sleep wake disorders

1. Presented by
Arshia Ambreen
MS (CP)

2. sleep-wake disorders
Sleep disorders are characterize by abnormality in amount,
quality and timing of sleep and some abnormal behaviours
and physiological events associated with sleep and specific stages
of
sleep often accompanied by
 depression
 anxiety
 cognitive changes
that must be addressed in treatment planning and management.
Furthermore, persistent
 sleep disturbances (both insomnia and excessive sleepiness) are
established risk factors for the subsequent development of
mental illnesses and substance use disorders.

3. Disorder groups
Sleep-wake disorders encompass 10 disorders or disorder
groups
1 Insomnia disorder.
2 Hyper somnolence disorder.
3 Narcolepsy.
4 Breathing-related sleep disorders.
5 Circadian rhythm sleep-wake disorders.
6 Non-rapid eye movement (NREM) sleep arousal disorders.
7 Nightmare disorder.
8 Rapid eye movement (REM) sleep behavior disorder.
9 Restless legs syndrome.
10 Substance/medication-induced sleep disorder.

4. Insomnia Disorder
Insomnia symptoms may include:
 Difficulty falling asleep at night
 Waking up during the night
 Waking up too early
 Not feeling well-rested after a night's sleep
 Daytime tiredness or sleepiness
 Irritability, depression or anxiety
 Difficulty paying attention, focusing on tasks or
remembering
 Increased errors or accidents

5. Diagnostic Criteria
A. A predominant complaint of dissatisfaction witli 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. (In
children, this may manifest as difficulty returning to sleep
without caregiver intervention.)
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.

6. Diagnostic Criteria
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 circadian rhythm sleep-wake
disorder, a parasomnia).
G. The insomnia is not attributable to the physiological 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 non-sleep disorder mental comorbidity, including substance use
disorders
 With other medical comorbidity
 With other sleep disorder

7. Prevalence
 Population-based estimates indicate that about one-
third of adults report insomnia symptoms, 10%-15%
experience associated daytime impairments, and 6%-
10% have symptomsthat meet criteria for insonmia
disorder.
 Insomnia is a more prevalent complaint among
females than among males, with a gender ratio of
about 4:1.
 For instance, 40%-50% of individuals with insomnia
also present with a comorbid mental disorder.

8. Risk Factors
 Anxiety AND tendency to repress emotions can
increase vulnerability to insomnia.
 Female gender and advancing age are associated with
increased vulnerability to insomnia.
 poor sleep hygiene practices (e.g., excessive caffeine
use, irregular sleep schedules).

9. Treatment
 For short-term insomnia, doctors may prescribe sleeping
pills.
 Most sleeping pills stop working after several weeks of
nightly use, however, and long-term use can actually
interfere with good sleep.
 Mild insomnia often can be prevented or cured by
practicing good sleep habits .
 For more serious cases of insomnia, researchers are
experimenting with light therapy and other ways to alter
circadian cycles.

10. Hypersomnolence Disorder
 sometimes idiopathic hypersomnia (meaning that it
arises from no known cause), is a sleep
disorder characterized by
 excessive daytime sleepiness,
 excessive sleep periods each day (usually taken to
mean more than 10 hours) and/or an inability to
achieve the feeling of refreshment that sleep usually
brings.
 Chronic sufferers may sleep up to 18 hours a day or
more and still not feel refreshed upon waking.

11. 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 nonrestorative (i.e., unrefreshing).
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.

12. Prevaience & onset
 Approximately 5%-10% of individuals who consult in sleep
disorders clinics with complaints of daytime sleepiness are
diagnosed as having hypersomnolence disorder.
 Hypersomnolence occurs with relatively equal frequency in
males and females.
 Hypersomnolence has a progressive onset, with symptoms
beginning between ages 15 and 25 years, with a gradual
progression over weeks to months.

13. Treatment & Management
 sodium oxybate, amphetamine, methamphetamine are effective
treatments for excessive sleepiness associated with hypersomnias.
 Behavioral approaches and sleep hygiene techniques are
recommended, although they have little overall positive impact on this
disease.
 Behavioral techniques can also be helpful for regulating one’s sleep
schedule in ways that promote optimal day-to-day functioning. For
example, avoiding late-night work and social activities may avoid
delayed bedtime (one cause of excessive daytime sleepiness). Patients
should also avoid ingesting alcohol and caffeine in the hours close to
bedtime.

