PPt is on disorders of sleep...

1. S L E E P C M E
1 8 T H M A RC H 2 0 2 2
Disorders of sleep
Dr. Donthu Raj Kiran
DNB, MSc Psychology, PGDMLE
Asst Prof, Psychiatry
KIMS & RF

2. Roadmap
 Different classificatory systems.
 ICSD classification
 Various disorders
 Diagnostic methods

3. Definitions
 Dyssomnias: disorders of quantity or timing of sleep- insomnia and
hypersomnia.
 Insomnia: a perceived disturbance in the quantity or quality of
sleep, which depending on the specific condition may be associated
with disturbances in objectively measured sleep.
 Hypersomnias: conditions that are clinically expressed as excessive
sleepiness.
 Parasomnias: abnormal behaviors during sleep or the transition
between sleep and wakefulness. Often, they reflect the appearance
of normal sleep processes at inappropriate times.

4. ICD- 11
 Classifies as sleep wake disorders as a separate chapter.
 Includes:
1. Insomnia disorders
2. Hypersomnolence disorders
3. Sleep related breathing disorders
4. Circadian rhythm sleep wake disorders
5. Sleep related movement disorders
6. Parasomnia disorders
7. Other specified sleep wake disorders
8. Sleep wake disorders, unspecified

5. DSM 5
 Insomnia disorder
 Hypersomnia disorder
 Narcolepsy
 Breathing related sleep
disorders
 Circadian rhythm sleep-
wake disorders
 NREM sleep arousal
dsiorders
 Nightmare disorder
 REM sleep behaviour
disorder
 Restless leg syndrome
 Substance/ medication
induced sleep disorder

6. ICSD- 3
 Published by American Academy of Sleep Medicine in
association with international sleep societies.
 Major diagnostic sections:
1. Insomnia
2. Sleep related breathing disorders
3. Central disorders of hypersomnolence
4. Circadian rhythm sleep- wake disorders
5. Parasomnias
6. Sleep related movement disorders
7. Other sleep disorders

7.  Insomnia
 Chronic
 Short term
 Sleep related breathing
disorders
 Obstructive sleep apnea
 Central sleep apnea
 Hypoventilation disorder
 Hypoxemia disorder.
 Hypersomnolence
 Narcolepsy
 Kleine-Levin syndrome
 Substance/ medical/
psychiatric condition
 Insufficient sleep syndrome
 Circadian rhythm sleep
wake disorders
 Shift work disorder
 Jet lag disorder
 Delayed/ Advanced/
Irregular/ Non 24 hr

8.  Parasomnias
 Confusional arousal
 Sleep walking
 Sleep terrors
 Sleep related eating disorder
 REM behaviour disorder
 Recurrent isolated sleep
paralysis
 Night mare
 Exploding head disorder
 Sleep related hallucinations
 Sleep enuresis
 Sleep related movement
disorder
 Restless leg syndrome
 Periodic limb movement
disorder
 Bruxism
 Leg cramps
 Rhythmic movement disorder
 Benign sleep myoclonus
 Proprospinal myoclonus at
sleep inset
 Substance/ medical condition

9. Insomnia
 Predominant complaint: dissatisfaction with sleep
quantity/ quality (difficulty initiating/ maintaining/ early
awakening).
 Causes significant distress/ impairment: social,
occupational, educational, academic, behavioural or other
important areas.
 Non-restorative sleep:
 Most common complaint.
 Poor sleep quality that does not leave the individual rested, upon on
awakening, despite adequate duration.

10.  Previously-
 Primary (psychophysiological/ paradoxical/ idiopathic/ behavioural
insomnia of childhood) &
 Secondary (comorbid to medical/ psychiatric illness/ substance).
 Old classification: from clinical perspective, proved to be
unreliable and therapeutic approaches do not differ significantly.
 Short term: less than 3 months duration, regardless of etiology.
 Chronic:
 At least 3 months duration
 At least 3 times per week.

11.  Chronic insomnia
 Despite adequate opportunity and circumstances.
 Day time consequences: fatigue, impaired concentration, mood
disturbance, occupational/ social / academic impairment.
 Complaints: initiation/ maintenance/ early awakening.
 Occur frequently along with medical/ psychiatric diagnosis.
 Diagnosis is made when insomnia is the focus of assessment &
treatment.

