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General Approach to Classification of Sleep Disorders

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Title: General Approach to Classification of Sleep Disorders


1
General Approach to Classification of Sleep
Disorders
  • Dr. Ahmet U. Demir

2
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ICSD-II (2005) Aims
  • In 2002 the American Academy of Sleep Medicine,
    set up a
  • committee to revise once again the classification
    of sleep disorders.
  • Under the direction of Dr Peter Hauri, the
    committee has proposed a
  • more pragmatic classification, based on current
    clinical concepts of
  • the grouping of sleep disorders.
  • The goals of ICSD-2 are
  • 1. To describe all currently recognized sleep and
    arousal disorders,
  • and to base the description on scientific and
    clinical evidence.
  • 2. To present the sleep and arousal disorders in
    an overall structure
  • that is rational and scientifically valid
  • 3. To render the sleep and arousal disorders as
    compatible with
  • ICD-9 and ICD-10 as possible.
  • Based on the thought express above, ICSD-2
    sorts the sleep
  • disorders into the following eight categories

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  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

5
  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

6
Insomnia
  • Insomnia is a symptom of perceived
  • reduction in the quantity or quality of sleep
  • and is not a single clinical entity.
  • However, certain causes of chronic
  • insomnia are believed to be due to intrinsic
  • disturbances of brain function.

7
General Criteria for Insomnia ICSD-2 ( 2005)
  • A. A complaint for difficulty initiating sleep,
    difficulty
  • maintaining sleep, or waking up too early or
    sleep that is
  • chronically nonrestorative or poor in quality. In
    children, the sleep
  • difficulty is often reported by the caretaker and
    may consist of
  • observed bedtime resistance or inability to sleep
    independently.
  • B. The above sleep difficulty occurs despite
    adequate opportunity
  • and circumstances for sleep.
  • C. At least one of the following forms of
    daytime impairment
  • related to the nighttime sleep difficulty is
    reported by the patient
  • i. Fatigue or malaise
  • ii. Attention, concentration, or memory
    impairment
  • iii. Social or vocational dysfunction or poor
    school performance
  • iv. Mood disturbance or irritability
  • v. Daytime sleepiness
  • vi. Motivation, energy, or initiative reduction
  • vii. Proneness for errors or accidents at work
    or while driving
  • viii. Tension, headaches, or gastrointestinal
    symptoms.

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Adjustment Insomnia (Acute Insomnia)
  • 1. Adjustment Insomnia (Acute Insomnia)
  • 2. Psychophysiological Insomnia
  • 3. Paradoxical Insomnia
  • 4. Idiopathic Insomnia
  • 5. Insomnia Due to Mental Disorder
  • 6. Inadequate Sleep Hygiene
  • 7. Behavioral Insomnia of Childhood
  • 8. Insomnia Due to Drug or Substance
  • 9. Insomnia Due to Medical Condition
  • 10. Insomnia Not Due to Substance or Known
    Physiological
  • Condition, Unspecified (Nonorganic Insomnia, NOS)
  • 11. Physiological (Organic) Insomnia,
    Unspecified

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Adjustment insomnia
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The sleep disturbance is temporally
    associated with an identifiable
  • stressor that is psychological, psychosocial,
    interpersonal, environmental, or
  • physical nature.
  • C. The sleep disturbance is expected to resolve
    when the acute stressor
  • resolves or when the individual adapts to the
    stressor.
  • D. The sleep disturbance lasts for less than
    three months.
  • E. The sleep disturbance is not better
    explained by another current sleep
  • disorder, medical or neurological disorder,
    mental disorder, medication use, or
  • substance use disorder.

