This document discusses classifications and types of sleep disorders according to diagnostic manuals like DSM-5 and ICD-10. It covers disorders like insomnia, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders including obstructive sleep apnea, and circadian rhythm sleep-wake disorders. For each type of sleep disorder, it provides diagnostic criteria, epidemiology, etiology and pathophysiology, treatment approaches and specific subtypes or related conditions. The document aims to comprehensively describe the major sleep disorders recognized in clinical practice and research according to standardized diagnostic systems.
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Approach to Neurogenic Dysphagia (1) 24_07.pptxNeurologyKota
Approach to neurogenic dysphagia GUSS Swallow test
Individuals with Subcortical Strokes have a higher incidence of dysphagia and aspiration than those with cortical damage.
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
This video explains the physics of this method and how it can be used in daily practice.
More about magnetic simulators: http://www.neurosoft.ru/eng/product/neuro-msd/index.aspx
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain.
This video explains the physics of this method and how it can be used in daily practice.
More about magnetic simulators: http://www.neurosoft.ru/eng/product/neuro-msd/index.aspx
Introduction
The sleep – wakefulness cycle is genetically determined rather than learned and is established sometime after birth.Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity and [inhibition of nearly all voluntary muscle during REM sleep] reduced interactions with surroundings.
Sleep can be regarded as a physiological reversible reduction of conscious awareness. Nearly one third of human life is spent in sleep. Disorders of sleep can affect activities of daily living (ADL) of an individual.
Definition
It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases:
1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person fifi rst passes through these stages of NREM-sleep.
Stages of sleep
The EEG recording during the waking state shows alpha waves of 8-12 cycles/sec. frequency. The onset of sleep is characterised by a disappearance of the alpha-activity.
Stage 1, NREM-sleep is the first and the ligh test stage of sleep characterised by an absence of alphawaves, and low voltage, predominantly theta activity.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two typical EEG changes:
i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a charac teristic waxing and waning amplitude.
ii. K-complexes: High voltage spikes present intermittently.
Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec.
Stage 4, NREM-sleep shows predominant δ-activity in EEG. NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1 NREM-sleep. One of the most characteristic features of the REM-sleep is presence of REM or rapid (conjugate) eye move ments. The other features include generalised mus cular atony, penile erection, autonomic hyperactivity (increase in pulse rate, respiratory rate and blood pressure), and movements of small muscle groups, occurring intermittently. Although it is a light stage of sleep, arousal is diffificult. These stages occur regularly throughout the whole duration of sleep. The first REM period occurs typically after 90 minutes of the onset of sleep, although it can start as early as 7 minutes after going off to sleep, e.g. in narcolepsy, in major depression, and after sleep deprivation.
Primary sleep disorders:
Primary sleep disorders are those disorders not attributable to another cause, which includes dyssomnias and parasomnias.
Dyssomnias: are primary disorders of initiating or maintaining sleep/ excessive sleepiness, characterized by abnormalities in the amount, quality, or timing of sleep.
Insomnia:
Difficulty initiating or maintaining sleep or nonrestorative sleep that lasts for 1 month and causes significant distress or impairment in social, occupational, or other important areas of functioning.
Hypersomnia:
Excessive sleepiness for atleast 1 month that involves either prolonged sleep episodes or daily daytime sleeping that causes significant distress or impairment in social, occupational or other functioning.
Narcolepsy:
A rare sleep disorder in which a person, usually under the age of 20, has recurrent sudden episodes of irresistible sleep attacks of short duration 10 - 15 minutes (directly enters into REM sleep).
Breathing related sleep disorder:
Sleep disruption leading to excessive sleepiness or, less commonly, insomnia, caused by abnormalities in ventilation during sleep. These disorders include obstructive sleep apnea (repeated episodes of upper airway obstruction), central sleep apnea (episodic cessation of sventilation without airway obstruction), and central alveolar hypoventilation (hypoventilation resulting in low arterial oxygen levels).
Circadian Rhythm Sleep Disorder:
Persistent or recurring sleep disruption resulting from altered functioning of circadian rhythm or a mismatch between circadian rhythm and external demands. Subtypes include; delayed sleep phase, jet lag, shift work and unspecified.
Delayed sleep phase: A persistent pattern of late sleep onset and late awakening times, with an inability to fall asleep and awaken at a desired earlier time.