12.  Patients present with multiple comorbidities 
difficult to ascertain cause & effect relationship
between insomnia and comorbid diagnosis.
 Normal variants:
 Short sleeper: ≤ 6 hrs of routine pattern without sleep
complaints or daytime consequences.
 Excessive time in bed.

13. Sleep related breathing disorders
 Characterized by disordered respiration during sleep.
 OSA:
 Complete/ partial obstruction of the airway during sleep 
absent/ reduced airflow despite adequate respiratory effort.
 Adult: repetitive episodes of apnea/ hypoapnea/ arousal
associated with increased airway resistance & respiratory effort.
 Snoring is commonly reported & SpO2 is reduced during apnea/
hypoapnea.

14.  Adult OSA:
 Diagnosis: presence of ≥ 5 obstructive events.
 Along with at least 1 sign/ symptom (snoring, observed pauses,
excessive sleepiness, insomnia).
 Pediatric OSA:
 Similar to adult OSA but cortical arousals do not occur (higher
arousal threshold).
 Absence of cortical arousal  sustained pattern of obstructive
hypoventillation, which requires CO2 monitoring for detection.

15.  Central sleep apnea:
 Reduced/ absent respiratory effort  airflow is diminished/
absent in an intermittent/ cyclic fashion.
 Require polysomnographic demonstration of central apnea/
hypoapnea index > 5.
 Associated signs/ symptoms: sleepiness, sleep disturbance,
awakening short of breath, snoring, apnea.
 Primary CSA: unknown etiology.

16.  Hypoventilation disorder:
 Elevated levels of PCO2 by ABG or end tidal/ transcutaneous
CO2.
 Hypoxemia disorder:
 Sustained drop in arterial O2 (≤88% for > 5 min) in absence of
elevated CO2.

17. Hypersomnolence
 Self reported excessive sleepiness despite a main sleep period
lasting at least 7 hrs.
 At least 3 times/ week for at least 3 months.
 Deteriorated quality of wakefulness: sleep propensity during
wakefulness.
 Sleep inertia: period of impaired performance and reduced
vigilance following awakening from regular sleep/ nap.
 Automatic behaviour: due to persistent need for sleep and
involves doing things with little/ no subsequent recall.

18.  Primary complaint: daytime sleepiness which is not due to
another sleep disorder.
 Caused by CNS abnormality except insufficient sleep
syndrome (behaviorally induced sleep deprivation).
 Excessive sleepiness (ICSD 3): daily episodes of an
irrepressible need to sleep or daytime lapses into sleep.
 Daytime sleepiness: inability to stay alert and awake
during major waking episodes of the day, resulting in
unintended lapses into sleep.

19.  Narcolepsy:
 Type 1 & 2: with & without cataplexy respectively.
 Type 1:
 Excessive sleepiness & presence of definite cataplexy plus multiple
sleep latency test (MSLT) findings (mean sleep latency ≤ 8 min & ≥ 2
sleep onset REM periods)
 Or subjective sleepiness & Hypocretin deficiency on absence of
cataplexy.
 Type 2:
 Subjective sleepiness with MSLT findings but without cataplexy or
hypocretin deficiency.

20.  Narcolepsy diagnosis:
 Recurrent periods of irrepressible need for sleep (3/ week for 3
months)
 Presence of one among these:
 Cataplexy
 Hypocretin deficiency (measured using CSF hypocretin-1
immunoreactivity levels).
 Nocturonal sleep polysomnography showing REM sleep latency ≤
15min.
 Others: hypnagogic/ hypnopompic hallucinations; nightmares;
vivid dreaming.

21. Clinical features of narcolepsy:

22.  Sleep attacks: irresistible sleepiness, leading to 10 to 20 minutes of sleep,
after which the patient feels refreshed, at least briefly.
 Occur at inappropriate times (e.g., while eating, talking, or driving and
during sex).
 Can include: hypnagogic and hypnopompic hallucinations, cataplexy,
and sleep paralysis.
 The appearance of REM sleep within 10 minutes of sleep onset (sleep-
onset REM periods) is also considered evidence of narcolepsy.
 The disorder can be dangerous because it can lead to automobile and
industrial accidents.

