2. SLEEP DISORDERS

3. Two Major Categories* ◦ Dyssomnias ◦ Parasomnias *This classification system is similar to that used by the American Sleep Disorders Association.

4. Dyssomnias ◦ The sleep itself is pretty normal. ◦ But the client sleeps too little, too much, or at the wrong time. ◦ So, the problem is with the amount (quantity), or with its timing, and sometimes with the quality of sleep.

5. Parasomnias ◦ Something abnormal occurs during sleep itself, or during the times when the client is falling asleep or waking up (e.g., bad dreams. ◦ The quality, quantity, and timing of the sleep are essentially normal.

6. The Sleep Disorders chapter has four major sections: I. Primary Sleep Disorders include all sleep disorders, except: II. Sleep Disorder Related to Another Mental Disorder III. Sleep Disorder Due to a General Medical Condition (GMC) IV. Substance-Induced Sleep Disorder

7. I. Primary Sleep Disorders ◦ Dyssomnias A. Primary Insomnia - too little sleep (criteria listed on p. 604) ◦ Characteristics ◦ Difficulty initiating or maintaining sleep ◦ Persists for 1 month or longer ◦ This diagnosis is rarely independent of an Axis I or II disorder or a GMC or substance use.

8. I. Primary Sleep Disorders (cont.) A. Primary Insomnia (too little sleep) Often due to: ◦ Major Depressive Episode, Manic Episode, or anxiety disorder ◦ Commonly misused substances, as well as some prescription medicines. ◦ Breathing-related problems ◦ The cause sometimes can not be identified.

9. I. Primary Sleep Disorders (cont.) A.Primary Insomnia (too little sleep) Treatment ◦ Vigorous daytime exercise, not exercising before sleep ◦ Sexual intercourse, if pleasurable ◦ Metronome or ticking clock- slow, 60 beats per minute or slower, beat of human heart ◦ Relaxation exercises, practice regularly but condensed to 5 minutes ◦ Decrease stimulation and increase soothing environments, such as ear plugs or calm reading ◦ Practice good sleep habits ◦ Read “How to Become an Insomniac”

10. I. Primary Sleep Disorders ◦ Dyssomnias B. Primary Hypersomnia (sleeping too much, as well as being drowsy at times when client should be alert) (criteria listed on p. 609) ◦ Characteristics ◦ Excessive sleepiness ◦ Persists for 1 month or longer ◦ Rarely a diagnosis independent of an Axis I or II disorder or a GMC or substance use. ◦ Specify if: Recurrent.

11. I. Primary Sleep Disorders (cont.) B. Primary Hypersomnia (too much sleep) (cont.) ◦ Often due to: ◦ Major Depressive Episode, Dysthymic Disorder with atypical features ◦ Use of substances is less likely to produce hyersomnia than insomnia, but it can happen (e.g., sleeping pills overdose) ◦ The cause sometimes can not be identified. Treatment: Exercise when becoming sleepy

12. I. Primary Sleep Disorders ◦ Dyssomnias C. Narcolepsy (Sleeping at the wrong time) (criteria listed on pg. 615) ◦ Characteristics ◦ Sleep intrudes into wakefulness, causing clients to fall asleep almost instantly ◦ Sleep is brief but refreshing ◦ May also have sleep paralysis, sudden loss of strength, and hallucinations as fall asleep or awaken. Treatment: Stimulants, sometimes antidepressants, with less success.

13. I. Primary Sleep Disorders ◦ Dyssomnias D. Breathing-Related Sleep Disorder (criteria listed on p. 622) Characteristics ◦ Sleep disruption (excessive sleepiness or insomnia) ◦ Due to sleep-related breathing condition (e.g., Obstructive Sleep Apnea Syndrome)

14. I. Primary Sleep Disorders ◦ Dyssomnias D.Breathing-Related Sleep Disorder Treatment (Criteria on p. 622)  In mild cases: weight loss, sleeping on one’s side, and avoiding hypnotics and alcohol (To sleep on side, a tennis ball can be sewn into back of client’s sleep wear)  In more serious cases: a machine that provides continuous positive airway pressure  Surgery: Few benefits

15. I. Primary Sleep Disorders ◦ Dyssomnias E. Circadian Rhythm Sleep Disorder (criteria on p. 629) Characteristics ◦ Persistent or recurrent pattern of sleep disruption leading to excessive sleepiness or insomnia, due to mismatch between sleep-wake schedule required by a person’s environment and his/her circadian sleep-wake pattern (e.g., shift work, jet lag).

