2. WHAT IS SLEEP? Sleep is a physical and
mental resting state in
which a person
becomes relatively
inactive and unaware
of the environment. In
essence, sleep is a
partial detachment
from the world, where
most external stimuli
are blocked from the
senses.
3. • Normal sleep is characterized by a general decrease in body
temperature, blood pressure, breathing rate, and most other bodily
functions. In contrast, the human brain never decreases inactivity.
Studies have shown that the brain is as active during sleep as it is
when awake. Throughout an eight-hour sleep cycle, a normal adult
alternates between two very different states, non-REM and REM
(Rapid Eye Movement) sleep.
4. FIVE STAGES OF HUMAN SLEEP
Stage 1 NREMsleep.Stage 1 NREMsleep. This stage occurs while a person is
falling asleep. It represents about 5% of a normal adult's
sleep time.
Stage 2 NREMsleep.Stage 2 NREMsleep. In this stage, (the beginning of
"true" sleep), the person's electroencephalogram (EEG)
will show distinctive wave forms called sleep spindles
and K complexes. About 50% of sleep time is stage 2
REM sleep.
Stages 3 and 4 NREMsleep.Stages 3 and 4 NREMsleep. Also called delta or slow
wave sleep, these are the deepest levels of human sleep
and represent 10-20% of sleep time. They usually occur
during the first 30-50% of the sleeping period. There is a
marked secretion of growth hormone in stage 4.
REMsleep.REMsleep. REM sleep makes up 20% of our sleep time
and during this stage we experience vivid dreams. It
usually begins about 90 minutes after the person falls
asleep, an important measure called REM latency. It
alternates with NREM sleep about every hour and a half
throughout the night. REM periods increase in length
over the course of the night.
5. HOURS BY AGE
CHILDREN NEED A GREATER AMOUNT OF SLEEP
PER DAY THAN ADULTS TO DEVELOP AND
FUNCTION PROPERLY: UP TO 18 HOURS FOR
NEWBORN BABIES, WITH A DECLINING RATE AS A
CHILD AGES.A NEWBORN BABY SPENDS ALMOST
HALF OF ITS SLEEP TIME IN REM-SLEEP. BY THE
AGE OF FIVE OR SO, ONLY A BIT OVER TWO
HOURS ARE SPENT IN REM.
6. SLEEP DISORDER DEFINED:
group of syndromes characterized by disturbance in the
patient's amount of sleep, quality or timing of sleep, or in
behaviors or physiological conditions associated with sleep.
There are about 70 different sleep disorders
The condition must be a persistent problem, cause the
patient significant emotional distress, and interfere with his
or her social or occupational functioning.
7. PREDISPOSING FACTORS TOPREDISPOSING FACTORS TO
SLEEP DISORDERSSLEEP DISORDERS
Genetic or familial patterns are thought to play a
contributing role in primary insomnia, primary
hypersomnia, narcolepsy, sleep terror disorder, and
sleepwalking.
A number of medical conditions, as well as aging
have been implicated in the etiology of insomnia.
Psychiatric or environmental conditions that can
contribute to insomnia or hypersomnia include
anxiety, depression, environmental changes,
circadian rhythm sleep disturbances, PTSD, and
schizophrenia.
8. Night terrors may be related
to minor neurological
abnormalities, particularly in
the temporal lobe.
Episodes of sleepwalking
are exacerbated by extreme
fatigue and sleep deprivation.
Activities that interfere with
24-hour circadian rhythm of
hormonal and
neurotransmitter functioning
within the body predispose
individuals to sleep-wake
schedule disturbances.
9. PRIMARY SLEEP
DISORDERS
Primary sleep disorders are distinguished from those
that are not caused by other mental disorders,
prescription medications, substance abuse, or medical
conditions
The two major categories of primary sleep disorders
are dyssomnias and the parasomnias.
12. PRIMARY INSOMNIA
difficulty in falling asleep or remaining
asleep that lasts for at least one
month.
can be caused by a traumatic event
related to sleep or bedtime, and it is
often associated with increased
physical or psychological arousal at
night
People who experience primary
insomnia are often anxious about not
being able to sleep
usually begins when the person is a
young adult or in middle age
13. DIAGNOSTIC CRITERIA FOR PRIMARY
INSOMNIA
A. The predominant complaint is difficulty initiating or
maintaining sleep, or nonrestorative sleep, for at least 1
month.
B. The sleep disturbance (or associated daytime fatigue)
causes clinically significant distress or impairment in
social, occupational, or other important areas of
functioning.
C. The sleep disturbance does not occur exclusively during
the course of Narcolepsy, Breathing-Related Sleep
Disorder, Circadian Rhythm Sleep Disorder, or a
Parasomnia.
