Podcast
Questions and Answers
What is the primary cause of daytime distress in sleep-wake disorders?
What is the primary cause of daytime distress in sleep-wake disorders?
Which sleep disorder is characterized by excessive sleepiness during the day?
Which sleep disorder is characterized by excessive sleepiness during the day?
In which population group are problems staying asleep most commonly reported?
In which population group are problems staying asleep most commonly reported?
What is the recommended amount of sleep per night for adults, according to the National Sleep Foundation?
What is the recommended amount of sleep per night for adults, according to the National Sleep Foundation?
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Which type of insomnia is more common and typically resolves without intervention?
Which type of insomnia is more common and typically resolves without intervention?
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What is NOT a criterion for diagnosing insomnia disorder?
What is NOT a criterion for diagnosing insomnia disorder?
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What is one of the potential consequences of poor sleep quality?
What is one of the potential consequences of poor sleep quality?
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Which sleep disorder involves arousal from NREM sleep?
Which sleep disorder involves arousal from NREM sleep?
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Which of the following is a symptom of insomnia as classified within its duration?
Which of the following is a symptom of insomnia as classified within its duration?
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What is the primary cause of narcolepsy as understood in current research?
What is the primary cause of narcolepsy as understood in current research?
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Which treatment option is specifically approved by the FDA for the management of cataplexy in narcolepsy?
Which treatment option is specifically approved by the FDA for the management of cataplexy in narcolepsy?
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In terms of sleep hygiene, which practice is recommended to improve sleep quality?
In terms of sleep hygiene, which practice is recommended to improve sleep quality?
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What distinguishes REM parasomnias from non-REM sleep events?
What distinguishes REM parasomnias from non-REM sleep events?
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What percentage of the general population is estimated to be affected by narcolepsy?
What percentage of the general population is estimated to be affected by narcolepsy?
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Which of the following is NOT typically considered effective for treating insomnia?
Which of the following is NOT typically considered effective for treating insomnia?
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Which behavioral condition may lead to a sudden loss of muscle tone, often triggered by emotions?
Which behavioral condition may lead to a sudden loss of muscle tone, often triggered by emotions?
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What is a common misconception about the safety of OTC medications for insomnia?
What is a common misconception about the safety of OTC medications for insomnia?
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What type of episodes might individuals experience during sleepwalking?
What type of episodes might individuals experience during sleepwalking?
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What can indicate a sustained diagnosis of REM sleep behavior disorder (RBD)?
What can indicate a sustained diagnosis of REM sleep behavior disorder (RBD)?
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Which of the following symptoms are commonly associated with sleepwalking in children?
Which of the following symptoms are commonly associated with sleepwalking in children?
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What is the primary characteristic of nightmares that distinguishes them from other sleep disorders?
What is the primary characteristic of nightmares that distinguishes them from other sleep disorders?
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What is one of the diagnostic criteria for NREM Parasomnia?
What is one of the diagnostic criteria for NREM Parasomnia?
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How can bruxism be effectively treated?
How can bruxism be effectively treated?
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Which treatment option is commonly considered for managing severe nightmares associated with PTSD?
Which treatment option is commonly considered for managing severe nightmares associated with PTSD?
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What is a common feature of Restless Leg Syndrome (RLS)?
What is a common feature of Restless Leg Syndrome (RLS)?
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What is a significant distressing experience related to sleep terrors?
What is a significant distressing experience related to sleep terrors?
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In treating Restless Leg Syndrome, which type of medication is often considered the first line of treatment?
In treating Restless Leg Syndrome, which type of medication is often considered the first line of treatment?
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What typically exacerbates the symptoms of Restless Leg Syndrome?
What typically exacerbates the symptoms of Restless Leg Syndrome?
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Which of the following is NOT a recommended precaution for patients with REM behavior disorders?
Which of the following is NOT a recommended precaution for patients with REM behavior disorders?
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Which characteristic differentiates sleepwalking from other sleep arousal disorders?
Which characteristic differentiates sleepwalking from other sleep arousal disorders?
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What is a primary goal in managing parasomnia in children?
What is a primary goal in managing parasomnia in children?
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Study Notes
Sleep-Wake Disorders
- Sleep-wake disorders are characterized by problems with the quality, timing, and/or amount of sleep.
