Podcast
Questions and Answers
A patient reports dissatisfaction with sleep quality, difficulty maintaining sleep, and early-morning awakening, occurring at least three nights a week for the past four months. Which additional criterion definitively establishes a diagnosis of insomnia disorder according to DSM-5?
A patient reports dissatisfaction with sleep quality, difficulty maintaining sleep, and early-morning awakening, occurring at least three nights a week for the past four months. Which additional criterion definitively establishes a diagnosis of insomnia disorder according to DSM-5?
- The symptoms are exacerbated by excessive daytime napping.
- The patient reports improvement in sleep quality with the use of over-the-counter antihistamines.
- The patient has a documented history of obstructive sleep apnea with an AHI > 15.
- The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (correct)
A patient is diagnosed with insomnia disorder. Which specifier, if present, would suggest the need for a more comprehensive psychiatric evaluation beyond sleep-focused interventions?
A patient is diagnosed with insomnia disorder. Which specifier, if present, would suggest the need for a more comprehensive psychiatric evaluation beyond sleep-focused interventions?
- Co-existing major depressive disorder inadequately controlled with current antidepressant therapy. (correct)
- Episodic insomnia lasting two months.
- Recurrent insomnia episodes occurring twice within the past year, resolving spontaneously.
- Comorbidity with a documented history of controlled hypertension.
A patient presents to the clinic complaining of chronic insomnia. Initial sleep hygiene education has proven ineffective. Considering the guidance, which intervention should be the MOST appropriate INITIAL pharmacological approach, assuming no contraindications?
A patient presents to the clinic complaining of chronic insomnia. Initial sleep hygiene education has proven ineffective. Considering the guidance, which intervention should be the MOST appropriate INITIAL pharmacological approach, assuming no contraindications?
- Trial use of chloral hydrate as a first-line sedative due to its rapid onset of action.
- Initiation of long-term, as-needed use of diazepam (Valium) to improve sleep maintenance.
- Prescription of high-dose melatonin (20mg) to promote sleep onset.
- Cognitive Behavioral Therapy for Insomnia (CBT-I). (correct)
A patient reports experiencing excessive daytime sleepiness despite obtaining over nine hours of sleep each night. They also report significant difficulty waking up in the morning, often feeling confused and disoriented for several hours. This occurs almost daily. Which diagnostic criterion is MOST essential to differentiate hypersomnolence disorder from other sleep disorders?
A patient reports experiencing excessive daytime sleepiness despite obtaining over nine hours of sleep each night. They also report significant difficulty waking up in the morning, often feeling confused and disoriented for several hours. This occurs almost daily. Which diagnostic criterion is MOST essential to differentiate hypersomnolence disorder from other sleep disorders?
A patient is diagnosed with hypersomnolence disorder. Which of the following specifiers would influence the urgency and intensity of treatment intervention?
A patient is diagnosed with hypersomnolence disorder. Which of the following specifiers would influence the urgency and intensity of treatment intervention?
A patient with hypersomnolence disorder has failed to respond adequately to both methylphenidate and dextroamphetamine. Which of the following represents the MOST appropriate NEXT-STEP pharmacological intervention?
A patient with hypersomnolence disorder has failed to respond adequately to both methylphenidate and dextroamphetamine. Which of the following represents the MOST appropriate NEXT-STEP pharmacological intervention?
A patient reports an overwhelming need to sleep, lapsing into naps multiple times daily for at least three months. To definitively diagnose narcolepsy according to DSM-5, which of the following MUST also be present?
A patient reports an overwhelming need to sleep, lapsing into naps multiple times daily for at least three months. To definitively diagnose narcolepsy according to DSM-5, which of the following MUST also be present?
A patient is suspected of having narcolepsy. What clinical feature would MOST strongly suggest the presence of cataplexy?
A patient is suspected of having narcolepsy. What clinical feature would MOST strongly suggest the presence of cataplexy?
The MOST accurate statement regarding narcolepsy specifiers is:
The MOST accurate statement regarding narcolepsy specifiers is:
Which pharmacological agent, used in the management of narcolepsy, carries the HIGHEST risk of potential abuse and requires careful monitoring due to its classification as a Schedule III controlled substance?