16. I. Primary Sleep Disorders ◦ Dyssomnias E.Circadian Rhythm Sleep Disorder Treatment: Difficult to treat, because it has to involve the entire family ◦ Darken bedroom and use soundproofing ◦ Limit caffeine and hard to digest food. ◦ Ensure all family members learns shift ◦ To help jet lag, exposure to sun helps Specify type: Delayed Sleep Phase Type, Jet Lag Type, Shift Work Type, and Unspecified Type

17. I. Primary Sleep Disorders Dyssomnias F.Dyssomnia NOS (listed on p. 629) This category is for insomnias, hypersomnias, or circadian rhythm disturbances that do not meet criteria for any specific Dyssomnia.

18. I. Primary Sleep Disorders ◦ Parasomnias A.Nightmare Disorder ( Criteria listed on p. 634) Characteristics: (1) Repeated awakenings from bad dreams (2) When awakened client becomes oriented and alert

19. I. Primary Sleep Disorders ◦ Parasomnias A. Information about Nightmare Disorder ◦ Usually occurs in early morning when REM sleep dominates. ◦ The same nightmare may recur repeatedly or different ones may pop up three times a week. ◦ Stress may induce 60% of nightmares. ◦ Half of the cases of nightmare disorder appear before age 10; 2/3 before age 20. ◦ Dreams are clearly remembered ◦ Drugs can trigger nightmares. ◦ Suddenly withdrawing REM-suppressant medications and drugs can cause REM rebound.

20. I. Primary Sleep Disorders ◦ Parasomnias B. Sleep Terror Disorder (criteria listed on pg. 639) Characteristics: (1)Abrupt awakening from sleep, usually beginning with a panicky scream or cry. (2)Intense fear and signs of autonomic arousal (3)Unresponsive to efforts from other to calm client (4)No detailed dream recalled (5)Amnesia for episode

21. I. Primary Sleep Disorders ◦ Parasomnias B.Sleep Terror Disorder Usually only children have sleep terror disorder. The client is not having a nightmare. The eyes are open, screams erupt. Usually happens in early evening. In contrast to nightmares, sleep terrors do not respond to psychotherapy. Probably due to brain wave upset, fever, or medications However, some medications may help.

22. I. Primary Sleep Disorders ◦ Parasomnias C.Sleepwalking Disorder (criteria listed on pg. 644) Characteristics: (1) Rising from bed during sleep and walking about. (2)Usually occurs early in the night. (3)On awakening, the person has amnesia for episode

23. I. Primary Sleep Disorders ◦ Parasomnias C.Sleepwalking Disorder Most sleepwalking children are psychologically normal. Runs in families. Begins between ages 6 and 12 and may be stress-related. Customarily sleepwalkers exhibit other delta-sleep interruptions. At some time 1-6% of children sleepwalk; of these, 15% do so occasionally. Adult sleepwalking is far less common, usually worse and more chronic.

24. I. Primary Sleep Disorders ◦ Parasomnias C.Sleepwalking Disorder Treatment: Relaxation techniques Biofeedback training Hypnosis. May need to sleep on the ground floor, have outside doors securely locked, and have car keys unavailable.

