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Sleep Disorders

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Title: Sleep Disorders


1
Sleep Disorders
  • Psy 610A
  • Gary S. Katz, Ph.D.

2
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

3
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.

4
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

5
Normal Stage 4 Sleep
6
Normal REM Sleep
7
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8
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.

9
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

10
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11
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

12
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.

13
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.

14
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)

15
Associated Features
  • In Children
  • Failure to thrive
  • Developmental delay
  • Learning difficulties
  • Poor attention
  • Hyperactive behavior
  • Decreased school performance
  • Also see numerous atypical polysomnography
    findings.

16
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

17
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

18
Gender Features
  • In adults, malefemale ratio ranges from 21 to
    41
  • In prepubertal children, no sex differences.

19
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.

20
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.

21
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

22
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23
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.

24
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.

25
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

26
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

27
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

28
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).

29
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.

30
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

31
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32
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.

33
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.

34
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

35
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

36
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)

37
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).

38
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.

39
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.

40
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

41
Familial Pattern
  • Individuals with autonomic dysfunction (e.g.,
    Raynauds, vascular headaches) show familial
    patterns.
  • Kleine-Levin syndrome does not show familial
    aggregation.

42
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

43
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44
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.

45
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.

46
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.

47
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.

48
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

49
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.

50
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.

51
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.

52
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.

53
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.

54
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

55
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56
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.

57
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

58
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.

59
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)

60
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)

61
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.

62
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?

63
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.

64
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.

65
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

66
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67
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

68
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.

69
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.

70
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.
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