Sleep Disorders

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Sleep Disorders

• Psy 610A
• Gary S. Katz, Ph.D.

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Normal Sleep

• Sleep progresses in stages throughout the night
• Four Non-REM (NREM) stages (1, 2, 3, 4)
• One REM stage
• Order
• 1, 2, 3, 4, 3, 2, REM
• Repeats every 80 to 100min
• REM Sleep
• Dreaming
• Inhibition of muscular activity
• Stages 3 and 4
• Restorative sleep
• Disinhibition of muscular activity
• Parasomnias

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Normal Sleep

• Stage 1
• Hypnagogic (falling asleep)
• and
• Hypnapompic (waking up) imagery
• Some loss of muscle tone
• Hypnic jerks
• Stage 2
• Deeper sleep, more prominent lack of awareness of
  surroundings.

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Sleep Assessment Tools

• Polysomnography sleep study
• Multiple Sleep Latency Test
• Five measurement periods in a dark, comfortable
  room dont resist going to sleep
• Time how long it takes for subject to fall asleep
• Index of sleepiness
• Shorter latencies to sleep indicate greater sleep
  debt
• Longer latencies to sleep indicate lesser sleep
  debt
• Maintenance of Wakefulness Test
• Five measurement periods in a dimly lit room
• Try to stay awake, time duration remaining awake
• Index of wakefulness
• Longer times indicate greater wakefulness
• Shorter times indicate lesser wakefulness

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Normal Stage 4 Sleep
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Normal REM Sleep
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Dyssomnias Parasomnias

• Dyssomnias
• Primary disorders of initiating or maintaining
  sleep or of excessive sleepiness and are
  characterized by a disturbance in the amount,
  quality, or timing of sleep.
• Parasomnias
• Disorders characterized by abnormal behavioral or
  physiological events occurring in association
  with sleep, specific sleep stages, or sleep-wake
  transitions.

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Dyssomnias Parasomnias

• Dyssomnias
• Breathing-Related Sleep Disorder
• Circadian Rhythm Sleep Disorder
• Hypersomnia
• Hypersomnia Related to Another Mental Disorder
• Insomnia
• Insomnia Related to Another Mental Disorder
• Narcolepsy
• Dyssomnia NOS

• Parasomnias
• Nightmare Disorder
• Sleep Terror Disorder
• Sleepwalking Disorder
• Parasomnia NOS

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Breathing-Related Sleep Disorder (780.57)

• Essential feature sleep disruption, leading to
  excessive sleepiness or, less commonly, to
  insomnia, that is judged o be due to
  abnormalities of ventilation during sleep.
• Most common complaint daytime sleepiness
• Less common insomnia or frequent awakenings
• May see apnea episodes, shallow breathing,
  hypoventilation

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Breathing-Related Sleep Disorder (780.57)

• 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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Three Forms

• Obstructive sleep apnea
• Almost exclusively the only subtype seen in
  childhood
• CNS and muscular drive for respiration exists
  however due to obstructions in the airway (e.g.,
  adipose tissue in overweight individuals, adenoid
  or tonsil tissues), respiration is prevented
• Leads to apnea or hyponea episodes, snoring,
  gasps, whole-body movements (snoring may be
  absent in children)
• Disturbing to bed partners
• Central sleep apnea
• Episodic cessation of ventilation during sleep
  without airway obstruction.
• CNS and muscular drive for respiration ceases
• Most common in the elderly or those with cardiac
  or neurological conditions
• Central alveolar hypoventilation syndrome
• Commonly occurs in very overweight individuals
• Lungs work normally, control of ventilation
  impaired, resulting in low arterial O2 levels.

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Associated Features

• Complaints of nocturnal chest discomfort,
  choking, suffocation, intense anxiety associated
  with apneic events.
• Body movements during sleep can be violent often
  see very restless sleep.
• Individuals awaken feeling unrefreshed and have
  great difficulty awakening.
• Severe dryness of the mouth leading to needing to
  drink during the night or in the morning leading
  to nocturia (awakening due to need to void
  bladder at night).
• Dull headaches upon awakening.
• Memory disturbances, poor concentration,
  irritability, personality changes.
• Mood Disorders (MDD, DD), Anxiety Disorders
  (Panic Disorder)

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Associated Features

• In Children
• Failure to thrive
• Developmental delay
• Learning difficulties
• Poor attention
• Hyperactive behavior
• Decreased school performance
• Also see numerous atypical polysomnography
  findings.

