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(PPT)

  1. 1. Sleep Disorders Psy 610A Gary S. Katz, Ph.D.
  2. 2. Normal Sleep <ul><li>Sleep progresses in stages throughout the night </li></ul><ul><ul><li>Four Non-REM (NREM) stages (1, 2, 3, & 4) </li></ul></ul><ul><ul><li>One REM stage </li></ul></ul><ul><ul><li>Order </li></ul></ul><ul><ul><ul><li>1, 2, 3, 4, 3, 2, REM </li></ul></ul></ul><ul><ul><ul><li>Repeats every 80 to 100min </li></ul></ul></ul><ul><li>REM Sleep </li></ul><ul><ul><li>Dreaming </li></ul></ul><ul><ul><li>Inhibition of muscular activity </li></ul></ul><ul><li>Stages 3 and 4 </li></ul><ul><ul><li>Restorative sleep </li></ul></ul><ul><ul><li>Disinhibition of muscular activity </li></ul></ul><ul><ul><li>Parasomnias </li></ul></ul>
  3. 3. Normal Sleep <ul><li>Stage 1 </li></ul><ul><ul><li>Hypnagogic (falling asleep) </li></ul></ul><ul><ul><ul><li>and </li></ul></ul></ul><ul><ul><li>Hypnapompic (waking up) imagery </li></ul></ul><ul><ul><li>Some loss of muscle tone </li></ul></ul><ul><ul><li>Hypnic jerks </li></ul></ul><ul><li>Stage 2 </li></ul><ul><ul><li>Deeper sleep, more prominent lack of awareness of surroundings. </li></ul></ul>
  4. 4. Sleep Assessment Tools <ul><li>Polysomnography – sleep study </li></ul><ul><li>Multiple Sleep Latency Test </li></ul><ul><ul><li>Five measurement periods in a dark, comfortable room – don’t resist going to sleep </li></ul></ul><ul><ul><li>Time how long it takes for subject to fall asleep </li></ul></ul><ul><ul><li>Index of sleepiness </li></ul></ul><ul><ul><ul><li>Shorter latencies to sleep indicate greater sleep debt </li></ul></ul></ul><ul><ul><ul><li>Longer latencies to sleep indicate lesser sleep debt </li></ul></ul></ul><ul><li>Maintenance of Wakefulness Test </li></ul><ul><ul><li>Five measurement periods in a dimly lit room </li></ul></ul><ul><ul><li>Try to stay awake, time duration remaining awake </li></ul></ul><ul><ul><li>Index of wakefulness </li></ul></ul><ul><ul><ul><li>Longer times indicate greater wakefulness </li></ul></ul></ul><ul><ul><ul><li>Shorter times indicate lesser wakefulness </li></ul></ul></ul>
  5. 5. Normal Stage 4 Sleep
  6. 6. Normal REM Sleep
  7. 8. Dyssomnias & Parasomnias <ul><li>Dyssomnias </li></ul><ul><ul><li>Primary disorders of initiating or maintaining sleep or of excessive sleepiness and are characterized by a disturbance in the amount, quality, or timing of sleep. </li></ul></ul><ul><li>Parasomnias </li></ul><ul><ul><li>Disorders characterized by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-wake transitions. </li></ul></ul>
  8. 9. Dyssomnias & Parasomnias <ul><li>Dyssomnias </li></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Circadian Rhythm Sleep Disorder </li></ul><ul><li>Hypersomnia </li></ul><ul><li>Hypersomnia Related to Another Mental Disorder </li></ul><ul><li>Insomnia </li></ul><ul><li>Insomnia Related to Another Mental Disorder </li></ul><ul><li>Narcolepsy </li></ul><ul><li>Dyssomnia NOS </li></ul><ul><li>Parasomnias </li></ul><ul><li>Nightmare Disorder </li></ul><ul><li>Sleep Terror Disorder </li></ul><ul><li>Sleepwalking Disorder </li></ul><ul><li>Parasomnia NOS </li></ul>
  9. 11. Breathing-Related Sleep Disorder (780.57) <ul><li>Essential feature: sleep disruption, leading to excessive sleepiness or, less commonly, to insomnia, that is judged o be due to abnormalities of ventilation during sleep. </li></ul><ul><li>Most common complaint: daytime sleepiness </li></ul><ul><li>Less common: insomnia or frequent awakenings </li></ul><ul><li>May see apnea episodes, shallow breathing, hypoventilation </li></ul>
  10. 12. Breathing-Related Sleep Disorder (780.57) <ul><li>A. Sleep disruption, leading to excessive sleepiness or insomnia, that is judged to be due to a sleep-related breathing condition (e.g., obstructive or central sleep apnea syndrome or central alveolar hypoventilation syndrome). </li></ul><ul><li>B. The disturbance is not better accounted for by another mental disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition (other than a breathing-related disorder). </li></ul><ul><li>Coding note: Also code sleep-related breathing disorder on Axis III. </li></ul>
  11. 13. Three Forms <ul><li>Obstructive sleep apnea </li></ul><ul><ul><li>Almost exclusively the only subtype seen in childhood </li></ul></ul><ul><ul><li>CNS and muscular drive for respiration exists; however due to obstructions in the airway (e.g., adipose tissue in overweight individuals, adenoid or tonsil tissues), respiration is prevented </li></ul></ul><ul><ul><li>Leads to apnea or hyponea episodes, snoring, gasps, whole-body movements (snoring may be absent in children) </li></ul></ul><ul><ul><li>Disturbing to bed partners </li></ul></ul><ul><li>Central sleep apnea </li></ul><ul><ul><li>Episodic cessation of ventilation during sleep without airway obstruction. </li></ul></ul><ul><ul><li>CNS and muscular drive for respiration ceases </li></ul></ul><ul><ul><li>Most common in the elderly or those with cardiac or neurological conditions </li></ul></ul><ul><li>Central alveolar hypoventilation syndrome </li></ul><ul><ul><li>Commonly occurs in very overweight individuals </li></ul></ul><ul><ul><li>Lungs work normally, control of ventilation impaired, resulting in low arterial O 2 levels. </li></ul></ul>
