake Disorder, non-24-hour sleep-wake type.

G47.22 Advanced sleep phase type: A pattern of advanced sleep onset and Awakening
times, with an inability to remain awake or asleep until the desired or Conventionally
acceptable later sleep or wake times.

Specify if:
Familial: A family history of advanced sleep phase is present.

G47.23 Irregular sleep-wake type: A temporally disorganized sleep-wake Pattern, such that
the timing of sleep and wake periods is variable throughout the 24-hour period.

Delayed Sleep Phase Type

Diagnostic Features

The delayed sleep phase type is based primarily on a history of a delay in the timing of the
major Sleep period (usually more than 2 hours) in relation to the desired sleep and wake-up
time, Resulting in symptoms of insomnia and excessive sleepiness. When allowed to set their
own Schedule, individuals with delayed sleep phase type exhibit normal sleep quality and
duration for Age. Symptoms of sleep-onset insomnia, difficulty waking in the morning, and
excessive Sleepiness early in the day are prominent.

Clinical case (Delayed sleep Phase type)

Patient Details:

Age:16 years old

Gender: Male

Presenting Complaint:

The patient presented with a two-year history of delayed sleep onset, difficulty waking up for
school, excessive daytime drowsiness, and associated mood and behavioral disturbances.

History and Symptoms:

 Sleep onset delayed by several hours despite a quiet, dark environment.

 Difficulty waking up in time for school, leading to frequent absenteeism.
 Daytime sleepiness and dozing off during classes.
 Increased irritability, impulsivity, distractibility, and restlessness.
  Referred to himself as a “night owl.”
 On weekends and holidays, he would wake up in the afternoon feeling well-rested,
indicating misalignment between his internal clock and daily schedule.

The condition progressively worsened over two years, significantly impairing his academic and
social functioning.

Clinical Presentation:

No history of manic episodes, psychosis, major depression, anxiety disorder, or substance use.

Similar sleep issues reported in his father during adolescence.

Previously misdiagnosed with ADHD and Bipolar Disorder and treated with stimulants, mood
stabilizers, and antipsychotics without improvement.

Mental Status Examination:

Irritable but cooperative.

Normal cognitive functions and speech.

No suicidal or delusional ideation.

Physical and Neurological Examination

Physical, neurological, and ENT exams: Unremarkable.

Diagnostic Evaluation:

Basic lab tests: NormalEEG and Polysomnography (sleep study): Normal

Diagnostic criteria met for Delayed Sleep-Wake Phase Disorder (DSPD) according to DSM-5.

Treatment:
Initiated on light therapy (10,000 lux) for 30–90 minutes at or before his spontaneous waking time.

Structured sleep hygiene routine established.

Outcome:

Marked improvement in symptoms.

No maintenance medications required.

No recurrence of sleep, mood, or school-related issues on follow-up.

Conclusion:

This case highlights a classic presentation of Delayed Sleep-Wake Phase Disorder, often
misdiagnosed as ADHD or mood disorder due to overlapping behavioral symptoms. Proper
diagnosis through clinical history, exclusion of other conditions, and successful treatment with light
therapy and sleep hygiene emphasize the importance of considering circadian rhythm disorders in
adolescents with academic and behavioral difficulties.

Parasomnias:

Parasomnias are disorders characterized by abnormal behavioral, experiential, or physiological

events occurring in association with sleep, specific sleep stages, or sleep-wake transitions.

Non-Rapid Eye Movement Sleep Arousal Disorder:

Diagnostic Criteria:

A. 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, such as mydriasis,
tachycardia, rapid breathing, and sweating, during each episode. There is relative
unresponsiveness to efforts of others to comfort the individual during the episodes.

B. No or little (e.g., only a single visual scene) dream imagery is recalled.

C. Amnesia for the episodes is present.

D. The episodes cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication).

F. Coexisting mental disorders and medical conditions do not explain the episodes of
sleepwalking or sleep terrors.

Specify whether:

F51.3 Sleepwalking type

Specify if:

With sleep-related eating

With sleep-related sexual behavior (sexsomnia)

F51.4 Sleep terror type

Diagnostic Features:

Non–Rapid Eye Movement (NREM) Sleep Arousal Disorders are characterized by repeated episodes
of incomplete arousals, typically occurring during the first third of the main sleep period. These episodes
are usually brief, lasting 1 to 10 minutes, but can sometimes extend up to an hour. The maximum duration
is not clearly defined. Individuals usually have their eyes open during these events.