14. Narcolepsy
 People with narcolepsy experience excessive daytime
sleepiness and intermittent, uncontrollable episodes of
falling asleep during the daytime. These
sudden sleep attacks may occur during any type of activity
at any time of the day.
 Narcolepsy usually begins between the ages of 15 and 25,
but it can become apparent at any age. In many cases,
narcolepsy is undiagnosed and, therefore, untreated.

15. 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.

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

17. Prevalence & Onset
 Narcolepsy-cataplexy affects 0.02%-0.04% of the
general population in most countries.Narcolepsy
affects both genders.
 Onset is typically in children and adolescents/young
adults but rarely in older adults.
 Two peaks of onset are suggested, at ages 15-25 years
and ages 30-35 years.

18. Treatment
 Once narcolepsy is diagnosed, stimulants, antidepressants, or
other drugs can help control the symptoms and prevent the
embarrassing and dangerous effects of falling asleep at
improper times.
 Lifestyle adjustments such as avoiding caffeine, alcohol,
nicotine, and heavy meals, regulating sleep schedules,
scheduling daytime naps (10-15 minutes in length), and
establishing a normal exercise and meal schedule may also
help to reduce symptoms.

19. Breathing-Related Sleep
Disorders
1 Obstructive Sleep Apnea Hypopnea
Diagnostic Criteria:
A. Either (1) or (2):
1. Evidence by polysomnography of at least five obstructive apneas or
hypopneas perhour of sleep and either of the following sleep
symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or
breathing pauses during sleep.
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient
opportunities to sleep that is not better explained by another mental
disorder (including a sleep disorder) and is not attributable to another
medical condition.
2. Evidence by polysomnography of 15 or more obstructive apneas and/or
hypopneas per hour of sleep regardless of accompanying symptoms.

20. 2 Central Sleep Apnea
Diagnostic Criteria:
 A. Evidence by polysomnography of five or more central
apneas per hour of sleep.
 B. The disorder is not better explained by another current
sleep disorder.
3 Sleep-Related Hypoventilation
A. Polysomnograpy demonstrates episodes of decreased
respiration associated with elevated CO2 levels.
B. The disturbance is not better explained by another current
sleep disorder.

21. Prevaience
 The prevalence of idiopathic central sleep apnea is
unknown but thought to be rare.
 Obstructive sleep apnea hypopnea is a very common
disorder, affecting at least l%-2% of children, 2%-15%
of middle-age adults, and more than 20% of older
individuals. In adults, the male-to-female ratio of
obstructive sleep apnea hypopnea ranges from 2:1 to
4:1.

22. treatment
 Treatment for Breathing-Related Sleep Disorders may
include:
 Lifestyle changes, such as losing weight. For more
information, see Home Treatment.
 Continuous positive airway pressure (CPAP) or a similar
machine that uses positive airway pressure to help you breathe.
 Oral breathing devices or other devices (such as nasal
dilators) that you wear at night.
 Medicine to help you stay awake during the day. For more
information, see Medications.

23. Circadian Rhythm Sleep-Wake
Disorders
 Physiological and behavioral changes in the body that
occur on roughly a 24 hour cycle, sometimes called
the body clock
 People with circadian rhythm sleep disorders are unable to
go to sleep and awaken at the times commonly required for
work and school as well as social needs. They are generally
able to get enough sleep if allowed to sleep and wake at the
times dictated by their "body clocks". The quality of their
sleep is usually normal unless they also have another sleep
disorder.

24. 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.

25. Types
 Five types of CSDs are defined below. The first four are
chronic, with neurological causes. The last is temporary,
with social and environmental causes
 Delayed Sleep Phase Syndrome (DSPS)
 Non-24-Hour Sleep-Wake Disorder (Non-24)
 Advanced Sleep Phase Syndrome (or Disorder) (ASPS
or ASPD)
 Irregular Sleep-Wake Disorder (ISWD)
 Shift Work Disorder

26. Prevaience
 Prevalence of delayed sleep phase type in the general population
is approximately 0.17%but appears to be greater than 7% in
adolescents.
 The estimated prevalence of advanced sleep phase type is
approximately 1% in middleage
adults.
 Prevalence of irregular sleep-wake type and non-24-hour sleep-
wake type in the general population is unknown.
 The prevalence of shift work type is unclear, but the disorder is
estimated to affect 5%-10% of the night worker population (16%-
20% of the workforce).