Jet lag: Sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone.
Shift work: Insomnia during the major sleep period or excessive sleepiness during the major awake period associated with night shift work or frequently changing shift work.
Parasomnias: are disorders characterized by abnormal behavioral or psychological events associated with sleep, specific sleep stages, or sleep–wake transition. These disorders involve activation of physiological systems, such as the autonomic nervous system, motor system, or cognitive processes, at inappropriate times during sleep.
Nightmare disorder:
Repeated occurrence of frightening dreams that lead to waking from sleep.
Sleep terror disorder:
Repeated occurrence of abrupt awakenings from sleep associated with a panicky scream or cry.
Sleepwalking disorder (Somnambulism):
Repeated episodes of complex motor behavior initiated during sleep, including getting out of bed and walking around.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. SLEEP DISORDERS
DR. RUJUL MODI
2 n d Year Resid en t Do cto r
Mah atma G an d h i Med ical Co lleg e& H o sp ital,Jaipur
2. CLASSIFICATIONS
Diagnostic & Statistical Manual of Mental Disorders
(DSM 5)
International Classification of Diseases (ICD 10)
International Classification of Sleep Disorders
(ICSD-3)
3. DSM-5 CLASSIFICATION
1. Insomnia Disorder
2. Hypersomnolence Disorder
3. Narcolepsy
4. Breathing-Related Sleep Disorders
a) Obstructive SleepApnea Hypopnea
b) Central SleepApnea
i. idiopathic central sleep apnea
ii. cheyne-stoke breathing
iii. central sleep apnea comorbid with opioid use
c) Sleep Related Hypoventilation
4. 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-REM SleepArousal Disorders
a) Sleep walking type
b) Sleep terror type
8. Nightmare Disorder
9. REM Sleep Behavior Disorder
10. Restless Legs Syndrome
11. Substance/Medication-Induced Sleep Disorder
5. Nonorganic sleep disorders
This group includes:
1. Dyssomnias:
Primarily psychogenic conditions in which the predominant
disturbance is in the amount, quantity or timing of sleep due to
emotional causes. i.e insomnia, hypersomnia and disorders of sleep-
wake schedule.
2. 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 and nightmares.
6. ICD 10 (Chapter – V) CLASSIFICATION
F-51 Nonorganic Sleep disorders
F 51.0 Nonorganic insomina
F 51.1 Nonorganic hypersomina
F 51.2 Nonorganic Disorders of the sleep-wake
schedule
F 51.3 Sleep walking [somnambulism]
F 51.4 Sleep terrors [night terrors]
F 51.5 Nightmares
F 51.8 Other Nonorganic sleep disorders
F 51.9 Nonorganic Sleep disorder, unspecified
Includes: emotional sleep disorder NOS
7. ICD 10 (Chapter – VI) CLASSIFICATION
G47.2 Disorders of the sleep-wake schedule
G47.3 Sleep apnoea
G47.4 Narcolepsy and cataplexy
G47.8 Other sleep disorders of organic origin such as
Kleine – Levin syndrome
G47.9 Sleep disorder, unspecified
G25.3 Episodic movement disorders
(Nocturnal myoclonus)
Enuresis (F-98.0) is listed with other emotional and behavioural
disorders with onset specific to childhood and adolescence.
8. International Classification of Sleep Disorders
(ICSD 3)
Major diagnostic section:
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
9. INSOMNIA DISORDER (DSM-5 Diagnostic criteria)
A. A predominant complaint of dissatisfaction with sleep
quantity or quality, associated with one (or more) of the
following symptoms:
1 . Difficulty initiating sleep. (In children, th is 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.
10. INSOMNIA DISORDER (DSM-5 Diagnostic criteria)
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.
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 breath i ng-related sleep disorder, a
circadian rhythm sleep-wake disorder, a parasomnia).
11. INSOMNIA DISORDER (DSM-5 Diagnostic criteria)
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.
Episodic: Symptoms last at least 1 month but less than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two (or more) episodes within the space of 1 year.
Note: Acute and short-term insomnia (i.e., symptoms lasting less
than 3 months but otherwise meeting all criteria with regard to
frequency, intensity, distress, and/or impairment) should be coded
as an other specified insomnia disorder.