Which pharmacological agent, used in the management of narcolepsy, carries the HIGHEST risk of potential abuse and requires careful monitoring due to its classification as a Schedule III controlled substance?
According to the diagnostic criteria, what is the MINIMUM number of obstructive apneas or hypopneas per hour of sleep (AHI) required to diagnose central sleep apnea (OSA) in a patient presenting with symptoms like snoring, daytime sleepiness and fatigue?
According to the diagnostic criteria, what is the MINIMUM number of obstructive apneas or hypopneas per hour of sleep (AHI) required to diagnose central sleep apnea (OSA) in a patient presenting with symptoms like snoring, daytime sleepiness and fatigue?
A patient undergoes polysomnography, revealing an apnea-hypopnea index (AHI) of 22. According to standard severity classifications for obstructive sleep apnea, this finding would categorize the patient's condition as:
A patient undergoes polysomnography, revealing an apnea-hypopnea index (AHI) of 22. According to standard severity classifications for obstructive sleep apnea, this finding would categorize the patient's condition as:
In managing obstructive sleep apnea, which intervention should be considered FIRST-LINE for most patients, assuming no contraindications?
In managing obstructive sleep apnea, which intervention should be considered FIRST-LINE for most patients, assuming no contraindications?
What is the MINIMUM frequency of central apneas per hour of sleep, as determined by polysomnography, to diagnose central sleep apnea?
What is the MINIMUM frequency of central apneas per hour of sleep, as determined by polysomnography, to diagnose central sleep apnea?
Which specific breathing pattern is characterized by a periodic crescendo-decrescendo variation in tidal volume, often associated with heart failure, stroke, and renal failure, and can be a specifier of central sleep apnea?
Which specific breathing pattern is characterized by a periodic crescendo-decrescendo variation in tidal volume, often associated with heart failure, stroke, and renal failure, and can be a specifier of central sleep apnea?
Sleep-related hypoventilation is characterized primarily by which physiological parameter?
Sleep-related hypoventilation is characterized primarily by which physiological parameter?
What treatment is MOST appropriate for sleep-related hypoventilation?
What treatment is MOST appropriate for sleep-related hypoventilation?
For an individual with Delayed Sleep Phase Disorder (DSPD), which intervention is MOST effective in realigning their sleep-wake cycle?
For an individual with Delayed Sleep Phase Disorder (DSPD), which intervention is MOST effective in realigning their sleep-wake cycle?
In the treatment of Advanced Sleep-Wake Phase Disorder, what is the rationale behind recommending bright light exposure during the afternoon?
In the treatment of Advanced Sleep-Wake Phase Disorder, what is the rationale behind recommending bright light exposure during the afternoon?
A patient is diagnosed with Shift Work Sleep Disorder. Besides pharmacological interventions, which non-pharmacological strategy holds the MOST promise for improving their sleep and wakefulness?
A patient is diagnosed with Shift Work Sleep Disorder. Besides pharmacological interventions, which non-pharmacological strategy holds the MOST promise for improving their sleep and wakefulness?
What is the defining characteristic of Non-REM Sleep Arousal Disorder?
What is the defining characteristic of Non-REM Sleep Arousal Disorder?
In cases of Non-REM Sleep Arousal Disorder presenting with sleepwalking, which additional feature would warrant further investigation for underlying neurological conditions?
In cases of Non-REM Sleep Arousal Disorder presenting with sleepwalking, which additional feature would warrant further investigation for underlying neurological conditions?
What best describes treatment for non-REM sleep arousal disorder?
What best describes treatment for non-REM sleep arousal disorder?
Which feature is MOST characteristic of nightmare disorder according to DSM-5 criteria?
Which feature is MOST characteristic of nightmare disorder according to DSM-5 criteria?
Which statement regarding Nightmare Disorder specifiers is MOST accurate?
Which statement regarding Nightmare Disorder specifiers is MOST accurate?
Which therapeutic approach is typically considered MOST effective for managing persistent Nightmare Disorder?
Which therapeutic approach is typically considered MOST effective for managing persistent Nightmare Disorder?
What is the key polysomnographic finding that differentiates REM Sleep Behavior Disorder (RBD) from typical REM sleep?
What is the key polysomnographic finding that differentiates REM Sleep Behavior Disorder (RBD) from typical REM sleep?