- These disorders often occur alongside medical conditions or other mental health issues like depression, anxiety, and cognitive disorders.
- The most common sleep-wake disorder is insomnia.
Sleep-Wake Disorder Classification (DSM-5)
- Ten sleep-wake disorders are categorized in the DSM-5 into several groups.
- Groups include insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep disorders, non-REM (NREM) sleep arousal disorders, nightmare disorder, REM sleep behavior disorder, restless legs syndrome, and substance- or medication-induced sleep disorder.
How Sleep Works
- There are two types of sleep: REM and non-REM.
- These sleep types happen in 3-5 cycles per night.
- REM is the phase where most dreaming occurs.
- Non-REM sleep consists of three phases, including the deepest sleep.
- Sleep timing is crucial, as the body naturally works on a 24-hour circadian rhythm cycle.
- Sleep requirements vary depending on age.
- The National Sleep Foundation recommends 7-9 hours of good sleep per night for adults.
Sleep Disorder Epidemiology
- Problems falling asleep are more prevalent among young adults.
- Difficulty staying asleep is more prevalent among middle-aged and older adults.
Consequences of Sleep Deprivation
- Lack of sleep or poor sleep quality can negatively impact physical and mental health.
- It leads to decreased brain function and performance.
- Common symptoms are fatigue, reduced energy, and irritability.
- Difficulty making decisions and focusing.
- Sleep problems often coexist with symptoms of depression or anxiety, and they can worsen these conditions.
- Depression and anxiety can, in turn, lead to sleep issues.
Insomnia Disorder
- Insomnia, the most common sleep disorder, involves difficulty falling asleep, staying asleep, and/or experiencing non-restorative sleep.
- Transient insomnia is more common than chronic insomnia, with transient insomnia often resolving without intervention.
Insomnia Disorder Diagnosis
- For a diagnosis of insomnia disorder, sleep difficulties must occur at least three nights per week for at least three months and cause significant distress or problems in work, school, or social life.
- Other sleep disorders, medication side effects, substance misuse, depression, and physical or mental illnesses must be ruled out.
- A comprehensive assessment for insomnia or other sleep problems may include a patient history, physical exam, sleep diary, and sleep study.
Insomnia Disorder Epidemiology
- Insomnia disorder is more common among women than men.
- The risk increases with age.
- Approximately 30-40% of adults in the U.S. report symptoms of insomnia each year.
- Insomnia disorder is often associated with medical, psychiatric, or substance use disorders.
Insomnia Disorder Treatment and Management
- Insomnia symptoms can be episodic (lasting one to three months), persistent (lasting three months or more), or recurrent (two or more episodes within a year).
- Good sleep habits and hygiene can often resolve insomnia and sleep problems.
- Chronic insomnia is typically treated with a combination of sleep medications and behavioral techniques, such as cognitive behavior therapy (CBT).
Insomnia Disorder: Medication and Complementary Health Approaches
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Over-the-counter medications, such as antihistamines, melatonin, etc.
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Non-controlled prescription medications, such as trazodone, ramelteon, hydroxyzine, etc.
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Controlled prescription medications, such as benzodiazepines (BZDs), Ambien, Lunesta, etc.
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Complementary Health Approaches:
- Relaxation techniques before bedtime can be helpful.
- Mind and body approaches, like mindfulness, meditation, yoga, massage therapy, and acupuncture, are generally considered safe, but their effectiveness for insomnia lacks strong evidence.
- Herbs and dietary supplements, including L-tryptophan and kava, have not been proven effective for insomnia and may pose safety concerns.
Insomnia Disorder: Sleep Hygiene Tips
- Stick to a regular sleep schedule, going to bed and waking up at the same time, even on weekends.
- Engage in calming activities before bed, such as reading away from bright lights; avoid electronic devices.
- Avoid naps, especially in the afternoon.
- Exercise daily.
- Pay attention to the bedroom environment; a quiet, cool, and dark room is optimal.
- Use a comfortable and supportive mattress and pillow.
- Avoid alcohol, caffeine, and heavy meals in the evening.
Narcolepsy
- Narcolepsy is characterized by overwhelming daytime drowsiness and sudden attacks of sleep.