D. The disturbance does not occur exclusively during the
course of another mental disorder (e.g., Major
Depressive Disorder, Generalized Anxiety Disorder, a
Delirium).
14. PRIMARY HYPERSOMNIA
a condition marked by excessive
sleepiness during normal waking
hours.
The patient has either lengthy
episodes of daytime sleep or
episodes of daytime sleep on a daily
basis even though he or she is
sleeping normally at night
In some cases, patients with
primary hypersomnia have difficulty
waking in the morning and may
appear confused or angry---
condition is sometimes called sleep
drunkenness and more common in
males.
usually affects young adults
between the ages of 15 and 30
15. DIAGNOSTIC CRITERIA FOR PRIMARY
HYPERSOMNIAA.The predominant complaint is excessive sleepiness for at least 1 month
(or less if recurrent) as evidenced by either prolonged sleep episodes or
daytime sleep episodes that occur almost daily.
B.The excessive sleepiness causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
C.The excessive sleepiness is not better accounted for by Insomnia and
does not occur exclusively during the course of another Sleep Disorder
(e.g., Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm
Sleep Disorder, or a Parasomnia) and cannot be accounted for by an
inadequate amount of sleep.
D.The disturbance does not occur exclusively during the course of another
mental disorder.
E.The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition.
Spe cify if:
Recurrent: if there are periods of excessive sleepiness that last at least 3
16. NARCOLEPSY
characterized by recurrent "sle e p attacks" that the patient cannot fight
The sleep attacks are about 10-20 minutes long.
The patient feels refreshed by the sleep, but typically feels sleepy again
several hours later.
About 40% of patients with narcolepsy have or have had another mental
disorder
Almost 18% of patients with narcolepsy are 10 years old or younger
Men and women are equally affected.
17. NARCOLEPSY
3 major symptoms:
1. Cataplexy is the sudden loss of
muscle tone and stability ("drop
attacks")
2. Hallucinations may occur just
before falling asleep (hypnagogic) or
right after waking up (hypnopompic)
and are associated with an episode
of REM sleep.
3. Sleep paralysis occurs during the
transition from being asleep to
waking up.
18. DIAGNOSTIC CRITERIA FOR
NARCOLEPSYA. Irresistible attacks of refreshing sleep that occur daily
over at least 3 months.
B. The presence of one or both of the following:
• cataplexy (i.e., brief episodes of sudden bilateral loss of
muscle tone, most often in association with intense
emotion)
• 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.
20. 4 TYPES OF BREATHING-RELATED SLEEP
DISORDERS:
Obstructive sleep apnea syndrome. This is the most
common form of breathing-related sleep disorder, marked
by episodes of blockage in the upper airway during sleep. It
is found primarily in obese people. Patients with this
disorder typically alternate between periods of snoring or
gasping (when their airway is partly open) and periods of
silence (when their airway is blocked). Very loud snoring is
a clue to this disorder.
Central sleep apnea syndrome. This disorder is primarily
found in elderly patients with heart or neurological
conditions that affect their ability to breathe properly. It is
not associated with airway blockage and may be related to
brain disease.
Central alveolarhypoventilation syndrome. This disorder
is found most often in extremely obese people. The
patient's airway is not blocked, but his or her blood oxygen
level is too low.
Mixed-type sleep apnea syndrome. This disorder
21. DIAGNOSTIC CRITERIA FOR BREATHING-RELATED
SLEEP DISORDER
A. Sleep disruption, leading to excessive
sleepiness or insomnia, that is judged to be due
to a sleep-related breathing condition (e.g.,
obstructive or central sleep apnea syndrome or
central alveolar hypoventilation syndrome).
B. The disturbance is not better accounted for by
another mental disorder and is not due to the
direct 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.
22. CIRCADIAN RHYTHM SLEEP
DISORDERS
results from a discrepancy between the person's daily sleep/wake
patterns and demands of social activities, shift work, or travel
24. JET LAG
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
25. SHIFT WORK
insomnia during the major sleep period or excessive sleepiness during the major awake
period associated with night shift work or frequently changing shift work
26. NON-24-HOUR SLEEP-WAKE
SYNDROME
rare and chronic circadian rhythm sleep
disorder.
"a chronic steady pattern comprising one- to
two-hour daily delays in sleep onset and wake
times in an individual living in society.“
The pattern of delay persists literally "around
the clock," typically taking a few weeks to
complete one cycle.
It affects less than 0.05% of the population
(fewer than 1 in 2000 people), which means that
it is classified as a "rare disease.
