Sleep is made up of two physiological states: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. There are several brain regions and neurotransmitters that regulate the sleep-wake cycle, including serotonin, norepinephrine, acetylcholine, melatonin, and dopamine. Sleep disorders are classified in the DSM-5 and ICSD-2 and include insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and other sleep-related movement disorders.

1. CLASSIFICATION OF SLEEP
DISORDERS AND PARASOMNIAS
DR.R.G.ENOCH
MD PSYCHIATRY II YR
GMKMCH, SALEM

2. • Introduction
• Electrophysiology of sleep
• Sleep regulation
• Terms
• Sleep disorder classification
• Parasomnias
• Tools used in Sleep medicine
• Treatment

3. INTRODUCTION
• Sleep occupies roughly one third of human life.
• It is a universal behavior that has been demonstrated in every animal species.
• Sleep is a process the brain requires for proper functioning.
• Prolonged sleep deprivation leads to severe physical and cognitive impairment
and, eventually, death.
• Sleep may appear to be a passive process but in fact is associated with a high
degree of brain activation.

4. • The ancient Greeks ascribed the need for sleep to the god Hypnos
(sleep) and his son Morpheus, also a creature of the night, who brought
dreams in human forms.
• Dreams have played an important role in psychoanalysis.
• Freud believed dreams to be the "royal road to the unconscious."

5. ELECTROPHYSIOLOGY OF SLEEP
• Sleep is made up of two physiological states:
1. non-rapid eye movement (NREM) sleep - physiological functions are
markedly lower than in wakefulness and
2. rapid eye movement (REM) sleep - physiological activity levels similar to
those in wakefulness
• Sleep is typically scored in epochs of 30 seconds.
• Stages of sleep is defined by the visual scoring of 3 parameters:
1. electroencephalogram (EEG), low-voltage, random, fast activity with sawtooth waves
2. electro-oculogram (EOG), records the rapid conjugate eye movements
3. electromyogram (EMG) recorded beneath the chin shows a marked reduction in
muscle tone

6. • The criteria defined by Allan Rechtschaffen and Anthony Kales in 1968 are accepted in
clinical practice and for research around the world.

8. Characteristics NREM Sleep REM Sleep
Eye movements Slow Rapid
Muscles Relaxed Muscle atonia
Frequent muscle
twitching
PR, BP, Respiration Low, few minute to
minute variation
High, high minute to
minute variation
Involuntary body
movements
Present Absent
Penile erections Rare Common
Dreams Rare - lucid and purposeful Common - abstract and
surreal.
Temperature
regulation
Homeothermic Poikilothermic
Brain oxygen use Low Increased
Ventilatory response
to increased pCO2
Normal Depressed

9. • The deepest portions of NREM sleep-stages 3 and 4- are sometimes associated with
unusual arousal characteristics.
• When persons are aroused 30 minutes to 1 hour after sleep onset they are disoriented,
and their thinking is disorganized.
• They are associated with amnesia for events that occur during the arousal.
• It may result in specific problems, including enuresis, somnambulism, and stage 4
nightmares or night terrors.
• Polygraphic measures during REM sleep show irregular patterns, sometimes close to
aroused waking patterns. Because of this observation, REM sleep has also been termed
paradoxical sleep.

10. • About 90 minutes after sleep onset, NREM yields to the first REM episode of the night. This
REM latency of 90 minutes is a consistent finding in normal adults; shortening of REM
latency frequently occurs with narcolepsy and depressive disorders.
• a REM period occurs about every 90 to 100 minutes during the night.
• The first REM period is the shortest, lasting
less than 10 minutes; later REM periods may
last 15 to 40 minutes each.
• Most REM periods occur in the last third of the
night, whereas most stage 4 sleep occurs in
the first third of the night.

11. SLEEPREGULATION
• There are a small number of interconnecting systems in the brainstem that control sleep
and that mutually activate and inhibit one another.
Serotonin
• Destruction of the dorsal raphe nucleus of the brainstem, which contains all the brain's
serotonergic cell bodies, reduces sleep.
• Ingestion of large amounts of L-tryptophan ( 1 to 15 g) reduces sleep latency and
nocturnal awakenings.
Norepinephrine
• Norepinephrine-containing neurons in the locus ceruleus markedly reduce REM sleep
(REM-off neurons) and increase wakefulness.

12. Acetylcholine
•Brain acetylcholine is involved in production of REM sleep.
•Activation of REM-on neurons in the pontine reticular formation neurons results in a shift
from wakefulness to REM sleep.
• Disturbances in central cholinergic activity are associated with the sleep changes
observed in major depressive disorder.
•In Alzheimer’s the loss of cholinergic neurons causes reduced REM and slow-wave sleep
Melatonin
•Melatonin secretion from the pineal gland is inhibited by bright light, so the lowest serum
melatonin concentrations occur during the day.
•The suprachiasmatic nucleus of the hypothalamus act as circadian pacemaker that
regulates melatonin secretion and the entrainment of the brain to a 24-hour sleep-wake
cycle.

13. Dopamine
•Dopamine has an alerting effect.
•Drugs that increase dopamine concentrations in the brain produce arousal and
wakefulness.
•In contrast, dopamine blockers, such as pimozide (Orap) and the phenothiazines, tend to
increase sleep time.
Othercompounds
•An endogenous substance-process S-may accumulate during wakefulness and act to
induce sleep.
•Another compound-process C-may act as a regulator of body temperature and sleep
duration.