  12. 14. Associated Features <ul><li>Complaints of nocturnal chest discomfort, choking, suffocation, intense anxiety associated with apneic events. </li></ul><ul><li>Body movements during sleep can be violent; often see very restless sleep. </li></ul><ul><li>Individuals awaken feeling unrefreshed and have great difficulty awakening. </li></ul><ul><li>Severe dryness of the mouth leading to needing to drink during the night or in the morning leading to nocturia (awakening due to need to void bladder at night). </li></ul><ul><li>Dull headaches upon awakening. </li></ul><ul><li>Memory disturbances, poor concentration, irritability, personality changes. </li></ul><ul><li>Mood Disorders (MDD, DD), Anxiety Disorders (Panic Disorder) </li></ul>
  13. 15. Associated Features <ul><li>In Children: </li></ul><ul><ul><li>Failure to thrive </li></ul></ul><ul><ul><li>Developmental delay </li></ul></ul><ul><ul><li>Learning difficulties </li></ul></ul><ul><ul><li>Poor attention </li></ul></ul><ul><ul><li>Hyperactive behavior </li></ul></ul><ul><ul><li>Decreased school performance </li></ul></ul><ul><li>Also see numerous atypical polysomnography findings. </li></ul>
  14. 16. Age Features <ul><li>In children </li></ul><ul><ul><li>Obstructive sleep apnea syndrome vastly most common </li></ul></ul><ul><ul><li>Signs and symptoms are more subtle (recommend sleep study with polysomnography) </li></ul></ul><ul><ul><li>Snoring may not be present </li></ul></ul><ul><ul><li>Abnormal sleep postures (sleeping on hands & knees) </li></ul></ul><ul><ul><li>Resumption of nocturnal enuresis a common sign </li></ul></ul><ul><ul><li>May see excessive daytime sleepiness, but not always </li></ul></ul><ul><ul><li>Daytime mouth breathing, difficulty swallowing, poor speech articulation commonly seen </li></ul></ul>
  15. 17. Age Features <ul><li>Under age 5 </li></ul><ul><ul><li>Nighttime symptoms more often the presenting complaint (e.g., observed apnea or labored breathing) </li></ul></ul><ul><li>Over age 5 </li></ul><ul><ul><li>Daytime symptoms more often the presenting complaint (e.g., sleepiness, behavioral problems, attention and learning difficulties </li></ul></ul>
  16. 18. Gender Features <ul><li>In adults, male:female ratio ranges from 2:1 to 4:1 </li></ul><ul><li>In prepubertal children, no sex differences. </li></ul>
  17. 19. Course <ul><li>Obstructive sleep apnea syndrome can occur at any age </li></ul><ul><li>Most individuals present between ages 40 and 60 with females most likely to present after menopause </li></ul><ul><li>Central sleep apnea more commonly seen in elderly individuals with CNS or cardiac disease </li></ul><ul><li>Central alveolar hypoventilation and central sleep apnea syndromes can occur at any age. </li></ul>
  18. 20. Course & Familial Pattern <ul><li>Breathing-Related Sleep Disorder usually has an insidious onset, gradual progression, and chronic course. </li></ul><ul><li>Often present for years before it has been diagnosed. </li></ul><ul><li>Weight loss can lead to spontaneous resolution </li></ul><ul><li>Management of underlying medical conditions (CNS, cardiac) may improve the central sleep apnea syndrome. </li></ul><ul><li>Do see a familial tendency for obstructive sleep apnea syndrome. </li></ul>
  19. 21. Differential Diagnosis <ul><li>Narcolepsy </li></ul><ul><ul><li>Absence of cataplexy, sleep-related hallucinations, sleep paralysis in Breathing-Related Sleep Disorder (BRSD) </li></ul></ul><ul><ul><li>Presence of loud gasps / snoring in BRSD </li></ul></ul><ul><li>Primary Hypersomnia and Circadian Rhythm Sleep Disorder </li></ul><ul><ul><li>Normal breathing and ventilation in these </li></ul></ul><ul><li>Hypersomnia related to a Major Depressive Episode </li></ul><ul><li>Asymptomatic adults who snore </li></ul><ul><li>Nocturnal Panic Attacks </li></ul><ul><li>ADHD </li></ul><ul><li>General Medical Condition </li></ul><ul><li>Substance use/abuse </li></ul>
  20. 23. Circadian Rhythm Sleep Disorder <ul><li>Essential feature: a persistent or recurrent pattern of sleep disruption that results from altered function of the circadian timing system or from a mismatch between the individual’s endogenous circadian sleep-wake system and exogenous demands regarding the timing and duration of sleep. </li></ul><ul><li>Need to see significant social or occupational impairment or marked distress related to the sleep disturbance. </li></ul>