27. DELAYED SLEEP PHASE
• also known as delayed sleep-phase disorder
(DSPD) or delayed sleep-phase type (DSPT)
• is a circadian rhythm sleep disorder, a chronic
disorder of the timing of sleep, peak period of
alertness, core body temperature, hormonal and
other daily rhythms relative to the usual norms.
• People with DSPS tend to fall asleep some
hours after midnight and have difficulty waking
up in the morning
• usually develops in early childhood or
adolescence, and sometimes disappears in
adolescence or early adulthood.
28. ADVANCED SLEEP PHASE SYNDROME
(ASPS)
also known as the advanced sleep-phase type
(ASPT) of circadian rhythm sleep disorder
a condition in which patients feel very sleepy early
in the evening (e.g. 18:00-19:00) and wake up very
early in the morning (e.g. 03:00).
ASPS is frequently encountered in the elderly and
in post-menopausal women.
It can be treated pharmacologically, with evening
bright lights, or behaviorally with chronotherapy or
free-running sleep
29. CIRCADIAN RHYTHM SLEEP
DISORDERS
Peoplewhoareordinarilyearlyrisers appeartobe
morevulnerabletojet lagandshift work-related
circadianrhythmdisorders thanpeoplewhoare
"night owls."
Therearesomepatients whodonot fit thepattern
of thesethreedisorders andappeartobethe
oppositeof thedelayedsleepphasetype. These
patients haveanadvancedsleepphasepatternand
cannot stayawakeintheevening, but wakeupon
theirownintheearlymorning.
30. DIAGNOSTIC CRITERIA FOR 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.
Spe cify type:
•Delayed Sleep Phase Type
•Jet Lag Type
•Shift WorkType:
•Unspecified Type
31. PARASOMNIAS
primary sleep disorders in which the patient's behavior is affected by
specific sleep stages or transitions between sleeping and waking. They
are sometimes described as disorders of physiological arousal during
sleep.
32. NIGHTMARE
DISORDER•a parasomnia in which the patient is
repeatedly awakened from sleep by
frightening dreams and is fully alert on
awakening.
•Approximately 10-50% of children
between three and five years old have
nightmares.
•They occur during REM sleep, usually
in the second half of the night
•The child is usually able to remember
the content of the nightmare and may
be afraid to go back to sleep.
•More females than males have this
disorder, but it is not known whether
the sex difference reflects a difference
in occurrence or a difference in
reporting.
•Nightmare disorder is most likely to
occur in children or adults under
severe or traumatic stress.
33. DIAGNOSTIC CRITERIA FOR NIGHTMARE
DISORDER
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.
34. SLEEPSLEEP
TERRORTERROR
DISORDERDISORDER
•is a parasomnia in which the patient awakens
screaming or crying.
•The patient also has physical signs of arousal,
like sweating, shaking, etc.
•It is sometimes referred to as pavornocturnus.
•Unlike nightmares, sleep terrors typically occur
in stage 3 or stage 4 NREM sleep during the first
third of the night.
•The patient may be confused or disoriented for
several minutes and cannot recall the content of
the dream.
•He or she may fall asleep again and not
remember the episode the next morning.
•Sleep terror disorder is most common in children
four to 12 years old and is outgrown in
adolescence.
•It affects about 3% of children.
•Fewer than 1% of adults have the disorder. I
•in adults, it usually begins between the ages of
20 and 30.
•In children, more males than females have the
disorder. In adults, men and women are equally
affected.
35. DIAGNOSTIC CRITERIA FOR SLEEP TERROR
DISORDER
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
36. SLEEPWALKING DISORDER
•sometimes called somnambulism
•occurs when the patient is capable of complex
movements during sleep, including walking.
•Like sleep terror disorder, sleepwalking occurs
during stage 3 and stage 4 NREM sleep during the
first part of the night.
•If the patient is awakened during a sleepwalking
episode, he or she may be disoriented and have no
memory of the behavior.
•In addition to walking around, patients with
sleepwalking disorder have been reported to eat, use
the bathroom, unlock doors, or talk to others. It is
estimated that 10-30% of children have at least one
episode of sleepwalking. However, only 1-5% meet
the criteria for sleepwalking disorder.
•The disorder is most common in children eight to 12
years old.
• It is unusual for sleepwalking to occur for the first
37. DIAGNOSTIC CRITERIA FOR SLEEPWALKING
DISORDER
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.
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)
38. PERIODIC LIMB
MOVEMENT
DISORDER•affects people only during sleep.
•The condition is characterized by behavior ranging from
shallow, continual movement of the ankle or toes, to wild and
strenuous kicking and flailing of the legs and arms.