A patient is diagnosed with REM Sleep Behavior Disorder. What co-existing condition is now recognized to have a STRONG association with RBD and requires careful monitoring?
A patient is diagnosed with REM Sleep Behavior Disorder. What co-existing condition is now recognized to have a STRONG association with RBD and requires careful monitoring?
What is the FIRST-LINE treatment for REM Sleep Behavior Disorder to improve patient safety?
What is the FIRST-LINE treatment for REM Sleep Behavior Disorder to improve patient safety?
What is the primary characteristic used to diagnose Restless Legs Syndrome?
What is the primary characteristic used to diagnose Restless Legs Syndrome?
If initial interventions for Restless Legs Syndrome (RLS) fail, which medication class represents the next appropriate pharmacological approach?
If initial interventions for Restless Legs Syndrome (RLS) fail, which medication class represents the next appropriate pharmacological approach?
Which of the following is a CRITICAL step in the management of Restless Legs Syndrome (RLS), particularly when ferritin levels are low?
Which of the following is a CRITICAL step in the management of Restless Legs Syndrome (RLS), particularly when ferritin levels are low?
Which class of substances has the HIGHEST likelihood of direct causation with 'Substance/Medication-Induced Sleep Disorder'?
Which class of substances has the HIGHEST likelihood of direct causation with 'Substance/Medication-Induced Sleep Disorder'?
A patient reports persistent insomnia symptoms that began shortly after starting a new medication for hypertension. To diagnose 'Substance/Medication-Induced Sleep Disorder,' the sleep disturbance MUST be:
A patient reports persistent insomnia symptoms that began shortly after starting a new medication for hypertension. To diagnose 'Substance/Medication-Induced Sleep Disorder,' the sleep disturbance MUST be:
A 70-year-old male with a history of Parkinson's disease presents with new-onset insomnia, vivid dreams, and acting out his dreams during sleep. Polysomnography reveals REM sleep without atonia. Which of the following is the MOST likely diagnosis?
A 70-year-old male with a history of Parkinson's disease presents with new-onset insomnia, vivid dreams, and acting out his dreams during sleep. Polysomnography reveals REM sleep without atonia. Which of the following is the MOST likely diagnosis?
A 35-year-old female reports excessive daytime sleepiness despite getting 9-10 hours of sleep per night. She also complains of difficulty waking up in the morning and feeling groggy for several hours. Polysomnography is normal. A multiple sleep latency test (MSLT) shows a mean sleep latency of 10 minutes and no sleep-onset REM periods. Which of the following is the MOST likely diagnosis?
A 35-year-old female reports excessive daytime sleepiness despite getting 9-10 hours of sleep per night. She also complains of difficulty waking up in the morning and feeling groggy for several hours. Polysomnography is normal. A multiple sleep latency test (MSLT) shows a mean sleep latency of 10 minutes and no sleep-onset REM periods. Which of the following is the MOST likely diagnosis?
A 50-year-old male with a history of hypertension and obesity presents with snoring, daytime sleepiness, and morning headaches. Polysomnography reveals an apnea-hypopnea index (AHI) of 35, with predominantly obstructive events. Which of the following is the MOST appropriate initial treatment for this patient?
A 50-year-old male with a history of hypertension and obesity presents with snoring, daytime sleepiness, and morning headaches. Polysomnography reveals an apnea-hypopnea index (AHI) of 35, with predominantly obstructive events. Which of the following is the MOST appropriate initial treatment for this patient?
A 25-year-old male reports difficulty falling asleep and prefers to go to bed around 2:00 AM and wake up around 10:00 AM. He has no difficulty staying asleep once he falls asleep. He reports significant distress due to his inability to adhere to a conventional sleep-wake schedule. Which of the following is the MOST likely diagnosis?
A 25-year-old male reports difficulty falling asleep and prefers to go to bed around 2:00 AM and wake up around 10:00 AM. He has no difficulty staying asleep once he falls asleep. He reports significant distress due to his inability to adhere to a conventional sleep-wake schedule. Which of the following is the MOST likely diagnosis?
A 10-year-old child presents with episodes of screaming and apparent terror during sleep. These episodes occur during the first third of the night, and the child is inconsolable and does not remember the event the next morning. Which of the following is the MOST likely diagnosis?