12. Epidemiology:
most common sleep disorder.
~ 30–50% of the adult population may experience
insomnia symptoms during the course of a year
M:F = 1.5:1
Age effect is not universally observed
13. Primary insomnia is diagnosed when the chief
complaint is nonrestorative sleep or difficulty in initiating
or maintaining sleep, and the complaint continues for at
least a month (according to ICD- 10, the disturbance
must occur at least three times a week for a month).
The term primary indicates that the insomnia is
independent of any known physical or mental condition.
14. • ADJUSTMENT INSOMNIA: Associated with anxiety,
anticipation of anxiety provoking event (exam). Transient
in nature.
• SLEEP STATE MISPERCEPTION or PSEUDOSOMNIA:
patient complaining of difficulty in sleep but no objective
evidence of sleep disruption is found.
• PSYCHOPHYSIOLOGICAL INSOMNIA: problem in
going to sleep. stress/object related to sleep becomes
conditioned to insomnia. Daytime adaptation is good.
• IDIOPATHIC INSOMNIA: Starts in early life.
Neurochemical imbalance of brainstem reticular
formation, impaired regulation of raphe nucleus, locus
ceruleus or basal forebrain dysfunction.
15. Psychiatric disorders and conditions associated
with insomnia:
1. Major depression, dysthymic disorder, Bipolar
disorder
2. Generalized anxiety disorder, panic disorder, PTSD
3. Schizophrenia
4. Substance use disorders
Medications and Substances Associated with Insomnia:
Alcohol (acute use, withdrawal), Caffeine, Nicotine,
Cannabis, Antidepressants, Corticosteroids,
𝛽agonists, theophylline derivatives, 𝛽antagonists, Statins,
Stimulants, Dopamine agonists
17. Etiology and Pathophysiology
Genetic Factors: Increased prevalence of insomnia
has been observed among monozygotic twins and
first-degree family members.
Neurobiological Factors: associated with
physiological hyperarousal. Patients with insomnia
have increased whole body metabolic rate, increased
cortisol and ACTH (particularly in the evening and
early sleep hours), altered heart rate variability, and
altered secretion of norepinephrine and cytokines
18. Psychological Factors: Individuals with insomnia
often have minor elevations in depressive and anxiety
symptoms
Social/Environmental Factors: Insomnia is often
precipitated by social or environmental stressors
19. Treatment
Treatment Goals:
To improve qualitative and quantitative aspects of sleep,
To reduce sleep-related distress, and
To improve daytime function.
1. NONPHARMACOLOGICAL
2. PHARMACOLOGICAL
20. Cognitive-Behaviour Therapy
Behavioral techniques include
1. Universal sleep hygiene,
2. Stimulus control therapy,
3. Sleep restriction therapy,
4. Relaxation therapies, and biofeedback.
21.
22. 2. Stimulus control therapy
It is a deconditioning paradigm, developed by Richard
Bootzin and colleagues at the University of Arizona. This
treatment aims to break the cycle of problems commonly
associated with difficulty initiating sleep.
1st rule: Go to bed only when sleepy to maximize success.
2nd rule: Use the bed only for sleeping. Do not watch
television in bed, do not read, do not eat, and do not talk on
the telephone while in bed.
3rd rule: Do not lie in bed and become frustrated if unable
to sleep. After a few minutes (do not watch the clock), get
up, go to another room, and do something non arousing
until sleepiness returns. The goal is to associate the bed
with rapid sleep onset.
23. 3. Sleep restriction therapy
Goal is to decrease the amount of time in bed to increase
the percentage of time spent in bed asleep.
• Patients should stay in bed only as long as their average
sleep time: but no less than 4 hr/night
• Get up at the same time each day.
• Do not nap during the day. (Except elderly pt. can take 30 min. nap)
• When sleep efficiency is 85% (i.e., sleeping for 85% of
the time in bed), go to bed 15 min earlier.
• Repeat this process until you are sleeping for 8 hours or
the desired amount of time.
24. 4. Relaxation therapies and biofeedback.
Progressive muscle relaxation
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 has the patient visualize a pleasant,
restful scene, engaging all of his or her senses.
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.
Abdominal breathing
25. Cognitive Training
The negative emotional response is thought to produce
emotional arousal, which in turn contributes to or
perpetuates insomnia.