14. SLEEP REQUIREMENTS
Short sleepers Long sleepers
6 hours 9 hours
have less REM periods and less rapid eye
movements within each period (known as
REM density)
have more REM periods and more rapid
eye movements within each period (known
as REM density)
efficient, ambitious, socially adept, and
content
mildly depressed, anxious, and socially
withdrawn
• Sleep needs increase with physical work, exercise, illness, pregnancy,
general mental stress.
• REM periods increase after strong psychological stimuli, such as difficult
learning situations and stress.

15. SLEEPWAKE RYTHM
Without external clues, the natural body clock follows a 25-hour cycle.
The influence of external factors-such as the light-dark cycle, daily routines,
meal periods, entrain persons to the 24-hour clock.
Within a 24-hour period, adults sleep once, sometimes twice. This rhythm is not present
at birth but develops over the first 2 years of life.
Naps taken at different times of the day differ greatly in their proportions of REM and
NREM sleep.
In a normal night time sleeper,
a nap taken in the morning - more of REM sleep, whereas
a nap taken in the afternoon or the early evening has much less REM sleep.

16. TERMS
• Sleep latency: Period of time from turning out the lights until the appearance of stage 2 sleep
• Early morning awakening: Time of being continuously awake from the last stage of the sleep
until the end of the sleep record (usually at 7 A.M.)
• Sleep efficiency: Total sleep time or total time of the sleep record x 100
• Nocturnal myoclonus index: Number of periodic leg movements per hour
• (REM) latency: Period of time from the onset of sleep to the first REM period of the night
• Sleep-onset REM period: REM sleep within the first 10 minutes of sleep.

17. SLEEP DISORDER CLASSIFICATION
• DSM 5
• ICSD 2
• ICD

18. DSM 5
1. Insomnia Disorder
2. Hypersomnolence Disorder
3. Narcolepsy
4. Breathing-Related Sleep Disorders:
a. Obstructive Sleep Apnea Hypopnea
b. Central Sleep Apnea
i. Idiopathic central sleep apnea
ii. Cheyne-Stokes breathing
iii. Central sleep apnea comorbid with opioid use
c. Sleep-Related Hypoventilation
5. Circadian Rhythm Sleep-Wake Disorders:
a. Delayed sleep phase type
b. Advanced sleep phase type
c. Irregular sleep-wake type
d. Non-24-hour sleep-wake type
e. Shift work type
f. Unspecified type
6. Parasomnias
7. Non-Rapid Eye Movement Sleep Arousal
Disorders:
a. Sleepwalking type
b. Sleep terror type
8. Nightmare Disorder
9. Rapid Eye Movement Sleep Behavior Disorder
10. Restless Legs Syndrome
11. Substance/Medication-Induced Sleep Disorder

19. ICSD 2
I. Insomnia
II. Sleep-Related Breathing Disorders
III. Hypersomnia of Central Origin Not Due to a Circadian Rhythm Sleep
Disorder,
Sleep - Related Breathing Disorder, or Other Cause of Disturbed Nocturnal
Sleep
IV. Circadian Rhythm Sleep Disorders
V. Parasomnias
VI. Sleep-Related Movement Disorders
VII. Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues
VIII. Other Sleep Disorders

20. I. Insomnia
1. Adjustment Insomnia
2. Psychophysiological Insomnia
3. Paradoxical lnsomnia
4. Idiopathic Insomnia
5. Insomnia Due to Mental Disorder
6. Inadequate Sleep Hygiene
7. Behavioral Insomnia of Childhood
8. Insomnia Due to Drug or Substance
9. Insomnia Due to Medical Condition
10. Insomnia Not Due to Substance or Known
Physiological Condition, Unspecified
(Nonorganic Insomnia, NOS)
11. Physiological (Organic) Insomnia,
Unspecified
II. Sleep-Related Breathing Disorders
A. Central Sleep Apnea Syndromes
B. Obstructive Sleep Apnea Syndrome
C. Sleep-Related Hypoventilation/Hypoxemic
Syndrome
D. Sleep-Related Hypoventilation/Hypoxemia
Due to Medical Condition
E. Other Sleep-Related Breathing Disorder

21. Ill. Hypersomnia of Central Origin
1. Narcolepsy with Cataplexy
2. Narcolepsy without Cataplexy
3. Narcolepsy Due to Medical Condition
4. Narcolepsy, Unspecified
5. Recurrent Hypersomnia Kleine-Levin Syndrome
Menstrual-Related Hypersomnia
6. Idiopathic Hypersomnia with Long Sleep Time
7. Idiopathic Hypersomnia without Long Sleep Time
8. Behaviorally Induced Insufficient Sleep Syndrome
9. Hypersomnia Due to Medical Condition
10. Hypersomnia Due to Drug or Substance
11. Hypersomnia Not Due to Substance Use or Known
Physiological Condition (Nonorganic Hypersomnia,
NOS)
12. Physiological (Organic) Hypersomnia, Unspecified
(Organic Hypersomnia, N OS)
IV. Circadian Rhythm Sleep Disorders
1. Circadian Rhythm Sleep Disorder, Delayed-Sleep-
Phase Type
2. Circadian Rhythm Sleep Disorder, Advanced-Sleep­
Phase Type
3. Circadian Rhythm Sleep Disorder, Irregular Sleep-
Wake Type
4. Circadian Rhythm Sleep Disorder, Free-Running
Type
5. Circadian Rhythm Sleep Disorder, Jet Lag Type (Jet
Lag Disorder)
6. Circadian Rhythm Sleep Disorder, Shift Work Type
(Shift Work Disorder)
7. Circadian Rhythm Sleep Disorder Due to Medical
Condition
8. Other Circadian Rhythm Sleep Disorder
9. Other Circadian Rhythm Sleep Disorder Due to
Drug or Substance Use