  21. 24. Circadian Rhythm Sleep Disorder <ul><li>A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep-wake schedule required by a person's environment and his or her circadian sleep-wake pattern. </li></ul><ul><li>B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>C. The disturbance does not occur exclusively during the course of another Sleep Disorder or other mental disorder. </li></ul><ul><li>D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  22. 25. Circadian Rhythm Sleep Disorder <ul><li>Specify type (code): </li></ul><ul><li>Delayed Sleep Phase Type (327.3): a persistent pattern of late sleep onset and late awakening times, with an inability to fall asleep and awaken at a desired earlier time </li></ul><ul><li>Jet Lag Type (327.35): sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone </li></ul><ul><li>Shift Work Type (327.36): insomnia during the major sleep period or excessive sleepiness during the major awake period associated with night shift work or frequently changing shift work </li></ul><ul><li>Unspecified Type (327.30): can see “advanced sleep phase” or “non-24-hour sleep-wake pattern” or “irregular sleep-wake pattern” </li></ul>
  23. 26. Associated Features <ul><li>Delayed Sleep Phase Type </li></ul><ul><ul><li>peak efficiency occurs after a delayed phase </li></ul></ul><ul><ul><li>Individuals often sleep in on weekends/vacations </li></ul></ul><ul><li>Jet Lag Type and Shift Work Type </li></ul><ul><ul><li>Individuals more often “early birds” </li></ul></ul><ul><li>Non-24-hour sleep-wake pattern more common in blind individuals with no light perception </li></ul><ul><li>Sleepless episodes may precipitate a Manic or Major Depressive Episode or an episode of a Psychotic Disorder </li></ul>
  24. 27. Age Features and Prevalence <ul><li>Onset of Delayed Sleep Phase Type most often occurs between late childhood and early adulthood (sleepy teenagers). </li></ul><ul><li>Other subtypes more common in adults. </li></ul><ul><li>Prevalence not well established except in Delayed Sleep Phase Type </li></ul><ul><ul><li>Adults: 0.1% to 4% </li></ul></ul><ul><ul><li>Adolescents: up to 7% </li></ul></ul>
  25. 28. Course <ul><li>Delayed Sleep Phase Type (DSPT) typically begins in adolescence, perhaps following a psychosocial stressor. </li></ul><ul><li>Without intervention, DSPT typically persists for years/decades. </li></ul><ul><li>DSPT may “correct” itself if endogenous circadian rhythms advance with age (i.e., as individual ages, they ‘fall into’ a normative sleep pattern requiring less sleep). </li></ul>
  26. 29. Familial Pattern <ul><li>Family history may be present in up to 40% of individuals with DSPT </li></ul><ul><li>Familial form of Advanced Sleep Phase Type has been identified. </li></ul>
  27. 30. Differential Diagnosis <ul><li>Normal sleep pattern adjustments </li></ul><ul><li>Volitional patterns of delayed sleep hours </li></ul><ul><li>Primary Insomnia </li></ul><ul><li>Primary Hypersomnia </li></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Delayed or advanced Sleep due to another mental disorder </li></ul><ul><li>Substance use/abuse </li></ul>
  28. 32. Primary Hypersomnia (307.44) <ul><li>Essential feature: excessive sleepiness for at least 1 month as evidenced either by prolonged sleep episodes or by daytime sleep episode occurring almost daily. </li></ul><ul><li>Duration of major sleep episodes may range from 8 to 12 hours, often followed by difficulty awakening in the morning. </li></ul><ul><li>Daytime naps may be long (>1hr) and are experienced as unrefreshing. </li></ul><ul><li>Sleepiness develops over a period of time (rather than as an attack). </li></ul><ul><li>Unintentional sleep episodes typically occur in low-stimulation and low-activity situations. </li></ul>
  29. 33. Primary Hypersomnia (307.44) <ul><li>A. The predominant complaint is excessive sleepiness for at least 1 month (or less if recurrent) as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily. </li></ul><ul><li>B. The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>C. The excessive sleepiness is not better accounted for by Insomnia and does not occur exclusively during the course of another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia) and cannot be accounted for by an inadequate amount of sleep. </li></ul>
  30. 34. Primary Hypersomnia (307.44) <ul><li>D. The disturbance does not occur exclusively during the course of another mental disorder. </li></ul><ul><li>E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul><ul><li>Specify if: </li></ul><ul><li>Recurrent: if there are periods of excessive sleepiness that last at least 3 days occurring several times a year for at least 2 years </li></ul>
  31. 35. Associated Features <ul><li>Sleep tends to be continuous but nonrestorative. </li></ul><ul><li>Individuals fall asleep quickly, sleep efficiently, but may have difficulty awakening. </li></ul><ul><li>“sleep drunkenness” : common to many sleep disorders, refers to difficulty transitioning from sleep to wakeful states. </li></ul><ul><li>Automatic behavior </li></ul><ul><ul><li>Very routine, low-complexity tasks </li></ul></ul><ul><ul><li>Carried out with little or no subsequent recall </li></ul></ul>