- Sleep attacks usually last 15-20 minutes but can be longer, and they can occur even while driving (individuals with narcolepsy should not drive).
- Sleepiness occurs daily and must occur at least three times a week for at least three months to be considered a diagnosis of narcolepsy.
- People with narcolepsy experience episodes of cataplexy, sudden brief loss of muscle tone triggered by emotions like laughter or joking. This can manifest as head bobbing, jaw-dropping, or falls.
- Individuals are awake and aware during cataplexy.
Narcolepsy Epidemiology and Etiology
- Narcolepsy is rare, affecting only an estimated 0.02-0.04% of the general population.
- It typically begins in childhood, adolescence, or young adulthood.
- Nearly always, narcolepsy results from the loss of hypothalamic hypocretin (orexin)-producing cells.
- This loss is thought to be caused by the immune system mistakenly attacking the hypocretin-producing cells or their receptors.
- A deficiency in hypocretin can be tested through cerebrospinal fluid (CSF) via a lumbar puncture.
Narcolepsy Diagnosis
- A Multiple Sleep Latency Test (MSLT) can confirm narcolepsy after a polysomnography (PSG) rules out other causes for abnormal MSLT results.
- If narcolepsy worsens in a patient with previously well-controlled symptoms, careful questioning should be conducted regarding possible causes of hypersomnia (medications, sleep apnea, periodic limb movement, etc.)
- It is recommended to obtain PSG confirmation or previous medical records to rule out fabricated histories of narcolepsy.
Narcolepsy Treatment and Management
- Narcolepsy has no cure, but many achieve reasonable control with scheduled naps.
- Many individuals require medication.
- Modafinil is the treatment of choice for excessive daytime sleepiness (EDS).
- Stimulants like methylphenidate and amphetamines are sometimes used.
- Sodium oxybate (gamma-hydroxybutyrate [GHB]) is the only FDA-approved medication for cataplexy.
Parasomnias
- Parasomnias are characterized by unusual events or behaviors during sleep or during sleep-wake transitions.
- Non-REM (NREM) sleep events are more often linked to difficulty waking up, confusion upon awakening, and lack of memory for the event.
- Examples of NREM sleep events include sleepwalking, sleep terrors, sleep-talking, and sexsomnia.
- REM parasomnias generally involve waking clearly and rapidly, with recall of the event (e.g., nightmare disorder, sleep-related painful erection, sleep paralysis).
- Careful distinction between different types of parasomnias is important for accurate diagnosis.
REM Sleep Behavior Disorder
- REM sleep behavior disorder (RBD) involves repeated episodes of arousal during sleep with vocalizations and/or complex motor behaviors.
- These occur during REM sleep, usually more than 90 minutes after sleep onset and are more frequent during the later part of the sleep period when REM periods are longer.
- Individuals are completely awake, alert, and not confused or disoriented when awakening from episodes.
- In RBD, the polysomnography (PSG) shows REM sleep without atonia (muscle paralysis).
- RBD can be associated with synucleinopathies like Parkinson's disease or multiple system atrophy.
- These behaviors cause significant distress or impairment and can lead to injury to the patient or bed partner.
- The disturbance is not attributable to physiological effects of a substance or another medical condition, and it is not explained by a coexisting psychiatric or medical disorder.
Treatment and Management of Parasomnias
- Treatment varies depending on the specific parasomnia.
- It is vital to reassure families of children with parasomnias.
- In sleepwalking and REM behavior disorders, creating a safe environment for the patient and others is essential.
- This can include locking balcony doors, taking special precautions when sleeping in hotels, and/or moving bedmates into a separate room.
- Careful instruction in sleep hygiene is important for all parasomnias.
- Dental devices can treat bruxism (tooth grinding).
- When treating bed-wetting (enuresis), it is crucial to use behavioral measures without shaming or punishing the child.
Non-Rapid Eye Movement Sleep Arousal Disorder (NREM Parasomnia)
- Non-rapid eye movement sleep arousal disorder (NREM parasomnia) involves episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode.
- The individual has either sleepwalking or sleep terrors during the episodes.
- These episodes cause significant distress or problems with functioning.
- NREM parasomnia is most common among children and becomes less common with increasing age.