22. V. PARASOMNIAS
A. Disorders of Arousal (from NREM
Sleep)
1. Confusional Arousals
2. Sleepwalking
3. Sleep Terrors
B. Parasomnias Usually Associated with
REM Sleep
4. REM Sleep Behavior Disorder
(including Parasomnia Overlap Disorder and
Status Dissociatus)
5. Recurrent Isolated Sleep Paralysis
6. Nightmare Disorder
C. Other Parasomnias
7. Sleep-Related Dissociative Disorder
8. Sleep enuresis
9. Sleep-related groaning (catathrenia)
10. Exploding head syndrome
11. Sleep-related hallucinations
12. Sleep-related eating disorder
13. Parasomnia, unspecified
14. Parasomnia due to drug or
substance
15. Parasomnia due to medical
condition

23. VI. Sleep-Related Movement Disorders
1. Restless Legs Syndrome
2. Periodic Limb Movement Disorder
3. Sleep-Related Leg Cramps
4. Sleep-Related Bruxism
5. Sleep-Related Rhythmic Movement
6. Sleep-Related Movement Disorder,
Unspecified
7. Sleep-Related Movement Disorder
Due to Drug or Substance
8. Sleep-Related Movement Disorder
Due to Medical Condition
VII. Isolated Symptoms, Apparently Normal
Variants, and Un resolved Issues
1. Long Sleeper
2. Short Sleeper
3. Snoring
4. Sleep Talking
5. Sleep Starts (Hypnic jerk)
6. Benign Sleep Myoclonus of Infancy
7. Hypnagogic Foot Tremor and Alternating
Leg Muscle Activation during Sleep
8. Propriospinal Cyclones at Sleep Onset
9. Excessive Fragmentary Myoclonus
VIII. OtherSleep Disorders
1. Other Physiological (Organic) Sleep
Disorders
2. Other Sleep Disorder Not Due to Substance
or Known Physiological Conditions
3. Environmental Sleep Disorder

24. ICD-10
• Their classification differ from DSM-5 and often lump multiple nosological entities into a
single diagnostic classification.
• The subject of sleep disorders covers only those of nonorganic type in ICD- 10.
• These disorders are classified as
1. Dyssomnias - disturbances in the amount, quality, or timing of sleep because of
emotional causes, and
2. Parasomnias, "abnormal episodic events occurring during sleep."
• The dyssomnias include insomnia, hypersomnia, and disorder of the sleep-wake
schedule.
• The parasomnias in childhood are related to development; those in adulthood are
psychogenic and include sleepwalking, sleep terrors, and nightmares.

25. F51 Nonorganic Sleep Disorders
• F51.0 Nonorganic Insomnia
• F51.1 Nonorganic Hypersomnia
• F51.2 Nonorganic Disorder Of The Sleep-wake Schedule
• F51.3 Sleepwalking [Somnambulism]
• F51.4 Sleep Terrors [Night Terrors]
• F51.5 Nightmares
• F51.8 Other Nonorganic Sleep Disorders
• F51.9 Nonorganic Sleep Disorder, Unspecified

26. PARASOMNIAS
• Referred to as disorders of partial arousal.
• characterized by physiological or behavioral phenomena that occur during or are potentiated by
sleep.
• One concept - there is overlap of one basic sleep–wake state into another.
• Wakefulness, NREM sleep, and REM sleep can be characterized as three basic states that differ in
their neurological organization.
1. During wakefulness, both the body and brain are active.
2. In nrem sleep, both the body and brain are much less active.
3. Rem sleep, however, pairs an atonic body with an active brain.

27. • In some parasomnias there are state boundary violations.
• For example, all of the arousal disorders (confusional arousals, sleepwalking, and sleep
terrors) involve partial wakeful behaviors suddenly occurring in NREM sleep.
• Similarly, isolated sleep paralysis is the persistence of REM sleep atonia into the wakefulness
transition.
• REM sleep behavior disorder is the failure of the mechanism creating paralytic atonia such
that individuals literally act out their dreams.

28. • A. Disorders of arousal (from NREM sleep)
• B. Parasomnias usually associated with REM sleep
• C. Other parasomnias

29. DISORDERS OF AROUSAL (from NREM sleep)
1. Confusional arousals
2. Sleepwalking
3. Sleep terrors
4. Sexsomnia

30. DSM-5 criteria for NREM sleep arousal disorders
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
2. Sleep terrors
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.
E. The disturbance 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 explain the episodes of sleepwalking or sleep terrors.
Specify whether:
307.46 (F51 .3) Sleepwalking type
Specify if:
With sleep-related eating
With sleep-related sexual behavior (sexsomnia)
307.46 (F51 .4) Sleep terror type

31. 1. CONFUSIONAL AROUSALS
• Mildest form of the slow wave-sleep–related parasomnia
• Very common in young children.
• The child will typically partially awaken from slow wave sleep and sit up.
• The episodes are marked by confusion, but usually the child lies back down and
resumes sleep.
• It is thought that confusional arousals, sleepwalking, and sleep terrors lie on a
continuum.