It is common for individuals to display both subtypes of arousal—sleepwalking and sleep terrors—at
different times, indicating a shared underlying neurological basis. These subtypes represent varying levels
of overlap between wakefulness and NREM sleep, leading to complex behaviors during sleep that involve
different levels of consciousness, physical movement, and autonomic activity.

Sleepwalking:

The key feature of sleepwalking is the occurrence of repeated episodes of complex movements during
sleep, such as getting out of bed and walking (Criterion A1). These episodes can begin in any stage of
NREM sleep but are most common during slow-wave sleep, typically in the first third of the night.
During a sleepwalking episode, individuals show decreased alertness, a blank stare, and limited
responsiveness to others. They are difficult to wake and often don’t remember the event. Afterward, there
may be a short period of confusion before normal cognitive functioning returns.

Sleep Terrors:

Sleep terrors involve sudden awakenings from sleep, usually marked by a loud scream or cry (Criterion
A2). Like sleepwalking, these episodes typically occur in the first third of the night and last from 1 to 10
minutes, though they may last longer in children. Episodes are marked by extreme fear and physical signs
of autonomic arousal (e.g., fast heartbeat, rapid breathing, sweating, pupil dilation). The person may sit
up suddenly, appear terrified, and be difficult to comfort or awaken. If they do wake, they usually recall
little to nothing of the experience. Sleep terrors are also known as "night terrors" or pavor nocturnus.

Determining Disorder and Severity:

Whether these behaviors qualify as a disorder depends on several individual factors, including how often
they occur, the risk of harm or injury, social embarrassment, and the level of disruption or distress caused
to others in the household. Severity should be assessed based on the impact or consequences of the
behavior, rather than frequency alone.

Case Study:

Adult-Onset Sleep Terrors with Hypnopompic Hallucinatory Pain

Patient Profile:

 Age: 43-year-old woman

 History: No personal or family history of parasomnias during childhood or adulthood

Symptoms:

The patient reported experiencing nighttime episodes marked by sudden, intense pain and
screaming during sleep. These episodes typically occurred within two hours of falling asleep.
She exhibited partial memory loss of the events and could not identify any specific triggers.

Clinical Course:

The episodes began around age 30 and progressively increased in frequency. Each event
involved abrupt awakenings accompanied by severe pain and vocal distress. Despite repeated
occurrences, the patient retained only fragmented recall of the experiences.

Diagnostic Evaluation:

 Polysomnography (PSG): Confirmed sleep terrors by documenting episodes arising

from NREM sleep.
 Neurological Workup: Imaging of the brain and spine, along with neurophysiological
testing, excluded alternative causes of the pain.
 Differential Diagnosis: Other potential sleep disorders such as nocturnal seizures and
periodic limb movements were ruled out.

Diagnosis:

A rare case of adult-onset sleep terrors associated with hypnopompic hallucinatory pain,
occurring in the absence of any psychiatric or neurological comorbidity.

Treatment and Outcome:

 Medications Attempted: Trials of some medicines were unsuccessful and poorly

tolerated. Trazodone exacerbated the episodes.
  Outcome: The sleep terror episodes continued despite pharmacological management,
underscoring the difficulty in treating this unusual presentation.

Clinical Significance:

This case highlights a rare and complex manifestation of NREM parasomnia, characterized by
hypnopompic hallucinatory pain without any associated comorbid conditions. It emphasizes
the necessity of thorough diagnostic evaluation in atypical sleep disorder presentations and the
challenges of managing refractory cases.

Nightmare disorder

Diagnostic criteria

A. Repeated occurrences of extended, extremely dysphoric, and well-remembered

dreams that usually involve efforts to avoid threats to survival, security, or
physical integrity and that generally occur during the second half of the major
sleep episode.

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.

D. The nightmare symptoms are not attributable to the physiological effects of a

substance (e.g., a drug of abuse, a medication).

E. Coexisting mental disorders and medical conditions do not adequately explain

the predominant complaint of dysphoric dreams.

Specifier

Specify if:

During sleep onset

Specify if:
With mental disorder, including substance use disorders

With medical condition

With another sleep disorder

Specify if:

Acute: Duration of period of nightmares is 1 month or less.

Subacute: Duration of period of nightmares is greater than 1 month but less

than 6 months.

Persistent: Duration of period of nightmares is 6 months or greater.

Specify current severity:

Severity can be rated by the frequency with which the nightmares occur:

Mild: Less than one episode per week on average.

Moderate: One or more episodes per week but less than nightly.

Severe: Episodes nightly.

