This document provides information about sleep disorders. It begins by defining normal sleep patterns, including non-REM and REM sleep. It then classifies and describes several types of sleep disorders, including insomnia, hypersomnolence, breathing-related sleep disorders, circadian rhythm disorders, and parasomnias. Treatment options are discussed for each disorder, including both pharmacological and behavioral approaches. The document aims to educate students on identifying, diagnosing, and managing various sleep disorders.

1. SLEEP DISORDERS
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2. Objectives
 At the end, students will be able to:
–Define normal sleep
–Differentiate wakefulness, REM Sleep and Non-REM sleep
–Identify methods to assess sleep
–List and define types of sleep disorders
–Identify sleep disorders management strategies
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3. Outlines
–Normal sleep
–Classification of sleep disorders
–Insomnia disorders
–Hypersomnolence disorders
–Breathing related sleep disorders
–Circadian rhythm sleep wake disorders
–Parasomnias
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4. Normal sleep
 Sleep is a regularly recurring, rapidly reversible neurobehavioral state
characterized by quiescence, postural recumbence, and reduced
awareness of the environment
 It is a process the brain requires for proper functioning
 Also considered as psychiatric “vital sign” and requires routine
evaluation of every individuals
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5. cont…
 Made up of two physiological states
–Non-rapid eye movement (NREM) sleep:
-Has 4 stages(1-4)
-most physiological functions a remarkably lower than in wakefulness
–Rapid eye movement (REM) sleep
-characterized by a high level of brain and physiological activity
- usually occurs 90 minutes after onset of sleep
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6. Cont…
• NREM (75%) -Stage 1: (5%) - Stage 2: (45% )
-Stage 3: (12% ) -Stage 4: (13%)
• REM (25 percent)
(FIG 1:Sleep pattern in a young adult, healthy subject. Source: K&S synopsis of psychiatry 11th ed)
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7. Wake NREM REM
EEG Fast, low
voltage
Slow, high voltage Fast, low voltage
Eye movement Vision-related Slow-irregular rapid
Muscle tone ++ + -
Blood pressure, heart
rate, respiratory rate
Variable Slow/low, irregular Variable, Higher than
NREM
Responses to hypoxia
and hypercarbia
Active Reduced responsiveness Lowest, responslveness
Thermoregulation Behavioral and
physiological
Physiological regulation Reduced physiological
Mental activity full None or limited Story-like dreams
Comparison of wakefulness, REM AND NREM sleep
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8. Assessment of sleep
 Should be evaluated routinely
 A thorough history of comorbid medical or psychiatric disorders
should be assessed
 Psychoactive substance use history
 Current medication (if any)
 Retrospective self report tools like Pittsburgh Sleep Quality
Index(PSQI), Epworth Sleepiness Scale (ESS), Insomnia Severity
Index(ISI) or prospective self report like sleep—wake diaries can be
used for assessment purpose.
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9. Sleep wake disorders
Sleep Disorder Classifications
 Classified based on three international classifications
–Diagnostic & Statistical Manual of Mental Disorders (DSM 5)
–International Classification of Diseases (ICD 10)
–International Classification of Sleep Disorders (ICSD-3)
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10. DSM 5 classification of sleep disorders
INSOMNIA DISORDER
 Insomnia is defined as difficulty initiating or maintaining sleep.
 Insomnia disorder: is dissatisfaction with sleep quantity or quality
associated with one or more of the following symptoms:
₋ difficulty in initiating sleep ,
₋ difficulty in maintaining sleep with frequent awakenings or
problems returning to sleep ,
₋ early morning awakening with inability to return to sleep
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11. Cont..
 Additional criterias for insomnia disorder :
₋ Causes clinically significant distress and impairment in functioning
₋ Sleep disturbance occurs at least three nights per week for at least
three months
₋ Sleep difficulty occurs despite adequate opportunity for sleep
₋ Not better explained by the course of other sleep disorders, effect
of substance use, coexisting mental or medical condition
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12. Cont..
 Subjective insomnia (Sleep state misperception): dissociation
between the patient’s experience of sleeping and the objective
polysomnographic measures of sleep
- patients frequently complain lack of sleep despite normal findings
on PSG.