32. TREATMENT
•Confusional arousals are generally harmless and don’t require treatment
•Treating the underlying condition like sleep apnea.
•Reassurance.
•Improving the sleep hygiene

33. 2. SLEEPWALKING
• Otherwise called somnambulism , Usually occurs during slow wave sleep
• An individual arises from bed and ambulates without full awakening.
• Individuals engage in a variety of complex behaviors while unconscious
ranging from sitting up and attempting to walk to conducting an involved sequence of
semipurposeful actions. .
• Sleep deprivation and interruption of slow-wave sleep exacerbate sleepwalking.
• The sleepwalker often can successfully interact with the environment (e.g., Avoiding tripping
over objects).
• However, the sleepwalker may interact with the environment inappropriately, which sometimes
results in injury (e.g., Stepping out of an upstairs window or walking into the roadway). There
are cases in which sleepwalkers have committed acts of violence.

34. • An individual who is sleepwalking is difficult to awaken.
• Once awake, they usually appear confused.
• It is best gently to attempt to lead sleepwalkers back to bed rather than to attempt to awaken
them by grabbing, shaking, or shouting.
• In their confused state, sleepwalkers may think they are being attacked and may react violently
to defend themselves.
• Sleepwalking in adults is rare, has a familial pattern, and may occur as a primary parasomnia or
secondary to another sleep disorder (e.G., Sleep apnea).
• By contrast, sleepwalking is very common in children and has peak prevalence between ages 4
and 8 years. After adolescence it usually disappears spontaneously.

36. Preventive measures
•Lock the doors and windows.
•Cover glass windows with heavy drapes.
•Place an alarm or bell on the bedroom door.
•Sleep on the ground floor
•Clear your bedroom of things that might cause you to trip or fall
Behavioral therapies
•Relaxation techniques, mental imagery, and anticipatory awakenings.
•Anticipatory awakenings consist of waking the child or person approximately 15-20 minutes before the usual time
of a sleepwalking episode, and then keeping him or her awake through the time during which the episodes usually
occur.
Pharmacotherapy
•Medications may be necessary if the sleepwalker is at risk of injury, if sleepwalking causes significant family
disruption or excessive daytime sleepiness, and when other treatment options have not worked.
•Medications that may be useful include: estazolam, clonazepam, trazodone

37. 3. SLEEP TERRORS
• It is characterized by a sudden arousal with intense fearfulness.
• They may begin with a piercing scream or cry. Autonomic and behavioral correlates of fright
typically mark the experience.
• usually sits up in bed, is unresponsive to stimuli, and, if awakened, is confused or disoriented.
• Vocalizations may occur, but they usually are incoherent.
• Amnesia for the episodes usually occurs.
• Like sleepwalking, these episodes usually arise from slow wave sleep.
• Fever and CNS depressant withdrawal potentiate sleep terror episodes.

38. • Unlike nightmares, in which an elaborate dream sequence unfolds, sleep terrors may be devoid
of images or contain only fragments of static images – brief, frightening, vivid
• It is sometimes called pavor nocturnus, incubus, or night terror
• sleep deprivation can provoke or exacerbate sleep terrors.
• In children, Psychopathology is seldom associated with sleep terrors;
• In adults, a history of traumatic experience or frank psychiatric problems is often comorbid
• Severity ranges from less than once per month to every night occurrence (with injury to the
patient or others).

39. TREATMENT
•Usually don’t require treatment.
•Practising good sleep hygiene
•Improving child’s sleeping space with appropriate temperature, light and bedding
•Wake your child up to a half hour before an expected night terror

40. 4. SEXSOMNIA.
• Sleep-related sexual behavior, or sexsomnia, is when a person engages in sexual
activities (e.g., Masturbation, fondling, sexual intercourse) during sleep without
conscious awareness.
• Treatment involves educating the patients concerning their disorder.
Clonazepam is also used. They are at higher risk of being charged for sexual
offences.

41. II. PARASOMNIAS USUALLY
ASSOCIATED WITH REM SLEEP

42. 1. REM SLEEP BEHAVIOR DISORDER
• Involves a failure of the patient to have atonia (sleep paralysis) during REM stage sleep
– the patient literally enacts his or her dreams.
• Normally, the dreamer is immobilized by hypopolarization of α and γ motor neurons.
• Without this paralysis, punching, kicking, leaping, and running from bed during
attempted dream enactment occur.
• In sleepwalking - harder to wake up, confused after waking up, less likely to remember
the dream. In contrast, it is easy to wake a person with RBD who is acting out a dream.
Once awake, he or she is also able to recall clear details of the vivid dream.
• Patients and bed partners frequently sustain injury
• RBD may result from diffuse hemispheric lesions, bilateral thalamic abnormalities, or
brainstem lesions.

