2. What is sleep?
A natural periodic state of rest for the body and mind , in
which:
1. The eyes usually close and consciousness is completely
partially lost,
2. There is decreased body movement and
3. Reduced responsiveness to external stimuli.
During sleep, the brains of humans and mammals undergo
a characteristic cycle of brain wave activity that includes
intervals of dreaming.
3. Types of non organic sleep disorders:
Dyssomnias:
Primarily psychogenic conditions in which the
predominant disturbance is in the amount,
quality, or timing of sleep due to emotional causes,
i.e.
• Insomnia,
• Hypersomnia,
• Disorder of sleep - wake schedule.
4. Parasomnias:
• Abnormal episodic events occurring during sleep;
• In childhood these are related mainly to the child's
development, while in adulthood they are predominantly
psychogenic,
i.e. sleepwalking,
sleep terrors,
nightmares.
Excludes: sleep disorders (organic) (G47.-)
6. What is insomnia?
Insomnia is a condition of unsatisfactory quantity and/or
quality of sleep, which persists for a considerable period of
time.
The actual degree of deviation from what is generally
considered as a normal amount of sleep should not be the
primary consideration in the diagnosis of insomnia, since it
is subjective and open to interpretation.
Among insomniacs, difficulty falling asleep is the most
prevalent complaint, followed by difficulty staying asleep
and early final wakening, or a combination of both.
7. Clinical Features:
Typically, insomnia develops at a time of increased life-stress.
Insomnia tends to be more prevalent among women,
older individuals and psychologically disturbed and
socioeconomically disadvantaged people.
Other risk factors include high levels of stress, change in
routine, sedentary lifestyle.
8. When insomnia is repeatedly experienced, it can lead to
an increased fear of sleeplessness and a preoccupation
with its consequences. This is cyclic in nature.
In the morning, they frequently report feeling physically
and mentally tired; during the day, they
characteristically feel depressed, worried, tense,
irritable, and preoccupied with themselves.
9. The presence of other psychiatric symptoms such as depression,
anxiety or obsessions does not invalidate the diagnosis of
insomnia, provided that insomnia is the primary complaint or the
chronicity and severity of insomnia cause the patient to perceive
it as the primary disorder.
Most chronic insomniacs are usually preoccupied with their sleep
disturbance and deny the existence of any emotional problems.
The present code does not apply to so-called "transient insomnia".
Transient disturbances of sleep are a normal part of everyday life
10.
11. Diagnostic Guidelines:
a. The complaint is either of difficulty falling asleep or
maintaining sleep, or of poor quality of sleep;
b. The sleep disturbance has occurred at least three times per
week for at least 1month;
c. There is preoccupation with the sleeplessness and excessive
concern over its consequences at night and during the day;
d. The unsatisfactory quantity and/or quality of sleep either
causes marked distress or interferes with ordinary activities
in daily living.
12. Differential Diagnosis:
1) Insomnia is a common symptom of other mental disorders, such
as affective, neurotic, organic, and eating disorders, substance
use, and schizophrenia, and of other sleep disorders such as
nightmares.
2) It is associated with physical disorders in which there is pain
and discomfort or with taking certain medications.
3) If insomnia occurs only as one of the multiple symptoms of a
mental disorder or a physical condition, the diagnosis should be
limited to that of the underlying mental or physical disorder.
13. Moreover, the diagnosis of another sleep disorder, such as
nightmares, should be made only when these disorders lead to a
reduction in the quantity or quality of sleep.
However, in all of the above instances, if insomnia is one of the
major complaints and is perceived as a condition in itself, the
present code should be added after that of the principal diagnosis.
14. Comorbidity:
An estimated 40% of individuals with insomnia
have a comorbid psychiatric condition. It was found
that insomnia predicted depression, anxiety,
substance abuse or dependence, and suicide. In
fact, the correlation between insomnia and later
development of depression within 1–3 years is
particularly strong.
In a community sample of adolescents that in 69%
of cases, insomnia preceded comorbid depression,
while an anxiety disorder preceded insomnia 73%
of the time.
15. . In a large group of subjects aged 15 to 100 years, insomnia
either appeared before (>40%) or at the same time (>22%) as
mood disorders. This study also found that insomnia appeared
at the same time (>38%) of the time or after (34%) as anxiety
disorders (Individuals with insomnia complaints in the last year
but without any previous psychiatric history were shown to have
an increased risk of first onset major depression, panic disorder,
and alcohol abuse the following year when compared to controls.
Furthermore, adolescents who completed suicide were found to
have higher rates of insomnia in the week preceding death than
community control adolescents.
16. Ms. W. was a 41-year-old, divorced, white female who presented with a 2 ½ year
complaint of sleeplessness. She had some difficulty falling asleep (30- to 45-
minute sleep-onset latency) and awakened every hour or two after sleep onset.
These awakenings might last 15 minutes to several hours, and she estimated
having approximately 4.5 hours of sleep on an average night. She rarely takes
daytime naps notwithstanding feeling tired and edgy. The patient described her
sleep problem with the following words. “It seems like I never get into a deep
sleep.”Sometimes I have a hard time getting my mind to shut down.” She
viewed the bedroom as an unpleasant place of sleeplessness.
