SLEEP DISORDERS

Luh Nyoman Alit Aryani

Departement of Psychiatric
Udayana University, Faculty of Medicine
SLEEP
 Universal behavior
 Electronic recording: EEG, EOG, EMG
 Repetitive state, regular, reversible, marked by
relatively no movement and higher respond treshold
to external stimuli compared to wake state
 Sleep disorder : first symptom of mental illness.
 Several mental disorder can cause sleep physiology
changes
 BRAIN WAVES
Character of the waves is dependent
on the degree of activity in respective
parts of the cerebral cortex
In normal healthy people, most waves
in the EEG can be classified as Alpha,
Beta, Theta, Delta waves

sec
SLEEP
Two types of sleep:

1. Slow wave sleep

2. Rapid Eye Movement Sleep

SLOW WAVE SLEEP
 The brain waves are very strong and very low
frequency
 Decrease in both peripheral vascular tone and
many other vegetative function of the body
 10-30 percent decrease in blood pressure,
respiratory rate and basal metabolic rate
 Dreamless sleep, dreams, and nightmares
REM SLEEP
 Characteristics of REM sleep:
1. It is usually associated with active dreaming and
active bodily muscle movements
2. The person is even more difficult to arouse by
sensory stimuli than during deep slow wave sleep,
and yet people usually awaken spontaneously in the
morning during an episode of REM sleep
3. Muscle tone throughout the body is exceedingly
depressed, indicating strong inhibition of the spinal
muscle control areas
REM SLEEP
4. Heart rate and respiratory rate usually become
irregular, which is characteristic of the dream state
5. Despite the extreme inhibition of the peripheral
muscle, irregular muscle movements do occur.
These are in addition to the rapid movements of
the eyes
6. The brain is highly active in REM sleep, and
overall brain metabolism may be increased as
much as 20 percent. The EEG shows a pattern of
brain waves similar to those that occur during
wakefulness
Who sleeps?
 Mammals and birds
 Opossums, bats: 19-20 hours daily
 Cats, dogs, rodents: 12-15 hours daily
 Ruminant herbivores: 2-3 hours daily
 Reptiles, amphibians, fish, and insects have cycles of
inactivity
Circadian rhythms
 Circadian rhythms (from the Latin circa dies, or
around a day)
→ are biological process that occur repeatedly on
approximately a twenty-four-hour cycle
Normal Sleep
 Differ for each person
 2 groups :
- Short sleepers: sleep < 6 hours
- Long sleepers: sleep > 9 hours
 Psychology Profile (w/ CMI and MMPI)
- Short sleepers→ energetic, efficient, outgoing, have
self confidence, free from psychopathology
-Long sleepers → higher score for anxiety scale,
pathologic mood, social introvert, low score for lie
scale, shy, worry too much, think a lot of the future
and self, mild psychopathology such as mild anxiety
and mild depression.
Sleep function
❖ protect
❖ energy conservation
❖ brain restoration
❖ homeostasis
❖ enhance immunity function
❖ temperature regulation
SLEEPWAKE DISORDERS
DSM V
Insomnia disorder
Hypersomnia Disorder
Breathing Related Sleep Disorder
Circadian Rhythm Sleep Wake Disorders
Parasomnias
Substance/Medication Induced Sleep Disoder
INSOMNIA
Diagnostic Criteria Insomnia Disorder
 A. Predominant complaint of dissatisfaction with
sleep quantity or quality
 Difficulty initiating sleep
 Difficulty maintaining sleep
 Early morning awakening with inability to return
to sleep
 B. The sleep disturbance causes clinically
significant distress or impairment social,
occupational, eductional, academic, behavioral or
other important areas of functioning
 C. The sleep difficulty occurs at least 3 night per
week
Insomnia disorder
 D. The sleep difficulty is present at least 3 months
 E. The sleep difficulty occur despite adequate oppornity
for sleep
 F. The insomnia is not better explained by and does
not occur exclusively during the course of another
sleep wake disorder
 G.The insomnia is not attributable to the physiological
effects of a substance
 H. Coexisting mental disorder and medical condition
do not adequately explain the predominant complaint
Differential Diagnosis
 Neuropsychiatric disorder
(depression,anxiety,dementia)
 Substance abuse
 Cirrcardian rhythm disorder
 Medical condition or other treatment
 Psychophysiological Insomnia
→sometimes called Conditioned Insomnia
→ primary complaint of difficulty in going to sleep
→having gone of for years and usually denies that it
is associated with stressful periods in his or her
→ objects associated with sleep (the bed, the
bedroom) likewise become conditioned stimuli
that evoke insomnia
→ occurs in combination with other causes of
insomnia, including episodes of stress and anxiety
disorders, delayed sleep phase syndrome, hypnotic
drug use, withdrawal
 Sleep state misperception
→also known as subjective insomnia
→ is characterized by a dissociation between the
patient’s experience of sleeping and the objective
polygraphic measures of sleep
→ is diagnosed when a patient complains of difficulty
initiating or maintaining sleep and no objective
evidence of sleep disruption is found
 Idiopathic insomnia
→ starts early in life sometimes at birth, and continues
throughout life
→ its cause is unknown
→ improved sleep hygiene, relaxation therapy
 Transient Insomnia
 Grief or life changing → mild
 CAUTION ! Severe psychotic episode/ severe depression
often began with acute insomnia.
 Spesificic therapy unnecessary
 Hypnotic therapy → short term → short reccurence
insomnia when stopping medication.
Primary Insomnia
 Nonrestorative sleep or difficulty in initiating or
maintaining sleep and the complaint continues for at
least a month
 Independent of any known physical or mental
condition
 Characterized both by difficulty falling a sleep and by
repeated awakening
 Insomnia most commonly related to
Symptom Insomnia Secondary to Insomnia Secondary to
medical condition enviroment
Difficulty to fall All uncomfortable condition Anxiety