43. PHARMACOTHERAPY
•Treatment for REM sleep behavior disorder is initiated with clonazepam at 0.5-1.5 mg taken at
bedtime. Clonazepam controls both the behavioral and the dream-disordered components of
REM sleep behavior disorder in the long term. Drug discontinuation often results in prompt
relapse.
•Tricyclic antidepressants are occasionally used. Imipramine has been used, but the effects are
unpredictable.
•Several reports of levodopa/carbidopa, gabapentin, pramipexole, and clonidine have been
published, but the benefit of these drugs has not been systemically evaluated.

44. 2. RECURRENT ISOLATED SLEEP PARALYSIS
• An inability to make voluntary movements during sleep.
• it occurs at sleep onset or on awakening, a time when the individual is partial conscious
and aware of the surroundings.
• extremely distressing, especially when it is coupled with the feeling that there is an
intruder in the house or when there is hypnagogic hallucination.
• Sleep paralysis is one of the tetrad of symptoms in narcolepsy along with cataplexy,
hypnagogic hallucinations, and excessive daytime sleepiness.;
• feature of normal REM sleep briefly intruding into wakefulness.
• The paralysis may last from one to several minutes.

45. • In sleep paralysis with hypnagogia - experiences of attack by some sort of “creature.”
• The common description is that a “presence” was felt to be near, the individual was
paralyzed, and the creature talks, attacks, or sits on the sleeper's chest and then
vanishes.
• Irregular sleep, sleep deprivation, psychological stress, and shift work aggrevates.
• at least one experience of sleep paralysis during the lifetime range from 25 to 50%
• Sometimes, if the individual voluntarily
makes very rapid eye movements or is
touched by another person, the episode
will terminate.

46. TREATMENT
•Sleep paralysis is usually benign, so drugs are not recommended.
•However, sleep paralysis can exacerbate pre-existing depression, anxiety, or sleep
disorders, and may create fear of sleep or difficulty falling asleep.
•Sleep hygiene is the main stay of treatment.
•In rare cases, medications such as antidepressants or the benzodiazepine clonazepam
are used to treat sleep paralysis.

47. 3. NIGHTMARE DISORDER
• Nightmares are frightening or terrifying dreams.
• also called dream anxiety attacks,
• they produce sympathetic activation and ultimately awaken the dreamer.
• occur in REM sleep and usually evolve from a long, complicated dream that becomes
increasingly frightening.
• he or she typically remembers the dream (in contrast to sleep terrors).
• Some nightmares are recurrent, and when they occur in PTSD there may be
recollections of actual events.
• Common in children ages 3 to 6 years (10 to 50 percent), nightmares are rare in adults
(<1%).
• Frequent nightmares causes insomnia because of “fear of sleeping”. Insomnia provokes
sleep deprivation, which in turn exacerbates nightmares. In this manner, a vicious cycle
is created.

48. • In freudian terms, the nightmare is an example of the failure of dream process that
defuses the emotional content of the dream.
• schizotypal, borderline, and schizoid personality disorders, schizophrenia – at risk
• Earnst hartmann posited that nightmares are more common in individuals with “thin
boundaries” who are open, trusting, and often have creative or artistic inclinations.
• Traumatic events are known to induce nightmares, sometimes immediately, but at other
times delayed.
• Several medications provoke nightmares, L-DOPA and β-adrenergic blockers, and so
does withdrawal from REM suppressant medications (ethanol, TCAs, trazodone, SSRIs,
MAOIs, lithium, amphetamines, methylphenidate, and clonidine).
• drug or alcohol abuse is associated with nightmares.

49. …nightmare
BEHAVIORAL TECHNIQUES
•Universal sleep hygiene, stimulus control therapy, lucid dream therapy, and cognitive therapy
reportedly improve sleep and reduce nightmares.
PHARMACOTHERAPY
•In nightmares related to PTSD, nefazodone gives benefit. Benzodiazepines may also be helpful;
however, systematic controlled trials are lacking.
•Evidence for the use of prazosin (minipress), a CNS α-1 antagonist, in the treatment of PTSD –
related nightmares is growing. Prazosin significantly increased total sleep time and REM sleep
time and significantly reduced trauma-related nightmares and distressed awakenings.

50. III. OTHER PARASOMNIAS

51. 1. SLEEP-RELATED DISSOCIATIVE DISORDER
• The DSM defines dissociative disorders as “a disruption in the usually integrated
functions of consciousness, memory, identity, or perception of the environment.” Three
types of dissociative disorders can be sleep related:
• 1. Dissociative identity disorder (multiple personality disorder),
• 2. Dissociative fugue, and
• 3. Dissociative disorder not otherwise specified.
• a history of violence, trauma, and/or psychiatric disorder is common in affected
individuals.
• Polysomnography reveals the dissociative episode occurs during eeg-defined
wakefulness, either during the transition from wakefulness to sleep or after an
awakening (from any stage of sleep).

52. TREATMENT
•CBT, supportive psychotherapy or treatment of PTSD
•Must be encouraged to develop effective coping skills
•All classes of psychotropic medications have been used
•Associated depression is treated with SSRI. Clonazepam is also used
•Atypical antipsychotics (risperidone, quetiapine) for associated irritability

53. 2. SLEEP ENURESIS
• The individual urinates during sleep while in bed.
• Bedwetting, as it is commonly called, has primary and secondary forms.
• In children, primary sleep enuresis is the continuance of bedwetting since infancy.
• Secondary enuresis refers to relapse after a period during which the child remained dry.
Usually, after toilet training bedwetting spontaneously resolves before age 6 years.
• Parental primary enuresis increases the likelihood that the children will also have enuresis.
• Secondary enuresis may occur with the birth of a sibling and represent a “cry for attention.”
• Secondary enuresis is also associated with nocturnal seizures, sleep deprivation, and urological
anomalies.

