The document provides information on sleep disorders and sleep medicine. It discusses the history and physiology of sleep, classification of sleep disorders, and assessment and management of sleep problems. Key points include: sleep is regulated by circadian and homeostatic systems in the brain; there are three main states of consciousness - wakefulness, non-REM sleep, and REM sleep; sleep disorders are classified into dyssomnias involving sleep quantity/quality and parasomnias involving abnormal events during sleep; and treatment involves lifestyle changes, psychotherapy, and medications in some cases.

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SLEEP DISORDERS
Antony Ayieko Ong’any
BScN, MSc (Nairobi), Cert. Addict. (UK)
Clinical Psychologist/Lecturer
University of Nairobi

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History of Sleep Medicine
 1809 - Luigi Rolando noted hypersomnolence in fowl
after "removing the front parts of the brain"
 1875 - R. Caton discovers EEG waves in dogs
 1890 - Santiago Ramon y Cajal discovered the neuron
 1928 - Hans Berger discovers EEG waves in humans
 1929 - Constantin von Economo describes two post-viral
sleep syndromes (excessive sleepiness and insomnia)
 1933 - Edgar Adrian studied the EEG response to stimuli
in the awake and sleep states in animals

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Regulation of Wakefulness and Sleep
 There are two major regulatory systems
proposed for sleep and wakefulness called
the
 circadian and
 homeostatic systems.
 They interact and influence each other.

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PHYSIOLOGY OF SLEEP
 Circadian
 circadian rhythmicity arises from within the organism
 the mammalian "clock" is located within the
suprachiasmatic nucleus (SCN) in the anterior
hypothalamus
 this rhythm is influenced through environmental cues
called "zeitgebers"
 Homeostatic
 sleepiness increases in proportion to prior awake
time; alertness increases in proportion to prior sleep
time
 there is a "pressure" to keep awake and sleep time
balanced
 there is a need for recovery sleep after sleep
deprivation despite the lack of a circadian influence

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PHYSIOLOGY OF SLEEP
 There are 3 states of consciousness:
 Wakefulness
 Non-REM sleep: Stages 1-4
 REM sleep
 Wakefulness
 Active (alert; eyes open)
 EEG - "active"/"desynchronized" (sinusoidal;
10-30 µvolts; 16-25 Hz) REM abundant
 Relaxed (eyes closed)
 EEG- alpha activity (20-40 µvolts; 8-12 Hz),
REM is scarce
 Submental EMG may be moderate/high in
both

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PHYSIOLOGY OF SLEEP
 Non-REM
Stage 1
 A transitional stage into sleep
 characterized by theta waves
 mixed frequency 3-7 Hz (cycles/sec)
 diminution of alpha wave activity
 slow rolling eye movements
 1-7 minutes

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PHYSIOLOGY OF SLEEP
 Stage II
 The most abundant stage (50% in young
adults).
 EEG records sleep spindles (12-14 Hz
activity lasting at least 0.5 sec) and K-
complexes
 lasts about 30-60 minutes
 no eye movements
 short mundane fragmented thoughts

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PHYSIOLOGY OF SLEEP
 Stages III & IV (slow wave sleep)
 slow wave/deep sleep
 Highest auditory arousal threshold to
awaken from stages III and IV.
 characterized by Delta waves
 high amplitude (>75 µv)
 low frequency (0.5-2 Hz)
 20-50% stage III
 >50% stage IV

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PHYSIOLOGY OF SLEEP
 REM - Rapid Eye Movements
 First REM sleep about 60 to 90 min after sleep
onset
 low amplitude desynchronized and saw tooth
waves on EEG
 First REM cycle usually lasts only few minutes
followed by NREM (stage II, III and IV). Later
REM cycles progressively increase up to one
hour through the night.
 Most dreams occur while awakening from
REM sleep
 Dreams are emotionally charged, complex and
bizarre

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PHYSIOLOGY OF SLEEP
 In REM the ascending reticular activating system
(ARAS) activity is virtually completely gone, but
high cholinergic activity from the basal forebrain
causes thalamic neurons to remain in tonic
mode. Thus,
 increased cerebral blood flow
 Atonia - marked reduction or absence of muscle
tone in weight-bearing muscles
 increased brain T°
 increased O2 consumption
 penile/clitoral tumesence
 autonomic dysregulation (T° /HR/RR/BP)

