3. Sleep Disorders in the DSM-5
Insomnia Disorder
Hypersomnia Disorder
Narcolepsy
Obstructive Sleep Apnea
Central Sleep Apnea
Sleep-Related Hypoventilation
Circadian Rhythm Sleep Wake Disorders
Non-REM Sleep Arousal Disorders
Nightmare Disorder
REM Sleep Behavior Disorder
Restless Legs Syndrome
Substance/Medication – Induced Sleep Disorder
4.
5. Insomnia
DSM-5 “Insomnia Disorder”
Dissatisfaction with sleep quantity/quality
Initiation, maintenance or early morning waking
Clinically significant distress
Minimum 3 nights/week
Minimum 3 months
Adequate sleep opportunity
Not better explained or exclusively during the course of another
sleep-wake disorder
Not caused by substance
Coexisting conditions don’t adequately explain
Specify: with non-sleep mental comorbidity; with other medical
comorbidity; with other sleep disorder
6. ICSD-3 “Chronic Insomnia Disorder”
One or more difficulty
Initiating sleep
Maintaining sleep
Waking too early
Resistance to appropriate bedtime
Difficulty sleeping without parent or caregiver intervention
Related to sleep difficulty, one or more
Fatigue
Attention/concentration/memory impairment
Social/family/occupational/academic impairment
Mood disturbance
Daytime sleepiness
Behavioral problems
Reduced motivation
Error proneness
Dissatisfaction with/concerns about sleep
Not explained by inadequate sleep opportunity
3 times per week
3 months
Not better explained by another sleep disorder
7.
8. Insomnia Diagnosis
Clinical interview, includes sleep history and rule out
of other sleep disorders
Data collection – sleep diary
Actigraph
Standardized measures: e.g., Insomnia Severity
Index, Dysfunctional Attitudes and Beliefs about
Sleep
11. Insomnia Treatment - Medication
Anecdotally, chronic patients report decreasing efficacy of most
hypnotics and sedating medications and they often prefer not to take
them
Psychological dependence is frequently an issue, rebound insomnia can
be an issue in discontinuation
Medication issues complicated by comorbid psychiatric tx
Most commonly prescribed are benzodiazepine receptor agonists,
including benzodiazepines (e.g., temazepam, lorazepam, alprazolam)
and non-benzodiazepine agents that act on the same site on the GABA-
A receptor complex (e.g., zolpidem, eszopiclone, zaleplon)
Sedating antidepressant drugs such as trazodone as well as sedating
tricyclic antidepressants (e.g., doxepin, imipramine, nortriptyline,
clomipramine, amitriptyline) are widely used
Melatonin agonist ramelteon
Melatonin
Diphenhydramine
Suvorexant (dual orexin receptor antagonist)
12. Evidence for the Efficacy of CBTI
Decades of research evidence that convincingly demonstrates the
efficacy of CBTI (e.g., Edinger & Carney, 2008; Espie, 2002) as the
“well established and proven” treatment approach
CBTI is just as effective as sedating hypnotics during acute treatment
(4-8 weeks) (e.g., Smith et al., 2005)
CBTI is more effective than sedating hypnotics long-term (e.g., Espie et
al., 2001; Morin et al., 2006)
CBTI has been established as the first line treatment approach for
insomnia (Smith et al., 2002)
CBTI is more effective than zolpidem (Jacobs et al., 2004)
CBTI is more effective than zopiclone (Sivertsen et al., 2006)
When given the option, people prefer CBTI to pharmacotherapy for
insomnia (Morin et al., 1992) and patients report greater satisfaction
with CBTI and rate it as more effective than sleep medication (Morin et
al., 1999)
13. Some techniques used in CBTI
Sleep education
Motivational interviewing
Sleep scheduling
Sleep restriction
Cognitive therapy
Relaxation training
Mindfulness
Self monitoring
Activity scheduling
14.
15. Components of CBTI
Behavioral
Stimulus control
Sleep restriction therapy
Both must be used cautiously and with appropriate understanding of factors that
impact patient safety as well as full sleep assessment
Cognitive
Thoughts and beliefs about sleep
Address dysfunctional thoughts and educate patient
16.