Diagnostic feature

Nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem

real and that incite anxiety, fear, or other dysphoric emotions. Nightmare content typically

focuses on attempts to avoid or cope with imminent danger but may involve themes that evoke

other negative emotions. Nightmares occurring after traumatic experiences may replicate the

threatening situation (“replicative nightmares”), but most do not. On awakening, nightmares are
well remembered and can be described in detail. They arise almost exclusively during REM

sleep and can thus occur throughout sleep but are more likely in the second half of the major

sleep episode when dreaming is longer and more intense. Factors that increase early-night REM

intensity, such as sleep fragmentation or deprivation, jet lag, and medications that affect REM

sleep, might facilitate nightmares earlier in the night, including at sleep onset.

Nightmares usually terminate with awakening and rapid return of full alertness. However, the

dysphoric emotions may persist into wakefulness and contribute to difficulty returning to sleep

and lasting daytime distress. Some nightmares, known as “bad dreams,” may not induce

awakening and are recalled only later. If nightmares occur during sleep-onset REM periods

(hypnagogic), the dysphoric emotion is frequently accompanied by an awakening and being

unable to move voluntarily (sleep paralysis), which may also occur in isolation without a

preceding dream or nightmare.

Case Study: Nightmare Disorder in a 24-Year-Old Female

Patient Information:

Name: A.M. (pseudonym)

Age: 24

Sex: Female

Occupation: University student

Referral Reason: Frequent, distressing nightmares causing daytime impairment.

Presenting Complaint:

A.M. reported experiencing vivid, terrifying nightmares approximately 4 to 5 times per week for
the past six months. The dreams often involved being chased, attacked, or witnessing harm to
loved ones. These episodes frequently caused her to awaken abruptly and left her feeling anxious
and fearful, impacting her ability to fall back asleep.

History:

Psychiatric History: No prior diagnosis. Some symptoms of mild anxiety.

Medical History: No significant issues.

Family History: Mother has generalized anxiety disorder.

Substance Use: Denied substance or alcohol use.

Sleep History: No history of sleepwalking, night terrors, or narcolepsy. Sleep hygiene is

generally poor due to academic stress.

Diagnostic Assessment:

Clinical Interview: Structured Clinical Interview for DSM-5 (SCID-5)

Sleep Diary & Nightmare Log: Maintained for 2 weeks

Polysomnography (optional): Not conducted, as symptoms aligned well with Nightmare

Disorder criteria

Diagnosis:

DSM-5 Criteria for Nightmare Disorder:

Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams.

The dreams usually involve threats to survival, security, or physical integrity.

On awakening, the individual rapidly becomes oriented and alert.

The episodes cause significant distress or impairment in social, occupational, or other

important areas.

Not attributable to substance use or another mental/medical disorder.

Final Diagnosis: Nightmare Disorder

Treatment Plan:

Imagery Rehearsal Therapy (IRT): A.M. was trained to rewrite her nightmares with
non-distressing endings and mentally rehearse them.

Cognitive Behavioral Therapy for Insomnia (CBT-I): Included to address sleep

hygiene and reduce anxiety.

Relaxation Training: Progressive muscle relaxation and deep breathing exercises before
bed.

Sleep Hygiene Education: Reduced caffeine intake, consistent sleep schedule, no screen
time before bed.

Outcome:

After 8 weeks of therapy, the frequency of nightmares reduced to once a week, with improved
sleep quality and reduced daytime anxiety. Follow-up at 3 months showed continued
improvement and no recurrence of distressing symptoms.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Rapid eye movement sleep behavior disorder:

Diagnostic criteria:

A: Repeated episodes of arousal during REM sleep associated with vocalization and complex
motor behavior.

B: These behavior arose during rapid eye movement sleep and therefore usually occur more than
9 minutes after sleep onset are more frequently during the later portion of sleep period and
uncommonly occure during day time naps.

C: Upon awaking from thses episode the individually is commonly awake,alert or not confused
or disoriented.
D: Either of following;
1: REM sleep without atonia was polysomnographic recording.
2: A history suggestive for REM sleep behavior disorder and established synocleinopathy
diagnosis(i,e Parkinson's disease during multiple system atrophy)
E: The behavior cause clinicaly significant distress or impairment in social occupational or other
important area of functioning ( which may include injury to self or the bed partner).
F: The disturbance is not attributable to physiological effect of substance(i,e is a drug abuse or
medication) or another medical condition
G: Coexisting mental disorder and medical condition do not explain episodes.