A 10-year-old child presents with episodes of screaming and apparent terror during sleep. These episodes occur during the first third of the night, and the child is inconsolable and does not remember the event the next morning. Which of the following is the MOST likely diagnosis?
A 40-year-old female reports an irresistible urge to move her legs, especially at night, which is relieved by movement. She also reports difficulty falling asleep and frequent awakenings due to these sensations. Which of the following is the MOST appropriate initial treatment for this patient?
A 40-year-old female reports an irresistible urge to move her legs, especially at night, which is relieved by movement. She also reports difficulty falling asleep and frequent awakenings due to these sensations. Which of the following is the MOST appropriate initial treatment for this patient?
A 60-year-old male with a history of chronic opioid use presents with frequent awakenings during sleep and reports feeling unrefreshed in the morning. Polysomnography reveals frequent central apneas. Which of the following is the MOST likely cause of this patient's sleep disturbance?
A 60-year-old male with a history of chronic opioid use presents with frequent awakenings during sleep and reports feeling unrefreshed in the morning. Polysomnography reveals frequent central apneas. Which of the following is the MOST likely cause of this patient's sleep disturbance?
In a patient presenting with persistent insomnia, what advanced neuroimaging technique could BEST differentiate between primary insomnia disorder and insomnia secondary to subtle neurodegenerative changes?
In a patient presenting with persistent insomnia, what advanced neuroimaging technique could BEST differentiate between primary insomnia disorder and insomnia secondary to subtle neurodegenerative changes?
A patient with insomnia is suspected of comorbid restless legs syndrome (RLS). Which polysomnographic finding would MOST strongly support a diagnosis of RLS influencing their insomnia?
A patient with insomnia is suspected of comorbid restless legs syndrome (RLS). Which polysomnographic finding would MOST strongly support a diagnosis of RLS influencing their insomnia?
What specific cognitive bias is MOST likely to perpetuate chronic insomnia, wherein a patient disproportionately focuses on and exaggerates the negative consequences of sleep loss?
What specific cognitive bias is MOST likely to perpetuate chronic insomnia, wherein a patient disproportionately focuses on and exaggerates the negative consequences of sleep loss?
In evaluating a patient for hypersomnolence disorder, measuring CSF levels of which neuropeptide would provide the MOST direct evidence against a diagnosis of narcolepsy?
In evaluating a patient for hypersomnolence disorder, measuring CSF levels of which neuropeptide would provide the MOST direct evidence against a diagnosis of narcolepsy?
A patient with hypersomnolence disorder is refractory to typical stimulant medications. Which neuroimaging finding, if present, would suggest a potential therapeutic role for clarithromycin?
A patient with hypersomnolence disorder is refractory to typical stimulant medications. Which neuroimaging finding, if present, would suggest a potential therapeutic role for clarithromycin?
Which of the following autoimmune-mediated mechanisms has been MOST convincingly implicated in the pathogenesis of narcolepsy with cataplexy?
Which of the following autoimmune-mediated mechanisms has been MOST convincingly implicated in the pathogenesis of narcolepsy with cataplexy?
In a patient with suspected narcolepsy but ambiguous cataplexy, which advanced electrophysiological measure during polysomnography could provide the STRONGEST confirmatory evidence?
In a patient with suspected narcolepsy but ambiguous cataplexy, which advanced electrophysiological measure during polysomnography could provide the STRONGEST confirmatory evidence?
A patient presents with symptoms of severe obstructive sleep apnea (OSA) but is completely intolerant to CPAP therapy. Which surgical intervention has demonstrated the MOST robust long-term efficacy in reducing AHI and improving sleep architecture, albeit with significant potential morbidity?
A patient presents with symptoms of severe obstructive sleep apnea (OSA) but is completely intolerant to CPAP therapy. Which surgical intervention has demonstrated the MOST robust long-term efficacy in reducing AHI and improving sleep architecture, albeit with significant potential morbidity?
In a patient with central sleep apnea (CSA) secondary to chronic opioid use, which specific respiratory pattern, identifiable on polysomnography, would suggest the addition of adaptive servo-ventilation (ASV) could be harmful?