asleep Central nervous lesion Muscular tension anxiety .

Other condition Environment changing
Cirrccardian rhytm disorder

Difficulty Sleep apnea Syndrome Depressiorn especially primary type

maintaining sleep Nocturnal Myoclonus and restless leg Enviromental changing

syndrome Cirrccardian rhytm disorder
Diet Factor Post trauma stress disorder
Episodic Schizophrenia
Direct drug effect
Substance withdrawal
Drug interaction
Metabolic and endocrin disorder
Infectious and metabolic disease
Pain
Brain lesion
Degenerative
Insomnia effect
 Insomnia patient quality of life lower than
non insomnia
 Insomnia is related to higher risk to
depression, pain in rheumatic disease,
absent/ lost of work days, accident, low
productivity, higher use of health
insurance, anxiety risk and substance
abuse
HYPERSOMNIA
Hypersomnolence Disorder
 A. Self Report Excessive sleepiness despite a main
sleep period lasting at least 7 hours with at least one of
the following symptom :
 Reccurent period of sleep or lapses into sleep within
the same day
 A prolonged main sleep episode of more than 9 hours
per day that is nonrestorative
 Difficulty being fully awake after abrupt awakening
 B. The hypersomnolence occurs at least 3 times per
week for at least 3 months
 C. The hypersomnolence is accompanied by significant
distress or impairment social, occupational, eductional,
academic, behavioral or other important areas of
functioning
Hypersomnolence Disorder
 D. The hypersomnolence is not better explained by
and does not occur exclusively during the course of
another sleep wake disorder
 G.The hypersomnolence is not attributable to the
physiological effects of a substance
 H. Coexisting mental disorder and medical condition
do not adequately explain the predominant complaint
of hypersomnolence

 Hipersomnia common etiology
Symptom Medical problem Environmental and mental
problem
hypersomnia Kleine-Levin syndrome Depression.
Somnolence related to menstruation Avoidance reaction .
Toxic or metabolic condition
Encephalitic condition
Alcohol and depression medication
Stimulant withdrawal

Sleepiness in daytime Narcolepsy. Depression

Sleep Apnea . Avoidance Reaction
hypoventilation syndrome . Circcardian rhytm disorder
Hyperthyroidisme.
Alcohol and depression medication
stimulan withdrawal.
Sleep deprivation
Other condition
Primary hypersomnia
 No other cause can be found for excessive somnolence
occurring for at least 1 month
 Treatment →
 Stimulant drugs, amphetamines (in the morning or
evening)
 Non sedative antidepressan → SSRI
Narcolepsy
 A. Recurrent periods of an irrepresible need to
sleep, lapsing into sleep, or napping occuring
within the same day, 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,
occuring at least a few times per month :
 a. In individual with long standing disease, brief,
episodes of sudden bilateral loss off muscle tone
with maintained consciousness that are
precipitated by laughter or joking
Narcolepsy
 b. In individual within 6 months of onset,
spontaneous grimaces or jaw opening episodes tongue
thrusting or a global hipotonia without any obvious
emotional triggers
 2. Hypocretin deficiency as measured using
cerebrospinal fluid) less than equalto one third of
values healthy subjects
 3. Nocturnal sleep polysomnography showing rapid
eye movement (REM)sleep latency less than or equal
to 15 minutes
 The REM sleep includes hypnagogic and hypnopompic
hallucinations, cataplexy, sleep paralysis
 Can be dangerous because it can lead to automobile
and industrial accidents
 Can occur at any age, but it most frequently begin in
adolescence or young adulthood, before the age of 30
 Comorbidity : Bipolar, Depressive, Anxiety disorder
 DD/ sleep deprivation, sleep apnea, Conversion,
Depression, ADHD, seizure, chorea and movement
disorders, Schizophrenia
 Breathing-Relating Sleep Disorder