 Idiopathic insomnia is a chronic insomnia which typically starts early
in life, sometimes at birth, and continues throughout life.
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13. Cont…
Epidemiology:
₋ Most common sleep disorder.
₋ 30—50% of the adult population may experience insomnia symptoms
during the course of a year
₋ Male to Female ratio; 1.5:1
₋ Age effect is not universally observed
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14. Cont…
Etiologies
 Genetic Factors: supported by family and twin studies
 Neurobiological Factors: physiological hyperarousal, 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
 Psychological Factors: depressive and anxiety symptoms
 Social/Environmental Factors: stressors
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15. Cont…
Treatments:
 Psychosocial Treatments:
₋ Stimulus control,
₋ Sleep restriction therapy,
₋ Relaxation training,
₋ Cognitive restructuring of irrational sleep-related beliefs and sleep
hygiene.
 Pharmacological Treatments:
₋ benzodiazepine receptor agonists,
₋ tricyclic drugs,
₋ melatonin receptor agonist,
₋ antihistamines, and barbiturates
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16.  Universal Sleep Hygiene. Focused on modifying environmental and
life style components that may interfere with sleep
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17. Hypersomnolence Disorder
 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 present at least 3 days per week for at least 3 months.
 Causes significant distress or impairment in important daytime
functions
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18. Cont…
Epidemiology
–Prevalence: 0.005—0.06% of Western populations
–Equal distribution among men and women
–Insidious onset in the second or third decade with a chronic
persistent courses
 Comorbidity: Autonomic dysfunction such as orthostatic
hypotension. Depression is also common
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19. Cont…
Etiologies
 Genetic Factors:
–Familial aggregation in approximately 50% of cases,
–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
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20. Cont…
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
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21. Cont…
Treatments
 Pharmacological Treatments:
– Monoaminergic stimulants (methylphenidate,
dextroamphetamine, and mixed amphetamine salts),
–Modafinil and armodafinil,
–Atomoxetine,
–Bupropion.
 Psychosocial Treatments:
–setting regular sleep—wake schedules
–using multiple alarms (including social interactions or bright light)
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22. Narcolepsy
 Excessive sleepiness, as well as auxiliary symptoms that represent the
intrusion of aspects of REM sleep into the waking state
 To diagnose Narcolepsy there must be:
₋ An extreme daytime sleepiness, marked by recurrent episodes of
an irresistible need to sleep, unintentional sleep episodes, or
napping. (at least 3 times per week for at least 3 months)
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23. Cont…
 In addition, Narcolepsy requires one of three additional findings:
₋ Episodes of cataplexy : Sudden and bilateral loss of muscle tone
with preserved consciousness, and often precipitated by strong
emotions such as laughter
₋ Hypocretin (orexin) deficiency in cerebrospinal fluid
₋ Specific PSG findings: reduced latency to REM sleep during
nocturnal PSG (15 minutes or less)
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24. Cont…
 Narcolepsy is associated with sleep-related hallucinations at sleep
onset (hypnagogic) or sleep offset (hypnopompic) 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
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25. Cont….
Epidemiology:
 Prevalence: 0.02% to 0.04% in general population
 Mostly chronic and persistent
Etiology
₋ Genetic Factors
₋ Neurobiological Factors (decreased Hypocretin (orexin) in CNS)
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26. Cont…
Treatments
 Pharmacological Treatments:
– Monoaminergic stimulants (Methylphenidate, Dextroamphetamine, and
mixed Amphetamine salts),
– Modafinil and Armodafinil,
– Atomoxetine,
– Bupropion,
– Anti-cataplectic drugs (Venlafaxine, Desmethyl venlafaxine, Duloxetine, or
Fluoxetine, TCAs)
 Psychosocial Treatments: Scheduling regular brief nap
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27. Breathing-related Sleep Disorders
 These disorders 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
 Include:
–Obstructive Sleep Apnea Hypopnea (OSAH)
–Central Sleep Apnea (CSA)
–Sleep-Related Hypoventilation (SRH).