Sleepwalking
- Sleepwalking entails repeated episodes of rising from bed and walking around during sleep.
- Sleepwalkers generally have a blank, staring face and are relatively unresponsive to others.
- It is difficult to wake them.
- Approximately 30% of people have experienced sleepwalking at some point in their lives.
Sleep Terrors
- Sleep terrors, also known as night terrors, involve episodes of waking up abruptly from sleep, usually starting with a panicky scream.
- During the episode, the person experiences intense fear and physical symptoms such as rapid breathing, accelerated heart rate, and sweating.
- They typically have little to no memory of the dream after the episode and are unresponsive to comfort attempts.
- Sleep terrors are common among very young children and decrease with age.
- Only about 2% of adults experience night terrors.
NREM Parasomnia Diagnostic Criteria (DSM-5)
- Repeated episodes of arising from bed during sleep and walking about.
- The individual has a blank, staring face and is unresponsive to others, awakening only with difficulty.
- There is typically little or no recall of dream imagery and none of the behavioral episodes.
- The episodes cause significant distress or impairment in social, occupational, or other areas of functioning.
- There is no influence from an exogenous substance, nor any coexisting psychiatric or medical disorders that explain the spells.
Nightmare Disorder (REM Parasomnia)
- Nightmare disorder is an REM disorder in which individuals experience repeated occurrences of lengthy, elaborate, and well-remembered story-like dreams that often involve efforts to avoid threats or dangers, causing intense fear, anxiety, and distress.
- They usually occur in the second half of a major sleep episode.
- Upon waking, individuals are quickly alert and generally recall the dream in detail, able to describe it.
- The onset is typically between the ages of 3 and 6.
- It is most prevalent and severe in late adolescence or early adulthood.
- Nightmares are considered a disorder when disturbing dreams lead to distress and/or prevent getting enough sleep.
Nightmare Disorder: Treatment and Management
- Underlying causes are investigated and treated.
- Imagery rehearsal therapy (a variant of CBT) involves changing the ending of the remembered nightmare while awake, rendering it less threatening. The new ending is then rehearsed in mind.
- Medication is not regularly used for nightmares unless they are severe (e.g., PTSD-associated nightmares).
- Medication used for severe nightmares, especially those associated with PTSD: Prazosin 3-15 mg po qhs
Restless Legs Syndrome (RLS)
- Restless Legs Syndrome (RLS) involves an urge to move one's legs, typically accompanied by uncomfortable sensations in the legs described as creeping, crawling, tingling, burning, or itching.
- The urges begin or worsen during periods of rest or inactivity and are partially or totally relieved by movement.
- Symptoms are worse in the evening or at night than during the day or occur only in the evening or at night.
- They occur at least three times a week for at least three months, causing significant distress or problems in daily functioning.
- RLS can make it difficult to fall asleep and often awakens individuals from sleep, leading to daytime sleepiness.
- RLS usually begins in one's teens or twenties, affecting an estimated 2-7.2% of the population.
RLS Etiology
- Most cases have unknown causes.
- However, RLS has a genetic component and can be found in families where the onset is before age 40.
- Low levels of iron in the brain may also be responsible for RLS.
- There is a link between ADHD and RLS due to dopamine levels in the brain.
- RLS can be triggered by alcohol and opioid withdrawals.
Medications Contributing to RLS
- Antidepressants, antihistamines, antiemetics, and antipsychotics have been shown to contribute to RLS.
RLS Treatment and Management
- It is crucial to correct any underlying condition.
- Medication treatment usually involves one of these three drug categories:
- Dopaminergic agents (e.g., ropinirole, pramipexole)
- GABAergic agents (e.g., baclofen, gabapentin, benzodiazepines)
- Opioid preparations (e.g., propoxyphene or codeine preparations)
- Dopaminergic agents are often considered the treatment of choice for RLS.
- Ropinirole is the only FDA-approved RLS treatment.
- Pramipexole has more benign side effects than older agents and fewer peripheral side effects.
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Test your knowledge on sleep-wake disorders with this quiz. Explore key concepts such as causes of daytime distress, excessive sleepiness, and insomnia. Understand the recommended sleep duration for adults and the characteristics of different sleep disorders.