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Age Features

• In children
• Obstructive sleep apnea syndrome vastly most
  common
• Signs and symptoms are more subtle (recommend
  sleep study with polysomnography)
• Snoring may not be present
• Abnormal sleep postures (sleeping on hands
  knees)
• Resumption of nocturnal enuresis a common sign
• May see excessive daytime sleepiness, but not
  always
• Daytime mouth breathing, difficulty swallowing,
  poor speech articulation commonly seen

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Age Features

• Under age 5
• Nighttime symptoms more often the presenting
  complaint (e.g., observed apnea or labored
  breathing)
• Over age 5
• Daytime symptoms more often the presenting
  complaint (e.g., sleepiness, behavioral problems,
  attention and learning difficulties

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Gender Features

• In adults, malefemale ratio ranges from 21 to
  41
• In prepubertal children, no sex differences.

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Course

• Obstructive sleep apnea syndrome can occur at any
  age
• Most individuals present between ages 40 and 60
  with females most likely to present after
  menopause
• Central sleep apnea more commonly seen in elderly
  individuals with CNS or cardiac disease
• Central alveolar hypoventilation and central
  sleep apnea syndromes can occur at any age.

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Course Familial Pattern

• Breathing-Related Sleep Disorder usually has an
  insidious onset, gradual progression, and chronic
  course.
• Often present for years before it has been
  diagnosed.
• Weight loss can lead to spontaneous resolution
• Management of underlying medical conditions (CNS,
  cardiac) may improve the central sleep apnea
  syndrome.
• Do see a familial tendency for obstructive sleep
  apnea syndrome.

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Differential Diagnosis

• Narcolepsy
• Absence of cataplexy, sleep-related
  hallucinations, sleep paralysis in
  Breathing-Related Sleep Disorder (BRSD)
• Presence of loud gasps / snoring in BRSD
• Primary Hypersomnia and Circadian Rhythm Sleep
  Disorder
• Normal breathing and ventilation in these
• Hypersomnia related to a Major Depressive Episode
• Asymptomatic adults who snore
• Nocturnal Panic Attacks
• ADHD
• General Medical Condition
• Substance use/abuse

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Circadian Rhythm Sleep Disorder

• Essential feature a persistent or recurrent
  pattern of sleep disruption that results from
  altered function of the circadian timing system
  or from a mismatch between the individuals
  endogenous circadian sleep-wake system and
  exogenous demands regarding the timing and
  duration of sleep.
• Need to see significant social or occupational
  impairment or marked distress related to the
  sleep disturbance.

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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.

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Circadian Rhythm Sleep Disorder

• Specify type (code)
• Delayed Sleep Phase Type (327.3) 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 (327.35) 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 (327.36) 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 (327.30) can see advanced
  sleep phase or non-24-hour sleep-wake pattern
  or irregular sleep-wake pattern

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Associated Features

• Delayed Sleep Phase Type
• peak efficiency occurs after a delayed phase
• Individuals often sleep in on weekends/vacations
• Jet Lag Type and Shift Work Type
• Individuals more often early birds
• Non-24-hour sleep-wake pattern more common in
  blind individuals with no light perception
• Sleepless episodes may precipitate a Manic or
  Major Depressive Episode or an episode of a
  Psychotic Disorder

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Age Features and Prevalence

• Onset of Delayed Sleep Phase Type most often
  occurs between late childhood and early adulthood
  (sleepy teenagers).
• Other subtypes more common in adults.
• Prevalence not well established except in Delayed
  Sleep Phase Type
• Adults 0.1 to 4
• Adolescents up to 7

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Course

• Delayed Sleep Phase Type (DSPT) typically begins
  in adolescence, perhaps following a psychosocial
  stressor.
• Without intervention, DSPT typically persists for
  years/decades.
• DSPT may correct itself if endogenous circadian
  rhythms advance with age (i.e., as individual
  ages, they fall into a normative sleep pattern
  requiring less sleep).

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Familial Pattern

• Family history may be present in up to 40 of
  individuals with DSPT
• Familial form of Advanced Sleep Phase Type has
  been identified.