54. BEHAVIORAL THERAPY
•Bladder training exercises, such as voluntarily
suspending voiding midstream during micturition,
using conditioning devices (bell and pad), and fluid
restriction, have reportedly had good success
• Motivational therapy for the management of SE
involves encouraging the parents and the child,
removing the guilt associated with bed-wetting and
providing emotional support
PHARMACOTHERAPY
•Desmopressin 0.2-0.6 mg oral or 10-40µg intranasally at bedtime,
•imipramine 10 mg for 6- to 8-year-old children, and 25 mg for children older than 8 years,
•oxybutynin 5–10 mg at bedtime

55. 3. SLEEP-RELATED GROANING (CATATHRENIA)
• Chronic condition characterized by prolonged, frequent loud groans during sleep.
• can occur in any stage of sleep.
• may begin during childhood but often remains occult until the child has to share a room.
• Catathrenia is not related to any psychiatric or physiologic abnormalities.
• In the polysomnogram, it is often confused for central sleep apnea.
• CPAP has been tried on people with catathrenia but hasn’t yet become a standard treatment.
Unlike apnea, catathrenia is not considered dangerous. There are no drugs available for
catathrenia.

56. 4. EXPLODING HEAD SYNDROME
• Individuals “hear” a loud imagined noise or a sense of a violent explosion in the head just as they are
about to fall asleep or during a nocturnal awakening.
• The experience can occur just once or recurrently.
• There is no pain associated with the noise, but the individual may be concerned about are having a
stroke or that something is very wrong.
• Even a single episode can trigger severe insomnia.
• There are no known neurological consequences to this syndrome.
• Reassurance and education as it is a benign condition that remits over time.
• Pharmacotherapy is not needed

57. 5. SLEEP-RELATED HALLUCINATIONS
• Sleep-related hallucinations are typically visual images occurring at sleep onset (hypnagogic) or
on awakening (hypnopompic) from sleep.
• Sometimes difficult to differentiate from dreams, they are common in patients with narcolepsy.
• Complex hallucinations are rare
• Cause abrupt awakening and there is no remembrance of the dream.
• Images tend to be vivid and immobile and persists for several minutes (usually disappearing
when a light is turned on). The images can be frightening.

58. TREATMENT
•Treatment for sleep-related hallucinations varies depending on their cause.
•When sleep-related hallucinations are brought on by using alcohol, drugs, or medications,
discontinuing those substances may end the hallucations.
•Treating underlying sleep disorders like narcolepsy or insomnia can help resolve
unwanted hallucinations.
•Avoiding stress and sleep deprivation is also recommended.

59. 6. SLEEP-RELATED EATING DISORDER
• Inability to get back to sleep after awakening unless the individual has something to eat or drink.
• After eating or drinking, return to sleep is normal.
• Nocturnal eating (drinking) syndrome
• predominantly affects infants and children; however, adult cases
have been reported.
• the problem is mainly associated with breast-feeding
and/or bottle feeding.
• Infants should be able to sleep through the night without feeding after age 6 months.
• An infant will drink 4 to 8 oz or more at each awakening. Wetting is also excessive.
• In adults, Eating may become obsessional, and several small meals may be eaten during the course of
a night. The individual may be unaware of the activity, and cause weight gain.

60. TREATMENT
•The treatment include dopamine agonists, opiates, trazodone, and topiramate.
•Treatment involves treating the underlying disorder.
•Benzodiazepines have a response rate of 37%, sertraline 80%.
•Topiramate used for binge eating disorder also helps in SRED

61. 7. PARASOMNIA DUE TO DRUG OR SUBSTANCE USE AND MEDICAL
CONDITIONS
• Many drugs and substances can trigger parasomnias, particularly those agents that lighten sleep
• Alcohol is notorious for producing sleepwalking
• RBD can be provoked or worsened by biperiden, tricyclic antidepressants, mao’s, caffeine,
venlafaxine, selegiline, and serotonin agonists. RBD may also occur during withdrawal from
alcohol, meprobamate, pentazocine, and nitrazepam.
• Medications provoke nightmares include l-dopa and β-blockers. Nightmares can also be caused
by drug-induced REM sleep rebound (e.G., Withdrawal from rem-suppressing drugs such as
methamphetamine) and alcohol abuse or withdrawal.

62. • Seizure disorder should always be on the top of a differential diagnosis list for most
parasomnias.
• Rbd is associated with a variety of neurological conditions, including parkinson's disease,
dementia, progressive supranuclear palsy, shy–drager syndrome, narcolepsy, and others.

63. RESTLESS LEGS SYNDROME
• Irresistible urge to move the legs when at rest or
while trying to fall asleep.
• Patients often report crawling feelings in their legs.
• Moving the legs or walking around helps to alleviate
the discomfort.
• It results in profound insomnia.
• Uremia, neuropathies, and iron and folic acid
deficiency anemias can produce secondary RLS.
• RLS is also reported in fibromyalgia, rheumatoid
arthritis, diabetes, thyroid diseases, and chronic
obstructive pulmonary disease.