23.  Not as rare as was once thought, occurs at any age, but generally before
the age of 30.
 Either progresses slowly or reaches a plateau that is maintained
throughout life.
 Patients often remain awake during brief cataplectic episodes, the long
episodes usually merge with sleep and show the electroencephalographic
(EEG) signs of REM sleep.
 A type of human leukocyte antigen called HLA-DR2 is found in 90 to 100
percent of patients with narcolepsy and only 10 to 35 percent of
unaffected persons.

24.  Kleine-Levin syndrome:
 Recurrent hypersomnia persisting for days- weeks
 Associated with: eating disorder , cognitive dysfunction,
perceptual disturbance, uninhibited behavior (often sexual).
 Menstrual KLS: women with recurrent hypersomnia as a mensus
related phenomenon.
 Normal variant:
 Long sleeper: ≥ 10 hrs in 24 hours.

25. Circadian rhythm sleep wake disorders
 Alteration of circadian clock or a recurrent misalignment
between the patient’s sleep pattern and pattern accepted
by society.
 Often experience: insomnia & excessive sleepiness.
 Delayed s-w phase: delay in phase of major sleep in
relation to desired sleep and wake time.
 Advanced s-w phase: advance in phase of major sleep in
relation to desired sleep and wake time.

26.  Irregular s-w phase: lack of clearly defined circadian rhythm of
sleep & wakefulness. (institutionalized elders).
 Non 24 hr s-w rhythm: lack of entrainment to 24 hr light-dark
cycle.
 Shift work disorder: insomnia/ excessive sleepiness occurring
as a result of work hours overlapping with the usual sleep
period.
 Jet lag disorder:
 Abrupt desynchronization between circadian s-w propensity and
environmental day-night cycle as a result of transmeridian travel across ≥ 2
time zones.
 Eastward travel  more disruptive.

27.  Shift Work Type
 Common experience: come home in the early morning, to go to bed feeling
exhausted, to sleep only 2 to 3 hours, and to awaken feeling un refreshed but
unable to continue sleeping.
 Treatment is complex and varies with the type of work schedule.
 Various strategies, including napping before going into work in the evening or
taking a scheduled nap during nighttime work hours, may be helpful.
 Using bright light at night and avoiding light during the day have been proposed.
It may be helpful, for instance, for a night-shift worker driving home in the
morning to wear sunglasses, so as not to get a large light exposure immediately
before going to bed.

28.  Jet lag disorder
 Depending on the length of the east-to-west trip and individual sensitivity, jet lag
sleep disorder usually disappears spontaneously in 2 to 7 days.
 Symptoms can be managed by altering the meal and sleep times in an appropriate
direction before traveling.
 For some what appear to be symptoms of jet lag (fatigue and so on) are actually
associated with sleep deprivation and that simply obtaining enough sleep helps.
 No specific treatment is required, Melatonin taken orally at prescribed times is
useful for some persons.
 Maximizing light exposure during the new daytime and minimizing light during the
new nighttime are also helpful.

29. Parasomnias
 Abnormal behavioural, experiential or physiological events
occurring in association with sleep or sleep wake transitions.
 Motor activity is complex than that seen in sleep related
movement disorders.
 Experiences include:
 Cognitive -emotional (night mares)
 Sensory (sleep related hallucinations)
 Arise during NREM, REM and sleep-wake transitions.
 Represents disassociation between either NREM & wake or REM
& wake.

30.  NREM parasomnias: disorders of arousal from slow
wave NREM sleep.
 Confusional arousal: mental confusion/ confusional behavior
during or after arousal from sleep. (MC: children)
 Sleep walking: series of complex behaviors that arise from
sudden arousal from slow wave sleep and result in locomotion
during impaired consciousness.
 Sleep terrors:
 Cry/ piercing scream accompanied by autonomic system activation
and behavioral manifestation of extreme fear.
 Difficult to be aroused and when aroused, can be confused &
amnestic for the episode.

31.  Sleep related eating disorder:
 Recurrent eating/ drinking episodes during partial arousal from
sleep.
 Uncontrollable, ingestion of unusual/ inedible substances.
 Associated with potential injury/ adverse health consequences.
 Limited recall/ awareness.

32.  REM parasomnias: related to pathophysiologic
mechanisms of REM sleep.
 REM behaviour disorder: involves dream enactment behaviour
that occurs in REM sleep.
 Behaviour is often violent & lead to injury/ sleep disruption.
 Occurs in narcolepsy, Parkinson disease, synucleopathies.
 Recurrent isolated sleep paralysis: inability to perform voluntary
movements at the sleep onset or awakening.
 Hallucinatory experiences may accompany.