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28. Obstructive Sleep Apnea Hypopnea (OSAH)
 Characterized by repetitive pharyngeal airway obstruction during
sleep
 Diagnosis: In the absence of symptoms, PSG documenting at least an
Apnea or Hypopnea of 15 OR AH index of greater than 5 with
predominantly obstructive respiratory events, accompanied by
symptoms of:
–nocturnal breathing disturbances like snoring, snorting/gasping, or
breathing pauses,
–daytime sleepiness, fatigue, or unrefreshing sleep despite
sufficient sleep opportunity
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29. Cont…
 Can be associated with memory disturbances, poor concentration,
irritability, and personality changes
 Affects multiple organs and may cause hypertension, heartburn,
nocturia, morning headaches, and sexual dysfunction
 Obesity and ageing increase the risk of OSAH
 Higher among males than females (2:1 to 4:1)
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30. Cont…
Treatments
 Somatic treatments: Continuous positive airway pressure (CPAP) 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
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31. Central Sleep Apnea
 Characterized by variability in respiratory effort that leads to episodes
of apnea and hypopnea during sleep
 Diagnostic criteria require at least five central apneas per hour
 subtypes
–Cheyne-Stokes Breathing (CSB) - heart failure, stroke, or renal
failure
– Central Sleep Apnea Comorbid with Opioid Use:Chronic use of
long-acting opioid medications, such as methadone
– Idiopathic Central Sleep Apnea
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32. Cont…
Treatment:
 Low-flow oxygen therapy
 CSA comorbid with opioid use may improve with reduction in opioid
dosage
 Continuous positive airway pressure (CPAP) therapy is effective
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33. Sleep Related Hypoventilation
 Characterized by inadequate ventilation during sleep
 Abnormal elevation of C02 levels (PSG), unassociated with apneas or
hypopneas
 Most commonly seen with medical or neurological disorders or
medications that depress ventilation
 Patients may report fatigue, sleepiness, awakenings during sleep,
morning headaches, or insomnia
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34. Cont…
Treatment
 Providing adequate ventilation to normalize blood gases during sleep
and wakefulness.
 Bi-level positive airway pressure: provides higher inspiratory
pressures relative to expiratory pressures
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35. Circadian Rhythm Sleep-wake Disorders
 Persistent or recurrent pattern of sleep—wake disturbance
characterized by abnormal timing of sleep or sleep propensity relative
to the physical environment.
 Misalignment between desired and actual sleep periods
oDelayed Sleep Phase Type:
 Sleep—wake cycle that is delayed by around 3 hours when compared
to the general population
 Individuals with this disorder are more alert during night time,
commonly referred to as night owls
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36. Cont…
oAdvanced Sleep Phase Type:
 Occurs when the circadian rhythm cycle is shifted earlier.
 Such patients are:
–drowsy in the evening,
–want to retire to bed earlier,
–awaken earlier,
–are more alert in the early morning
– sometimes called early birds or larks.
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37. Cont…
oIrregular Sleep—Wake Type:
 Irregular pattern of sleep, with at least three distinct sleep periods
occurring during a 24-hour period.
 Timing of sleep and wakefulness is unpredictable.
oNon-24-Hour Sleep—Wake Disorder (free running):
 Results when an individual's sleep—wake pattern is no longer
entrained to the 24-hour physical environment, instead following the
endogenous circadian rhythm that is usually slightly more than 24
hours
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38. Cont…
oShift Work Disorder:
 Characterized by sleep and wake disturbances for at least 3 months in
the context of chronic shift work
 Excessive sleepiness while at work, or difficulty falling asleep during
the time allowed for rest
oJet Lag Type:
 With the advent of high speed air travel, an induced desynchrony
between circadian and environmental clocks became possible.
 Travels across many time zones induce either a circadian phase
advance or a phase delay , depending on the direction of travel.
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39. Cont…
Treatment of circadian rhythm sleep wake disorders :
 Both light and melatonin, when given at specific times, can act to
reset the circadian clock.
 Modafinil: FDA-approved for use in shift workers with excessive
daytime sleepiness
 Behavioral interventions (regular sleep scheduling)
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40. Parasomnias
 Parasomnias are unpleasant or undesirable behavioral or experiential
phenomena which occur predominately or exclusively during the
sleep period
 Categorized into two broad categories:
– those occurring in association with Non-REM sleep,
–those occurring in association with REM sleep.