In a patient with central sleep apnea (CSA) secondary to chronic opioid use, which specific respiratory pattern, identifiable on polysomnography, would suggest the addition of adaptive servo-ventilation (ASV) could be harmful?
What is the MOST critical consideration when initiating positive airway pressure (PAP) therapy for sleep-related hypoventilation in patients with severe COPD and concomitant hypercapnia?
What is the MOST critical consideration when initiating positive airway pressure (PAP) therapy for sleep-related hypoventilation in patients with severe COPD and concomitant hypercapnia?
For a blind individual with Non-24-Hour Sleep-Wake Disorder, what intervention has shown the MOST promise in entraining their circadian rhythm?
For a blind individual with Non-24-Hour Sleep-Wake Disorder, what intervention has shown the MOST promise in entraining their circadian rhythm?
Which advanced behavioral intervention strategy is MOST likely to benefit patients with persistent Delayed Sleep-Wake Phase Disorder who have failed to respond adequately to standard chronotherapy and light exposure?
Which advanced behavioral intervention strategy is MOST likely to benefit patients with persistent Delayed Sleep-Wake Phase Disorder who have failed to respond adequately to standard chronotherapy and light exposure?
In managing Non-REM Sleep Arousal Disorder, what clinical finding would warrant an urgent referral for neurological evaluation and advanced neuroimaging?
In managing Non-REM Sleep Arousal Disorder, what clinical finding would warrant an urgent referral for neurological evaluation and advanced neuroimaging?
A patient with nightmare disorder also exhibits symptoms suggestive of PTSD. The MOST appropriate evidence-based intervention to address both conditions simultaneously would be:
A patient with nightmare disorder also exhibits symptoms suggestive of PTSD. The MOST appropriate evidence-based intervention to address both conditions simultaneously would be:
What ethical consideration is MOST paramount when recommending clonazepam for REM Sleep Behavior Disorder, given its potential long-term neurological consequences?
What ethical consideration is MOST paramount when recommending clonazepam for REM Sleep Behavior Disorder, given its potential long-term neurological consequences?
Flashcards
Insomnia Disorder
Insomnia Disorder
A sleep disorder characterized by difficulty initiating or maintaining sleep, or early-morning awakening with inability to return to sleep, occurring at least 3 nights per week for 3 months.
Hypersomnolence Disorder
Hypersomnolence Disorder
A sleep disorder characterized by excessive sleepiness despite 7 hours of sleep, including recurrent lapses into sleep, unrefreshing sleep, or difficulty being awake after abrupt awakening, occurring 3 times per week for 3 months.
Narcolepsy
Narcolepsy
A sleep disorder characterized by an irrepressible need to sleep, with recurrent periods of sleep or napping, occurring three times per week for 3 months, and at least one of cataplexy, hypocretin deficiency, or REM sleep abnormalities.
Breathing-Related Sleep Disorders
Breathing-Related Sleep Disorders
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Parasomnias
Parasomnias
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Non-REM Sleep Arousal Disorder
Non-REM Sleep Arousal Disorder
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Nightmare Disorder
Nightmare Disorder
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Cataplexy
Cataplexy
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Cataplexy
Cataplexy
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Circadian Rhythm Sleep-Wake Disorders
Circadian Rhythm Sleep-Wake Disorders
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Treatment of Delayed Sleep wake phase
Treatment of Delayed Sleep wake phase
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REM Behavior Disorder
REM Behavior Disorder
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Restless Legs Syndrome
Restless Legs Syndrome
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Obstructive Sleep Apnea/Hypopnea
Obstructive Sleep Apnea/Hypopnea
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Sleep Related Hypoventilation
Sleep Related Hypoventilation
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Study Notes
Objectives in Diagnosing Patients
- Diagnose patients using DSM 5 diagnostic criteria
- Insomnia Disorder
