Sleep-Wake Disorders and Insomnia

Sleep-Wake Disorders Overview

• Sleep-wake disorders include insomnia, hypersomnolence, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, parasomnias, restless legs syndrome, and substance/medication-induced sleep disorder.
• The diagnosis of these disorders is based on DSM 5 diagnostic criteria.

Insomnia Diagnostic Criteria

• Characterized by dissatisfaction with sleep quantity or quality.
• It involves difficulty initiating or maintaining sleep, and/or early-morning awakening with inability to return to sleep.
• It causes clinical distress or impairment.
• Occurs at least 3 nights per week for at least 3 months.
• Happens despite adequate opportunity to sleep.
• It is not secondary to another sleep-wake disorder, a substance, or another medical or mental disorder, if associated not completely explained by the disorder.

Insomnia Specifiers

• Can be specified by comorbidity with a mental disorder, a medical condition, or another sleep-wake disorder.
• Length can be episodic (1 to <3 months), persistent (≥3 months), or recurrent (2 or more episodes within a year).

Sleep Deprivation Complications

• Increased risk of depression and anxiety.
• Lower performance and decreased reaction time.
• Increased risk of diabetes.
• Increased risk of heart disease and high blood pressure.
• Decreased immune system function.
• Increased weight.

Insomnia Treatments

• Improve sleep hygiene and employ CBT for insomnia.
• Can treat with Benzodiazepines but are habit forming and can cause daytime somnolence (Temazepam (Restoril), Triazolam (Halcion), Estazolam (ProSom)).
• Can treat with Non-benzodiazepines because they have less abuse potential, little tolerance, and no daytime somnolence (Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta), Ramelteon (Rozerem), Suvorexant (Belsomra)).
• Chloral hydrate (discovered in chlorination of Ethanol, augments effect of alcohol, not FDA approved for sedation but can be used for studies and procedures).
• Antihistamines (Diphenhydramine (benadryl) & Doxylamine (unisom), have low potency, tolerance is developed fast and can impair sleep in long term use).
• Trazodone and doxepin (Silenor).

Hypersomnolence Disorder Diagnostic Criteria

• Excessive sleepiness despite at least 7 hours of sleep with recurrent lapses into sleep within the same day, unrefreshing sleep of >9 hours, or difficulty being awake after abrupt awakening
• Experiences clinical distress or impairment.
• Occurs at least 3 times per week for at least 3 months.
• It is not due to another sleep disorder, a substance, or a medical or mental disorder if associated not completely explained by the disorder.

Hypersomnolence Disorder (Specifiers)

• Can be specified by comorbidity with a mental disorder, a medical condition, or another sleep disorder.
• Length: can be acute (less than a month), subacute (1 to 3 months), or persistent (more than 3 months).
• Severity (difficulty maintaining daytime alertness): mild (1-2 days/week), moderate (3-4 days/week), or severe (5-7 days/week).

Hypersomnolence Disorder (Treatment)

• Improve sleep hygiene.
• Use stimulants like methylphenidate (5 to 60 mgs/day) or dextroamphetamine (10 to 60 mg/day).
• Use Modafinil (Provigil) at 200-400 mg/day but watch for erythema multiforme or Stevens-Johnson syndrome.
• Schedule naps if treatment is ineffective.

Narcolepsy Diagnostic Criteria

• Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day at least three times per week over the past 3 months.
• Present with at least one of cataplexy, hypocretin deficiency (CSF Value ≤110pg/mL), or nocturnal sleep polysomnography showing REM latency ≤15 minutes or mean sleep latency ≤ 8 minutes.

Cataplexy

• Brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness.
• Episodes are precipitated by laughter or joking.
• Spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia occur without any obvious emotional triggers.

Narcolepsy Specifiers

• Without cataplexy but with hypocretin deficiency.
• With cataplexy but without hypocretin deficiency.
• Secondary to other medical condition.
• Autosomal dominant cerebellar ataxia, deafness, and narcolepsy.
• Autosomal dominant narcolepsy, obesity, and type 2 diabetes.