 Obstructive Sleep Apnea Syndrome : Blocked nose

or mouth air flow for 10 seconds or more.
 Sleep related hypoventilation : Breathing
dysfunction → tidal volume or inadequate
breathing rate while sleeping
Circadian rhythm sleep Disorder
- Delayed sleep phase type : Sleep and wake later
than expected
- Jet lag type : Depend on travel from east to west
and individual
- Shift work type
- Advanced sleep phase : Early sleep onset and
wake time
- Irregular Sleep-wake : Irregular sleep and wake
pattern
- Unspecified
PARASOMNIAS
 Is an unusual or undesirable phenomenon that
appears suddenly during sleep or that occurs at the
threshold between waking and sleeping
 Usually occurs in stages III and IV Associated with
poor recall of the disturbance
PARASOMNIAS
NON REM Sleep Arousal Disorders

1. Nightmare disorder
2. Sleep terror disorder
3. Sleepwalking disorder
 Nightmare disorder
→ are vivid dreams that become progressively more
anxiety producing, ultimately resulting in an
awakening
→almost always occur during REM sleep and
usually after a long REM period late in the night
 Sleep terror disorder
→ an arousal in the first third of the night during
deep NREM (stages III and IV) sleep
→ almost invariably inaugurated by a piercing
scream or cry and accompanied by behavioral
manifestations of intense anxiety bordering on
panic
→ typically patient sit up in bed with a frightened
expression, scream loudly and sometimes
awaken immediately with a sense of intense
terror
 Sleep-walking disorder
→ also known as somnambulism
→ consists of a sequence of complex behaviors
that are initiated in the first third of the night
during deep NREM (stages III and IV) sleep
→ without full consciousness or later memory of
the episode to leaving bed and walking about
→ patient sit up and perform preservative motor
acts, such as walking, dressing, going to the
bathroom, talking, screaming, and even driving
 Parasomnia
 REM Sleep behavior disorder
 - Sleep-related bruxism
- Sleeptalking (Somniloquy)
- Sleep-related head banging (Jactatio Capitis Nocturna)
- Sleep paralysis
- Restless Legs Syndrome : Movement sensation in leg
when sitting or lie down
Other Sleep Disorders
 Sleep disorder due to a general medical condition
- Sleep-related Epileptic Seizures
- Sleep-related cluster headaches and chronic Paroxysmal
Hemicrania
- Sleep-related abnormal swallowing syndrome
- Sleep-related asthma
- Sleep-related cardiovascular syndrome
- Sleep-related gastroesophageal reflux
- Sleep-related hemolysis (paroxysmal nocturnal
hemoglobinuria)
 Substance-induced sleep disorder
Etiology
 Insomnia/Hypersomnia Related to other mental
disorder
 Related to Axis I or Axis II disorder
 Not caused by direct substance physiologic effect
(substance abuse), or general medical condition
Sleep Disorder caused by general medical
condition
 Almost all medical condition with pain and discomfort →
insomnia.
 Endocrin and metabolic disease : several sleep disorder
 Epileptic seizure related to sleep.
 Cluster type headache and chronic paroxysmal
hemicrania related to sleep.
 Abnormal swallow syndrom related to sleep
 Asthma related to sleep .
 Cardio vascular symptom related to sleep.
 Gastroesophageal reflux related to sleep
 Haemolysis (paroxysmal nocturnal Haemoglobinuria ).
Sleep disorder caused by substance
 Disorder onset ? Intoxication or withdrawal.
 Somnolens
 Tolerance or central nervous system stimulant withdrawal
(amphetamin, cocain, caffein)
 Central nervous system depressan (alcohol)
 May also accompanied by major depression → suicide
proportion
 Tolerance effect from sedative hypnotic long use
 Antimetabolit and cancer chemotherapy
 Sedative drug or tranquilizer withdrawal
 Nicotine withdrawal → sleep disorder
Sleep disorder main treatment
1.Sleep hygiene and sleep disorder prophilaxis
2.Psychotherapy
3.Physical and surgical intervention
4.Pharmacology
Treatment insomnia
Deconditioning technique
Patient are asked to use their bed for sleeping and for
nothing else, if they are not asleep after 5 minutes in
bed, they are instructed simply to get up and do
something else. Sometimes changing to another bed
or another is useful
Somatized tension/muscle tension → relaxation tapes,
transcendental meditation, practicing the relaxation
response
Sleep Hygiene
1. Regular sleep and wake up at the same time
everyday
2. Sleep with enough time
3. Exercise everyday, not before sleep or late at
night
4. Regular eating
5. Listen to soft music before turning off light to
sleep
6. Use twin bed when sleep partner is restless
7. Avoid physical disturbance, noises, light, hot,
cold
8. Check with your doctor for mediation needed,
avoid stimulating drug
9. Use soft medium mattress and soft comfortable
pillow
10. Regular nap at the same time. Sleep less than
45 minutes.
11. avoiding excessive caffeine
12. not eating heavy meals before bedtime
13. getting adequate exercise
Pharmacotherapy
 Benzodiazepine : long acting for late insomnia
(Clobazam, Diazepam), short acting
(alprazolam, lorazepam)
 Zaleplon
 Zolpidem : short acting for early insomnia
 Antidepressan
 Antipsychotic and Anti convulsan
 Melatonin Agonist
Psychotherapy
 Sleep hygiene education
 Cognitive Behavior Therapy (CBT)