64. International study group diagnostic criteria for RLS
Essential features
•An urge to move the legs, accompanied by uncontrollable or unpleasant sensations in the legs
•The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity
such as lying down or sitting
•The urge to move or unpleasant sensations are partially or totally relieved by movement, such as
walking or stretching
•The urge to move or unpleasant sensations are worse in evening or night than during the day or
only occur in the evening or night

65. Common features
•Positive family history: A three- to fivefold higher prevalence among first-degree relatives
•Response to dopaminergic therapy
•Clinical course: middle-age onset and usually with progressive course
•Sleep disturbance resulting in sleep-onset insomnia or daytime sleepiness

66. • Pharmacologically, the dopaminergic agonists pramipexole and ropinirole are FDA approved
and represent the treatments of choice.
• Other agents used to treat RLS include dopamine precursors (e.g., Levodopa), benzodiazepines,
opiates, and antiepileptic drugs (e.G., Gabapentin [neurontin]).
• Nonpharmacological treatments include avoiding alcohol use close to bed time, massaging the
affected parts of the legs, taking hot baths, applying hot or cold to the affected areas, and
engaging in moderate exercise.

67. PERIODIC LIMB MOVEMENT DISORDER
• Previously called nocturnal myoclonus
• involves brief, stereotypic, repetitive, nonepileptiform movements of the limbs, usually the legs.
• It occurs primarily in NREM sleep and involves extension of the big toe. A partial flexion of the ankle,
knee, and hip may also occur.
• These movements range from .5 to 5 seconds in duration and occur every 20 to 40 seconds.
• cause brief arousals from sleep.
• prevalence increases with aging and can occur in association with folate deficiency, renal disease,
anemia, and the use of antidepressants.
• Clinical trials of pharmacotherapy for are lacking. However, benzodiazepines, especially clonazepam,
and opiates improve sleep in patients with PLMD.

68. SLEEP-RELATED BRUXISM
• Individual grinds or clenches the teeth during sleep.
• produce abnormal wear on the teeth, damage teeth, provoke tooth and jaw pain, and/or make loud
unpleasant sounds that disturb the bed partner.
• More than 85 percent of the population may brux at one time or another; however, it is clinically
significant in only about 5 percent.
• It is most common at transition to sleep, in stage 2 sleep, and during rem sleep.
• It worsens during periods of stress.
• Sleep bruxism may occur secondary to sleep-related breathing disorders, the use of psychostimulants
(e.g., Amphetamine, cocaine), alcohol ingestion, and treatment with SSRI.
• Sleep bruxism can occur infrequently (monthly), regularly (weekly), or frequently (nightly).

69. • Treatment involves wearing an oral appliance to
protect the teeth during sleep.
• There are two basic types of appliance.
• The soft one (mouth guard) is typical used in the short
term, whereas the hard acrylic one (bite splint) is use
longer term and requires regular follow-up.
• Relaxation, biofeedback, hypnosis, physical therapy,
and stress management are also used to treat sleep
bruxism. A variety of drug therapies have been tried
(benzodiazepines, muscle relaxants, dopaminergic
agonists, and propranolol [inderal]), but outcome
data are not available.

70. SLEEP TALKING
• Involves unconscious speech during sleep.
• It is seldom recognized in an individual unless it annoys the bed partner.
• It can be induced by fever, stress.
• Somniloquy may accompany sleep terror, sleepwalking, confusional arousals, OSA, and REM
sleep behavior disorder.
• Sleep talking can occur at any point in the sleep cycle. The lighter the sleep, the more intelligible
the speech. In stages 1 and 2, the talking might sound intelligible. Practicing proper sleep
hygiene helps.

71. SLEEP STARTS (HYPNIC JERK)
• Sleep starts are sudden, brief muscle contractions that occur at the transition between
wakefulness and sleep
• Occurs in 60 to 70 percent of adults.
• The contractions commonly involve the legs; however, sometimes there is movement in the
arms and head.
• It is usually benign.
• can interfere with the ability to fall asleep and may be accompanied by sensations of falling, a
hallucinated flash of light, or a loud crackling sound.
• In severe cases the sleep start produces profound sleep-onset insomnia.

72. TOOLS IN SLEEP MEDICINE
POLYSOMNOGRAPHY
•Polysomnography is the continuous, attended, comprehensive
recording of the biophysiological changes that occur during sleep.
•Each 30-second segment of the recording is considered an “epoch.”
•typically recorded at night and lasts between 6 and 8 hours.

73. Measurement Use
Brain wave activity, eye
movements, and submental
electromyogram
identifying sleep stages
Muscle tension and movements diagnosis of periodic limb
movement disorder and RLS
Nasal airflow, respiratory effort,
and oxyhemoglobin saturation
diagnosing sleep apnea and other
sleep-related breathing disorders.
Indications for polysomnography include
1.diagnosis of sleep-related breathing disorders,
2.positive airway pressure titration and assessment of treatment efficacy, and
3.evaluation of sleep-related behaviors that are violent or may potentially harm the patient or
bed partner.
4.diagnose parasomnias, sleep problems secondary to neuromuscular disorders, and arousals
secondary to seizure disorder.