- Hypersomnolence Disorder
- Narcolepsy
- Breathing-Related Sleep Disorders (Obstructive Sleep Apnea, Central Sleep Apnea, Sleep Related Hypoventilation)
- Circadian Rhythm Sleep-Wake Disorders
- Parasomnias (Non-REM Sleep Arousal Disorders, REM Sleep Behavior Disorder)
- Restless Legs Syndrome
- Substance/Medication-Induced Sleep Disorder
Further Objectives
- Classify sleep disorders using specifiers
- Compare and contrast nightmares and sleep terrors
- Predict the course and prognosis of sleep-wake disorders
- Construct a strategy for assessment and treatment of sleep-wake disorders in general medical practice
Insomnia Diagnostic Criteria
- Characterized by dissatisfaction with sleep quantity or quality. Includes one or more:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early-morning awakening with inability to return to sleep
- Leads to clinical distress or impairment
- Occurs at least 3 nights per week for at least 3 months
- Happens despite adequate opportunity for sleep
- Not during another sleep-wake disorder or secondary to substance use
- Not caused by other medical or mental disorders, or is not fully explained by these disorders
Insomnia Specifiers
- Comorbidity:
- With a mental disorder
- With a medical condition
- With another sleep-wake disorder
- Length:
- Episodic is 1 - 3 months
- Persistent is over 3 months
- Recurrent includes 2 or more episodes within a year
Complications of Sleep Deprivation
- Sleep deprivation is linked to increased risk of:
- Depression and anxiety
- Reduced performance and slower reaction time
- Diabetes
- Heart disease and high blood pressure
- Decreased immune system function
- Weight gain
Insomnia Treatments
- Focus on improving sleep hygiene and using CBT for insomnia
- Benzodiazepines considerations:
- Not the first choice of treatment due to risk of habit forming and daytime somnolence
- Examples of Benzodiazepines: Temazepam (Restoril), Triazolam (Halcion), and Estazolam (ProSom)
- Non-benzodiazepines:
- Have a lower abuse potential, little tolerance development, and no daytime somnolence
- Examples: Zaleplon (Sonata), Zolpidem (Ambien), Eszopiclone (Lunesta), Ramelteon (Rozerem), and Suvorexant (Belsomra)
- Chloral hydrate:
- Discovered during the chlorination of Ethanol
- Augments the effects of alcohol
- Not FDA approved; used for sedation in studies and procedures
- Antihistamines:
- Have low potency, fast tolerance development, and can impair sleep with long-term use
- Examples: Diphenhydramine (Benadryl) and Doxylamine (Unisom)
- Trazodone and Doxepin (Silenor)
Hypersomnolence Disorder Diagnostic Criteria
- Features excessive sleepiness despite at least 7 hours of sleep
- Includes one of the following:
- Recurrent lapses into sleep within the same day
- Unrefreshing sleep of over 9 hours
- Difficulty being awake after abrupt awakening (sleep drunkenness)
- Clinical distress or impairment
- Present at least 3 times per week for at least 3 months
- Not caused by other sleep disorders or a substance
- Cannot be better explained by other medical or mental disorders
Hypersomnolence Disorder Specifiers
- Comorbidity:
- With a mental disorder
- With a medical condition
- With another sleep disorder
- Length:
- Acute is less than a month
- Subacute is 1 to 3 months
- Persistent is more than 3 months
- Severity determined by challenges in maintaining daytime alertness:
- Mild is 1-2 days per week
- Moderate is 3-4 days per week
- Severe is 5-7 days per week
Hypersomnolence Disorder Treatment
- Includes sleep hygiene.
- Stimulants:
- Methylphenidate dose is 5 to 60 mg per day.
- Dextroamphetamine dose is 10 to 60 mg per day.
- Modafinil (Provigil) dose is 200-400 mg per day, which can cause Erythema multiforme or Stevens-Johnson syndrome.
- Scheduled naps are recommended if treatment is ineffective.
Narcolepsy Diagnostic Criteria
- Recurrent, irrepressible need to sleep, with lapses into sleep or naps occurring within the same day
- Occurs at least three times per week over the past 3 months
- Presence of at least one of the following:
- Cataplexy
- Hypocretin deficiency; CSF Value ≤110pg/mL
- Nocturnal sleep polysomnography showing REM latency ≤15 minutes
- Mean sleep latency ≤ 8 minutes
Cataplexy
- Brief episodes of sudden bilateral loss of muscle tone with maintained consciousness are precipitated by laughter or joking
- Spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without obvious emotional triggers.