25. I. Primary Sleep Disorders ◦ Parasomnias D. Parasomnia NOS (listed on p. 644) Characteristics: Abnormal behavioral or physiological events during sleep or sleep- wake transitions, but that do not meet criteria for a more specific Parasomnia

26. I. Primary Sleep Disorders ◦ Parasomnias D. Parasomnia NOS (listed on p. 644) Examples Sleep-Talking: Often more annoying to partner than to sleeper. Has no memory in morning. Can be during REM or delta sleep. In REM sleep, pronunciation is clear and understandable; in deep sleep (delta) apt to be mumbled and unintelligible Sleep paralysis: inability to perform voluntary movement during the transition between waking and sleep. Usually associated with extreme anxiety, and sometimes fear of impending death. REM sleep behavior disorder: characterized by agitated and violent behavior. Parasomnia is present but unable to determine whether it is primary, due to GMC, or substance induced.

27. The Sleep Disorders chapter has four major sections: I. Primary Sleep Disorders include all sleep disorders, except: II. Sleep Disorder Related to Another Mental Disorder III. Sleep Disorder Due to a General Medical Condition (GMC) IV. Substance-Induced Sleep Disorder

28. II.Sleep Disorder Related to Another Mental Disorder ◦ Two Diagnoses 1.Insomnia Related to Another Mental Disorder (criteria listed on p. 650) 2. Hypersomnia Related to Another Mental Disorder (criteria listed on p. 650)

29. II.Sleep Disorder Related to Another Mental Disorder 1.Insomnia Related to Another Mental Disorder Characteristics ◦ Difficulty in initiating or maintaining sleep ◦ Persists for at least 1 month 2. Hypersomnia Related to Another Mental Disorder Characteristics: ◦ Excessive sleepiness ◦ Persists for at least 1 month

30. II.Sleep Disorder Related to Another Mental Disorder ◦ Two Diagnoses 1.Insomnia Related to… another mental disorder – indicate the Axis I or II disorder (criteria listed on p. 650) 2. Hypersomnia Related to…another mental disorder – indicate the Axis I or II disorder (criteria listed on p. 650)

31. III. 327.xx Sleep Disorder Due to … a General Medical Condition (list the GMC) (criteria on p. 654) Also GMC on Axis III Prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention. ◦ Evidence has to be present that the sleep disturbance is a direct physiological consequence of a general medical condition. ◦ Specify Type: (1).52Insomnia Type (2).54Hypersomnia Type (3).59Parasomnia Type (4).59Mixed Type

32. IV. Substance-Induced Sleep Disorder (Indicate Substance) (criteria is on p. 660) Characteristics ◦ Evidence must be present that the sleep disturbance is a direct physiological consequence of substance use. ◦ Substance use that produces a sleep disorder severe enough to warrant independent clinical attention Code: 291.8 Alcohol; 292.89 Amphetamine; 292.89 Caffeine; 292.89 Cocaine; 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other (or unknown) Substance

33. IV. Substance-Induced Sleep Disorder (Indicate Substance) (criteria is on p. 660) Types: Insomnia Type Hypersomnia Type Parasomnia Type Mixed Type Specify if: With Onset During Intoxication With Onset During Withdrawal

34. INSOMNIA

35. Insomnia ◦ A broad term denoting unsatisfactory sleep ◦ Perception that sleep is inadequate or abnormal ◦ Common problem ◦ A symptom, not a disease or sign, therefore difficult to measure

36. Diagnosis ◦ Complaint that the sleep is: ◦ Brief or inadequate ◦ Light or easily disrupted ◦ Non-refreshing or non-restorative

37. International Congress of Sleep Disorders Classification ◦ Based on the duration of symptoms ◦ Transient or acute ◦ Few days to 2-4 weeks ◦ Chronic ◦ Persisting for more than 1-3 months

38. Definitions ◦ Mild ◦ Almost nightly complaint of non-restorative sleep ◦ Associated with little or no impairment of social or occupational functioning ◦ Moderate ◦ Nightly complaints of disturbed sleep ◦ Mild to moderate impairment of social or occupational function ◦ Severe ◦ Nightly complaints of disturbed sleep ◦ Severe daytime dysfunction