17. Obstructive Sleep Apnea
DSM-5 “ Obstructive Sleep Apnea Hypopnea”
Either 1 or 2
(1)Evidence by polysomnography of at least 5 obstructive sleep
apneas &/or hypopneas AND
snoring, snorting, breathing pauses OR
daytime sleepiness not attributable to inadequate sleep
opportunity or another medical/mental condition
(2)Evidence by polysomnography of 15 or more apneas &/or
hypopneas
Rated by events per hour: mild (<15), moderate (15-30) or severe
(>30)
18. ICSD-3 “Obstructive Sleep Apnea, Adult”
(A and B) or C
(A) One or more of the following:
Sleepiness/nonrestorative sleep/fatigue/insomnia
Observer reports snoring/breathing interruptions
Patient wakes breath holding, gasping, choking
Diagnosis of mood disorder, hypertension, cognitive
dysfunction, coronary artery disease, stroke, congestive heart
failure, atrial fibrillation, T2 diabetes
(B) PSG demonstrates 5 or more predominantly obstructive
respiratory events
(C) PSG or OCST demonstrates 15 or more predominantly
obstructive respiratory events per hour
19. ICSD-3 “Obstructive Sleep Apnea, Pediatric”
Presence of one or more of the following:
Snoring
Labored or obstructed breathing during sleep
Sleepiness/hyperactivity/behavioral problems/learning problems
AND PSG demonstrates
One or more apneas/hypopneas per hour of sleep
OR
A pattern of obstructive hypoventilation
20. Obstructive Sleep Apnea Treatment
Estimated 60% of moderate to severe OSA is attributable
to obesity; in those cases, weight loss may reduce or
eliminate the OSA
Positive airway pressure still most common treatment
(CPAP, BiPAP, AutoPAP)
Dental device (OPT, oral pressure treatment)
UPPP (surgery)
Patient compliance is a key factor. Anxiety and
claustrophobic reactions can reduce PAP therapy
compliance. Appropriate gradual desensitization treatment
can be effective to address those concerns.
21. Latest treatments for OSA
Hypoglossus Nerve Stimulation
A relatively new advancement (approved by the FDA in 2014), a small device is
surgically implanted in the chest, and can be turned on and off by the patient. While
you sleep, the device monitors your breathing and stimulates a nerve that keeps the
upper airway open. Initial research has shown that HGS improved
patients’ symptoms, and had few side effects and good compliance. Doctors may
recommend this therapy for patients with moderate to severe obstructive sleep apnea
who are not helped by PAP therapy.
Expiratory Positive Airway Pressure (EPAP)
The EPAP system uses disposable adhesive valves that are placed over the nose when
you sleep. When you inhale, the valve opens and helps the airway remain
unobstructed. When you exhale, the airflow is directed into small channels, which
creates pressure and, again, keeps the airways open. Open airways mean fewer
incidences of obstructed breathing and interruptions in sleep. Initial research has
shown EPAP therapy has a high level of adherence—a good sign for successful OSA
treatment.
Source: National Sleep Foundation
22.
23. Circadian Rhythm Sleep Wake Disorders
DSM-5 subtypes:
Delayed sleep phase
Advanced sleep phase
Irregular sleep wake type
Non 24 hour type
Shift work type
Unspecified type
25. Treatment of Circadian Rhythm Sleep Wake Disorders
Light
Activity scheduling
Nap scheduling
Melatonin
Ramelteon
Stimulant medications (???)
Sedating/hypnotic medications (???)
26. Parasomnias
Non-REM parasomnias:
Disorders of arousal
Confusional arousals
Sleepwalking
Sleeptalking
Sleep terrors
Sleep related eating disorder
REM related parasomnias:
REM Sleep Behavior Disorder
Recurrent isolated sleep paralysis
Nightmare disorder
Other parasomnias include sleep enuresis, sleep related
hallucinations and exploding head syndrome
Differential diagnosis may require overnight sleep study but can
often be made based on specific symptoms
27. Narcolepsy
DSM-5 specifies with and without cataplexy,
hypocretin deficiency, autosomal dominant
subtypes, secondary to medical condition
ICSD-3 specifies Type 1 and Type 2 narcolepsy
among other central disorders of hypersomnolence
Diagnosis requires polysomnography and/or
measurement of CSF hypocretin concentration
Treatment may include antidepressant medications
that suppress REM, sodium oxibate, lifestyal and
behavioral changes, activity scheduling and
scheduled naps
28. May require medication and/or medical management:
Hypersomnia Disorder
Central Sleep Apnea
Sleep-Related Hypoventilation
Restless Legs Syndrome
Substance/Medication – Induced Sleep Disorder
29. Thank you!
“When I woke up this morning, my girlfriend asked
me, “Did you sleep good?” I said, “No, I made a few
mistakes.”
Stephen Wright
30. References
American Academy of Sleep Medicine (2016) AASM invites public comment on draft clinical practice guideline for
pharmacological treatment of chronic insomnia. An American Academy of sleep medicine practice guideline (draft).
Advance online publication. Retrieved from http://www.aasmnet.org/articles.aspx?id=6241
American Academy of Sleep Medicine (2014). The International Classification of Sleep
Disorders (3rd Ed.) Westchester, IL: The American Academy of Sleep Medicine.
American Academy of Sleep Medicine (2014). The International Classification of Sleep
Disorders (3rd Ed.) Darien, IL: The American Academy of Sleep Medicine
Carney, C., & Manber, R. (2009). Quiet Your Mind and Get To Sleep. Oakland, CA: New
Harbinger Publications, Inc.