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Differential Diagnosis

• Normal sleep pattern adjustments
• Volitional patterns of delayed sleep hours
• Primary Insomnia
• Primary Hypersomnia
• Breathing-Related Sleep Disorder
• Delayed or advanced Sleep due to another mental
  disorder
• Substance use/abuse

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Primary Hypersomnia (307.44)

• Essential feature excessive sleepiness for at
  least 1 month as evidenced either by prolonged
  sleep episodes or by daytime sleep episode
  occurring almost daily.
• Duration of major sleep episodes may range from 8
  to 12 hours, often followed by difficulty
  awakening in the morning.
• Daytime naps may be long (gt1hr) and are
  experienced as unrefreshing.
• Sleepiness develops over a period of time (rather
  than as an attack).
• Unintentional sleep episodes typically occur in
  low-stimulation and low-activity situations.

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Primary Hypersomnia (307.44)

• 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.

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Primary Hypersomnia (307.44)

• 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.
• Specify if
• Recurrent if there are periods of excessive
  sleepiness that last at least 3 days occurring
  several times a year for at least 2 years

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Associated Features

• Sleep tends to be continuous but nonrestorative.
• Individuals fall asleep quickly, sleep
  efficiently, but may have difficulty awakening.
• sleep drunkenness common to many sleep
  disorders, refers to difficulty transitioning
  from sleep to wakeful states.
• Automatic behavior
• Very routine, low-complexity tasks
• Carried out with little or no subsequent recall

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Associated Features

• Often see symptoms of depression that may meet
  criteria for a mood disorder.
• Risk for Substance-Related Disorders,
  particularly self-medication with stimulants.
• A subset of individuals with Primary Hypersomnia
  have a family history of Hypersomnia and other
  autonomic nervous system dysfunction including
  vascular headaches, Raynauds phenomenon, and
  fainting.
• Kleine-Levin form exceedingly rare (also see
  hyperphagia)

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Age or Gender Features

• In children, hyperactivity may present as daytime
  sleepiness.
• Voluntary napping increases with age, but this is
  different from Primary Hypersomnia.
• Sex difference unknown in general Primary
  Hypersomnia however, Kleine-Levin syndrome
  predominates in males (3-4x more common in males).

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Prevalence

• True prevalence unknown.
• Frequently see daytime sleepiness in adults (0.5
  to 5.0 without regard to specific diagnoses).
• Teenagers often appear sleepy due to voluntary
  sleep-cycle shifts.

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Course

• Primary Hypersomnia typically begins between ages
  15 and 30 years
• Gradual progression over weeks to months
• Course is then chronic and stable, unless
  treatment is initiated.
• Development of other sleep disorders (e.g.,
  Breathing-Related Sleep Disorder) may worsen the
  degree of sleepiness.
• Kleine-Levin syndrome also begins during
  adolescence (very rare) and may continue periodic
  course for decades, resolving sometimes in middle
  age.

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Kleine-Levin Syndrome

• Rare disorder that can cause a recurrent form of
  Primary Hypersomnia
• Symptoms also include
• excessive food intake, irritability,
  disorientation, lack of energy, hypersensitivity
  to noise
• Hallucinations and an abnormally uninhibited sex
  drive also possible
• Coded on Axis III as well as the Dx of Primary
  Hypersomnia on Axis I

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Familial Pattern

• Individuals with autonomic dysfunction (e.g.,
  Raynauds, vascular headaches) show familial
  patterns.
• Kleine-Levin syndrome does not show familial
  aggregation.

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Differential Diagnosis

• Inadequate nocturnal sleep (teens, grad students)
• Primary Insomnia (PI)
• Sleepiness not as severe in PI as it is in
  Primary Hypersomnia (PH)
• Narcolepsy
• Key feature in Narcolepsy is cataplexy, absent in
  PH
• Cataplexy brief episodes of sudden bilateral
  loss of muscle tone
• Breathing-Related Sleep Disorder
• Circadian Rhythm Sleep Disorder
• Mental disorders that include hypersomnia as a
  clinical feature
• Major Depressive Disorder
• Bipolar Disorder
• Sleep Disorder Due to a General Medical Condition
• Substance-Induced Sleep Disorder

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Insomnia / Hypersomnia Related to Another Mental
Disorder

• Essential feature presence of either insomnia or
  hypersomnia that is judged to be related
  temporally and causally to another mental
  disorder.
• Insomnia or hypersomnia due to substances is not
  included here. These would be diagnosed as a
  Substance-Induced Sleep Disorder.