Narcolepsy Specifiers
- Can occur with or without cataplexy
- Associated with hypocretin deficiency
- Secondary to other medical conditions
- Autosomal dominant cerebellar ataxia
- Deafness, narcolepsy, obesity, and type 2 diabetes may be present.
Narcolepsy Diagnostic
- Mild is Cataplexy less than once per week, 1-2 naps per day and minimal Sleep disruption and responsive to treatment
- Moderate is Cataplexy once per day, more than 2 naps per day and moderately Sleep disruption and responsive to treatment
- Severe is Cataplexy multiple times per day, constant sleepiness and Very Sleep disruption and not responsive to medications
Narcolepsy Treatment
- Pharmacotherapy like Stimulants, Modafinil, Sodium Oxybate and Tricyclic antidepressants
- Stimulants: Methylphenidate, Modafinil, Dextroamphetamine
- Sodium Oxybate (Xyrem): Dosed at bedtime and 2.5-4 hours later; Schedule III drug
- Family and employer education
- Address concerns about potential sleep attacks while driving.
Breathing Related Disorders
- Includes Central Sleep Apnea
- Includes Obstructive Sleep Apnea / Hypopnea
- Includes Sleep Related Hypoventilation
Obstructive Sleep Apnea / Hypopnea
- Polysomnography indicates at least five obstructive apneas or hypopneas per hour of sleep
- Also linked to snoring or breathing pauses during sleep
- Excessive daytime sleepiness, fatigue, or unrefreshing sleep can occur, unrelated to other conditions
Diagnosis of Obstructive Sleep Apnea
- Polysomnography is needed, must indicate 15 or more obstructive apneas with hypopneas per hour
- Symptoms include snoring, gasping, breathing pauses, daytime sleepiness, and fatigue
- Obstructive Sleep Apnea/Hypopnea can also be categorized by:
- Mild has an apnea-hypopnea index less than 15
- Moderate has an apnea-hypopnea index between15 and 30
- Severe has an apnea-hypopnea index greater than 30
Obstructive Sleep Apnea / Hypopnea Treatment
- Involves weight loss of 10% is recommended
- Avoidance of sedatives
- Sleeping in a non-supine position
- Oral appliances to keep airway open
- CPAP (Continuous Positive Airway Pressure)
- Uvulopalatopharyngoplasty for severe or refractory cases
Central Sleep Apnea
- Polysomnography shows five or more central apneas per hour of sleep
- The disorder is not better explained by another current sleep disorder.
Central Sleep Apnea Specifiers
- Idiopathic central sleep apnea with episodes of apneas and hypopneas without evidence of airway obstruction
- Cheyne-Stokes breathing shows crescendo-decrescendo, variation in tidal volume
- This is associated with CHF, stroke, and renal failure
- Severity is tied to the frequency of breathing disturbances and the extent of oxygen desaturation
Sleep Related Hypoventilation
- Polysomnography reveals episodes of decreased respiration with elevated CO2 levels
- The disturbance is not better explained by another current sleep disorder
Sleep Related Hypoventilation Specifiers
- Idiopathic hypoventilation
- Congenital central alveolar hypoventilation presents rarely in the perinatal period
- Comorbid sleep-related hypoventilation caused by pulmonary disorders and neuromuscular chest wall disorders
- Can also be caused by medications, or obesity
- Severity is graded according to hypoxemia and hypercarbia and is indicated by end-organ impairment
Hypoventilation Treatment Options
- Bronchodilators like Albuterol
- Theophylline
- Avoid CNS depressants is need
- Weight loss of 10% is recommended
- CPAP devices may be indicated
- Endotracheal ventilation with mechanical intubation
Circadian Rhythm Sleep-Wake Disorders
- Sleep disruption is due to alteration or misalignment of endogenous circadian rhythm and sleep-wake schedule
- Characterized by sleep disruption which leads to excessive sleepiness or insomnia or both
- Can cause significant impairment or distress
Circadian Rhythm Sleep-Wake Disorders Specifiers
- Delayed Sleep phase
- Familial
- Overlapping with non-24hr sleep/wake
- Advanced sleep phase is Familial
- Irregular sleep-wake type
- Non-24hr sleep/wake
- Shift work type
- Unspecified
Circadian Rhythm Sleep-Wake Disorders Severity Specifiers
- Episodic which can last 1 - 3 months
- Persistent which is more than 3 months
- Characterized by Recurrent patterns with two or more episodes per year