74. OTHERTOOLS
•Multiple sleep latency test
•Maintenance of wakefulness test
•Actigraphy
•Home sleep testing

75. BEHAVIOURAL THERAPIES IN SLEEP
MEDICINE

76. COGNITIVE- BEHAVIORAL THERAPY
• Cognitive-behavioral therapy (CBT) uses a combination of behavioral and cognitive techniques
to overcome dysfunctional sleep behaviors, misperceptions, and disruptive thoughts about
sleep.
• Behavioral techniques include universal sleep hygiene, stimulus control therapy, relaxation
therapies, and bio- feedback.
• significant improvement in sleep symptoms, including number and duration of awakenings and
sleep latency from CBT.
• tends to have lasting benefits even 36 months after treatment.
• With cessation of the medication, insomnia frequently returns or rebound insomnia occurs. CBT
has not been shown to produce rebound insomnia .

77. • The effects of CBT take longer to emerge than effects of medications.
• They must be active participants.
• patients must commit to come to multiple sessions
• open to the idea that modifying thoughts and behaviors about sleep can improve the
symptoms of insomnia.
• Requires a greater time commitment than prescribing a sleep aid.

78. UNIVERSAL SLEEP HYGIENE.
• The focus of universal sleep hygiene is on modifiable environmental and lifestyle
components that may interfere with sleep, as well as behaviors that may improve sleep.
Treatment should focus on one to three problem areas at a time.
Do’s
• Maintain regular hours of bedtime and arising
• If you are hungry, have a light snack before bedtime
• Maintain a regular exercise schedule
• Give yourself approximately an hour to wind, down before going to bed
• If you are preoccupied or worried about, write it down and Deal with it in the morning
• Keep the bedroom cool, dark, quiet.

79. DONT’S
•Take naps
•Exercise right before going to bed in order to wear yourself out
•Watch television in bed when you cannot sleep
•Eat a heavy meal before bedtime
•Drink coffee in the afternoon and evening
•If you cannot sleep, smoke a cigarette
•Use alcohol to help in going to sleep
•Read, eat, talk in phone in bed when you cannot sleep

80. STIMULUS CONTROL THERAPY
Stimulus control therapy is a deconditioning model developed by Richard bootzin. This treatment aims
to break the cycle of problems commonly associated with difficulty initiating sleep. The rules enhance
stimulus cues for sleeping and diminish associations with sleeplessness. The instructions must be
followed consistently.
The first rule is, go to bed only when sleepy.
Second, use the bed only for sleeping. Do not watch television in bed, do not read, eat and talk on
the telephone while in bed.
Third, if unable to sleep, get up, go to another room, and do something nonarousing until sleepiness
returns.
Fourth, awaken at the same time every morning (regardless of bedtime, total sleep time, or day of
week) and totally avoid napping.

81. RELAXATION THERAPY AND BIOFEEDBACK
• The important aspects of relaxation therapy are that it be performed properly. The goal is to
find the optimal technique for each patient.
• Progressive muscle relaxation is especially useful for patients who experience muscle tension.
The patients should purposefully tense (5 to 6 seconds) and then relax (20 to 30 seconds)
muscle groups, beginning at the head and ending at the feet. The patient should appreciate the
difference between tension and relaxation.
• Guided imagery - the patient visualize a pleasant, restful scene, engaging all of his or her
senses.

82. • Breathing exercises are practiced for at least 20 minutes per day for 2 weeks. Once mastered,
the technique should be used once at bedtime for 30 minutes. The patient is instructed to
perform abdominal breathing.
• Biofeedback provides stimulus cues for physiological markers of relaxation and can increase
self-awareness. A machine is used to measure muscle tension in the forehead or finger
temperature. Finger temperature rises when a person becomes more relaxed.
• Relaxation techniques is combined with sleep hygiene and stimulus control therapies.

83. PARADOXICAL INTENTION
• The theory is that performance anxiety interferes with sleep onset.
• Thus, when the patient tries to stay awake for as long as possible rather than trying to fall
asleep, performance anxiety will be reduced and sleep latency will improve.

84. CONCLUSION
• Sleep disorders significantly alter an individual's health, mood, quality of life, and cognitive
ability.
• They may be primary; or secondary to other medical, neurological, and psychiatric conditions.
• For psychiatrists, sleep disorders are particularly important because insomnia and hypersomnia
commonly occur in a wide range of psychiatric conditions.
• With appropriate treatment, most sleep disorders can be effectively managed.
• The extent of improvement in a patient's general well-being after treatment is usually
dramatic.
• A good night of sleep is as important to health as nutrition and exercise.

85. SUMMARY
• In NREM sleep the physiological functions are markedly lower than REM sleep
• Sleep is regulated by a number of systems including serotonin, norepinephrine, aceylcholine,
and melatonin.
• Three types of classification systems. ICSD 2 consists of 8 categories
• Parasomnias are behavioral phenomenon during sleep caused by overlap of one basic sleep–
wake state into another
• NREM disorders, REM disorders and other parasomnias.
• CBT, universal sleep hygiene, stimulus control therapy, relaxation therapies, and bio- feedback
are treatment techniques.

86. REFERENCES
 Kaplan and Sadocks Comprehensive textbook of Psychiatry
– 10th
edition
 Kaplan and Sadocks Synopsis of Psychiatry – 11th
edition
 Postgraduate Textbook of Psychiatry – Ahuja
 The Parasomnias and Other Sleep-Related Movement
Disorders - Michael J. Thorpy