  32. 36. Associated Features <ul><li>Often see symptoms of depression that may meet criteria for a mood disorder. </li></ul><ul><li>Risk for Substance-Related Disorders, particularly self-medication with stimulants. </li></ul><ul><li>A subset of individuals with Primary Hypersomnia have a family history of Hypersomnia and other autonomic nervous system dysfunction including vascular headaches, Raynaud’s phenomenon, and fainting. </li></ul><ul><li>Kleine-Levin form – exceedingly rare (also see hyperphagia) </li></ul>
  33. 37. Age or Gender Features <ul><li>In children, hyperactivity may present as daytime sleepiness. </li></ul><ul><li>Voluntary napping increases with age, but this is different from Primary Hypersomnia. </li></ul><ul><li>Sex difference unknown in general Primary Hypersomnia; however, Kleine-Levin syndrome predominates in males (3-4x more common in males). </li></ul>
  34. 38. Prevalence <ul><li>True prevalence unknown. </li></ul><ul><li>Frequently see daytime sleepiness in adults (0.5% to 5.0% without regard to specific diagnoses). </li></ul><ul><li>Teenagers often appear sleepy due to voluntary sleep-cycle shifts. </li></ul>
  35. 39. Course <ul><li>Primary Hypersomnia typically begins between ages 15 and 30 years </li></ul><ul><li>Gradual progression over weeks to months </li></ul><ul><li>Course is then chronic and stable, unless treatment is initiated. </li></ul><ul><li>Development of other sleep disorders (e.g., Breathing-Related Sleep Disorder) may worsen the degree of sleepiness. </li></ul><ul><li>Kleine-Levin syndrome also begins during adolescence (very rare) and may continue periodic course for decades, resolving sometimes in middle age. </li></ul>
  36. 40. Kleine-Levin Syndrome <ul><li>Rare disorder that can cause a recurrent form of Primary Hypersomnia </li></ul><ul><li>Symptoms also include: </li></ul><ul><ul><li>excessive food intake, irritability, disorientation, lack of energy, hypersensitivity to noise </li></ul></ul><ul><ul><li>Hallucinations and an abnormally uninhibited sex drive also possible </li></ul></ul><ul><li>Coded on Axis III as well as the Dx of Primary Hypersomnia on Axis I </li></ul>
  37. 41. Familial Pattern <ul><li>Individuals with autonomic dysfunction (e.g., Raynaud’s, vascular headaches) show familial patterns. </li></ul><ul><li>Kleine-Levin syndrome does not show familial aggregation. </li></ul>
  38. 42. Differential Diagnosis <ul><li>Inadequate nocturnal sleep (teens, grad students) </li></ul><ul><li>Primary Insomnia (PI) </li></ul><ul><ul><li>Sleepiness not as severe in PI as it is in Primary Hypersomnia (PH) </li></ul></ul><ul><li>Narcolepsy </li></ul><ul><ul><li>Key feature in Narcolepsy is cataplexy, absent in PH </li></ul></ul><ul><ul><li>Cataplexy: brief episodes of sudden bilateral loss of muscle tone </li></ul></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Circadian Rhythm Sleep Disorder </li></ul><ul><li>Mental disorders that include hypersomnia as a clinical feature </li></ul><ul><ul><li>Major Depressive Disorder </li></ul></ul><ul><ul><li>Bipolar Disorder </li></ul></ul><ul><li>Sleep Disorder Due to a General Medical Condition </li></ul><ul><li>Substance-Induced Sleep Disorder </li></ul>
  39. 44. Insomnia / Hypersomnia Related to Another Mental Disorder <ul><li>Essential feature: presence of either insomnia or hypersomnia that is judged to be related temporally and causally to another mental disorder. </li></ul><ul><li>Insomnia or hypersomnia due to substances is not included here. These would be diagnosed as a Substance-Induced Sleep Disorder. </li></ul>
  40. 45. Insomnia / Hypersomnia Related to Another Mental Disorder <ul><li>Individuals in a Major Depressive Episode or Dysthymic Disorder often complain of difficulty falling asleep, staying asleep, or awakening too early (insomnia) </li></ul><ul><li>Hypersomnia more often associated with Bipolar, Most Recent Episode Depressed or a Major Depressive Episode, With Atypical Features. </li></ul><ul><li>Nocturnal panic attacks can also lead to insomnia. </li></ul>
  41. 46. Hypersomnia Related to Axis I or Axis II disorder (327.15) <ul><li>A. The predominant complaint is excessive sleepiness for at least 1 month as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily. </li></ul><ul><li>B. The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>C. The hypersomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Disorder, Dysthymic Disorder), but is sufficiently severe to warrant independent clinical attention. </li></ul><ul><li>D. The disturbance is not better accounted for by another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, a Parasomnia) or by an inadequate amount of sleep. </li></ul><ul><li>E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  42. 47. Insomnia Related to Axis I or Axis II disorder (327.02) <ul><li>A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month that is associated with daytime fatigue or impaired daytime functioning. </li></ul><ul><li>B. The sleep disturbance (or daytime sequelae) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>C. The insomnia is judged to be related to another Axis I or Axis II disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder With Anxiety), but is sufficiently severe to warrant independent clinical attention. </li></ul><ul><li>D. The disturbance is not better accounted for by another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, a Parasomnia). </li></ul><ul><li>E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  43. 