"There must be something really wrong with me if I can't fall
asleep in 40 minutes.”
They also tend to have unrealistic expectations like "If I
don't sleep 8 hours a night then my whole day will be ruined.
The first step is to identify these cognitions, then challenge
their validity, and finally substitute them with more adaptive
cognitions.
26. Paradoxical Intention.
• This is a cognitive technique with conflicting evidence
regarding its efficacy.
• 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.
29. NARCOLEPSY
The hallmark of Narcolepsy is
sleepiness, marked by recurrent
extreme daytime
episodes of an
irresistible need to sleep, unintentional sleep episodes,
or napping. (at least 3 times per week for at least 3
months)
In addition, Narcolepsy requires one of three
additional findings:
1. Episodes of cataplexy: Sudden and bilateral loss of
muscle tone with preserved consciousness, and often
precipitated by strong emotions such as laughter,
Love failure, death of loved one etc.
30.
31. 2. Hypocretin (orexin) deficiency in cerebrospinal fluid
3. Specific PSG findings: reduced latency to REM sleep
during nocturnal PSG (15 minutes or less)
Narcolepsy is associated with sleep-related hallucinations at
sleep onset (hypnagogic) or sleep offse (hynpnopompic) in
20–60% of patients.
Sleep paralysis at sleep onset or offset is also typical of
narcolepsy, and consists of episodes of alertness with an
inability to move skeletal muscles
Nightmares and vivid dreams also occur frequently
32. Mild:
Infrequent cataplexy (< 1 per week),
Need for naps only once or twice per day, and
Less disturbed nocturnal sleep.
Moderate:
Cataplexy once daily or every few days,
Disturbed nocturnal sleep, and
Need for multiple naps daily.
Severe:
Drug-resistant cataplexy with multiple attacks daily,
Nearly constant sleepiness, and disturbed nocturnal sleep
33. Prevalence: 0.02–0.04% of the general population
Narcolepsy follows chronic persistent courses.
Etiology and Pathophysiology:
Genetic Factors
Strong association with HLA marker DQB1*0602
Neurobiological Factors:
Narcolepsy is associated with deficiency of
Hypocretin (orexin) in central nervous system
Postmortem studies of humans with narcolepsy show
loss of orexinergic cells and reduced orexin immuno-
reactivity in the lateral hypothalamus
34. Treatment:
Treatment Goals: to reduce daytime sleepiness and
to manage the symptoms of cataplexy, sleep paralysis,
and sleep-related hallucinations when present
Pharmacological Treatments: Monoaminergic
stimulants (Methylphenidate, Dextroamphetamine,
and mixed Amphetamine salts), Modafinil and
Armodafinil, Atomoxetine, Bupropion, Anti-
cataplectic drugs (Venlafaxine, Desmethylvenlafaxine,
Duloxetine, or Fluoxetine, TCAs)
Psychosocial Treatments: Scheduling regular brief
nap
35. HYPERSOMNOLENCE DISORDER
Main feature of Hypersomnolence Disorder is
excessive sleepiness despite a normal sleep duration at
night.
Repeated episodes of sleep during daytime hours;
prolonged night time sleep, typically 9 hours or
longer; and/or difficulty transitioning from sleep to
wakefulness, often called sleep inertia.
Must be present at least 3 days per week for at least 3
months.
Significant distress or impairment in important
daytime functions
36. Prevalence: 0.005–0.06% of Western populations
Comorbidity: Autonomic dysfunction such as
orthostatic hypotension. Depression is also common
Equal distribution among men and women
Insidious onset in the second or third decade with a
chronic persistent courses.
37. Types of Hypersomnia:
Kleine-Levin Syndrome
Menstrual-Related Hypersomnia
Idiopathic Hypersomnia
Behaviorally Induced Insufficient Sleep Syndrome
Hypersomnia Due to a Medical Condition
Hypersomnia Due to Drug or Substance Use
38. Kleine-Levin Syndrome
It predominantly afflicts males in early adolescence.
Usually the first attack occurs between 10 and 21 years.
Consisting of recurrent periods of prolonged sleep (from
which patients may be aroused) with intervening periods of
normal sleep and alert waking
In its classic form, the recurrent episodes are associated with
extreme sleepiness ( 18-hour to 20-hour sleep periods),
voracious eating, hypersexuality, and disinhibition (e.g.,
aggression).