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 Non-REM and REM Sleep
 Each sleep cycle lasts approximately 90 to 110
minutes
 There are usually 4 to 6 sleep cycles in a nights sleep
 The first 2 cycles are dominated by NREM stage III
and IV sleep
 Sleep Deprivation /Humans 150-200 hrs:
 brief psychotic episodes but does not result in
permanent psychological effects
 irritability
 stimuli misperception
 decreased waking alpha activity
 disorientation
 Lack of attentiveness

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 Neurologic consequences:
 Seizures
 Tremors
 Horizontal nystagmus
 Older patients
 delta sleep is less pronounced
 Daytime sleepiness increases
 Sleep is shorter, shallower (less slow-wave
sleep) and more fragmented.
 Average adult sleep is 7 to 8 hours

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 Age Related Differences
 Total Sleep Time
 greatest in infancy
 progressively declines with age
 waking time after sleep onset increases with
age
 Slow Wave Sleep
 highest in infancy, declines across the
lifetime.
 REM
 highest in infancy, declines across the lifetime.

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Summary
 3 states of consciousness are wakefulness, REM
and NREM sleep
 wakefulness and sleep are regulated by both
circadian and homeostatic influences
 the areas in the brain that control awake and
sleep states are located in the hypothalamus ,
basal forebrain, and pontine brainstem
 sleep consists of:
 an active dreaming state called REM and
 an inactive slow wave state called non-REM
 there are many age related differences in sleep
patterns

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Sleep Disorders
 Difficulty initiating or maintaining sleep /
Non-restorative sleep
 Excessive sleep / Irresistible attacks of
refreshing sleep
 Awakening from major sleep e.g. from
frightening dreams, Talking/walking
 Psychological+++
 Organic--

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CLASSIFICATION
 Primary Sleep Disorders
 Dyssomnias
 Primary insomnia
 Primary Hypersomnia
 Narcolepsy
 Breathing-Related SD
 Circadian Rhythm SD
 Dyssomnias NOS

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Parasomnias
 Nightmare Disorder,
 Sleep Terror Disorder,
 Sleepwalking Disorder, and
 Parasomnia Not Otherwise Specified

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SLEEP DISORDERS
The sleep disorders are organized into four
Primary Sleep Disorders : presumed to arise from endogenous abnormalities in
sleep-wake generating or timing mechanisms, often complicated by conditioning factors.
Subdivided into
Dyssomnias : Characterized by abnormalities in the amount, quality, or timing of sleep
Parasomnias:Characterized by abnormal behavioral or physiological events occurring
in association with sleep, specific sleep stages, or sleep-wake transitions).
Sleep Disorder Related to Another Mental Disorder: Involves a prominent
complaint of sleep disturbance that results from a diagnosable mental disorder often a
Mood Disorder or Anxiety Disorder but that is sufficiently severe to warrant independent
clinical attention. Presumably, the pathophysiological mechanisms responsible for the
mental disorder also affect sleep-wake regulation.
Sleep Disorder Due to a General Medical Condition: involves a prominent
complaint of sleep disturbance that results from the direct physiological effects of a
general medical condition on the sleep-wake system.
Substance-Induced Sleep Disorder involves prominent complaints of sleep
disturbance that result from the concurrent use, or recent discontinuation of use, of a
substance (including medications).

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Primary Insomnia
 Diagnostic criteria for Primary Insomnia
 A. The predominant complaint is difficulty initiating or maintaining sleep, or
nonrestorative sleep, for at least 1 month.
 B. The sleep disturbance (or associated daytime fatigue) causes clinically
significant distress or impairment in social, occupational, or other important
areas of functioning.
 C. The sleep disturbance does not occur exclusively during the course of
Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep
Disorder, or a Parasomnia.
 D. The disturbance does not occur exclusively during the course of another
mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety
Disorder, a delirium).
 E. The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition.