48. Associated Features <ul><li>Include the associated features and characteristics of the related mental disorder. </li></ul><ul><li>Similar features seen in Primary Insomnia </li></ul><ul><ul><li>Increased anxiety when bedtime approaches </li></ul></ul><ul><ul><li>Conditioned arousal and negative conditioning may be a factor in sustaining the insomnia </li></ul></ul><ul><ul><li>See improved sleep when taken out of the usual sleep environment </li></ul></ul><ul><ul><li>Spend too much time in bed </li></ul></ul><ul><ul><li>May have a history of inappropriate medication treatments for insomnia </li></ul></ul>
  44. 49. Associated Features <ul><li>Include the associated features and characteristics of the related mental disorder. </li></ul><ul><li>Similar features seen in Primary Hypersomnia </li></ul><ul><ul><li>Symptoms of fatigue </li></ul></ul><ul><ul><li>“ leaden paralysis” – arms and legs feel heavy, difficult to move </li></ul></ul><ul><ul><li>Complete lack of energy </li></ul></ul><ul><li>Careful questioning reveals more distress regarding the fatigue-related symptoms than the true sleepiness itself. </li></ul>
  45. 50. Associated Features <ul><li>Multiple Sleep Latency Testing findings indicate normal or mild levels of physiological sleepiness compared to individuals with Primary Hypersomnia or Narcolepsy. </li></ul><ul><li>Individuals may appear tired, fatigued, or haggard during routine examination. </li></ul>
  46. 51. Culture, Age, & Gender Features <ul><li>In some cultures, sleep complaints are viewed as relatively less stigmatizing than mental disorders. </li></ul><ul><li>As such, may see sleep complaints as a presenting concern rather than symptoms of depression or anxiety. </li></ul><ul><li>Children and adolescents with Major Depressive Disorder generally present with less subjective sleep disturbance. </li></ul><ul><li>Hypersomnia is more common in depressed adolescents and young adults; insomnia more common in older adults. </li></ul><ul><li>Sleep Disorders Related to Another Mental Disorder are more common in females than in males. Likely due to the increased prevalence of Mood and Anxiety Disorders in females rather than any difference in sleep problems. </li></ul>
  47. 52. Prevalence <ul><li>Sleep problems very common to all types of mental disorders. </li></ul><ul><li>Insomnia Related to Another Mental Disorder most frequent diagnosis (35% to 50%) in individuals presenting to sleep disorder centers. </li></ul><ul><li>Hypersomnia much less frequent (fewer than 5%) among individuals evaluated at sleep disorder centers. </li></ul>
  48. 53. Course <ul><li>Course tends to follow the course of the underlying mental disorder itself. </li></ul><ul><li>Sleep disturbance may be one of the earliest symptoms to appear in individuals who develop an associated disorder. </li></ul><ul><li>For many individuals with depression – particularly those treated pharmacologically – sleep improvement is rapid. </li></ul><ul><li>Other individuals continue to experience sleep problems chronically, even after primary symptoms of the underlying disorder remit. </li></ul>
  49. 54. Differential Diagnosis <ul><li>Major Depressive Disorder </li></ul><ul><ul><li>Only make the additional diagnosis when the sleep disturbance is severe and an independent focus of clinical attention. </li></ul></ul><ul><li>Primary Insomnia / Hypersomnia </li></ul><ul><li>Sleep Disorder Due to a General Medical Condition </li></ul><ul><li>Substance-Induced Sleep Disorder </li></ul><ul><li>Normal Sleep Patterns </li></ul>
  50. 56. Primary Insomnia (307.02) <ul><li>Essential feature: a complaint of difficulty initiating or maintaining sleep or of nonrestorative sleep that lasts for at least 1 month. </li></ul><ul><li>Most often report difficulty falling asleep and intermittent wakefulness during sleep. </li></ul><ul><li>Infrequently complain of nonrestorative sleep, but sleep nonetheless </li></ul><ul><li>Not all individuals with nighttime sleep disturbances are distressed by this or have any functional impairments – diagnosis of Primary Insomnia does not apply here. </li></ul>
  51. 57. Primary Insomnia (307.02) <ul><li>Often associated with increased physiological, cognitive or emotional arousal in combination with negative conditioning for sleep. </li></ul><ul><li>As distress and preoccupation with sleep increases, difficulty getting to sleep increases – the more the individual strives for sleep, the harder it is for them to sleep. </li></ul><ul><li>Practice good sleep hygiene! </li></ul><ul><ul><li>Have a good sleep schedule </li></ul></ul><ul><ul><li>Don’t spend too much time in bed </li></ul></ul><ul><ul><li>Don’t engage in non-sleep-related activities in bed </li></ul></ul>