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Insomnia / Hypersomnia Related to Another Mental
Disorder

• Individuals in a Major Depressive Episode or
  Dysthymic Disorder often complain of difficulty
  falling asleep, staying asleep, or awakening too
  early (insomnia)
• Hypersomnia more often associated with Bipolar,
  Most Recent Episode Depressed or a Major
  Depressive Episode, With Atypical Features.
• Nocturnal panic attacks can also lead to insomnia.

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Hypersomnia Related to Axis I or Axis II disorder
(327.15)

• A. The predominant complaint is excessive
  sleepiness for at least 1 month 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 hypersomnia is judged to be related to
  another Axis I or Axis II disorder (e.g., Major
  Depressive Disorder, Dysthymic Disorder), but is
  sufficiently severe to warrant independent
  clinical attention.
• D. The disturbance is not better accounted for by
  another Sleep Disorder (e.g., Narcolepsy,
  Breathing-Related Sleep Disorder, a Parasomnia)
  or by an inadequate amount of sleep.
• 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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Insomnia Related to Axis I or Axis II disorder
(327.02)

• A. The predominant complaint is difficulty
  initiating or maintaining sleep, or
  nonrestorative sleep, for at least 1 month that
  is associated with daytime fatigue or impaired
  daytime functioning.
• B. The sleep disturbance (or daytime sequelae)
  causes clinically significant distress or
  impairment in social, occupational, or other
  important areas of functioning.
• C. The insomnia is judged to be related to
  another Axis I or Axis II disorder (e.g., Major
  Depressive Disorder, Generalized Anxiety
  Disorder, Adjustment Disorder With Anxiety), but
  is sufficiently severe to warrant independent
  clinical attention.
• D. The disturbance is not better accounted for by
  another Sleep Disorder (e.g., Narcolepsy,
  Breathing-Related Sleep Disorder, a Parasomnia).
• 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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Associated Features

• Include the associated features and
  characteristics of the related mental disorder.
• Similar features seen in Primary Insomnia
• Increased anxiety when bedtime approaches
• Conditioned arousal and negative conditioning may
  be a factor in sustaining the insomnia
• See improved sleep when taken out of the usual
  sleep environment
• Spend too much time in bed
• May have a history of inappropriate medication
  treatments for insomnia

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Associated Features

• Include the associated features and
  characteristics of the related mental disorder.
• Similar features seen in Primary Hypersomnia
• Symptoms of fatigue
• leaden paralysis arms and legs feel heavy,
  difficult to move
• Complete lack of energy
• Careful questioning reveals more distress
  regarding the fatigue-related symptoms than the
  true sleepiness itself.

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Associated Features

• Multiple Sleep Latency Testing findings indicate
  normal or mild levels of physiological sleepiness
  compared to individuals with Primary Hypersomnia
  or Narcolepsy.
• Individuals may appear tired, fatigued, or
  haggard during routine examination.

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Culture, Age, Gender Features

• In some cultures, sleep complaints are viewed as
  relatively less stigmatizing than mental
  disorders.
• As such, may see sleep complaints as a presenting
  concern rather than symptoms of depression or
  anxiety.
• Children and adolescents with Major Depressive
  Disorder generally present with less subjective
  sleep disturbance.
• Hypersomnia is more common in depressed
  adolescents and young adults insomnia more
  common in older adults.
• Sleep Disorders Related to Another Mental
  Disorder are more common in females than in
  males. Likely due to the increased prevalence of
  Mood and Anxiety Disorders in females rather than
  any difference in sleep problems.

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Prevalence

• Sleep problems very common to all types of mental
  disorders.
• Insomnia Related to Another Mental Disorder most
  frequent diagnosis (35 to 50) in individuals
  presenting to sleep disorder centers.
• Hypersomnia much less frequent (fewer than 5)
  among individuals evaluated at sleep disorder
  centers.

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Course

• Course tends to follow the course of the
  underlying mental disorder itself.
• Sleep disturbance may be one of the earliest
  symptoms to appear in individuals who develop an
  associated disorder.
• For many individuals with depression
  particularly those treated pharmacologically
  sleep improvement is rapid.
• Other individuals continue to experience sleep
  problems chronically, even after primary symptoms
  of the underlying disorder remit.

