The Dyssomnias

1. The Dyssomnias BabatundeIdowuOgundipe M.D. M.P.H. Comprehensive Clinical Services P.C. January 20 2012

2. What is Sleep? • A reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment. • Typically accompanied by postural recumbence, behavioral quiescence, closed eyes, and other associations. • Other behaviors that can occur during sleep include: • (1)Sleepwalking • (2)Sleeptalking • (3)Tooth Grinding • (4)Other physical activities.

3. What are Dyssomnias? • Primary disorder of sleep or wakefulness characterized by inability to sleep (insomnia) or excessive sleepiness(hypersomnia) • Disorders of duration, quality, & timing of sleep. • Normal sleep is divided into cycles: • (1) Rapid Eye Movement (REM) • (2)Non Rapid Eye Movement • Non Rapid Eye Movement made up of 4 stages of increasing depth of sleep: • Stage 1 • Stage 2 • Stage 3 • Stage 4 end-your-sleep-deprivation.com

4. bama.ua.edu

5. Approach to Patient with Dyssomnia • In depth sleep history including onset, frequency, duration, & severity of sleep complaints. • Mental status examination to rule out insomnia or hypersomnia due to mental illness. • Physical examination to rule out general medical causes of dyssomniai.e.neurologic, cardiac, respiratory, rheumatologic, or endocrine disorders. • Laboratory Tests may useful to evaluate for conditions such as hyperthyroidism & pheochromocytoma. • Instruments to differentiate dyssomniasi.e. Epworth Sleepiness Scale or Sleep Disorders Questionnaire. • Polysomnography if patient symptoms suggestive of Sleep Apnea, Periodic Limb movement, Narcolepsy, or violent behavior in sleep.

6. Primary Insomnia • Complaint of(nonspecific symptom) poor sleep quality with daytime functional impairment or distress for at least 1 month. • Sleep-Onset Insomnia: Sleep Latency > 30 minutes. • Sleep maintenance insomnia: difficulty staying asleep with frequent & extended awakenings totaling 30 minutes or premature awakenings with less than 6.5 hours of total sleep. • Psychophysiologic Primary Insomnia: individual with anxiety about getting sleep when attempting to fall asleep, thus preventing him or her from doing so. • Idiopathic Insomnia: begins in childhood & chronic w/o associated cause. • Adjustment Sleep Disorder: loss of sleep secondary to an acute emotional stressor. • Sleep-state misperception (paradoxical insomnia): form of primary insomnia in which patient complains of nonrestorative, inadequate sleep, but findings on PSG normal.

7. DSM IV 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 physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

8. Management Primary Insomnia • Cognitive Behavioral therapy(CBT): • > effect to pharmacologic therapy& includes: • (1)Sleep Hygiene • (2)Relaxation therapy • (3)Sleep restriction • (4)Cognitive strategies • (5)Stimulus control • (6)Paradoxical Intention simpleinsomniacures.info

9. onestopgate.com Management Primary Insomnia • Pharmacotherapy: • Sedative hypnotics (short term treatment, 3-6 weeks): benzodiazepines effective in initiating & maintaining sleep. cnsforum.com

10. Primary Hypersomnia • Complaint of excessive sleepiness with daytime functional impairment or distress > 1 month. • Long periods of nonrefreshing sleep with difficulty awakening. • Idiopathic etiology but depression associated with primary hypersomnia (15-25%). • Recurrent Primary Hypersomnia = Kleine-Levin syndrome (KLS): excessive sleepiness x > 3 days, several times per year, for > 2 years.