  52. 58. Primary Insomnia (307.02) <ul><li>A. The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month. </li></ul><ul><li>B. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>C. The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia. </li></ul><ul><li>D. The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a Delirium). </li></ul><ul><li>E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  53. 59. Associated Features <ul><li>History of “light” or easily disturbed sleep prior to developing Primary Insomnia </li></ul><ul><li>Anxious overconcern with general health and increased sensitivity to daytime effects of mild sleep loss </li></ul><ul><li>Anxiety or depressive symptoms not meeting criteria for an Anxiety or Mood Disorder </li></ul><ul><li>Interpersonal, social, and occupational problems. </li></ul><ul><li>Problems with inattention and concentration (may lead to accidents) </li></ul>
  54. 60. Associated Features <ul><li>Some polysomnographic abnormalities </li></ul><ul><li>Elevated scores on self-report psychological or personality inventories: </li></ul><ul><ul><li>Chronic, mild depression and anxiety </li></ul></ul><ul><ul><li>Internalizing style of conflict resolution </li></ul></ul><ul><ul><li>Somatic focus from anxiety-related concerns </li></ul></ul><ul><li>Individuals may appear fatigued or haggard but show no other abnormalities on physical exam </li></ul><ul><li>Increased incidence of stress-related psychophysiological problems (e.g., tension headache, increased muscle tension, gastric distress) </li></ul>
  55. 61. Age & Gender Features <ul><li>Survey studies suggest that complaints of insomnia are more prevalent with increasing age and among women. </li></ul><ul><li>May be due to increased physical health complaints among the elderly. </li></ul><ul><li>Young adults more often complain of difficulty falling asleep, midlife and elderly adults more likely to have difficulty maintaining sleep and early morning awakening. </li></ul><ul><li>Polysomnography more useful for older adults than younger adults in making differential diagnoses. </li></ul>
  56. 62. Prevalence <ul><li>Population surveys among adults: 30% to 45% one-year prevalence rate </li></ul><ul><li>1% to 10% in general adult population </li></ul><ul><li>25% of the elderly </li></ul><ul><li>Children and adolescents? </li></ul>
  57. 63. Course <ul><li>Precipitating factors may differ from perpetuating factors in Primary Insomnia </li></ul><ul><li>Most cases have a fairly sudden onset at a time of psychological, social, or medical stress </li></ul><ul><li>This onset is then maintained by negative conditioning long after the original stressor has abated. </li></ul><ul><li>Typically begins in young adulthood; rare in childhood or adolescence. </li></ul>
  58. 64. Familial Pattern <ul><li>Predisposition toward light and disrupted speech has a familial association. </li></ul><ul><li>Limited data from twin studies reveal mixed results regarding importance of genetic factors in Primary Insomnia. </li></ul>
  59. 65. Differential Diagnosis <ul><li>Normal sleep variation </li></ul><ul><li>Short sleepers </li></ul><ul><ul><li>Fall sleep easily, decreased need for sleep. </li></ul></ul><ul><ul><li>May try to “treat” short sleeping by staying in bed longer, increasing risk for Primary Insomnia </li></ul></ul><ul><li>Primary Hypersomnia </li></ul><ul><ul><li>Both have daytime sleepiness </li></ul></ul><ul><li>Circadian Rhythm Sleep Disorder </li></ul><ul><li>Narcolepsy – rarely exhibit Insomnia </li></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Parasomnias </li></ul><ul><li>Other mental disorders that include insomnia </li></ul><ul><li>Insomnia Related to Another Mental Disorder </li></ul><ul><li>Sleep Disorder Due to a General Medical Condition </li></ul><ul><li>Substance-Induced Sleep Disorder </li></ul>
  60. 67. Narcolepsy (347.00) <ul><li>Essential feature: repeated irresistible attacks of refreshing sleep, cataplexy, and recurrent intrusions of REM sleep into the transition period between sleep and wakefulness. </li></ul><ul><li>Sleepiness typically decreases after a sleep attack, only to return several hours later. </li></ul><ul><li>Key issue </li></ul><ul><ul><li>sleep “attacks” + cataplexy + REM intrusion </li></ul></ul><ul><li>Note: some sleep experts will diagnose Narcolepsy without cataplexy if you see pathological sleepiness and two or more sleep-onset REM periods during a MSLT </li></ul>
  61. 68. Narcolepsy (347.00) <ul><li>A. Irresistible attacks of refreshing sleep that occur daily over at least 3 months. </li></ul><ul><li>B. The presence of one or both of the following: </li></ul><ul><ul><li>(1) cataplexy (i.e., brief episodes of sudden bilateral loss of muscle tone, most often in association with intense emotion) </li></ul></ul><ul><ul><li>(2) recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes </li></ul></ul><ul><li>C. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition. </li></ul>