Episodes typically last for a few days up to several weeks
and appear once to ten times per year.
39. Etiology and Pathophysiology
Genetic Factors:
Familial aggregation in approximately 50% of cases, with
a suggestion of autosomal dominant inheritance
20-fold risk in first-degree family members
Neurobiological Factors:
Dysfunction of monoaminergic arousal systems have been
suggested by studies showing reduced CSF dopamine
and/or norepinephrine metabolites
40. Treatment:
Treatment Goals: to reduce the impact of long night
time sleep and excessive daytime sleepiness
Pharmacological Treatments: Monoaminergic
stimulants (methylphenidate, dextroamphetamine, and
mixed amphetamine salts), Modafinil and armodafinil,
Atomoxetine, Bupropion.
Psychosocial Treatments: setting regular sleep–wake
schedules and using multiple alarms (including social
interactions or bright light) may help to ease the sleep–
wake transition.
41. BREATHING-RELATED SLEEP DISORDERS
1. Obstructive SleepApnea Hypopnea (OSAH)
2. Central SleepApnea (CSA)
3. Sleep-Related Hypoventilation (SRH).
All are associated with impaired ventilation during
sleep, often associated with intermittent or sustained
hypoxemia, as well as with sleep disruption that may
result in awakenings as well as daytime sleepiness or
fatigue
42. Reductions in airflow lasting at least 10 seconds are
classified as either apnea (absent airflow) or
hypopnea (reduced airflow), and the frequency of
these events per hour of sleep, termed the apnea
hypopnea index (AHI)
AHI is an important measure of the severity of
OSAH and CSA
43. OBSTRUCTIVE SLEEPAPNEA HYPOPNEA
(OSAH)
Characterized by repetitive pharyngeal airway
obstruction during sleep
Diagnosis: In the absence of symptoms, PSG
documenting at least anAHI of 15
Or
AHI > 5 with predominantly obstructive respiratory
events, accompanied by symptoms of
44. 1. nocturnal breathing disturbances: snoring,
snorting/gasping, or breathing pauses, or
2. daytime sleepiness, fatigue, or unrefreshing sleep
despite sufficient sleep opportunity
Habitual snoring is a sensitive indicator
Increasing loudness of snoring is associated with
higher risk
Snoring may be interrupted by silent periods (apneas),
which are often terminated by resuscitative breathing.
45. Memory disturbances, poor concentration, irritability,
and personality changes
OSAH affects multiple organs and may cause
hypertension, heartburn, nocturia, morning headaches,
and sexual dysfunction
Age (>55), gender (male), BMI (>30) and neck
circumference (>16 inches women, >17 inches men)
identify higher risk groups.
Male: Female = 2:1 to 4:1
46.
47. Treatment:
Treatment Goals: to improve symptoms and
quality of life and minimize risks of comorbidity
Medical management: Continuous positive airway
pressure (CPAP) and and Mandibular advancement
devices (MAD) and surgical procedures like
uvulopalatopharyngoplasty.
Psychosocial Treatments: Weight loss, avoiding the
supine sleep position, reducing evening alcohol
consumption, and getting adequate sleep duration.
48.
49. CENTRAL SLEEPAPNEA
Characterized by variability in respiratory effort that
leads to episodes of apnea and hypopnea during sleep.
Airway remains open but Blood O2 saturation falls.
Diagnostic criteria require at least five central apneas
per hour
Subtypes:
1. Cheyne–Stokes Breathing (CSB) - heart failure,
stroke, or renal failure
2. Central Sleep Apnea Comorbid with Opioid Use -
Chronic use of long-acting opioid medications, such
as methadone
3. Idiopathic Central Sleep Apnea
50. Treatment:
The goals of treatment are to improve symptoms and
quality of life and minimize cardiopulmonary risks
CPAP therapy is effective
Adaptive servo-ventilation (ASV)
Low-flow oxygen therapy
CSA comorbid with opioid use may improve with
reduction in opioid dosage
51. SLEEP RELATED HYPOVENTILATION
Characterized by inadequate ventilation during sleep
Diagnosis is made by PSG, which demonstrates
abnormal elevation of CO2 levels, unassociated with
apneas or hypopneas
Patients may report fatigue, sleepiness, awakenings
during sleep, morning headaches, or insomnia
Most commonly SRH is seen with medical or
neurological disorders or medications that depress
ventilation
52. Rarely, SRH can occur independently (Idiopathic
Sleep-Related Hypoventilation or Congenital
CentralAlveolar Hypoventilation)
Obesity Hypoventilation Syndrome requires the
presence of obesity (BMI > 30 kg/m2), awake
hypercapnia (pCO2 > 45 mmHg) and the exclusion of
other causes of hypoventilation.