11. DSM IV Criteria for 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 physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

12. Narcolepsy • Excessive sleepiness & REM intrusion into the wakeful state, occurring daily for > 3 months. • Classic Tetrad: • Sleep attacks • Cataplexy • Sleep paralysis • Hypnagogic/ • hypnopompic • hallucinations psychology.wikia.com

13. DSM IV Criteria for Narcolepsy • A. Irresistible attacks of refreshing sleep that occurs daily for 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 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 physiologic effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition

14. Management of Narcolepsy • Pharmacotherapy(Sleep Attacks): • Modafinil (alpha-1 adrenergic agonist)-lacks side effects stimulants thus consider 1st line. • Stimulants (Dextroamphetamine, methylphenidate, & amphetamine). • Selegiline (MAOI) effective at high doses but caution given diet restrictions & hypertension. • Pharmacotherapy(cataplexy, sleep paralysis, REM-associated hallucinations): • SSRI’s & TCA’s  serotonergic properties suppress REM. • Sodium oxybate(gamma-hydroxybutyricacid;GHB)- CNS depressant vs cataplexy + monotherapyvs daytime sleepiness & works as adjunct to modafinil. • Adjunctive Behavioral therapy: scheduled nap times, advise patients not to operate vehicles + avoid potentially dangerous situations until symptoms well controlled.

15. Breathing-Related Sleep Disorders • Occur as a result of sleep apnea or alveolar hypoventilation & cause nighttime arousals daytime sleepiness. • Obstructive Sleep Apnea (OSA ) is most common breathing related sleep disorder (> 5% adults affected). • Others: • Central Sleep Apnea syndrome • Central alveolar hypoventilation syndrome primaryissues.org

16. DSM IV Diagnosis of 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 physiologic effects of a substance (e.g., a drug of abuse, a medication) or another general medical condition (other than a breathing ­related disorder).

17. Management of Obstructive Sleep Apnea functionalconditioning.com • Weight Reduction + continuous positive airway pressure (CPAP)devices are 1st line. • Protriptyline (tricyclic antidepressant)used as adjunct. • Positional therapy keeps patient in nonsupine position. • Surgical Techniques for anatomical abnormalities that cause obstruction: • Palatal surgery & oral appliances if patient intolerant of CPAP. • Tracheostomy as last resort is only surgical procedure consistently successful in treating OSA. jama.ama-assn.org

18. Circadian Rhythm Disorder • Result from events in patient’s life interfering with their sleep-wake pattern. • Circadian Rhythms initiated by the suprachiasmatic nuclei in the hypothalamus, which is synchronized by sunlight to about 24 hours. • Classified into 4 subtypes based on characteristics of a patient’s sleep phase: • (1)Delayed Sleep Phase Type • (2)Unspecified type(includes advanced sleep phase, non-24-hour sleep-wake pattern, or irregular sleep wake pattern) • (3)Jet lag type • (4)Shift work type medscape.org

19. DSM IV Diagnosis of Circadian Rhythm Disorder • A. A persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia that is due to a mismatch between the sleep­wake schedule required by a person's environ­ment and his or her circadian sleep­wakepattern. • 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 physiologic effects of a substance (eg, 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

20. Dyssomnia Not Otherwise Specified • Includes: • (1)Dyssomnias caused by an environmental disturbance such as noise or light. • (2)Restless legs syndrome(RLS). • (3)Periodic limb movement syndrome (PLMS). • Restless leg syndrome: • An intense urge to move ones legs associated with sensory complaints & motor restlessness. • Occurs while awake but symptoms worsen at rest and at night often resulting in sleep-onset insomnia. • Periodic Limb Movement Syndrome: • Brief, repetitive stereotyped limb movement that occurs while asleep arousals that can lead to daytime sleepiness.

21. References • National Center on Sleep Disorders Research. 2003 National Sleep Disorders Research Plan. Available at www.nhlbi.nih.gov/health/prof/sleep/res_plan/sleep-rplan.pdf. Accessed 27 Dec 2006. • Shapiro, C M. Dement, W C . ABC of sleep disorders. Impact and epidemiology of sleep disorders.(1993) BMJ. June 12; 306(6892): 1604–1607. • Kay, Jerald.Ignatowski, Michael. Primary Sleep Disorders: The Dyssomnias(2008). Hospital Physician Board Review Manual.11, 1-10 • Pocket Handbook of Primary Care Psychiatry. Harold I kaplan, M.D. Benjamin J. Sadock, M.D. • Normal Human Sleep: An Overview. Mary A Carskadan, William C Dement.