  62. 69. Associated Features <ul><li>Some folks experience daytime sleepiness between narcoleptic episodes; they may be described as “able to sleep at any time in any situation.” </li></ul><ul><li>Automatic behavior may occur as a result of profound sleepiness. </li></ul><ul><ul><li>Automatic behavior: drive, converse, work </li></ul></ul><ul><li>Frequent, intense dreams common in nocturnal sleep of narcoleptics </li></ul><ul><li>Also see fragmented nighttime sleep due to spontaneous awakenings or periodic limb movements. </li></ul>
  63. 70. Associated Features <ul><li>Individuals may avoid social activities for fear of having a narcoleptic attack or cataplexy. </li></ul><ul><li>Attempts to control their emotional expression may lead to a generalized lack of expressiveness, which, in turn, leads to social problems. </li></ul><ul><li>Risk for accidental injury due to falling asleep in dangerous situations. </li></ul><ul><li>40% of individuals with Narcolepsy also have a concurrent mental disorder or history of another mental disorder. </li></ul><ul><ul><li>Most common: Mood Disorders, Substance-Related Disorders, Generalized Anxiety Disorder </li></ul></ul><ul><li>Parasomnias also common in individuals with Narcolepsy </li></ul>
  64. 71. Associated Features <ul><li>Two out of three individuals with narcolepsy will be identified by the following two criteria: </li></ul><ul><ul><li>Average MSLT daytime sleep latencies under 5 minutes. </li></ul></ul><ul><ul><li>REM sleep intrusions during 2 or more MSLT naps </li></ul></ul><ul><li>Other polysomnographic findings also seen specifically in Narcolepsy </li></ul><ul><li>Specific HLA typing found in almost all individuals with Narcolepsy and cataplexy. </li></ul><ul><ul><li>Same marker also found in 20% to 25% of general population </li></ul></ul><ul><li>Can see cataplexy and narcoleptic episodes during interview, particularly when emotional issues are discussed. </li></ul>
  65. 72. Age Features & Epidemiology <ul><li>Hyperactivity also seen in children with Narcolepsy with daytime sleepiness </li></ul><ul><li>Cataplexy and mild daytime sleepiness may be more difficult to identify in children </li></ul><ul><li>Prevalence: 0.02% to 0.16% in the adult population </li></ul><ul><li>Equal male : female ratio </li></ul>
  66. 73. Course <ul><li>Daytime sleepiness first symptom of Narcolepsy; becomes clinically-significant during adolescence. </li></ul><ul><li>Upon careful review, can also see evidence of sleepiness in preschool and early school ages </li></ul><ul><li>Onset after age 40 is unusual </li></ul><ul><li>Acute psychosocial stressors or alterations in sleep-wake schedule may trigger onset of Narcolepsy. </li></ul><ul><li>Excessive sleepiness is stable over time. </li></ul><ul><li>Cataplexy has a similar stable course. </li></ul>
  67. 74. Familial Pattern <ul><li>Genetic/heritability studies suggest a role for genetic factors; mode of inheritance not determined. </li></ul><ul><li>Approximately 5% to 15% of first-degree biological relatives of Narcoleptic-positive probands have the disorder. </li></ul><ul><li>25% to 50% of first-degree relatives have other disorders characterized by excessive sleepiness. </li></ul>
  68. 75. Differential Diagnosis <ul><li>Normal variations in sleep </li></ul><ul><li>Sleep deprivation </li></ul><ul><li>Primary Hypersomnia </li></ul><ul><ul><li>Similar levels of daytime sleepiness </li></ul></ul><ul><ul><li>No cataplexy </li></ul></ul><ul><ul><li>MSLT shows no REM intrusions </li></ul></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Hypersomnia Related to Another Mental Disorder </li></ul><ul><li>Use of, or withdrawal from, substances </li></ul><ul><li>Substance-Induced Sleep Disorder </li></ul><ul><li>Sleep Disorder Due to a General Medical Condition </li></ul>
  69. 77. Dyssomnia NOS (307.47) <ul><li>The Dyssomnia Not Otherwise Specified Category is for insomnias, hypersomnias, or circadian rhythm disturbances that do not meet criteria for any specific Dyssomia. Examples include: </li></ul><ul><li>1) Complaints of clinically significant insomnia or hypersomnia that are attributable to environmental factors (e.g., noise, light) </li></ul><ul><li>2) Excessive sleepiness that is attributable to ongoing sleep deprivation. </li></ul><ul><li>3) “Restless legs syndrome” </li></ul><ul><li>4) Periodic limb movements. </li></ul><ul><li>5) Situations in which the clinician has concluded that a Dyssomnia is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. </li></ul>
  70. 79. Nightmare Disorder (307.47) <ul><li>Essential feature: repeated occurrence of frightening dreams that lead to awakenings from sleep. </li></ul><ul><li>Nightmares often occur in lengthy, elaborate dream sequences that are highly anxiety-provoking to the individual. </li></ul><ul><li>Since the individual awakens shortly after or during the REM period, often maintains memory or awareness of dream content. </li></ul><ul><li>Later evening REM periods longer, thus more likely to have more intense nightmares later in the evening. </li></ul>