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Primary Hypersomnia
A. The predominant complaint is excessive sleepiness for at least
1 month (or less if recurrent) as evidenced by either
prolonged sleep episodes or daytime sleep episodes that
occur almost daily.
 B. The excessive sleepiness causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.
 C. The excessive sleepiness is not better accounted for by
insomnia and does not occur exclusively during the course of
another Sleep Disorder (e.g., Narcolepsy, Breathing-Related
Sleep Disorder, Circadian Rhythm Sleep Disorder, or a
Parasomnia) and cannot be accounted for by an inadequate
amount of sleep.
 D. The disturbance does not occur exclusively during the
course of another mental disorder.
 E. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or
a general medical condition.
 Recurrent: if there are periods of excessive sleepiness that
last at least 3 days occurring several times a year for at least

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Narcolepsy
 Diagnostic criteria for 347 Narcolepsy
 A. Irresistible attacks of refreshing sleep that occur daily over at least 3
months.
 B. The presence of one or both of the following:
 (1) cataplexy (i.e., brief episodes of sudden bilateral loss of muscle tone,
most often in association with intense emotion)
 (2) recurrent intrusions of elements of rapid eye movement (REM) sleep
into the transition between sleep and wakefulness, as manifested by either
hypnopompic or hypnagogic hallucinations or sleep paralysis at the
beginning or end of sleep episodes
 C. The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or another general medical
condition

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Breathing-Related Sleep Disorder
 Diagnostic criteria for 780.59 Breathing-Related Sleep Disorder
 A. Sleep disruption, leading to excessive sleepiness or insomnia, that
is judged to be due to a sleep-related breathing condition (e.g.,
obstructive or central sleep apnea syndrome or central alveolar
hypoventilation syndrome).
 B. The disturbance is not better accounted for by another mental
disorder and is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or another general
medical condition (other than a breathing-related disorder).
 Coding note: Also code sleep-related breathing disorder on Axis III.

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Circadian Rhythm Sleep Disorder
A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or
insomnia that is due to a mismatch between the sleep-wake schedule required by a
person's environment and his or her circadian sleep-wake pattern.
 B. The sleep disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
 C. The disturbance does not occur exclusively during the course of another Sleep
Disorder or other mental disorder.
 D. The disturbance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition.
 Specify type:
 Delayed Sleep Phase Type: 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 Type: 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 Type: insomnia during the major sleep period or excessive sleepiness
during the major awake period associated with night shift work or frequently
changing shift work
 Unspecified Type

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Parasomnias
 Disorders characterized by abnormal behavioral
or physiological events occurring in association
with sleep, specific sleep stages, or sleep-wake
transitions.
 Parasomnias do not involve abnormalities of the
mechanisms generating sleep-wake states, nor
of the timing of sleep and wakefulness.
 Parasomnias represent the activation of
physiological systems at inappropriate times
during the sleep-wake cycle.
 In particular, involve autonomic nervous system,
motor system, or cognitive processes during
sleep or sleep-wake transitions.

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Epidemiology
 One of the most common
 Occur with other mental / physical
disorders
 Over 20% of adults

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ASSESSMENT
 Hx + MSE
 Sleep Hx (+ partner as corroborator)
 Complaint, duration, severity, factors, stressors, Daily
routine (Sleeping & waking time/method/ activities,
naps, day alertness, drugs, Rxs, etc)
 (Partner): ?stops breathing, snores+, leg jerks, mood,
drugs, role??
 Sleep Diary – for 2 wks+
 Lab – EEG, EMG, ECG,

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MANAGEMENT - EDUCATION
1. Establish a regular waking time
(+weekends)
2. Establish proper sleep environment –
comfort (physically, psych., bed, env); noise (!traffic
etc – earplugs, close room); Light (darken room)
3. Allow a wind-down time prior to sleep –
stop everything else at least 30 min b4 bed / do a
nonstresful e.g. music, etc
4. Use your bed only for sleep (+…Sex) –
not eating, working, TV, reading, or discussion of
problems!!!

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MANAGEMENT - EDUCATION
5. Cope with worry & anxiety
• Set aside time for problem solving during
the day
• Do not stay in bed when you are not asleep
6. Avoid napping during the day
7. Avoid drugs – caffeine, Nicotine, Khatt,
Alcohol, Sleeping pills
8. Take a snack – warm milk, banana

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MANAGEMENT - MEDICAL
 Psychotherapy
 PMR
 Hypnosis
 Meditation, yoga
 etc
 Medications
 Benzodiazepines e.g. Diazepam