53. Severity is determined by the amount of blood gas
abnormalities measured during sleep (elevation of
CO2 and decrease in SpO2) and evidence of end
organ dysfunction, which may include pulmonary
hypertension, cor pulmonale, polycythemia, and
neurocognitive abnormalities.
Congenital CentralAlveolar Hypoventilation is
caused by mutations of PHOX2B
54. Treatment:
The goal of therapy is to provide adequate ventilation
in order to normalize blood gases during sleep and
wakefulness.
Bi-level positive airway pressure: provides higher
inspiratory pressures relative to expiratory pressures
to augment tidal volume of spontaneous breaths.
55. CIRCADIAN RHYTHM SLEEP–WAKE
DISORDERS
The essential feature is a persistent or recurrent pattern
of sleep–wake disturbance characterized by abnormal
timing of sleep or sleep propensity relative to the
physical environment.
Manifest as insomnia, excessive sleepiness, or some
combination of both.
56. Delayed Sleep Phase Type:
Individuals exhibit a sleep–wake cycle that is
delayed by around 3 hours when compared to the
general population
If allowed to sleep at times that are consistent with
their endogenous biological night, sleep duration
and quality are typically normal
57. Advanced Sleep Phase Type:
Individuals exhibit a stable sleep–wake cycle that is
advanced (earlier) in relation to conventional times.
Individuals are drowsy in the evening, want to retire to
bed earlier, awaken earlier, and are more alert in the
early morning. Typically with a history of falling
asleep between 6 pm and 9 pm, and waking up
between 2 am and 5 am.
Called as “Early birds or larks”
58. Irregular Sleep–Wake Type:
Characterized by an irregular pattern of sleep, with at
least three distinct sleep periods occurring during a 24-
hour period.
Occurs when the circadian sleep-wake rhythm is
absent / pathologically diminished
Patients or their caregivers report symptoms of
insomnia, excessive sleepiness, or both.
59. Non-24-Hour Sleep–Wake Disorder:
When the circadian sleep-wake pacemaker has a cycle
length greater or less than 24 hours and is not reset each
morning, a patient may develop this type of disorder.
Daytime napping is common, and is associated with
impairment of function, particularly in blind
individuals.
Also called as periodic insomnia & periodic excessive
sleepiness.
60. Characterized by sleep and wake disturbances for at
least 3 months in the context of chronic shift work.
Ex. Transportation, Health care)
Complaints include excessive sleepiness while at
work, or of difficulty falling asleep during the time
allowed for rest.
The natural low point in the normal sleep-wake
rhythm occurs at 3 to 5 am. (Precisely the time frame during
which transportation & industrial accidents commonly occurs)
Shift Work Disorder:
61. Jet Lag Type:
With the advent of high speed air travel, an induced
desynchrony between circadian and environmental clocks
became possible. Thus, the term jet lag came into use.
When an individual rapidly travels across many time zones,
either a circadian phase advance or a phase delay is
induced, depending on the direction of travel.
Normally, healthy individuals can easily adapt to one to
two time zone changes per day; therefore, natural
adjustment to an 8-hour translocation may take 4 or more
days
“Not included in DSM-5 but in ICSD-3”
62. Circadian Rhythm Sleep-wake disorder
Unspecified type:
Circadian rhythm affects during illnesses that keep patients
bedridden, during hospitalization etc.
Sleep in Patients in the ICU is disturbed by noise, Light,
and the therapeutic and monitoring procedures being
performed.
It produces significant sleep-wake disorder.
63. Assessment:
Sleep logs and/or actigraphy measurements for 7–14
days
Biological markers of circadian phase: Dim-light
melatonin onset (DLMO) or core body temperature
64. Treatment :
Both light therapy and melatonin, when given at
specific times, can act to reset the circadian clock.
