Sleep-Wake Disorders

Question 1

Sleep-Wake Disorders

Answer 1

DSM-5

1. mandate for concurrent specification of coexisting conditions (medical and mental):
   
   1. sleep disorders related to another mental disorder and
   2. sleep disorder related to a general medical condition have been removed.
2. individual has a sleep disorder warranting independent clinical attention, in addition to other medical/mental dx
3. bi-directional and interactive effects between sleep dx and coexisting medical and mental dx.
4. primary insomnia is now Insomnia Disorder
5. Narcolepsy associated with hypocretin deficiency, separate from other hypersomnolence
6. Sleep-wake disorders and pediatric and developmenal criteria are integrated, to focus on the developmenal perspective.

Question 2

Types of Sleeping Disorders

dsm 5 changes.

Answer 2

1. Breathing-Related Sleep Disorders:
   
   1. obstructive sleep apnea hypopnea (most common)
      
      1. relaxation of soft tissue at the back of the throat that blocks the passage of air in the nose/throat.
      2. Treat with continuous positive airway pressure (CPAP) nasal mask
      3. oral appliances for mild cases and tracheostomy for severe cases.
   2. central sleep apnea, and
   3. sleep-related hypoventilation
      
      1. pathophysiology of all three
   • abnormal breathing during sleep, disruption in sleep that leads to insomnia and excessive sleepiness.
2. Circadian Rhythm Sleep-Wake Disorders
   
   1. advanced sleep phase syndrome
   2. irregular sleep-wake type
   3. non-24-hour sleep-wake type
      
      1. jet-lag type removed.
3. Rapid Eye Movement Sleep Behavior Disorder
4. Restless Legs Syndroms (3-4 now separate).

Question 3

Narcolepsy

Answer 3

Narcolepsy is a neurologically based, chronic, hypersomnic type of sleep disorder, which typically appears in childhood, adolescence or young adulthood.

Despite adequate nocturnal sleep, the individual will experience daytime fatigue, or EDS (Excessive Daytime Sleepiness)

The individual will experience sudden loss of muscle tonus ranging from isolated muscle weakness to bilateral, full body loss of muscle tonus (cataplexy), and will fall asleep in inappropriate times and places, which may place themselves or others in danger, if they are driving or doing another potentially hazardous activity.

Narcolepsy is accompanied by unusually rapid onset of REM sleep. The sleep episodes will typically be triggered by a strong emotional response in the individual or a heavy meal, or general psychosocial stressors (Simon, 2012). Their should be an objective laboratory finding of abnormally low levels of hypocretin, a neuropeptide associated with sleep/wake and arousal levels, (Tsujino & Sakurai, 2009), and according to a polysomnography study, unusually low amounts of REM sleep during nocturnal sleep.

Hypnogogic hallucinations (vivid dreams upon onset of sleep) hypnopompic hallucination (vivid dreams upon waking) and sleep paralysis (inability to move upon waking) can be part of the clinical presentation (Simon, 2012).

Question 4

Disorder of Arousal

confusional arousal

sleepwalking

sleep terrors

Answer 4

DSM 5 Sleep Disorders Overhaul

DSM-5 into three major categories: insomnia, hypersomnia and arousal disorder.

** Kleine Levin Syndrome**

This syndrome is characterized by a person who experiences recurrent episodes of excessive sleep (more than 11 hours/day). These episodes occur at least once a year, and are between 2 days and 4 weeks in duration.

During one of these episodes, when awake, cognition is abnormal with feeling of unreality or confusion. Behavioral abnormalities such as megaphagia or hypersexuality may occur in some episodes.

The patient has normal alertness, cognitive functioning, and behavior between the episodes.

Obstructive Sleep Apnea Hypopnea Syndrome

(Previously known as Breathing Related Sleep Disorder)

Symptoms of snoring, snorting/gasping or breathing pauses during sleep

AND/OR

Symptoms of daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep and unexplained by another medical or psychiatric morbidityAND
Evidence by polysomnography (a type of measurement of sleep breathing used in a sleep lab) of 5 or more obstructive apneas or hypopneas per hour of sleep or evidence by polysomnography of 15 more obstructive apneas and/or hypopneas per hour of sleep.

Primary Central Sleep Apnea

(Previously known as Breathing Related Sleep Disorder)

At least one of the following is present:

Excessive daytime sleepiness
Frequent arousals and awakenings during sleep or insomnia complaints
Awakening short of breath

Polysomnography (a type of measurement of sleep breathing used in a sleep lab) shows five or more central apneas per hour of sleep.

Rapid Eye Movement Behavior Disorder

This disorder is characterized by repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors which may be sufficient to result in injury to the individual or bed partner.

These behaviors arise during REM sleep and therefore usually occur greater that 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and rarely occur during daytime naps.

Upon awakening, the individual is completely awake, alert, and not confused or disoriented.

The observed vocalizations or motor behavior often correlate with simultaneously occurring dream mentation leading to the report of “acting out of dreams”.

The behaviors cause clinically significant distress or impairment in social or other important areas of functioning — particularly pertaining to distress to bed partner or injury to self or bed partner.

At least one of the following is present: 1) Sleep related injurious, potentially injurious, or disruptive behaviors arising from sleep and 2) Abnormal REM sleep behaviors documented by polysomnographic recording.

Restless Legs Syndrome

The exact criteria used to diagnose Restless Legs Syndrome has not been decided. But one set of criteria proposed include a patient meeting all of the following:

An urge to move the legs usually accompanied or caused by uncomfortable and unpleasant sensations in the legs (or for pediatric RLS the description of these symptoms should be in the child’s own words).
The urge or unpleasant sensations begin or worsen during periods of rest or inactivity.
Symptoms are partially or totally relieved by movement
Symptoms are worse in the evening or at night than during the day or are present only at night or in the evening. (The worsening occurs independently of any differences in activity, which is important for pediatric RLS as children are sitting much of the day at school).

These symptoms are accompanied by significant distress or impairment in social, occupational, academic, behavioral or other important areas of functioning indicated by the presence of at least one of the following:

Fatigue or low energy
Daytime sleepiness
Cognitive impairments (e.g., attention, concentration, memory, learning)
Mood disturbance (e.g., irritability, dysphoria, anxiety)
Behavioral problems (e.g., hyperactivity, impulsivity, aggression)
Impaired academic or occupational function
Impaired interpersonal/social functioning

Circadian Rhythm Sleep Disorder

This disorder is characterized by a persistent or recurrent pattern of sleep disruption leading to excessive sleepiness, insomnia, or both that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by a person’s physical environment or social/professional schedule.

Disorder of Arousal

(Includes previous diagnoses of Sleepwalking Disorder and Sleep Terror Disorder)

Recurrent episodes of incomplete awakening from sleep usually occurring during the first third of the major sleep episode.

Subtypes:

Confusional Arousals: Recurrent episodes of incomplete awakening from sleep without terror or ambulation, usually occurring during the first third of the major sleep episode. There is a relative lack of autonomic arousal such as mydriasis, tachycardia, rapid breathing, and sweating during an episode.

Sleepwalking: Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. 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. Starts 4-8 and remits spontaneously in adolescence.

Sleep terrors: Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode.

Relative unresponsiveness to efforts of others to comfort the person during the episode.

No detailed dream is recalled and there is amnesia for the episode.

starts at ages 4-12 but remits spontaneously during adolscence.