  71. 80. Nightmare Disorder (307.47) <ul><li>A. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security, or self-esteem. The awakenings generally occur during the second half of the sleep period. </li></ul><ul><li>B. On awakening from the frightening dreams, the person rapidly becomes oriented and alert (in contrast to the confusion and disorientation seen in Sleep Terror Disorder and some forms of epilepsy). </li></ul><ul><li>C. The dream experience, or the sleep disturbance resulting from the awakening, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>D. The nightmares do not occur exclusively during the course of another mental disorder (e.g., a Delirium, Posttraumatic Stress Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  72. 81. Associated Features <ul><li>Mild autonomic arousal after awakening from the nightmare. </li></ul><ul><li>Body movements & yelling not common since the nightmare is occurring during REM sleep (skeletal muscle tone inhibited). </li></ul><ul><li>Nightmares that accompany body movements and yelling often occur in PTSD, in Stage 4 sleep. </li></ul>
  73. 82. Culture, Age, & Gender Features <ul><li>Significance of nightmares vary with cultural background. </li></ul><ul><li>Nightmares frequently occur during childhood. </li></ul><ul><ul><li>Need to have persistent, significant distress or impairment that warrants independent clinical attention for this diagnosis. </li></ul></ul><ul><li>Female report having nightmares more often than males (2:1 to 4:1 ratio). </li></ul><ul><ul><li>Not sure if this is due to true discrepancy in nightmares or variance in reporting. </li></ul></ul>
  74. 83. Prevalence <ul><li>10% to 50% of children ages 3-5 years have nightmares scary enough to disturb parents. </li></ul><ul><li>3% of young adults report frequent nightmares </li></ul><ul><li>Actual prevalence of Nightmare Disorder is unknown. </li></ul>
  75. 84. Course <ul><li>Nightmares often begin between 3 and 6 years. </li></ul><ul><li>When the frequency approaches several per week, may become a source of concern and distress. </li></ul><ul><li>Many children outgrow frequent nightmares. </li></ul><ul><li>In a minority, may persist at high frequency into adulthood. </li></ul>
  76. 85. Differential Diagnosis <ul><li>Sleep Terror Disorder </li></ul><ul><li>Breathing-Related Sleep Disorder </li></ul><ul><li>Narcolepsy </li></ul><ul><li>Panic Attacks during sleep </li></ul><ul><li>Parasomnia Not Otherwise Specified </li></ul><ul><li>Substance-Induced Sleep Disorder, Parasomia Type </li></ul><ul><li>Sleep Disorder Due to a General Medical Condition, Parasomnia Type </li></ul><ul><li>Occasional, isolated nightmares </li></ul>
  77. 87. Sleep Terror Disorder (307.46) <ul><li>A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream. </li></ul><ul><li>B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode. </li></ul><ul><li>C. Relative unresponsiveness to efforts of others to comfort the person during the episode. </li></ul><ul><li>D. No detailed dream is recalled and there is amnesia for the episode. </li></ul><ul><li>E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  78. 89. Sleepwalking Disorder (307.46) <ul><li>A. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. </li></ul><ul><li>B. While sleepwalking, the person 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. </li></ul><ul><li>C. On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the episode. </li></ul>
  79. 90. Sleepwalking Disorder (307.46) <ul><li>D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation). </li></ul><ul><li>E. The sleepwalking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. </li></ul><ul><li>F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. </li></ul>
  80. 92. Parasomnia NOS (307.47) <ul><li>The Parasomnia Not Otherwise Specified category is for disturbances that are characterized by abnormal behavioral or physiological events during sleep or sleep-wake transitions, but that do not meet criteria for a more specific Parasomnia. Examples include: </li></ul><ul><li>1) REM sleep behavior disorder: motor activity, often of a violent nature, that arises during rapid eye movement (REM) sleep. Unlike sleepwalking, these episodes tend to occur later in the night and are associated with vivid dream recall. </li></ul>
  81. 93. Parasomnia NOS (307.47) <ul><li>2) Sleep paralysis: an inability to perform voluntary movement during the transition between wakefulness and sleep. The episodes may occur at sleep onset (hypnagogic) or with awakening (hypnopompic). The episodes are usually associated with extreme anxiety, and, in some cases, fear of impending death. Sleep paralysis occurs commonly as an ancillary symptom of Narcolepsy and, in such cases, should not be coded separately. </li></ul><ul><li>3) Situations in which the clinician has concluded that a Parasomnia is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced. </li></ul>

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