Diagnostic feature:

The essential feature of REM sleep behavior disrorder is vocalization and or complex motor
behavior arises from REM sleep(criteria A). These behavior often reflects motor response to the
content of action filled or violent dream of being attacked or trying to escape from threatening
situation which may be tearm as dream enacting behavior. The vocalization are often loud
emotional filled profane. These behavior may be var bothersome to the individual or the bad
partner and may result in significant injury (i.e falling,jumping or flying out of bed
running,punching, trusting or hitting or kicking). However individual with REM sleep behavior
may also present with relatively subtle with vocal or motor behavior during REM sleep which
are typically not the primary presentating sleep complaints but manifest during history taking
orpolysomnography sleep neurological and psychiatric clinical visit upon awaking than
individual is usually immediately awake,alert and oriented ( criteria C),and is often able to recall
dream mentioned which closely corelate with observed behavior. The eyes typically remain
closed during these events. The presence of REM sleep without atnoia during apolysomnography
is typically required for diagnosis of REM sleep behavior disrorder. Alternatively if
polysomnography is no being performed a provisional diagnosis of probable REM sleep
behavior disrorder may be given if there is an established synucleinopathy diagnosis (e.g
parkinson's, multiple system atrophy) and history is suggestive of REM sleep behavior disrorder
(criteria D). The diagnosis of REM sleep behavior disrorder required clinical significance
distress or impairment ( criteria E). This determination depend on a number of factors including
the frequency of events,the potential of violence or injurious behavior, embarrassement and
distress in other house members. Severity determination is best made based on nature of
consequences of behavior rather than simply on frequency. Although the behavior are
typically,violent lesser behavior may also occure.

Case study of Rapid eye movement sleep behavior disorder:

Patient information:
Name: Ahmad
Age: 62
Gender: Male
Occupation: Retired Army officer
Marital status: Married
Mrs. Ahmad presented to the sleep clinic with history of violent movement during sleep,
including punching or kicking for the last 6 months. His wife reported several incident of him
shouting,swearing and falling his arms at night sometime result is injuries to both himself and
her.
History of patients illness:
The patient reported vivid and often flighting dreams typicalky being attack or chased. He would
physically act out these dreams kicking,punching or falling out of bed. He would unaware abouth
his actions untile his wife brought them to his attention. The behavior occur several time or week
and we're most noticeable during the later half of night.

Medical history:
Parkinsonism: mild termors noticed over the past year not formally diagnosed.
Hypertension controlled with medication.
Non history of seizuras substances abuse or psychiatric illness
Family history:
No family history of sleep disorder or Neurodegenarative disease.

Medication:
Amlodipine (for hypertension)
Non recent medication change.
Physical and Neurogolical examination.
Normal physical exam physical exam,mild bradykinesia observe in neurological exam.
Diagnostic work-up:
Polysomnography(sleep study), increase muscle tone(loss of REM atnoia during REM),complex
motor behavior observe during REM phase.

Diagnosis: REM sleep behavior disorder.

Safety measures:
Remove sharap objects from bedroom, install pepped bed rails,place mattresses on floor if
necessary

Discussion:
RBD is parasomnia chaterizard by loss of muscle during REM sleep resulting is dream
enactment behavior. It often preceds Neurodegenarative disease such as parkinson disease and
lewy body dementia. Early identification is important for both symptoms management and
Neurologic surveillance.

Observed symptoms (case study) Related DSM-5 criteria

His wife reported that frequently shouted use Repeated episodes of arousal during REM
abusive language and displayed physically sleep associated with vocalization and complex
aggressive behavior such motor behavior.
kicking,punchingduring sleep.
His behaviors were more noticeable at second These behavior arise during rapid eye
half of night aligning with the typical timing movement sleep and therefore usually occur
REM sleep phases. more than 9 minutes after sleep onset are more
frequently during the later portion of sleep
period and uncommonly occure during day
time naps.
 He was unawera of his behaviors untile Upon awaking from thses episode the
informed by his wife but he did not experience individually is commonly awake,alert or not
any confusion and deorienttation upon awaking confused or disoriented.
fulfilling his criteria.
A sleep study confrimed absence of normal : Either of following;
muscle atonia during REM sleep ( i.e elevated
muscle tone). Additionally he shown early 1: REM sleep without atonia was
symptoms of Parkinson's which support the polysomnographic recording.
diagnosis further.
2: A history suggestive for REM sleep
behavior disorder and established
synocleinopathy diagnosis(i,e Parkinson's
disease during multiple system atrophy)
This cause physical harm for himself and his The behavior cause clinicaly significant
wife along with increased fear and anxiety distress or impairment in social occupational or
around sleep. This highlights significant other important area of functioning ( which
functional and safety impairment. may include injury to self or the bed partner).
There was no history of substance use or other The disturbance is not attributable to
acute medical condition that could explain the physiological effect of substance(i,e is a drug
symptoms. abuse or medication) or another medical
condition
Coexisting mental disorder and medical Coexisting mental disorder and medical
condition do not explain episodes. condition do not explain episodes.
So, Mr,Ahmad clearly meet all key DSM-5 diagnostoc criteria for REM sleep behavior disrorder.