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Differential Diagnosis

• Major Depressive Disorder
• Only make the additional diagnosis when the sleep
  disturbance is severe and an independent focus of
  clinical attention.
• Primary Insomnia / Hypersomnia
• Sleep Disorder Due to a General Medical Condition
• Substance-Induced Sleep Disorder
• Normal Sleep Patterns

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Primary Insomnia (307.02)

• Essential feature a complaint of difficulty
  initiating or maintaining sleep or of
  nonrestorative sleep that lasts for at least 1
  month.
• Most often report difficulty falling asleep and
  intermittent wakefulness during sleep.
• Infrequently complain of nonrestorative sleep,
  but sleep nonetheless
• Not all individuals with nighttime sleep
  disturbances are distressed by this or have any
  functional impairments diagnosis of Primary
  Insomnia does not apply here.

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Primary Insomnia (307.02)

• Often associated with increased physiological,
  cognitive or emotional arousal in combination
  with negative conditioning for sleep.
• As distress and preoccupation with sleep
  increases, difficulty getting to sleep increases
  the more the individual strives for sleep, the
  harder it is for them to sleep.
• Practice good sleep hygiene!
• Have a good sleep schedule
• Dont spend too much time in bed
• Dont engage in non-sleep-related activities in
  bed

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Primary Insomnia (307.02)

• 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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Associated Features

• History of light or easily disturbed sleep
  prior to developing Primary Insomnia
• Anxious overconcern with general health and
  increased sensitivity to daytime effects of mild
  sleep loss
• Anxiety or depressive symptoms not meeting
  criteria for an Anxiety or Mood Disorder
• Interpersonal, social, and occupational problems.
• Problems with inattention and concentration (may
  lead to accidents)

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Associated Features

• Some polysomnographic abnormalities
• Elevated scores on self-report psychological or
  personality inventories
• Chronic, mild depression and anxiety
• Internalizing style of conflict resolution
• Somatic focus from anxiety-related concerns
• Individuals may appear fatigued or haggard but
  show no other abnormalities on physical exam
• Increased incidence of stress-related
  psychophysiological problems (e.g., tension
  headache, increased muscle tension, gastric
  distress)

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Age Gender Features

• Survey studies suggest that complaints of
  insomnia are more prevalent with increasing age
  and among women.
• May be due to increased physical health
  complaints among the elderly.
• Young adults more often complain of difficulty
  falling asleep, midlife and elderly adults more
  likely to have difficulty maintaining sleep and
  early morning awakening.
• Polysomnography more useful for older adults than
  younger adults in making differential diagnoses.

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Prevalence

• Population surveys among adults 30 to 45
  one-year prevalence rate
• 1 to 10 in general adult population
• 25 of the elderly
• Children and adolescents?

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Course

• Precipitating factors may differ from
  perpetuating factors in Primary Insomnia
• Most cases have a fairly sudden onset at a time
  of psychological, social, or medical stress
• This onset is then maintained by negative
  conditioning long after the original stressor has
  abated.
• Typically begins in young adulthood rare in
  childhood or adolescence.

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Familial Pattern

• Predisposition toward light and disrupted speech
  has a familial association.
• Limited data from twin studies reveal mixed
  results regarding importance of genetic factors
  in Primary Insomnia.

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Differential Diagnosis

• Normal sleep variation
• Short sleepers
• Fall sleep easily, decreased need for sleep.
• May try to treat short sleeping by staying in
  bed longer, increasing risk for Primary Insomnia
• Primary Hypersomnia
• Both have daytime sleepiness
• Circadian Rhythm Sleep Disorder
• Narcolepsy rarely exhibit Insomnia
• Breathing-Related Sleep Disorder
• Parasomnias
• Other mental disorders that include insomnia
• Insomnia Related to Another Mental Disorder
• Sleep Disorder Due to a General Medical Condition
• Substance-Induced Sleep Disorder

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Narcolepsy (347.00)

• Essential feature repeated irresistible attacks
  of refreshing sleep, cataplexy, and recurrent
  intrusions of REM sleep into the transition
  period between sleep and wakefulness.
• Sleepiness typically decreases after a sleep
  attack, only to return several hours later.
• Key issue
• sleep attacks cataplexy REM intrusion
• Note some sleep experts will diagnose Narcolepsy
  without cataplexy if you see pathological
  sleepiness and two or more sleep-onset REM
  periods during a MSLT

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Narcolepsy (347.00)

• 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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Associated Features

• Some folks experience daytime sleepiness between
  narcoleptic episodes they may be described as
  able to sleep at any time in any situation.
• Automatic behavior may occur as a result of
  profound sleepiness.
• Automatic behavior drive, converse, work
• Frequent, intense dreams common in nocturnal
  sleep of narcoleptics
• Also see fragmented nighttime sleep due to
  spontaneous awakenings or periodic limb movements.