39. Classification ◦ Sleep initiating insomnia ◦ Sleep maintaining insomnia ◦ Early morning insomnia ◦ Short period of sleep ◦ Non-restorative sleep ◦ Multiple awakenings ◦ Combination of above patterns

40. Presentation Goals ◦ Review of normal sleep cycle ◦ Causes of insomnia ◦ Diagnosis and assessment of insomnia ◦ Treatment modalities

41. Stages of Sleep ◦ Non-Rapid Eye Movement (NREM) sleep ◦ Stage I ◦ Stage II ◦ Stages I & II are light sleep ◦ Stage III ◦ Stage IV ◦ Stages III & IV are deep sleep ◦ Rapid Eye Movement (REM) sleep

42. Normal Sleep Pattern

43. ◦ Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.) ◦ Why do we sleep? ◦ Not clear, but has to do with regeneration (NREM) and brain development/memory (REM) – REM sleep is essential for the development of the mammalian brain ◦ Stages III & IV are involved in synaptic “pruning and tuning” ◦ Why do we get sleepy? ◦ Circadian factors ◦ Process S: linear increase in sleepiness ◦ Process C: rhythmic fluctuations of the circadian alert system ◦ Other factors: sleep duration, quality, time awake, etc.

44. Causes ◦ Insomnia is a downstream symptom of an upstream problem, for example: ◦ Medical ◦ Psychological/ Psychiatric ◦ Behavioral ◦ Parasomnias ◦ Drug-induced ◦ Combination of factors in chronic insomnia

45. Normal Sleep Values ◦ Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle ◦ 4-6 NREM/REM cycles per night ◦ Sleep structure changes throughout life ◦ Wakefulness after sleep ◦ Less than 30 minutes ◦ Sleep Onset Latency (SOL) ◦ Less than 30 minutes ◦ REM Sleep Latency ◦ 70-120 minutes

46. Epidemiology ◦ Studies throughout the world show that it occurs everywhere ◦ Depending on the area, study, etc., between 10-50% of the population are affected ◦ Increases with age ◦ Twice as common in females ◦ Up to the age of 30, there is little difference between sexes ◦ Beyond 30 years, it is more common in females ◦ Beyond 70 years, females are affected twice as much as males

47. Etiology ◦ Symptom of numerous diverse etiologies ◦ Usually due to more than one factor and each needs a separate evaluation ◦ In all cases, one should strive to find the cause as it will dictate the proper treatment

48. 3 P’s of Acute Insomnia ◦ Predisposition ◦ Anxiety, depression, etc. ◦ Precipitation ◦ Sudden change in life ◦ Perpetuation ◦ Poor sleep hygiene ◦ Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia ◦ Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia

49. Acute Insomnia ◦ Resolves with the management of inciting factors ◦ Adjustment sleep disorder ◦ Acute stress such as momentous life events or unfamiliar sleep environments ◦ PSG: increased SOL, increased awakenings and sleep fragmentation with poor sleep efficiency ◦ More common in women and those with anxiety ◦ Jet Lag ◦ Symptoms last longer with eastbound travel ◦ Remits spontaneously in 2-3 days ◦ More common in the elderly

50. Chronic Insomnia ◦ Primary or Intrinsic ◦ Secondary or Extrinsic ◦ Causes ◦ Changes in circadian rhythm, behavior, environment ◦ Body movements in sleep ◦ Medical, neurological, psychiatric disorders ◦ Drugs

51. Primary/Intrinsic Insomnia ◦ Idiopathic ◦ Starts early in childhood, rare but relentless course ◦ Rare disorders affect both genders ◦ CNS abnormalities, unknown etiology, etc. ◦ Sleep State Misinterpretation (5%) ◦ Underestimate of the sleep obtained ◦ Females affected more than males ◦ Psychophysiological insomnia (30%) ◦ Maladaptive sleep-preventing behaviors develop and progress to become dominant factors ◦ Females more than males