•Furthermore, abdominal, oral, and nasal movement
sometimes accompanies PLMD.
•Movement of the legs is more typical than movement of the
arms in cases of PLMD.
•Movements typically occur for 0.5 to 10 seconds, in intervals
separated by five to 90 seconds.
•A formal diagnosis of nocturnal myoclonus requires three
periods during the night, lasting from a few minutes to an hour
or more, each containing at least 30 movements followed by
partial arousal or awakening. (ASDC 1979)
•These limb movements usually occur in deep stage two sleep,
but often cause arousal.
39. RESTLESS LEGS SYNDROME
(RLS)•People with RLS complain of an irresistible urge to move
their legs while at rest.
•A person with RLS will experience a vague, uncomfortable
feeling while at rest that is only relieved by moving the legs.
•Symptoms of RLS may be present all day long, making it
difficult for an individual to sit motionless. Or they may be
present only in the late evening. Late evening symptoms
can lead to sleep onset insomnia, which tends to
compound the effects of RLS.
•Pregnancy, uremia, and post-surgery conditions have also
been known to increase the incidence of RLS. And,
surprisingly, fever seems to decrease it.
•Although one study found RLS to be most prevalent in
middle-aged females, its incidence increases with age.
•Restless legs syndrome is estimated to affect 5% of the
population. Approximately 80% of people with RLS have
40. SLEEP DISORDERS RELATED TO OTHER
CONDITIONS
In addition to the primary sleep disorders, there are three categories of
sleep disorders that are caused by or related to substance use or other
physical or mental disorders.
41. SLEEP DISORDERS RELATED TO
MENTAL DISORDERS
Many mental disorders, especially depression or one of the anxiety
disorders, can cause sleep disturbances. Psychiatric disorders are the
most common cause of chronic insomnia.
42. SLEEP DISORDERS DUE TO MEDICAL
CONDITIONS
Some patients with chronic neurological conditions like Parkinson's
disease or Huntington's disease may develop sleep disorders. Sleep
disorders have also been associated with viral encephalitis, brain
disease, and hypo- or hyperthyroidism.
43. SUBSTANCE-INDUCED SLEEP
DISORDERS
The use of drugs, alcohol, and caffeine
frequently produces disturbances in
sleep patterns. Alcohol abuse is
associated with insomnia. The person
may initially feel sleepy after drinking,
but wakes up or sleeps fitfully during
the second half of the night. Alcohol
can also increase the severity of
breathing-related sleep disorders. With
amphetamines or cocaine, the patient
typically suffers from insomnia during
drug use and hypersomnia during drug
withdrawal. Opioids usually make short-
term users sleepy. However, long-term
users develop tolerance and may suffer
from insomnia.
•In addition to alcohol and drugs that are abused, a variety of
prescription medications can affect sleep patterns. These
medications include antihistamines, corticosteroids, asthma
medicines, and drugs that affect the central nervous system.
44. TREATMENT MODALITIESTREATMENT MODALITIES
Sleep Disorders
Primary Insomnia
Relaxation Therapy
Biofeedback
Drug therapy: Sedatives and Hypnotics-
Benzodiazepines (Dalmane, Restoril, Halcion);
Nonbenzodiazepines (Noctec, Ambien)
Primary Hypersomnia/Narcolepsy
Drug Therapy: The usual treatment for
hypersomnia is with CNS stimulants such as
amphetamines. In some instances, the nonsedating
Serotonin-specific reuptake inhibitor
antidepressants (flouxetine, sertaline, and
paroxetine) may be helpful.
45. Narcolepsy is also treated with CNS
stimulants, such as amphetamine,
methylphenidate, or pemoline.
Tricyclic antidepressants have been
effective in the treatment of symptoms of
cataplexy.
Parasomnias
Treatment usually centers around
measures to relieve obvious stress
within the family:
A. Individual or family therapy
B. Interventions to prevent injury
C. Use of tricyclic antidepressants
or low-dose benzodiazepines.
46. SLEEP EDUCATIONSLEEP EDUCATION"Sleep hygiene" or sleep education for sleep disorders often
includes instructing the patient in methods to enhance
sleep. Patients are advised to:
•wait until he or she is sleepy before going to bed
•avoid using the bedroom for work, reading, or watching
television
•get up at the same time every morning no matter how
much or how little he or she slept
•avoid smoking and avoid drinking liquids with caffeine
•get some physical exercise early in the day every day
•limit fluid intake after dinner; in particular, avoid alcohol
because it frequently causes interrupted sleep
•learn to meditate or practice relaxation techniques
•avoid tossing and turning in bed; instead, he or she should
get up and listen to relaxing music or read