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Psychophysiological Insomnia
  • Alternate Names Learned insomnia, conditioned
    insomnia, functionally
  • autonomous insomnia, chronic insomnia, primary
    insomnia, chronic somatized
  • tension, internal arousal without
    psychopathology.
  • Diagnostic Criteria
  • A.The patients symptoms meet the criteria for
    insomnia
  • B. The insomnia is present for at least one
    month.
  • C. The patient has evidence of conditioned
    sleep difficulty and/or heightened arousal in bed
  • as indicated by one or more of the following
  • i. Excessive focus on and heightened anxiety
    about sleep
  • ii. Difficulty falling asleep in bed at the
    desired bedtime or during planned naps,
  • but no difficulty falling asleep during other
    monotonous activities when not intending to
  • sleep
  • iii. Ability to sleep better away from home
    than at home
  • iv. Mental arousal in bed characterized either
    by intrusive thoughts or a perceived
  • inability to volitionally cease sleep-preventing
    mental activity
  • v. Heightened somatic tension in bed reflected
    by a perceived inability to relax
  • the body sufficiently to allow the onset of sleep
  • D. The sleep disturbance is not better
    explained by another sleep disorder, medical or
  • neurological disorder, mental disorder,
    medication use, or substance use disorder.

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Paradoxical Insomnia
  • Alternate Names Sleep state misperception,
    subjective insomnia, pseudo-insomnia,
  • subjective complaint of sleep initiation and
    maintenance difficulty without objective
  • findings, insomnia without objective findings,
    sleep hypochondriasis, subjective
  • sleep complaint.
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The insomnia is present for at least one
    month.
  • C. One or more of the following criteria apply
  • i. The patient reports a chronic pattern of
    little or no sleep most nights with rare nights
    during which
  • relatively normal amounts of sleep are obtained.
  • ii. Sleep-log data during one or more weeks of
    monitoring show an average sleep time well below
    published
  • age-adjusted normative values, often with no
    sleep at all indicated for several nights per
    week typically there is an
  • absence of daytime naps following such nights
  • iii. The patients show a consistent marked
    mismatch between objective findings from
    polysomnography or
  • actigraphy and subjective sleep estimates derived
    either from self-report or a sleep diary
  • D. At least one of the following is observed
  • i. The patients reports constant or near
    constant awareness of environmental stimuli
    throughout most nights
  • ii. The patient reports a pattern of conscious
    thoughts or rumination throughout most nights
    while
  • maintaining a recumbent posture

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Idiopathic Insomnia
  • Alternate Names Childhood-onset insomnia,
    life-long insomnia,
  • insomnia first evident during infancy or
    childhood.
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The course of the disorder is chronic, as
    indicated by each of the
  • following
  • i. Onset during infancy or childhood
  • ii. No identifiable precipitant or cause
  • iii. Persistent course with no periods of
    sustained remission
  • C. The sleep disturbance is not better
    explained by another sleep
  • disorder, medical or neurological disorder,
    mental disorder,
  • medication use, or substance use disorder.

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Insomnia Due to Mental Disorder
  • Alternate Names Insomnia related to
    psychopathology, psychiatric insomnia
  • insomnia due to depression, insomnia due to
    anxiety disorder.
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The insomnia is present at least one month.
  • C. A mental disorder has been diagnosed
    according to standard criteria (i.e.,
  • formal criteria as provided in the Diagnostic and
    Statistical Manual of Mental
  • Disorders- see Appendix B).
  • D. The insomnia is temporally associated with
    the mental disorder, however, in
  • some cases, insomnia may appear a few days or
    weeks before the emergence of
  • the underlying mental disorder.
  • E. The insomnia is more prominent than that
    typically associated with the
  • mental disorders, as indicated by causing marked
    distress or constituting an
  • independent focus of treatment.
  • F. The sleep disturbance is not better
    explained by another sleep disorder,
  • medical or neurological disorder, medication use,
    or substance use disorder.

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Inadequate Sleep Hygiene
  • Alternate Names Poor sleep hygiene, sleep
    hygiene abuse, bad sleep habits,
  • irregular sleep habits, excessive napping, sleep
    incompatible behaviors .
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The insomnia is present for at least one
    month
  • C. Inadequate sleep hygiene practices are
    evident as indicated by the presence of at least
  • one of the following
  • i. Improper sleep scheduling consisting of
    frequent daytime napping, selecting
  • highly variable bedtimes or rising times, or
    spending excessive amounts of time in bed
  • ii. Routine use of products containing alcohol,
    nicotine, or caffeine especially in
  • the period preceding bedtime
  • iii. Engagement in mentally stimulating
    physically activating, or emotionally
  • upsetting activities to close to bedtime
  • iv. Frequent use of the bed for activities
    other than sleep (e.g., television watching,
  • reading studying, snacking, thinking, planning)
  • v. Failure to maintain a comfortable sleeping
    environment
  • The sleep disturbance is not better explained
    by another sleep disorder, medical or
  • neurological disorder, mental disorder,
    medication use, or substance use disorder.