Edinger, J. & Carney, C. (2008). Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach. New York: Oxford
university Press, Inc.
Espie, C. (2002). Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults.
Annual Review of Psychology, 53, 215-243.
Espie CA, Inglis SJ, Harvey L. (2001). Predicting clinically significant response to cognitive behavior therapy for chronic
insomnia in general medical practice: Analyses of outcome data at 12 months posttreatment. Journal of Consulting and
Clinical Psychology, 69, 58–66.
Jacobs, G., Pace-Schott, E., Stickgold, R., & Otto, M. (2004). Cognitive behavior therapy and pharmacotherapy for insomnia:
a randomized controlled trial and direct comparison. Archives of Internal Medicine, 164(17), 1888-96.
Khurshid, K. (2015). A review of changes in DSM-5 sleep wake disorders. Psychiatric Times, 32(9).
Kryger, M. H. (2010). Atlas of Clinical Sleep Medicine. Philadelphia, PA: Saunders
Elsevier.
Krystal, A. D. (2012). Psychiatric disorders and sleep. Neurologic Clinics, 30(4), 1389–1413.
Morin, C., Bastien, C., Guay, B., Radouco-Thomas, M., Leblance, J., & Vallieres, A.
(2004). Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine
discontinuation in older adults with chronic insomnia. American Journal of Psychiatry, 161(2), 332-342.
Morin C., Bootzin R., Buysse D., Edinger J., Espie C., & Lichstein , K. (2006). Psychological and behavioral treatment of
insomnia: Update of the recent evidence (1998-2004). Sleep, 29(11), 1398-414.
Morin, C., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life
insomnia: A randomized controlled trial. Journal of the American Medical Association, 281, 991–999.
31. References (cont’d)
Morin, C. & Espie, C. (2004). Insomnia: A Clinical Guide to Assessment and Treatment.
New York: Springer Science + Business Media, LLC.
Morin, C., Gaulier, B., Barry, T., & Kowatch, R. (1992). Patients’ acceptance of psychological and pharmacological therapies
for insomnia. Sleep: Journal of Sleep Research & Sleep Medicine,15, 302-305.
Perlis, M., Jungquist, C., Smith, M., & Posner, D. (2005). Cognitive Behavioral
Treatment of Insomnia. New York: Springer.
Qaaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, E. (2016). Management of chronic insomnia disorder in
adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-
139.
Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O., Kvale, G., Nielsen, G., & Nordhus, I. (2006). Cognitive
behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized
controlled trial. JAMA, 295(24), 2851-8.
Smith, M., Huang, M. , & Manber, R. (2005). Cognitive behavior therapy for chronic insomnia occurring within the context
of medical and psychiatric disorders. Clinical Psychology Review, 25(5), 559-592.
Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al. (2002). Comparative meta-analysis of
pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159, 5–11.
Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C,
Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. (2015). Joint consensus statement of the American Academy of
Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: Methodology and
discussion. Sleep 38(8):1161-83.
Wright, K. P. (Ed.) (2009). Circadian rhythm sleep disorders. Sleep Medicine Clinics,
4(2), 1-311.
Editor's Notes
Previous classification systems in ICSD differentiated subtypes of insomnia – review
Discuss the methods by which diagnosis occurs, NOT overnight sleep study (although some options for paradoxical) – sleep diary and interview (next slides)
Review a general assessment to determine whether insomnia or behavioral
Already reviewed population stats: 10% pop, 30% have acute insomnia at any time, females slightly more than males, higher in older adults. Behavioral insomnia of childhood 10 – 30% children
Review benefits and potential consequences of the above options
Population, pediatric 1 – 4%, adult estimates as high as 24% males (when include mild criterion) 9% females, age increase neck circum >17 in men, > 15 in women, family hx
Why does this diagnosis matter? Significant impact on other sleep disorders and daytime function, cognitive, behavioral and emotional. Children misdiagnosed with behavioral disorders and/or adhd. Potentially significant safety factor. If obese, especially, even if sleep is reported as “good” consider referral to sleep medicine. Will do initial consult and follow up as appropriate with screening or overnight sleep study. Refer to the appropriate professional!!!
Uvulopalatopharyngoplasty (UPPP) Uvulopalatopharyngoplasty (UPPP) is surgery to open the upper airways by taking out extra tissue in the throat. It may be done to treat mild obstructive sleep apnea (OSA) or severe snoring.DescriptionUPPP removes soft tissue at the back of the throat. This includes:All or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth).Parts of the soft palate and tissue at the sides of the throat.Tonsils and adenoids, if they are still there.
Hypersomnia is NOT narcolepsy! Narcolepsy with cataplexy occurs in .02 - .18% population, slight preponderence of males, overall rate of narcolepsy 1 in 4000 in North America