Restless Legs Syndrome (RLS)

Overview:

Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease, is a neurological

sensorimotor disorder characterized by an uncontrollable urge to move the legs, usually
accompanied by unpleasant sensations in the limbs. These symptoms are particularly pronounced
during periods of rest or inactivity and are relieved by movement. RLS significantly affects sleep
quality and can result in daytime fatigue and distress.

Diagnostic Criteria :

A. Urge to Move the Legs + Sensations

An urge to move the legs, often with unpleasant or uncomfortable sensory symptoms such as:
creeping, crawling, tingling, burning, itching, pulling or aching.

A1. Onset or Worsening with Rest

Symptoms start or get worse during rest or inactivity, such as lying or sitting for long periods.

A2. Relief by Movement

Moving the legs (walking, stretching, rubbing) brings partial or complete relief as long as the
activity continues.

A3. Evening or Nighttime Worsening

Symptoms are worse in the evening or night, or only occur at night, regardless of activity.

B. Frequency and Duration

Symptoms occur at least 3 times per week and persist for at least 3 months.

C. Impact on Functioning

The symptoms cause significant distress or impairment in:

Social life, work or academic performance, emotional well-being, daytime functioning.

D. Rule Out Other Disorders

Symptoms are not better explained by: Leg cramps, arthritis, peripheral neuropathy, positional
discomfort, anxiety-related fidgeting.

D. Not Due to Substances or Medications

Symptoms are not attributable to:

Drugs of abuse or medications such as antipsychotics or antidepressants, Akathisia (movement

disorder caused by some drug).

Diagnostic features :

RLS is a sensorimotor, neurological sleep disorder marked by an irresistible urge to move the
limbs, usually the legs. It is often accompanied by unpleasant sensations such as creeping,
tingling, burning, or itching. Symptoms tend to:

Worsen at night

Improve temporarily with movement

Interfere with sleep initiation and continuity

Delayed sleep onset

Frequent night awakenings

Associated Features:

Periodic Limb Movements (PLMs) during sleep:

Involuntary leg jerks seen during sleep in 80-90% in patients of RLS.

Sleep fragmentation

Daytime sleepiness ,fatigue and irritability

Increased prevalence in pregnancy (symptoms often appear or worsen during third trimester) and
family members ( genetics )

Common Differentials:

Leg cramps
Iron deficiency:

Low serum ferritin levels are linked to symptom onset and severity

Chronic Diseases:

ESRD, diabetes and peripheral neuropathy may increase risk.

Prognosis and Management: RLS can be managed effectively with dopaminergic agents (e.g.,
pramipexole), iron supplementation (if deficient), and lifestyle modifications. Untreated, it may
lead to significant impairment in quality of life.

Case History :

Patient : Sara

Age: 35 year old

Referral Reason:

She has 6 month history of discomfort in her legs particularly at night. The symptoms were
worse when lying down to sleep , often delaying sleep onset or waking her up several times at
night.

Upon further questioning she tells:

Bedtime is 11pm and generally takes her 45-60 min to fall asleep.

Wake time is 7am on weekdays and 8am on weekends.

While trying to fall asleep , feels restless and is constantly moving her legs.

Doesn’t watch TV or read in bed.

Doesn’t smoke or assume alcohol.

Feels fatigued, irritability during the day.

Restlessness in her leg often feel like something is crawling upon them.

Restlessness generally improve if she moves her legs around.

Night time awakening occurs 3-4 times per week, impacting her overall sleep quality.

Past Medical History:

Had similar symptoms about five years ago during her pregnancy.

Iron deficiency anemia (diagnosed 1 year ago , not treated consistently).

Mild hypertension , managed with medication.

Family History:

Her father and brother have similar symptoms .

Mental status Examination:

Feeling frustrated and tired.

Mild impairment in concentration and attention during tasks.

No hallucinations, delusions and suicidal thoughts .

Treatment:

Prescribed pramipaxole 0.25 mg during bedtime.

Returns after 1 month with marked improvement in :

Symptoms of restlessness: now bother her only 1 times a month .

Sleep latency most night is approximately 15 minutes.