Narcolepsy Diagnostic Specifiers

• Severity is determined based on cataplexy occurring weekly or daily, naps occurring 1-2/day or >2/day
• and whether sleep disruption is minimal, moderate or very disturbed resulting in a responsive treatment to medications or non responsive.

Narcolepsy Treatment

• Includes pharmacotherapy with stimulants (methylfenidate, modafinil, dextroamphetamine).
• Modafinil and Sodium oxybate (Xyrem), dosed at bedtime and 2 ½-4 hours later, it's a Schedule III drug..
• Tricyclic antidepressants.
• Family and employer education.
• Concern with potential sleep attacks while driving.

Breathing Related Disorders

• Central Sleep Apnea.
• Obstructive Sleep Apnea / Hypopnea.
• Sleep Related Hypoventilation.

Obstructive Sleep Apnea / Hypopnea

• Polysomnography showing at least five obstructive apneas or hypopneas per hour of sleep.
• Accompanied with Snoring, snorting/gasping, or breathing pauses during sleep, and/or Daytime sleepiness, fatigue, or unrefreshing sleep
• Polysomnography showing 15 or more obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms

Obstructive Sleep Apnea / Hypopnea Specifiers

• Severity is categorized by apnea hypopnea index: mild (less than 15), moderate (15-30), or severe (greater than 30).

Obstructive Sleep Apnea / Hypopnea Treatment

• Weight loss (at least 10% recommended).
• Avoid sedatives.
• Sleep supine or inclined.
• Oral appliances to keep airway open.
• CPAP (Continuous Positive Airway Pressure).
• Uvulopalatopharyngoplasty (severe/refractory cases).

Central Sleep Apnea

• Evidence by polysomnography shows five or more central apneas per hour of sleep.
• Not better explained by another current sleep disorder.

Central Sleep Apnea Specifiers

• Idiopathic central sleep apnea is repeated episodes of apneas and hypopneas without evidence of airway obstruction.
• Cheyne-Stokes breathing is periodic crescendo-decrescendo variation in tidal volume and it's associated with CHF, stroke, and renal failure.
• Comorbid with opioid use.
• Severity is associated with the frequency of breathing disturbances and the extent of associated oxygen desaturation.

Sleep Related Hypoventilation

• Polysomnography shows episodes of decreased respiration associated with elevated CO2 levels.
• Disturbance is not better explained by another current sleep disorder.

Sleep Related Hypoventilation Specifiers

• Idiopathic hypoventilation
• Congenital central alveolar hypoventilation is rare and presents in perinatal period.
• Can be due to pulmonary disorder, neuromuscular chest wall disorder, medications, or obesity.
• Severity is graded according to hypoxemia and hypercarbia, and evidence of end organ impairment.

Hypoventilation Treatment

• Bronchodilators (Albuterol).
• Theophylline can be used.
• Avoid CNS depressants.
• Weight loss (at least 10% recommended).
• CPAP support can be used.
• Endotracheal ventilation with mechanical intubation may also be implemented.

Circadian Rhythm Sleep Wake Disorders Criteria

• Characterized by sleep disruption due to alteration or misalignment of endogenous circadian rhythm and sleep-wake schedule.
• Causes excessive sleepiness, insomnia, or both.
• Clinically significant impairment or distress.

Circadian Rhythm Sleep Wake Disorders Specifiers

• Include delayed sleep phase, advanced sleep phase, irregular sleep-wake type, non-24hr sleep-wake type, shift work type and Familial.
• Can be Familial or Unspecified.

Circadian Rhythm Sleep Wake Disorders Specifiers (Severity)

• Severity can be episodic (from 1 to 3 months).
• Can also be Persistent (at least three months).
• Lastly can be Recurrent (two or more episodes per year).

Circadian Rhythm Sleep Wake Disorders (Treatment for delayed sleep wake phase)

• Chronotherapy, light restriction at night and bright light exposure during morning along with hypnotics or melatonin.