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41. NON-REM Sleep Arousal Disorders
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
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42. Cont…
oSleepwalking:
 Repeated episodes of rising from bed during sleep and walking about
having eyes 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
 Subtypes:
–Sleep-Related Eating Disorder
–Sleep-Related Sexual Behavior (Sexsomnia):
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43. Cont…
oSleep 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 followed by
prominent motor activities resulting in personal injury or property
damage
 Individuals have complete amnesia for what happened
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44. Cont…
Treatment
 Environmental safety!!!!!
 Tricyclic antidepressants such as imipramine
 Benzodiazepines such as clonazepam
 Dopaminergic agents, opiates, or topiramate has been reportedly
effective in sleep-related eating disorder
 Sleep-related sexual behaviors may respond to clonazepam
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45. REM-sleep Related Parasomnias
oNightmare disorder
 Frequent frightening and bad dreams associated with high degree of
dysphoria, and distress or impairment in social, occupational, or other
important areas of functioning.
 Usually remembered in great detail, and immediately upon
awakening.
 More commonly seen in the setting of physical/sexual abuse and
posttraumatic stress disorder (PTSD
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46. Cont…
Treatments:
–Prazosin 10—16mg reduces nightmare frequency in PTSD
–Cyproheptadine, Guanfacine, and Clonidine have been reportedly
helpful
–Dream rehearsal therapy - scripting and rehearsal of a new dream
scenario to replace a common dream
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47. Cont…
REM Sleep Behavior Disorder
 Repeated episodes of awakening from sleep accompanied by agitated
or violent behaviors, such as shouting, screaming, kicking, and
punching.
 Following an event, arousal from sleep to alertness and orientation is
usually rapid and accompanied by complete dream recall.
 Associated with neurodegenerative disorders(most commonly
Parkinson's disease).
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48. Cont…
Treatment:
–Environmental safety !!!!
–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.
.
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49. SLEEP-RELATED MOVEMENT DISORDERS
oRestless Legs Syndrome (RLS)
 Uncomfortable leg sensations described as aching, grabbing, burning,
tingling, creeping, crawling, or electric sensations in the legs and
irresistible urge to move the legs when at rest or while trying to fall
asleep.
 May be aggravated Antihistamines, Lithium, Tricyclic antidepressants,
Serotonin reuptake inhibitors, and Monoamine oxidase inhibitors,
Sleep deprivation/fatigue, alcohol, tobacco and caffeine use, lack of
or excessive exercise etc.
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50. Cont…
 5-15% prevalent in general population and slightly common among
women than men.
Treatments:
–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
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51. Cont…
Sleep-Related Bruxism:
 Grinding or clenching the teeth during sleep
 Worsens during periods of stress
 Treatment involves having the patient wear an oral appliance to
protect the teeth during sleep
 Relaxation, biofeedback, hypnosis, physical therapy, and stress
management are also used to treat sleep bruxism
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52. Substance/Medication-induced Sleep Disorder
 Sleep disorders that occur due to subsances like Alcohol (acute use,
withdrawal), Caffeine, Nicotine, Cannabis, Antidepressants,
Corticosteroids , Beta-agonists, theophylline derivatives, antagonists,
Statins, Stimulants, Dopamine agonists.
 May be associated with Mood symptoms ranging from depression
and anxiety to irritability and excitement
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53. References
 American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Washington DC: New School Library; 2013
 Benjamin J. Sadock, Virginia A. Sadock Pedro R. Kaplan and Sadock’s
comprehensive textbook of psychiatry. 10th edition. 2017
 Satela MJ. International Classification of Sleep Disorders. 3rd Edition.
American Academy of Sleep Medicine; 2014
 Benjamin J. Sadock, Virginia A. Sadock PR. Kaplan & Sadock’s Synopsis of
Psychiatry: behavioral sciences/clinical psychiatry. 11th edition. Vol. 1.
2015.
 World Health Organization. The International Classification of Diseases,
10th edition. Geneva. WHO; 1996
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54. THANK YOU!!!!!
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