33.  Night mare:
 Repeated occurrences of extended, extremely dysphoric and well
remembered dreams (usually bad).
 On awakening individual rapidly becomes oriented and alert.
 Mild autonomic arousal, like sweating, tachycardia and tachypnea
can occur. Body movements & vocalisations are not seen because of
REM related loss of muscle tone.
 Replicative nightmare: occurring after traumatic experience and
replicates the threatening situation.

34.  Exploding head syndrome: loud imagined noise/ sense of a
violent explosion in the head of a patient while falling asleep or
during waking.
 Sleep related hallucinations: occurs when clearly awake at sleep
onset/ awakening.
 Sleep talking: arise during NREM/ REM sleep.

35. Sleep related movement disorders
 Relatively simple, usually stereotyped movements that
disturb sleep.
 Restless leg syndrome:
 Strong, irresistible urge to move limbs accompanied by
uncomfortable/ painful symptoms.
 Sensations are worse at rest, occur frequently at evening-night.
 Walking/ moving relieves the sensation temporarily.

36.  Periodic limb movement disorder:
 Repetitive, stereotyped limb movements occurring during sleep.
 Causes sleep disturbance/ daytime sleepiness.
 Leg cramps are painful sensations associated with muscle contractions,
usually of calves or small muscles of foot.
 Relieved by stretching of affected muscle.
 Bruxism:
 Clenching of teeth during any stage of sleep & results in arousal
 Activity is severe/ frequent  TMJ pain/ damage.

37.  Rhythmic movement disorder:
 Stereotyped, repetitive rhythmic motor behaviour occurring during
drowsiness/ light sleep.
 Benign sleep myoclonus of infancy:
 Myoclonic jerks during sleep in infancy (0 to 6 months).
 No adverse consequences and resolves spontaneously.
 Propriosomal myoclonus: recurrent sudden muscular jerks
in transition from wakefulness to sleep.
 Normal variants: sleep starts, excessive fragmentary
myoclonus & hypnogogic foot tremor.

38. Other sleep disorders
 Used when sleep disorder cannot be placed elsewhere.
 Sleep disturbance due to environmental disturbance
such as physical stimulus or environmental danger.

39. Sleep related medical & neurologic disorders
 Fatal familial insomnia
 Sleep related epilepsy
 Sleep related headaches
 Sleep related laryngospasms
 Sleep related gastroesophageal reflux
 Sleep related myocardial ischemia

40. Diagnostic tools in sleep disorders
 Polysomnography
 Home sleep apnea testing
 Multiple sleep latency & maintenance of wakefullness
testing
 Actigraphy monitoring

41. Polysomnography (PSG)
 Gold standard
 Diagnostic test performed in a sleep lab.
 Physiological variables measured are:
 Electromyography
 Electroencephalography
 Oronasal airflow
 Electrocardiography
 Respiratory effort
 Sleeping position

42. Home sleep apnea testing
 Done by home monitoring devices.
 Measures: airflow, breathing effort, oxygen saturation,
snoring, actigraphy, position sensors, sleep time etc.
 Considered for evaluation of OSA and not suitable for
diagnostic evaluation of other sleep dsiorders.
 Low sensitivity, hence negative test should be followed
with PSG.

43. Multiple sleep latency (MSLT) and maintenance of
wakefulness testing (MWT)
 Provides objective measure of sleepiness compared with normal
individuals lacking sleep disorders.
 Indication: narcolepsy, idiopathic hypersomnia, kleine-levin
syndrome.
 Done during daytime in a sleep lab following nocturnal PSG,
with 4 to 5 nap opportunities at standard time and intervals.
 Mean sleep latency is obtained; < 8 min is abnormal and
indicates pathologic excessive daytime sleepiness.
 MWT: assess the ability to remain awake. (hypersomnia
evaluation)

44. Actigraphy
 Provides rigorous estimation of sleep quantity and its
circadian pattern.
 Worn like a wristwatch and contains acclerometer (detects
movements).
 Recorded over time periods lasting over weeks.
 Uses: suspected circadian rhythm disorder, assess response
to treatment of insomnia, hypersomnia prior to PSG and
prior to MSLT to increase accuracy.