(Blue light)
Melatonin is available as OTC in the U.S
Modafinilis FDA-approved for use in shift workers
with excessive daytime sleepiness
Behavioural interventions (regular sleep scheduling)
66. PARASOMNIAS
Parasomnias are unpleasant or undesirable behavioral
or experiential phenomena which occur predominately
or exclusively during the sleep period.
Contrary to popular belief, most parasomnias are not
the manifestation of underlying psychiatric disease
Two broad categories: those occurring in association
with Non-REM sleep, and those occurring in
association with REM sleep.
67. NON-REM SLEEPAROUSAL
DISORDERS
Diagnosis:
They are a set of parasomnias with varying clinical
manifestations, linked by a common mechanism of
arousal from Non-REM sleep.
The essential feature of these disorders is recurrent
episodes of partial arousals from sleep, usually during
the first third of the night.
Regardless of the specific behavioral manifestation,
the individual recalls little, if any dream imagery, and
has little or no recall for the event.
68. Sleepwalking:
Characterized by repeated episodes of rising from bed
during sleep and walking about.
The individual’s eyes are open with a blank, staring
face.
The sleepwalker is relatively unresponsive to the
efforts of others to communicate with him or her, and
can be awakened only with great difficulty.
69. Sleep Terrors:
Initiated by a loud scream associated with extreme
panic and signs of intense fear.
The individual may have signs of autonomic arousal,
such as mydriasis, tachycardia, tachypnea, and
diaphoresis.
This is followed by prominent motor activity such as
hitting the wall, or running around or out of the
bedroom, occasionally resulting in personal injury or
property damage
Complete amnesia for the activity is typical
70. Confusional Arousals:
Often seen in children
Characterized by movements in bed, occasionally
thrashing about, or inconsolable crying.
Sleep-Related Eating Disorder:
DSM-5 – subtype of sleepwalking.
It is characterized by frequent episodes of nocturnal
eating, generally without full conscious awareness.
71. Sleep-Related Sexual Behavior (Sexsomnia):
Asubtype of Sleepwalking.
Consists of inappropriate sexual behaviors occurring
during the sleep state without conscious awareness
Such behaviors may result in feelings of guilt, shame,
or depression and may have medico-legal implications
72. Treatment:
Treatment Goals: environmental safety: heavy
curtains over windows, alarms at bedroom doors, and
sleeping on the ground floor.
Somatic Treatments:
Tricyclic antidepressants such as imipramine, and
benzodiazepines such as clonazepam, may be
effective.
Dopaminergic agents, opiates, or topirimate has been
reportedly effective in sleep-related eating disorder
Sleep-related sexual behaviors may respond to
clonazepam
73. REM-SLEEP RELATED PARASOMNIAS
Nightmare Disorder and REM Sleep Behavior
Disorder (RBD)
Normal REM sleep is characterized by increased
physiological activation, active mentation (dreams),
and muscle atonia
Nightmare Disorder and RBD are characterized by
heightened mental activity and, in the case of RBD,
absence of usual muscle atonia
74. NIGHTMARE DISORDER
Bad dreams and nightmares are normal
What differentiates Nightmare Disorder from normal
bad dreams or nightmares is the frequency of events,
degree of dysphoria, and the extent of distress or
impairment in social, occupational, or other important
areas of functioning.
Usually remembered in great detail, and immediately
upon awakening, the individual is completely alert
and oriented
75. More commonly seen in the setting of physical/sexual
abuse and posttraumatic stress disorder (PTSD)
May be comorbid with a number of medical or
antagonists
conditions, and may be induced by
or
notably beta-adrenergic
from alcohol or other sedating
psychiatric
medication,
withdrawal
medications.
76. Treatment:
Somatic Treatments:
Prazosin 10–16mg reduces nightmare frequency in
PTSD
Cyproheptadine, Guanfacine, and Clonidine have
been reportedly helpful
Psychosocial Treatments:
Dream rehearsal therapy - scripting and rehearsal of a
new dream scenario to replace a common dream.
77. REM SLEEP BEHAVIOR DISORDER
Defined by repeated episodes of awakening from
sleep accompanied by agitated or violent behaviors,
such as shouting, screaming, kicking, and punching.
Commonly occur in the second half of the sleep
period and usually accompany vivid, action-packed
dreams.