15
Behavioral Insomnia of Childhood
  • Alternate Names Childhood insomnia,
    limit-setting sleep disorder, sleep-onset
  • association disorder.
  • Diagnostic Criteria
  • A. A childs symptoms meet the criteria for
    insomnia based upon reports of parents or other
    adult
  • caregivers.
  • B. The child shows a pattern consistent with
    either the sleep-onset association or
    limit-setting type
  • of insomnia described below.
  • i. Sleep-onset association type includes each
    of the following
  • 1. Falling asleep in an extended process that
    requires special conditions.
  • 2. Sleep-onset associations are highly
    problematic or demanding.
  • 3. In the absence of the associated conditions,
    sleep onset is significantly delayed or sleep is
  • otherwise disrupted.
  • 4. Nighttime awakenings require caregiver
    intervention for the child to return to sleep.
  • ii. Limit-setting type includes each of the
    following
  • 1. The individual has difficulty initiating or
    maintaining sleep.
  • 2. The individual stalls or refuses to go to
    bed at an appropriate time or refuses to return t
    o bed
  • following a nighttime awakening.
  • 3. The caregiver demonstrates insufficient or
    inappropriate limit setting to establish
    appropriate
  • sleeping behavior in the child.

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Insomnia Due to Medical Condition
  • Alternate Names Sleep disorder due to a general
    medical condition, medically based
  • insomnia, organic insomnia, insomnia due to a
    known organic condition.
  • Diagnostic Criteria
  • A. The patients symptoms meet the criteria for
    insomnia.
  • B. The insomnia is present for at least one
    month.
  • C. The patient has a coexisting medical or
    physiologic condition known to disrupt sleep.
  • D. Insomnia is clearly associated with the
    medical or physiologic condition. The insomnia
  • began near the time of onset or with significant
    progression of the medical or
  • physiologic condition and waxes and wanes with
    fluctuations in the severity of this
  • condition.
  • The sleep disturbance is not better explained by
    another sleep disorder, mental disorder,
  • medication use, or substance use disorder.

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Physiologic (Organic) Insomnia,Unspecified
  • This diagnosis is used for forms of insomnia
    that cannot be classified
  • elsewhere but are suspected to be related to an
    underlying medical disorder,
  • physiological state, or substance used or
    exposure. In some cases, this
  • diagnosis may be assigned on a temporary basis
    when an insomnia diagnosis
  • seems appropriate but further evaluation is
    required to determine the specific
  • medical condition or toxin exposure responsible
    for the reported sleep
  • difficulty. This diagnosis can also be assigned
    when substance abuse or
  • dependence-related insomnia is suspected but is
    yet to be confirmed. In other
  • cases, this diagnosis may be assigned when an
    endogenous physiologic
  • disorder or condition appears to contribute to
    the insomnia but the patients
  • symptoms fail to meet the criteria for one of the
    other insomnia diagnoses.

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  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

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Hypersomnias not related torespiratory issues
  • Certain disorders of excessive daytime
  • somnolence are believed to be caused by intrinsic
  • brain dysfunction.
  • Narcolepsy, recognized for over a century,
    consist
  • of excessive daytime sleepiness usually
    associated
  • with weakness of muscles with emotion (known as
  • cataplexy) and the premature occurrence of rapid
  • eye movement (REM) sleep. In most instances this
  • appears to be due to dysfunction of the
    hypocretin
  • (orexin) neurotransmitter system.

21
Hypersomnias not related torespiratory issues
  • Idiophatic hypersomnia is a similar but less
    well
  • defined disorder, with hypersomnolence but no
  • cataplexy and no disturbance in the timing of
  • REM sleep.
  • Recurrent hypersomnia is a very rare disorder
  • with periods of sleep lasting days to weeks,
    often
  • associated with behavioral disturbances ( KLS).