Circadian Rhythm Sleep-Wake Disorders Treatment
- Delayed Sleep wake phase:
- Chronotherapy
- Light restriction at night
- Bright light exposure during morning
- Hypnotics
- Melatonin
- With Advanced Sleep wake phase:
- Bright light exposure during afternoon
- Chronotherapy
- For Work Shift type:
- Taking Armodafinil
- Changing job or shift
Parasomnia
- Involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, during sleep, or while waking up
- Includes Non-REM Sleep Arousal Disorder
Non-REM Sleep Arousal Disorder Criteria
- Incomplete awakening from sleep occurs during the first third of the major sleep episode with Sleepwalking or Sleep terrors
- Amnesia for the episodes and no recall of the dream
- Causes clinically significant distress
- Not due to a substance, medical condition, or other mental disorders
Non-REM Sleep Arousal Disorder Specifiers
- Sleepwalking type:
- Can be associated with with sleep-related eating or with sleep-related sexual behavior (sexsomnia)
- Sleep terror type
More on Non-REM Sleep Arousal Disorder
- Occurs in stage 3 Non-REM sleep with high amplitude slow waves
- 15% of children present with sleep walking; 5% with sleep terrors
- Usually disappear by adulthood
- If new or continues into adulthood explore other sleep or mental disorders
- Can be Familial
Non-REM Sleep Arousal Disorder Treatment
- Involve good sleep hygiene
- Reducing episodes when patient is excessively tired, using caffeine, stimulants, or going to bed upset
- Protection from injury
- Benzodiazepines can suppress stage 3 sleep
- TCA, SSRIs and Melatonin might be effective
Nightmare Disorder Criteria
- Repeated episodes of extended and dysphoric well-remembered dreams
- Involves efforts to avoid threats to survival, security, or physical integrity
- Typically, occur during the second half of the major sleep episode
- Rapidly becomes oriented and alert after they awaken
- Creates clinically significant distress or impairment
- Not attributed to substance use or explained by other mental/medical disorders
Specifiers for Nightmare Disorder Criteria
- During sleep onset
- Co-occurring non-sleep disorder, including substance use disorders
- Occurs With other medical conditions
- Occurs With associated other sleep disorder
Sub-Classifications and Severity
- Divided by Acute lasting one month or less
- Sub acute lasting one to six months
- As well as Persistent dreams that continue for more than six months
- These disorders come in degrees of severity
- Mild: one episode per week on average
- Moderate: one or more episodes per week
- Severe: nightly episodes
REM Behavior Disorder Criteria
- Episodes of arousal with vocalization or movement occur during REM sleep
- Easily awakens, is alert, and is oriented
- Confirmed by polysomnogram where It shows REM sleep without atonia
- Has a suggestive history of synucleinopathy (Parkinson’s, Lewi body, multiple system atrophy)
- Causes clinically significant distress
- Not secondary to medications
- Must be unrelated to other disorders
REM Behavior Disorder Treatment
- Have patients sleep in different rooms
- Clonazepam helps but symptoms relapse on discontinuation
- Melatonin can be helpful
- Consider Tricyclic antidepressants, SSRIs, serotonin-norepinephrine reuptake inhibitors, and beta-blockers
Restless Legs Syndrome Criteria
- Have an urge to move the legs due to uncomfortable sensations
- Sensations that get Worse in periods of rest
- Relieved by movement
- Presents mostly Worse or only at night
- Must occur at least 3 times per week for 3 months
More Restless Legs Syndrome Criteria
- Must have Clinically observed distress and this is not secondary to a medical disorder
- Arthritis, edema, positional discomfort, and foot tapping can trigger this syndrome
- Not associated with substance use
Restless Legs Syndrome Treatment
- Dopamine agonists Pramipexole, Ropinirole, And Rotigotine
- Gabapentin enacarbil
- Add Iron replacement when the patient`s ferritin levels are less than 50ng/mL
Substance Medication Induced Sleep Disorder
- Characterized by sleep disturbance
- Associated with the effects of a substance of abuse or a medication
- Causes can be from Caffeine, Stimulants, Cocaine, Benzodiazepines, and Alcohol
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