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Associated Features

• Individuals may avoid social activities for fear
  of having a narcoleptic attack or cataplexy.
• Attempts to control their emotional expression
  may lead to a generalized lack of expressiveness,
  which, in turn, leads to social problems.
• Risk for accidental injury due to falling asleep
  in dangerous situations.
• 40 of individuals with Narcolepsy also have a
  concurrent mental disorder or history of another
  mental disorder.
• Most common Mood Disorders, Substance-Related
  Disorders, Generalized Anxiety Disorder
• Parasomnias also common in individuals with
  Narcolepsy

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Associated Features

• Two out of three individuals with narcolepsy will
  be identified by the following two criteria
• Average MSLT daytime sleep latencies under 5
  minutes.
• REM sleep intrusions during 2 or more MSLT naps
• Other polysomnographic findings also seen
  specifically in Narcolepsy
• Specific HLA typing found in almost all
  individuals with Narcolepsy and cataplexy.
• Same marker also found in 20 to 25 of general
  population
• Can see cataplexy and narcoleptic episodes during
  interview, particularly when emotional issues are
  discussed.

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Age Features Epidemiology

• Hyperactivity also seen in children with
  Narcolepsy with daytime sleepiness
• Cataplexy and mild daytime sleepiness may be more
  difficult to identify in children
• Prevalence 0.02 to 0.16 in the adult
  population
• Equal male female ratio

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Course

• Daytime sleepiness first symptom of Narcolepsy
  becomes clinically-significant during
  adolescence.
• Upon careful review, can also see evidence of
  sleepiness in preschool and early school ages
• Onset after age 40 is unusual
• Acute psychosocial stressors or alterations in
  sleep-wake schedule may trigger onset of
  Narcolepsy.
• Excessive sleepiness is stable over time.
• Cataplexy has a similar stable course.

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Familial Pattern

• Genetic/heritability studies suggest a role for
  genetic factors mode of inheritance not
  determined.
• Approximately 5 to 15 of first-degree
  biological relatives of Narcoleptic-positive
  probands have the disorder.
• 25 to 50 of first-degree relatives have other
  disorders characterized by excessive sleepiness.

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Differential Diagnosis

• Normal variations in sleep
• Sleep deprivation
• Primary Hypersomnia
• Similar levels of daytime sleepiness
• No cataplexy
• MSLT shows no REM intrusions
• Breathing-Related Sleep Disorder
• Hypersomnia Related to Another Mental Disorder
• Use of, or withdrawal from, substances
• Substance-Induced Sleep Disorder
• Sleep Disorder Due to a General Medical Condition

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Dyssomnia NOS (307.47)

• The Dyssomnia Not Otherwise Specified Category
  is for insomnias, hypersomnias, or circadian
  rhythm disturbances that do not meet criteria for
  any specific Dyssomia. Examples include
• 1) Complaints of clinically significant insomnia
  or hypersomnia that are attributable to
  environmental factors (e.g., noise, light)
• 2) Excessive sleepiness that is attributable to
  ongoing sleep deprivation.
• 3) Restless legs syndrome
• 4) Periodic limb movements.
• 5) Situations in which the clinician has
  concluded that a Dyssomnia is present but is
  unable to determine whether it is primary, due to
  a general medical condition, or substance induced.

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Nightmare Disorder (307.47)

• Essential feature repeated occurrence of
  frightening dreams that lead to awakenings from
  sleep.
• Nightmares often occur in lengthy, elaborate
  dream sequences that are highly anxiety-provoking
  to the individual.
• Since the individual awakens shortly after or
  during the REM period, often maintains memory or
  awareness of dream content.
• Later evening REM periods longer, thus more
  likely to have more intense nightmares later in
  the evening.