Circadian Rhythm Sleep Wake Disorders (Treatment for advanced sleep wake phase)

• Bright light exposure during afternoon and chronotherapy.
• Work Shift type: Armodafinil, or consider job shift change.

Non-REM Sleep Arousal Disorder Criteria

• Incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, with sleepwalking or sleep terrors.
• There is no dream recall, amnesia for the episodes, and clinically significant distress.
• Not due to a substance, medical condition, or other mental disorders.

Non-REM Sleep Arousal Disorder Specifiers

• Sleepwalking type is specified if it includes sleep-related eating or sexual behavior.
• Sleep terror type.

Non-REM Sleep Arousal Disorder Characteristics

• Occurs in stage 3 Non-REM sleep with high amplitude slow waves.
• 15% of children present with sleep walking and 5% with sleep terrors.
• They usually disappear by adulthood, but if new or continues into adulthood need to explore other sleep or mental disorders.
• It's Familial.

Non-REM Sleep Arousal Disorder Treatment

• Establish good sleep hygiene.
• Episodes occur more when excessively tired, using caffeine or stimulants, and going to bed upset.
• Focus on Protection from injury.
• May need Benzodiazepines for it's ability to suppress stage 3 sleep.
• TCA, SSRIs and Melatonin might be effective.

Nightmare Disorder Criteria

• Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams.
• Dreams usually involve efforts to avoid threats to survival, security, or physical integrity.
• Dreams generally occur during the second half of the major sleep episode.
• On awakening rapidly becomes oriented and alert.
• Causes Clinically significant distress or impairment.
• Not attributable to the physiological effects of a substance.
• Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams.

Nightmare Disorder Criteria Specifiers

• Specifiers During sleep onset.
• Specifiers With associated non–sleep disorder, including substance use disorders.
• Specifiers With associated other medical condition.
• Specifiers With associated other sleep disorder.

Nightmare Disorder Criteria Specifiers (Length)

• Specifiers include Acute(1 month or less), Subacute(1 month to 6 month) and Persistent(6 month or greater).

Nightmare Disorder Criteria Specifiers (Severity)

• Severity includes Mild(one episode per week), Moderate(one or more episodes per week), or Severe(nightly episodes).

REM Behavior Disorder Criteria

• Repeated episodes of arousal with vocalization and/or movement during REM sleep.
• The person awakens easily, is alert, and oriented.
• Either Polysomnogram indicates REM sleep without atonia
• Suggestive history and synucleinopathy (Parkinson’s, Lewi body, multiple system atrophy).
• Clinically significant distress.
• Not secondary to a substance or medical condition.
• Existing disorders do not explain episodes.

REM Behavior Disorder Treatment

• Sleeping in different rooms.
• Treat with Clonazepam, but symptoms relapse on discontinuation.
• Melatonin can be helpful.
• Tricyclic antidepressants, SSRIs, serotonin-norepinephrine reuptake inhibitors, and beta-blockers.

Restless Legs Syndrome Criteria

• Urge to move the legs in response to uncomfortable sensations in the legs.
• Worse in periods of rest.
• Relieved by movement.
• Worse or only present at night.
• Occurs At least 3 times per week for 3 months.
• Clinically significant distress.
• Not secondary to medical or mental disorder, or behavior.
• Associated with Arthritis, edema, positional discomfort, foot tapping.
• and is Not due to a substance.

Restless Legs Syndrome Treatment

• Dopamine agonists, Pramipexole (Mirapex), Ropinirole (Requip), Rotigotine (Neupro).
• Treat with Gabapentin enacarbil.
• Iron replacement is a must if ferritin levels are less than 50ng/mL.

Substance Medication Induced Sleep Disorder

• Characterized by prominent sleep disturbance primarily associated with the known effects of a substance of abuse or a medication.
• Included substances are Caffeine, Stimulants, Cocaine, Benzodiazepines, and Alcohol.