Following an event, arousal from sleep to alertness
and orientation is usually rapid and accompanied by
complete dream recall
78. Patient may have repeated injury, including
ecchymosis, lacerations, and fractures.
The resulting injuries to the patient or bed partner may
result in legal issues, such as charges for assault
Many patients adopt self-protection measures such as
tethering themselves to the bed, using sleeping bags or
pillow barricades, or sleeping on a mattress in an
empty room
79. RBD is a frequent harbinger of neurodegenerative
disorders
Upto 70% of affected individuals will eventually
develop a neurodegenerative disorders (most
commonly Parkinson’s disease)
80. Treatment:
Somatic Treatments:
About 90% of patients respond well to clonazepam 0.5–
2.0mg
Melatonin at doses up to 12 mg at bedtime or Pramipexole
may also be effective.
Psychosocial Treatments:
Environmental safety - Potentially dangerous objects
should be removed from the bedroom, cushions put
around the bed or the mattress placed on the floor, and
windows protected.
81. RESTLESS LEGS SYNDROME (RLS)
Neurological sensorimotor disorder characterized by
uncomfortable leg sensations described as aching,
grabbing, burning, tingling, creeping, crawling, or
electric sensations that occur deep in the leg.
Symptoms occur in one or both of the legs, most often
between the ankle and the knee, but may also extend
to the arms or even trunk
Typically worse in the evening, may occur prior to
sleep onset, and are exclusively present at rest
82. Generally relieved by motor activity, such as walking,
pacing, shaking, stretching, or simply standing and
bearing weight.
Associated features include sleep disturbance, daytime
fatigue/sleepiness, and involuntary, repetitive, and
jerking limb movements
Several medications can either evoke or aggravate
RLS, including Antihistamines, Lithium, Tricyclic
antidepressants, Serotonin reuptake inhibitors, and
Monoamine oxidase inhibitors
83. Sleep
caffeine
deprivation/fatigue,
use, lack of or
alcohol,
excessive
tobacco and
exercise, and
exposure to extremes of temperature (either hot or
cold) may also worsen symptoms
Assessment:
Neurological examination, including peripheral nerve
function and peripheral vascular examination.
Laboratory studies - a complete blood count with
RBC indices, iron binding capacity, ferritin, B12,
folate, thyroid function tests, electrolytes and renal
and liver function tests
84. Prevalence - between 5% and 15% in the general
population
Slightly more common in women
Differential diagnosis
Hypnic myoclonus (sleep starts)
Phasic twitches (normal muscle twitches that occur
during REM sleep)
Nocturnal leg cramps
Akathisia (neuroleptic-induced)
85. Treatment:
Dopamine precursors, such as regular or sustained-release
carbidopa/levodopa.
Dopamine agonists Pergolide, Pramipexole, and
Ropinirole.
Benzodiazepines decrease nocturnal arousals and improve
the quality of sleep.
When nutritional deficiencies are present, replacement
with iron, folate, B12, or magnesium may be indicated.
86. SUBSTANCE/MEDICATION-INDUCED
SLEEP DISORDER
This is a prominent sleep disturbance associated with
use, intoxication, or withdrawal from a medication or
substance.
May be associated with Mood symptoms ranging
from depression and anxiety to irritability and
excitement.
Physical symptoms may also be present
89. REFERENCES
Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s
Comprehensive textbook of Psychiatry. 9th edition.
Philadelphia: Lippincott Williams and Wilkins; 2009.
DavidAS, Fleminger S, et al. Lishman’s Organic Psychiatry.
4th edition. John Wiley & Sons Ltd. Publication; 2009.
Stahl SM. Stahl’s Essential Psychopharmacology. 4th edition.
Cambridge University Press; 2014.
Tasman A, Kay J, Lieberman JA, First MB, Riba MB.
Psychiatry. 4th ed. West Sussex: John Wiley & Sons Ltd; 2015
90. REFERENCES
American PsychiatricAssociation, Diagnostic and Statistical
Manual of Mental Disorders. 5th ed. Washington DC: New
School Library; 2013
World Health Organisation. The International Classification of
Diseases, 10th edition. Geneva. WHO; 1996.
Satela MJ. International Classification of Sleep Disorders. 3rd
Edition.AmericanAcademy of Sleep Medicine; 2014.