52. Secondary/Extrinsic Insomnia 1.Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness ◦ Advanced sleep phase syndrome ◦ Delayed sleep phase syndrome ◦ Irregular sleep/wake patterns ◦ Non-24 hour sleep/wake syndrome ◦ Shift work sleep disorder ◦ Short sleeper

53. 2.Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep ◦ Inadequate sleep ◦ Limit setting sleep disorder ◦ Nocturnal eating/drinking syndrome ◦ Sleep onset association disorder 3.Environmental factors ◦ Environmental sleep disorder ◦ Food allergy insomnia ◦ Toxin-induced sleep disorder

54. 4.Movement disorders ◦ PLMS disorder (5%) ◦ RLS syndrome (12%) ◦ REM behavior disorder 5.Medical Disorders: Respiratory ◦ Altitude insomnia ◦ Central alveolar hypoventilation syndrome ◦ Central apnea syndrome ◦ COPD ◦ OSAS (4-6%) ◦ Sleep-related asthma

55. 6.Medical: Cardiac ◦ Nocturnal myocardial ischemia 7.Medical: GI ◦ Peptic ulcer disease ◦ GERD 8.Medical: Musculoskeletal ◦ Fibromyalgia ◦ Arthritis 9.Medical: Endocrine ◦ Hyperthyroidism ◦ Cushing’s disease ◦ Menstrual cycle association ◦ Pregnancy

56. 10.Medical: Neurological ◦ Cerebral degeneration disorder ◦ Dementia ◦ Fatal familial insomnia ◦ Parkinson’s disease ◦ Sleep related epilepsy ◦ Sleep related headaches 11.Medical: Psychiatric ◦ Alcoholism ◦ Anxiety disorders ◦ Mood disorders ◦ Panic disorders ◦ Psychosis ◦ Drug dependency

57. 12.Pharmacological causes ◦ Alcohol dependent sleep disorder ◦ Hypnotic dependent sleep disorder ◦ Stimulus dependent sleep disorder ◦ Medications ◦ B-blockers ◦ Theophylline ◦ L-dopa

58. Parasomnia Events ◦ Physical phenomena occurring in sleep ◦ Confusional arousals ◦ Nightmares ◦ Nocturnal leg cramps ◦ Nocturnal paroxysmal dystonia ◦ REM sleep behavior disorder ◦ Rhythmic movement disorder ◦ Painful erections ◦ Sleep starts ◦ Sleep terrors ◦ Sleep walking ◦ Abnormal swallowing ◦ Hyperhidrosis ◦ Laryngospasms

59. Physical, Emotional, and Cognitive Effects of Insomnia ◦ Mood changes, irritability, poor concentration, memory defects, etc. ◦ Impairs creative thinking, verbal processing, problem solving ◦ Risk of errors, accidents due to excessive daytime sleepiness ◦ Markedly increases if awake more than 16-18 hours (micro-sleep attacks) ◦ Increased appetite, decreased body temperature ◦ Physiologic effects ◦ Rats die after 11-12 days of sleep deprivation ◦ Hippocampal atrophy in chronic jet lag or shift work

60. Evaluation ◦ HISTORY! ◦ Precipitating factors ◦ Psychiatric and medical disturbances ◦ Medications ◦ Sleep hygiene ◦ Circadian tendencies ◦ Cognitive distortions and conditional arousals ◦ Sleep diary

61. Evaluation ◦ PSG ◦ if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM ◦ Not routinely employed in the evaluation of transient or chronic insomnia ◦ Should not be substituted for a careful clinical history

62. Epworth Sleepiness Scale A good measure of excessive daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation: 0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance Sitting and reading ____ Watching TV ____ Sitting inactive in a public place (ex. theater, meeting) ____ As a passenger in a car for an hour without a break ____ Lying down to rest in the afternoon ____ Sitting and talking to someone ____ In a car, while stopped for a few minutes in traffic ____ ____ Total Score Normal 15

63. Insomnia questionnaire  I have real difficulty falling asleep.  Thoughts race through my mind and this prevents me from sleeping.  I wake during the night and can’t go back to sleep.  I wake up earlier in the morning than I would like to.  I’ll lie awake for half an hour or more before I fall asleep.  I anticipate a problem with sleep almost every night If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.