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Nightmare Disorder (307.47)

• A. Repeated awakenings from the major sleep
  period or naps with detailed recall of extended
  and extremely frightening dreams, usually
  involving threats to survival, security, or
  self-esteem. The awakenings generally occur
  during the second half of the sleep period.
• B. On awakening from the frightening dreams, the
  person rapidly becomes oriented and alert (in
  contrast to the confusion and disorientation seen
  in Sleep Terror Disorder and some forms of
  epilepsy).
• C. The dream experience, or the sleep disturbance
  resulting from the awakening, causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning.
• D. The nightmares do not occur exclusively during
  the course of another mental disorder (e.g., a
  Delirium, Posttraumatic Stress Disorder) and are
  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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Associated Features

• Mild autonomic arousal after awakening from the
  nightmare.
• Body movements yelling not common since the
  nightmare is occurring during REM sleep (skeletal
  muscle tone inhibited).
• Nightmares that accompany body movements and
  yelling often occur in PTSD, in Stage 4 sleep.

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Culture, Age, Gender Features

• Significance of nightmares vary with cultural
  background.
• Nightmares frequently occur during childhood.
• Need to have persistent, significant distress or
  impairment that warrants independent clinical
  attention for this diagnosis.
• Female report having nightmares more often than
  males (21 to 41 ratio).
• Not sure if this is due to true discrepancy in
  nightmares or variance in reporting.

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Prevalence

• 10 to 50 of children ages 3-5 years have
  nightmares scary enough to disturb parents.
• 3 of young adults report frequent nightmares
• Actual prevalence of Nightmare Disorder is
  unknown.

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Course

• Nightmares often begin between 3 and 6 years.
• When the frequency approaches several per week,
  may become a source of concern and distress.
• Many children outgrow frequent nightmares.
• In a minority, may persist at high frequency into
  adulthood.

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Differential Diagnosis

• Sleep Terror Disorder
• Breathing-Related Sleep Disorder
• Narcolepsy
• Panic Attacks during sleep
• Parasomnia Not Otherwise Specified
• Substance-Induced Sleep Disorder, Parasomia Type
• Sleep Disorder Due to a General Medical
  Condition, Parasomnia Type
• Occasional, isolated nightmares

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Sleep Terror Disorder (307.46)

• A. Recurrent episodes of abrupt awakening from
  sleep, usually occurring during the first third
  of the major sleep episode and beginning with a
  panicky scream.
• B. Intense fear and signs of autonomic arousal,
  such as tachycardia, rapid breathing, and
  sweating, during each episode.
• C. Relative unresponsiveness to efforts of others
  to comfort the person during the episode.
• D. No detailed dream is recalled and there is
  amnesia for the episode.
• E. The episodes cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• F. 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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Sleepwalking Disorder (307.46)

• A. Repeated episodes of rising from bed during
  sleep and walking about, usually occurring during
  the first third of the major sleep episode.
• B. While sleepwalking, the person has a blank,
  staring face, is relatively unresponsive to the
  efforts of others to communicate with him or her,
  and can be awakened only with great difficulty.
• C. On awakening (either from the sleepwalking
  episode or the next morning), the person has
  amnesia for the episode.

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Sleepwalking Disorder (307.46)

• D. Within several minutes after awakening from
  the sleepwalking episode, there is no impairment
  of mental activity or behavior (although there
  may initially be a short period of confusion or
  disorientation).
• E. The sleepwalking causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• F. 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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Parasomnia NOS (307.47)

• The Parasomnia Not Otherwise Specified category
  is for disturbances that are characterized by
  abnormal behavioral or physiological events
  during sleep or sleep-wake transitions, but that
  do not meet criteria for a more specific
  Parasomnia. Examples include
• 1) REM sleep behavior disorder motor activity,
  often of a violent nature, that arises during
  rapid eye movement (REM) sleep. Unlike
  sleepwalking, these episodes tend to occur later
  in the night and are associated with vivid dream
  recall.

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Parasomnia NOS (307.47)

• 2) Sleep paralysis an inability to perform
  voluntary movement during the transition between
  wakefulness and sleep. The episodes may occur at
  sleep onset (hypnagogic) or with awakening
  (hypnopompic). The episodes are usually
  associated with extreme anxiety, and, in some
  cases, fear of impending death. Sleep paralysis
  occurs commonly as an ancillary symptom of
  Narcolepsy and, in such cases, should not be
  coded separately.
• 3) Situations in which the clinician has
  concluded that a Parasomnia is present but is
  unable to determine whether it is primary, due to
  a general medical condition, or substance induced.