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Hypersomnias not related torespiratory issues
  • Insufficient sleep syndrome is a major societal
  • problem in which voluntary sleep deprivation can
  • result in impairment of alertness and cognitive
  • abilities.
  • Medications and illicit drug use can cause
  • excessive daytime sleepiness.
  • Hypersomnia may also be due to medical
  • conditions, such as Parkinsons disease and
  • dementias.

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Narcolepsy
  • Canine narcolepsy was first reported in the early
  • 1970s
  • The term narcolepsy was first coined by Glinean
  • in 1880 to designate a pathologic condition
  • characterized by irresistible episodes of sleep
    of
  • short duration recurring at close intervals. (
    Gelinean,
  • 1880 Gaz Hop Paris).

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  • Prevalence (0.02 to 0.18in US)
  • (narcolepsy with cataplexy)
  • In Finland0.026. ( Hublin et al.,1996)
  • Great Britain, France , Czech Republic and US
  • 0.013 to 0.067 . ( Dauvilliers et al., 2003
    Mignot, 1998)
  • African Americans 0.02. ( Solomon, 1945)
  • Japan0.16 and 0.18(did not use PSG to
  • confirm the diagnosis). ( Honda et al., 1979)
  • Israel as low as 0.002. ( Lavie and Peled,
    1987)
  • Southern Chinese (Hong Kong) 0.034.
  • ( Yun-Kwok Wing et al., 2002)
  • The prevalence of narcolepsy
  • without cataplexy
  • Unknown cases of narcolepsy without cataplexy
  • represent 10 to 50 of the narcoleptic
    population.
  • (45.5 in Chang Gung hospital).
  • ( Rosen et al., 2003)
  • Adult population 1 to 3 may have unexplained
  • sleepiness and SoREM during MSLT.
  • Higher Prevalence in adolescents or young
    adults
  • Because of voluntary chronic sleep deprivation.

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PSG Criteria and Findings
  • Short sleep latency
  • Sleep-onset REM period occurs in about
  • 50 of narcoleptics
  • Increased frequency of arousals
  • Increased amounts of Stage 1 sleep
  • If cataplexy is absent, narcolepsy is difficult
  • to diagnose in the presence of sleep
  • fragmentation from other sleep disorders

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MSLT Criteria for Narcolepsy
  • Mean sleep latency of less than 8 minutes
  • 2 or more sleep-onset REM periods
  • (SOREMPs)
  • No other sleep disorder that accounts for the
  • findings
  • MSLT should be performed following
  • sufficiend nocturnal sleep (minimum 6
  • hours).

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Clinical Features Cataplexy
  • Most often occurs with in a year of onset
  • Recurrent, brief episodes of muscle weakness
  • triggered by laughter or at least two of the
  • following anger, surprise, elation, amusement
  • One or more of the following symptoms knees
  • buckling, weakness in legs, jaw, head and neck,
  • complete fall with no injury
  • At least 5 episodes over lifetime

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Clinical Features Cataplexy
  • Most episodes are bilateral
  • Consciousness is maintained, at least at the
  • beginning of the episodes
  • Most episodes last less than 2 minutes( a few
  • seconds to several minutes).
  • Twitches and jerks may occur, particularly in
    face
  • (as pt is trying to fight the episode).
  • Cataplexy may vary in pattern, frequency and
  • severity.

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Associated Features Hypnagogic hallucinations
  • ??Are vival perceptual experience typically
  • occurring at sleep onset
  • ??Include visual, tactile, kinetic, and auditory
  • phenomena.
  • ??Recurrent hypnagogic hallucinations are
  • experience by 40 to 80 of patients with
  • narcolepsy with cataplexy.

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Sleep paralysis
  • ??A transient, generalized inability to move or
  • to speak during the transition between sleep
  • and wakefulness.
  • ??Sleep paralysis is experienced by 40 to
  • 80 of narcoleptic patients.

32
Nocturnal sleep disruption
  • ??Occurs in approximately 50 of
  • narcoleptics.
  • ??Most typically sleep-maintenance rather
  • than sleep-onset insomnia.