64. Treatment Selection 1.Meet and educate about disease, goals, options, side effects, and document safety. 2.Identify the 3 P’s. 3.Intrinsic v. Extrinsic 4.Treat perpetuating causes ◦ Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT

65. CBT ◦ Longest lasting improvements, assuming the precipitating cause is dealt with ◦ “counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances ◦ Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones

66. CBT Examples ◦ “I need more hours of sleep or I will not function” ◦ “I can never die” ◦ Uses restructuring techniques ◦ Short circuit cycle of insomnia, cognitive distortions, distress ◦ Sleep hygiene, relaxation, stimulus control, sleep restrictions

67. Sleep Hygiene ◦ Exercise earlier during the day, and no more than 4-6 hours before sleep ◦ Keep bedroom dark and quiet, to be used only for sex or sleep ◦ Curtail time in bed to only when sleepy ◦ Fixed sleep/wake times for 365 days ◦ Avoid naps ◦ Avoid stimulus or stimulating activities before sleep or in bed ◦ No alcohol at least 4 hours before sleep, no caffeine after noon, and quit smoking!! ◦ Light snack before bedtime

68. Stimulus Control ◦ Use bedroom for sleep or sex only ◦ Go to bed only when tired and sleepy ◦ Remove clock from the bedroom to avoid constantly watching it ◦ Regular sleep/wake times ◦ Light therapy if required ◦ No bright lights when you wake up at night

69. Sleep Restriction ◦ An effective form of treatment ◦ Estimate the time actually asleep then limit bedtime to that amount, but no less than 5 hours ◦ Add time in bed gradually once the patient sleeps more than 85% of that time

70. Pharmacotherapy ◦ Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics ◦ Trazadone ◦ Seroquel ◦ Self-medication with alcohol and over-the-counter medications ◦ Benadryl ◦ Nyquil

71. Hypnotics ◦ 5 questions to ask when choosing a hypnotic: 1.Are you looking for sleep initiation or maintenance? 2.What are the daytime residual effects of the drug? 3.Does tolerance develop to this drug? 4.Will rebound withdrawal insomnia occur when discontinued? 5.What is the half-life of the medication?

72. Benzodiazepines DoseHalf-lifeComments Flurazepam(Dalmane)15,30 mgLongDaytime drowsiness common; rarely used Clonazepam(Klonopin)0.5-2 mgLongUsed for PLM, REM behavior disorder; can cause morning drowsiness Temazepam (Restoril)15,30 mgIntermediate Estazolam (ProSom)1-2 mgIntermediateCan cause agranulocytosis Triazolam (Halcion)0.125,0.25 mgShortRebound insomnia may occur Zolpidem (Ambien)5,10 mgShortA nonbenzodiazepam Zopliclone (Sonata)5,10 mgShort, 1-1.5 hours A nonbenzodiazepam

73. Recent Medication Additions ◦ Eszopiclone1,2,3 mgIntermediate ◦ Approved for chronic insomnia ◦ (Lunesta)Action 6-8 hrs. ◦ Zolpidem10 mg Action same as above ◦ (Amvien CR) ◦ Rozerem ◦ (Ramelton)

74. Alternative Medications ◦ Antidepressants ◦ Not much research ◦ Some, including SSRIs, can cause daytime drowsiness ◦ Melatonin ◦ Good for jet leg, especially in elderly, but not much information on long-term use ◦ Reported to cause depression, vasoconstriction ◦ Benadryl ◦ Rarely indicated, can cause a hangover ◦ Herbal supplements ◦ Use in conjunction with a sleep log

75. Conclusion ◦ Insomnia is a complex symptom with many causes and perpetuating influences ◦ It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated ◦ It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder ◦ Depression in turn confers an increased risk of suicide, cardiovascular disease, death, etc.