SLEEP-WAKE DISORDERS

Brenda S. Kirkby, Ph.D.

Professor
Department of Behavioral Sciences

Major Learning Objective

To review the DSM-5 sleep-wake
disorders with an emphasis on their key
symptoms, etiology and treatment.

Review of Sleep Stages

1) Non
Non-REM
REM
Stage 1:
Transitional
Stage 2:
Light sleep
Stage 3&4 (slow wave, delta, deep sleep)
Restorative sleep
Disorientation upon awakening
Amnesia for a brief awakening
2) REM (Rapid Eye Movement)
Physiological activation
Dreaming
Paralysis

Sleep-Wake Disorders (SWDs)

Insomnia Disorder
Hypersomnolence Disorder
Breathing-Related Sleep Disorders
Obstructive Sleep Apnea
Central Sleep Apnea
Narcolepsy
Circadian
Ci di Rhythm
Rh h Sleep-Wake
Sl
W k Disorder
Di d
Parasomnias
In

these disorders, the problem is NOT due to another mental

disorder, medical condition or drug. If so, the diagnosis will
specify the causal medical condition.

Diagnostic Tools for SWDs

To differentiate the SWDs,
SWDs an interview is
conducted and often followed by
polysomnography (PSG)
(PSG).
PSG

involves measuring a variety of

physiological parameters including brain
waves muscle contractions
waves,
contractions, breathing,
breathing etc.
etc
during sleep.
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A. Insomnia Disorder
(formerly primary
primary insomnia
insomnia))
Difficulty

initiating or maintaining sleep for

>3 mos.
Etiology:

Classical conditioning the bed

gets associated with wakefulness (due to poor
sleep habits, known as poor sleep hygiene).
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Insomnia Treatment
Behavioral Methods focus on improving
sleep hygiene:
a. Stimulus Control Technique
Make

the bed a cue ffor rapid-sleep

p
p onset
use bed only as place to sleep
y when tired
lie down only
if not asleep in 10 min, depart bed
y when tired
return only
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Insomnia Treatment (cont.)

b. Additional Sleep Hygiene Methods
y in bedtime/awakeningg
consistency
no naps (unless always taken)
no caffeine past noon
avoid noise & excessive temps during night
exercise
i (more
(
than
h 2 hrs
h bbefore
f
bbedtime)
di )
hot bath (within 2 hrs of bedtime)
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Insomnia Treatment (cont.)

Pharmacological Approaches

a Sedatives (benzodiazepines like diazepam)

a.
induces sleep and increases sleep duration.
recommended only for short-term use (2-4 wks)
due to long-term side effects:
poor sleep quality due slow wave sleep
and REM
tolerance & withdrawal

b. Benzodiazepine
Benzodiazepine-like
like drugs (e.g.,
(e g zolpidem)
usually have fewer side effects.
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B. Hypersomnolence Disorder
(formerly Primary
Primary Hypersomnia
Hypersomnia))
Excessive

sleepiness despite sufficient sleep

(at least 7 hrs) for >3 mos.

Features
Average sleep episode = 9.5 hrs
Normal PSG
Unknown etiology
Exclude other causes before diagnosing
Treatment:
T t
t

Stimulants
Sti
l t (e.g.,
(
methylphenidate)
th l h id t ) to
t
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promote wakefulness.

C. Narcolepsy

1. Recurrent irresistible sleep occurring within the

same day, several times per week, for >3 months.
2. At least 1 of the following:
a) Cataplexy
b) Hypocretin deficiency
c) Characteristic PSG abnormalities
(See next slides for elaboration of each of these)
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Narcolepsy (cont.)
a) Cataplexy
Sudden loss of muscle tone while awake
Sudden
Typically precipitated by emotion
Considered an aberrant manifestation of REM
Considered
sleep
Note: Other REM-related behaviors may be
present but are NOT diagnostic criteria:

sleep paralysis
hypnagogic
yp g g ((upon
p fallingg asleep)
p) hallucinations
hypnopompic (upon awakening) hallucinations

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Narcolepsy
p y ((cont.))
b) Hypocretin deficiency (spinal tap needed)
Hypothalamic neuropeptide
Hypothalamic
Deficiency may be autoimmune-related
c) Characteristic PSG abnormalities
(either of the following)
REM sleep latency on a nocturnal PSG.

sleep latency & sleep-onset REM on a

daytime PSG (Multiple Sleep Latency Test
[MSLT]).
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Narcolepsy
p y Treatment
Polytherapy

1) Stimulants
Sti l t for
f somnolence
l
(
(e.g.,
modafinil)
d fi il)
and
2) Antidepressants for cataplexy
Monotherapy
M
h

1) Xyrem (sodium oxybate)

A schedule III drug that treats both somnolence
& cataplexy.
Available via a restricted distribution system.
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D. Breathing-Related
D
Breathing Related Sleep Disorder
Excessive sleepiness or insomnia that is
due to a sleep-related
sleep related breathing condition:
1 Obstructive Sleep Apnea Hypopnea
1.
2 Central Sleep Apnea
2.

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1) Obstructive Sleep Apnea Hypopnea

(OSAH)
Multiple

episodes of breathing
cessation/reduction occur per night due to
an upper airway obstruction.
Obstruction

is from extra tissue in the

throat that occludes the trachea when
person lies on back.
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OSAH (cont.)
Apneas/hypopneas

cause sleepiness why?