At times, Ms. W. was unsure whether she was asleep or awake. She had a history
of clock watching (to time her wakefulness. Reportedly the insomnia is
unrelated to seasonal changes, menstrual cycle, or time-zone translocation. Her
basic sleep hygiene was good. Appetite and libido were unchanged. She denied
mood disturbance, except for being quite frustrated and concerned about
sleeplessness and its effect on her work. Her work involved sitting at a
microscope 6 hours of a 9-hour working day and meticulously documenting her
findings. Her final output hadn't suffered, but she had to “double check” for
accuracy.
18. What is Hypersomnia?
Hypersomnia is defined as a condition of either excessive
daytime sleepiness and sleep attacks (not accounted for by
an inadequate amount of sleep) or prolonged transition to
the fully aroused state upon awakening.
19. Nonorganic hypersomnia can be primary or associated with a
number of psychiatric disorders such as :
o reaction to severe stress
o adjustment disorders,
o affective disorders,
o other functional disorders,
o tolerance to or withdrawal of CNS-stimulating substances
o chronic use of CNS-sedating substances.
20.
21.
22. Diagnostic Guidelines:
a) Excessive daytime sleepiness or sleep attacks, not accounted for by
an inadequate amount of sleep, and/or prolonged transition to the
fully aroused state upon awakening (sleep drunkenness);
b) Sleep disturbance occurring daily for more than 1 month or for
recurrent periods of shorter duration, causing either marked
distress or interference with ordinary activities in daily living;
c) Absence of auxiliary symptoms of narcolepsy (cataplexy, sleep
paralysis, hypnogogic hallucinations) or of clinical evidence for sleep
apnea (nocturnal breath cessation, typical intermittent snorting
sounds, etc.);
d) Absence of any neurological or medical condition of which daytime
somnolence may be symptomatic.
23. Differential Diagnosis:
Narcolepsy (G47.1) : Hypersomnia F(51.1) :
1. One or more auxiliary
symptoms such as cataplexy,
sleep paralysis, and
hypnogogic hallucinations are
usually present;
2. The sleep attacks are
irresistible and more
refreshing
3. And nocturnal sleep is
fragmented and curtailed.
1. Daytime sleep attacks in
hypersomnia are usually
fewer per day.
2. Each of longer duration; the
patient is often able to
prevent their occurrence.
3. Nocturnal sleep is usually
prolonged, and there is a
marked difficulty in
achieving the fully aroused
state upon awakening (sleep
drunkenness)
24. Hypersomnia and sleep apnea:
In addition to the symptom of excessive daytime sleepiness,
most patients with sleep apnea have a history of nocturnal
cessation of breathing, typical intermittent snorting sounds,
obesity, hypertension, impotence, cognitive impairment,
nocturnal hypermotility and sweating, morning headaches and
in coordination.
Hypersomnia due to an unidentified organic cause can be
differentiated from non organic hypersomnia by proof of the
presence of the organic disorder.
25. Mr. J. was a 28-year-old, single, African-American male with an approximately 10-year
history of fatigue and sleepiness in the daytime. He began to recognize the daytime
sleepiness as a problem in his freshman year of college, when he would fall asleep in class
or in the dormitory. He admitted that his sleep-wake schedule was disrupted during college
due to taking long naps and then having to stay up until 1:00 or 2:00 AM to complete his
studies. His grades and social life suffered and he described himself as depressed, isolated,
and hopeless. As a child, Mr. J. said he slept “normally”.
Mr. J.'s excessive sleepiness continued, notwithstanding some improved sleep hygiene, like
more-consistent bedtime, trying not to nap, and a month-long trial without caffeine. He
remained dysphoric and discouraged about his future, blaming his chronic sleepiness as
the continuing impediment to his life plans. “I'm just tired of being tired,” he said.
When last seen his bedtime was between 10:00 and 10:30 PM; his wake-up alarm was set for
6:30 AM. He oversleeps at least once a week on work days and sleeps from 10:30 PM until
10:00 AM on weekends in an attempt to “catch up.” He has difficulty awakening and feels
unrefreshed or mildly refreshed. He drinks 6-8 cups of coffee in the morning. After lunch he
falls asleep at the computer while working. He sleeps for 20 to 60 minutes. He then drinks
another two cups of coffee and continues with his work. he has “nodded off” while driving.
He sleeps alone; He does not awaken gasping or choking. He denied hypnagogic
hallucinations and sleep paralysis but thought he might feel weak after the rare occasions
when he participated in a heated argument.
27. What are disorders of the sleep wake schedule?
A disorder of the sleep-wake schedule is defined as a lack
of synchrony between the individual's sleep-wake
schedule and the desired sleep-wake schedule for the
environment, resulting in a complaint of either insomnia
or hypersomnia
28. This disorder may be either psychogenic or of presumed organic
origin, depending on the relative contribution of psychological or
organic factors.
Individuals with disorganized and variable sleeping and waking
times most often present with significant psychological
disturbance, usually in association with various psychiatric
conditions such as personality disorders and affective disorders
29. Diagnostic Guidelines:
a) The individual's sleep-wake pattern is out of synchrony with
the sleep-wake schedule that is normal for a particular
society and shared by most people in the same cultural
environment;
b) Insomnia during the major sleep period and hypersomnia
during the waking period are experienced nearly every day
for at least 1 month or recurrently for shorter periods of
time;
c) The unsatisfactory quantity, quality, and timing of sleep
cause marked distress or interfere with ordinary activities in
daily living.