33
Memory lapses
  • ??Especially during automatic behavior
  • without awareness of sleepiness.
  • ??It may show inappropriate activity and poor
  • adjustment to abrupt environmental
  • demands.

34
  • Many of the symptoms of
  • narcolepsy can occur in any person
  • who is severe sleep deprived, only
  • cataplexy is unique to narcolepsy.

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Functions potentially interested byHypocretin
containing neurons
  • ??FEEDING
  • ??BLOOD PRESSURE REGULATION
  • ??NEURO-ENDOCRINE REGULATION
  • ??THERMOREGULATION
  • ??SLEEP-WAKING CYCLE (effect on
  • arousal)
  • Peyron et al., 1998

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  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

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  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

43
Parasomnias
  • Parasomnias are undesirable physical phenomena
  • that occur predominantly during sleep.
  • Arousal disorders, comprising sleep-walking,
  • sleep terrors and confusional arousals, are a
  • spectrum of conditions in which a sudden arousal
  • from slow-wave sleep is associated with abnormal
  • behavior due to the patients inability to make a
  • rapid transition to complete wakefulness. They
    are
  • common in childhood but can persist or even
  • develop in adulthood, and may be associated with
  • potentially injurious behavior.

44
Parasomnias
  • Parasomnias usually associated with REM sleep
    include
  • nightmares, which are frightening dreams during
    REM sleep
  • resulting in wakening.
  • Sleep paralysis,occurign at sleep onset or on
    wakening, is an
  • inability to move from seconds to minutes. It is
    believed to be
  • due to the muscle atonia of REM sleep developing
  • inappropriately, and may occur both as a normal
    phenomenon
  • and in patients with narcolepsy.
  • REM sleep behavior disorder occurs when the
    normal
  • muscle atonia of REM sleep is lost, allowing the
    enactment of
  • dreams. Patients flail their arms, kick and
    vocalize, frequently
  • resulting in injuries to themselves or their bed
    partners. The
  • conditions occurs predominantly in older men, and
    is often
  • associated with neurodegenerative diseases,
    especially
  • Parkinsonian syndromes.

45
Parasomnias
  • Other parasomnias (not state-related) include
    sleep
  • enuresis, the continued occurrence of bedwetting
    in
  • children beyond the age when it normally ceases.
  • Parasomnias related to a known psychiatric
    disorder
  • include nocturnal panic attacks and nightmares in
    posttraumatic
  • stress disorder.
  • Parasomnias related to medical conditions
    include
  • confusional behavior at night in patients with
    dementia.

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  • I. Insomnias
  • II. Sleep Related Breathing Disorders
  • III. Hypersomnias of Central Origin Not Due to
    a Circadian
  • Rhythm, Sleep Disorder, Sleep Related Breathing
    Disorder, or
  • Other Cause of Disturbed Nocturnal Sleep.
  • IV. Circadian Rhythm Sleep Disorders
  • V. Parasomnias
  • VI. Sleep Related Movement Disorders
  • VII. Isolated Symptoms, Apparently Normal
    Variants, and
  • Unresolved Issues.
  • VIII. Other Sleep Diorders.

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Sleep-related movementdisorders
  • Restless legs syndrome, is characterized by an
    overwhelming
  • urge to move the legs while sitting or lying and
    relief by
  • movement. It is a very common cause of insomnia,
    It is often
  • familial and appears to be due to central
    dopaminergic
  • dysfunction.
  • Periodic limb movements disorder is usually
    associated with
  • rhythmic kicking of the legs during sleep. But
    PLM may also
  • accompany other sleep disorders and may
    occasionally alone
  • be a cause of insomnia or hypersomnina.

49
Sleep-related movementdisorders
  • Rhythmic movement disorder can occur during any
    stage
  • of sleep, but is commonest during drowsiness. It
    consist of
  • large rhythmic movements, usually of the axial
  • musculature, and includes the conditions
    previously known
  • as body rocking and head banging.
  • Bruxism (tooth grinding) may occur during any
    stage of
  • sleep and can result in jaw pain and damage to
    teeth.

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Sleep, Paris Louvre
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