27. treatment
 Bright light therapy. People who have a circadian
rhythm disorder respond well to light therapy,
especially bright light therapy.
 Lifestyle changes: People with circadian rhythm
disorders may respond to shifts in their active phases
by exhibiting signs of sleep deprivation. For example,
teenagers may have difficulty keeping late hours and
getting up for an early morning class.

28. Non-Rapid Eye Movement
Sleep Arousal Disorders
 refer to the repeated episodes of incomplete
awakening from sleep that include behaviors such as
sleepwalking and sleep terrors. These episodes usually
happen during the first third of the night and people
will be confused and disoriented if awakened during
an episode. People with this condition will have no
memory of their dreams or sleep behavior in the
morning.

29. 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, rapid
breathing, and sweating.
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.

30. Prevalence & development
 From 10% to 30% of children have had at least one
episode of sleepwalking, and 2%-3% sleepwalk often.
 is 1.0%-7.0% among adults, with weekly to monthly
episodes.
 NREM sleep arousal disorders occur most commonly
in childhood and diminish in frequency with
increasing age.

31. treatment
 If no violent behavior is observed, initial treatment focuses on
reassuring and educating the patient and his or her family about
the fact that these arousal disorders are typically benign and
tend to dissipate over time.
 Treatment may be required if the Non-Rapid Eye Movement
(NREM) Sleep Arousal Disorders are dangerous or distressing to
the individual (i.e. violent). In this case, non-pharmacological
therapies for long-term management include psychotherapy,
progressive relaxation, and hypnosis.

32. Nightmare Disorder
 A nightmare is a disturbing dream associated with
negative feelings, such as anxiety or fear that awakens
you. Nightmares are common in children, but can
happen at any age, and occasional nightmares usually
are nothing to worry about. Its causes are
 Sleep deprivation
 Substance abuse.
 Scary books and movies and Trauma.

33. 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 and medical disorders do not adequately explain the
predominant complaint of dysphoric dreams.

34. Prevalence & Treatment
 From 1.3% to 3.9% of parents report that their
preschool children have nightmares.
 Prevalence increases from ages 10 to 13 for both males
and females but continues to increase to ages 20-29 for
females (while decreasing for males).
 Treatment
 CBT
 Image Rehearsal Therapy (IRT)

35. Restless Legs Syndrome
 Restless Legs Syndrome
 Restless legs syndrome (RLS), a familial disorder causing
unpleasant crawling, prickling, or tingling sensations in
the legs and feet and an urge to move them for relief.
 one of the most common sleep disorders, especially
among older people.

36. Diagnostic Criteria
A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant
sensations in the legs, characterized by all of the following:
1. The urge to move the legs begins or worsens during periods of rest or inactivity.
2. The urge to move the legs is partially or totally relieved by movement.
3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in
the evening or at night.
B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3
months.
C. The symptoms in Criterion A are accompanied by significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of functioning.
D. The symptoms in Criterion A are not attributable to another mental disorder or medical condition
(e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by
behavioral condition (e.g., positional discomfort, habitual foot tapping).
E. The symptoms are not attributable to the physiological effects of a drug of abuse.

37. Prevalence & Treatment
Prevalence rates of RLS vary widely when broad
criteria are utilized but range from 2% to 7.2%
when more defined criteria are employed.
Treatment:
 RLS often can be relieved by drugs that affect the
neurotransmitter dopamine, suggesting that dopamine
abnormalities underlie these disorders’ symptoms.

38. Treatment
 we may also benefit from physical therapy and self-
care treatments, such as stretching, taking hot or cold
baths, whirlpool baths, applying hot or cold packs to
the affected area, limb massage,

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

40. Diagnostic Criteria
C. The disturbance is not better explained by a sleep disorder that is not substance/
medication-induced. Such evidence of an independent sleep disorder could include
the following:
The symptoms precede the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence suggesting the
existence of an independent non-substance/medication-induced sleep disorder
(e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

41. Treatment
 How is Substance/Medication-Induced Sleep
Disorder treated?
 Since the condition is caused by use of a medication,
treatment would focus on stopping that medication or
dealing with the symptoms of having stopped taking
it.