The rise in CO2 during apneas causes

temporary arousal (not awakening) from sleep,
which bumps the person from a deep to a light
stage of sleep.
Duration of sleep may be adequate, but the
p is unrefreshing.
g
sleep
Classic

Profile:
f
Middle-aged,
g overweight
g male
who snores loudly and intermittently.
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OSAH Treatment
Continuous Positive Airway Pressure
(CPAP): A device that maintains an open
airway by delivering compressed air at a specific
air pressure to the masks nasal pillow.
Additional

approaches to maintaining open

airway at night include weight loss,
loss avoiding
back sleeping, orthodontic devices, and surgery.
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2. Central Sleep Apnea (CSA)

Multiple

episodes of cessation of breathing per

night caused by CNS dysregulation of breathing.
breathing
Multiple Causes: Examples
ExamplesPrimary (idiopathic)
Opioid use
Opioid
Congestive heart failure
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CSA (cont.)
(cont )
A PSG

distinguishes OSA from CSA based on

whether thoracic movements occur at the start of
apneic episode:
OSAH (thoracic effort occurs)
CSA (no thoracic effort occurs)
Treatment: Varies depending on the cause and
may include CPAP, respiratory stimulants (e.g.,
acetazolamide) nocturnal oxygen,
acetazolamide),
oxygen etc.
etc
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E. Circadian Rhythm Sleep-Wake

E
Sleep Wake Disorder
(CRSWD)
Excessive sleepiness or insomnia resulting from
a mismatch between a persons circadian sleepwake pattern and the sleep-wake
sleep wake schedule required
by the environment.
Example
CRSWD, Delayed Sleep Phase Type: Delayed sleep
CRSWD
onset and awakening times, with the inability to fall
asleep and awaken at a desired earlier time.
time
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CRSWD Treatment
Phototherapy at strategic times during the day
to adjust the timing of the sleep-wake cycle.
cycle
Setting
g of Circadian Clock
(governed by the suprachiasmatic nucleus [SCN])

Light SCN inhibits

i hibit pineal gland
decreases melatonin alert
No light SCN activates pineal gland
increases melatonin drowsy
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F. Parasomnias
Disorders characterized by abnormal
behaviors associated with sleep.
1. Non-REM Sleep Arousal Disorder
2 Nightmare Disorder
2.
3. REM Sleep Behavior Disorder
4 Restless Legs Syndrome
4.
5. Periodic Limb Movements
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1. Non-REM Sleep Arousal Disorder

Repeated

episodes of incomplete awakening

from sleep with either of the following:
a)) Sleep
S eep Walking:
W
g: Rising
s g from
o bed aandd wa
walking
g
about with a blank and staring face, relative
unresponsiveness,
p
, and difficultyy awakening.
g
b)) Sleep
p Terrors: Abrupt
p terror arousals ((usually
y
with panicky scream), intense fear and autonomic
arousal, and unresponsiveness to comforting by
others.
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Non-REM Sleep Arousal Disorder (cont.)

Subtypes
Sleep Walking Type
Sleep Terror Type
Characterized by
episodes

occurring within first 1/3 of sleep

(during slow wave sleep [SWS]).
[SWS])
no (or little) dream imagery
amnesia
i for
f the
th episodes
i d
p
to SWS;; If
Treatment: If needed,, benzodiazepines
sleep walker, then consider environmental protection.25

2. Nightmare Disorder
Extremely dysphoric dreams that typically
involve threats to survival, security or physical
integrity.
integrity
Characterized

by
awakening in the 2nd half of sleep period
(during REM sleep)
rapid alertness upon awakening
dream
dream content is well remembered
good recall of the awakening the next morning

Treatment:

If needed, antidepressants to REM.

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3. REM Sleep Behavior Disorder (RSBD)

Vocalizations and/or complex motor
movements occur during REM sleep.

REM sleep without atonia is confirmed by PSG.

The disturbance is not induced by a substance.

RSBD Features
Typically action-filled, violent dreams
Immediately awake, oriented and alert with
detailed dream recall Video

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RSBD (cont.)
(
)
Most common in males >50 years old
Course is progressive and associated with
neurodegenerative
g
disease ((e.g.,
g , Parkinsons
disease, Lewy body dementia)
Treatment
Clonazepam (a benzodiazepine) the
therapeutic
h
i mechanism
h i off action
i iis unclear.
l
Modification
M difi i off sleep
l
environment
i
for
f safety
f
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4) Restless Legs Syndrome (RLS): Urge to

move legs
l
in
i response to
t uncomfortable
f t bl
sensations with all the following features:
occurs/worsens during inactivity
nocturnal
t
l worsening
i off symptoms
t
temporary relief from discomfort by moving
Patient is aware of symptoms and complains of
insomnia
Treatment: Anti
Anti-parkinsons
parkinson s drugs to DA (also,
benzos, anticonvulsants, etc.)
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5) Periodic Limb Movements (PLMs):

Repetitive muscle contractions during sleep,
usually of the lower limb.
associated with multiple sleep stage arousals
patient complains of daytime sleepiness but is
unaware of movements
confirm using leg electromyogram during PSG
treat using
g similar drugs
g as for RLS
Note: PLMs differ from sleep
sleep startles
startles, which are
contractions that occur only upon falling asleep.

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