Sleep Disorders

Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York ni!ersity School of Medicine; Pri!ate Practice Coauthor(s): Curley L Bonds II, MD, Ad"unct Primary insomnia is the 'eneral term for difficulty Associate Professor and Chair, Department of in initiatin' or maintainin' sleep1 $ecause sleep Psychiatry and #uman $eha!ior, Charles Drew re2uirements !ary from indi!idual to indi!idual, ni!ersity of Medicine and Science; Associate Clinical Professor, Department of Psychiatry and insomnia is considered clinically si'nificant when a $io%eha!ioral Sciences, ni!ersity of California at patient percei!es the loss of sleep as a pro%lem1 +nsomnia may %e characteri:ed further as acute &os An'eles; Mi hael A Lu ia, MD, !AASM, 6transient8 or chronic1 (wner)C*(, Pulmonary, Aller'y and Sleep Medicine, Sierra Pulmonary and Sleep Consultants, &&C Pathophysiolo#y Contri%utor +nformation and Disclosures Rapid eye $o%e$ent and nonrapid eye pdated, May -., -//0 $o%e$ent

Assessin' if a sleep disorder is primary or secondary is important1 At times, assessin' if an5iety and depression are causin' sleep pro%lems or if the an5iety and depression are secondary to a primary sleep pro%lem is difficult1 See Medscape3s An5iety Disorders and Depression 9esource Centers1

Introdu tion
Ba "#round

Sleep is di!ided into - cate'ories, rapid eye mo!ement 69*M8 and nonrapid eye mo!ement 6N9*M81 *ach of these sleep states is associated with distinct central ner!ous system acti!ity1

N9*M sleep is further di!ided into 7 pro'ressi!e Sleep disorders are amon' the most common cate'ories, termed sta'es .47 sleep1 ;he arousal clinical pro%lems encountered in medicine and threshold rises with each sta'e of sleep, with sta'e psychiatry1 Sleep pro%lems can %e primary or result 7 6delta8 %ein' the sleep state from which a person from a !ariety of psychiatric and medical is least a%le to %e aroused, characteri:ed %y hi'h4 conditions1 +nade2uate or nonrestorati!e sleep can amplitude slow wa!es1 markedly impair a patient3s 2uality of life1. 9*M sleep is characteri:ed %y muscle atonia, Primary sleep disorders result from an endo'enous episodic 9*Ms, and low4amplitude fast wa!es on distur%ance in sleep4wake 'eneratin' or timin' electroencephalo'ram 6**<8 readin's1 Dreamin' mechanisms, often complicated %y %eha!ioral occurs mainly durin' 9*M sleep1 conditionin'1 Primary sleep disorders Distur%ances in the pattern and periodicity of 9*M are su%di!ided into parasomnias and dyssomnias1 and N9*M sleep are often found when people a!er Parasomnias are unusual e5periences or %eha!iors to e5periencin' sleep disorders1 durin' sleep and include sleep terror disorder and sleepwalkin' 6which occur durin' Sta'e 7 sleep8 Sleep&'a"e y les and ni'htmare disorder 6which occurs durin' 9*M Sleep4wake cycles are 'o!erned %y a comple5 sleep81 Dyssomnias are characteri:ed %y 'roup of %iolo'ical processes that ser!e as internal a%normalities in the amount, 2uality, or timin' of clocks1 sleep1 ;hese include primary insomnia and hypersomnia, narcolepsy, %reathin'4related sleep ;he suprachiasmatic nucleus, located in the hypothalamus, is thou'ht to %e the %ody3s anatomic disorder 6ie, sleep apnea8, and circadian rhythm timekeeper, responsi%le for the release of melatonin sleep disorder1 on a -=4hour cycle1

;he pineal 'land secretes less melatonin when e5posed to %ri'ht li'ht; therefore, the le!el of this chemical is lowest durin' the daytime hours of wakefulness1

Multiple neurotransmitters are thou'ht to play a role in sleep1 ;hese include serotonin from the dorsal raphe nucleus, norepinephrine contained in neurons with cell %odies in the locus ceruleus, and A#e acetylcholine from the pontine reticular formation1 +ncreasin' a'e predisposes to sleep Dopamine, on the other hand, is associated with disorders 6=> in persons a'ed @/4=/ y and wakefulness1 @/> in those a'ed =/ y or older81 A%normalities in the delicate %alance of all of these People who are elderly e5perience a chemical messen'er systems may disrupt !arious decrease in total sleep time, with more physiolo'ic, %iolo'ic, %eha!ioral, and **< fre2uent awakenin's durin' the ni'ht1 parameters responsi%le for 9*M 6ie, acti!e8 sleep People who are elderly ha!e a hi'her and N9*M 6slow4wa!e8 sleep1 incidence of 'eneral medical conditions and are more likely to %e takin' medications !re(uen y that cause sleep disruption1 )nited States Appro5imately one third of all Americans ha!e sleep disorders at some point in their li!es1 Appro5imately -/47/> of adults report difficulty sleepin' at some point each year1 Appro5imately .?> of adults consider the pro%lem to %e serious1 Sleep disorders are a common reason for patient !isits throu'hout medicine1 Appro5imately one third of adults ha!e insufficient sleep syndrome1 ;wenty percent of adults report chronic insomnia1

women, with a female4to4male ratio of @,-1 #ormonal !ariations durin' the menstrual cycle or durin' menopause may cause disruptions in sleep1 (%structi!e sleep apnea is more common in men 67>8 than in women 6-1=>81

Clini al
History
+nsomnia may present as decreased sleep efficiency or decreased total hours of sleep, with some associated decrease in producti!ity or well4%ein'1 Sleep 2uality is more important than the total num%er of hours slept %ecause sleep re2uirements !ary from person to person1 Compare the total num%er of hours slept with each indi!idual3s lifelon' normal ni'ht sleep time1 +nitial insomnia is characteri:ed %y difficulty fallin' asleep, with increased sleep latency 6time %etween 'oin' to %ed and fallin' asleep81 +nitial insomnia is fre2uently related to an5iety disorders1 Middle insomnia refers to difficulty maintainin' sleep1 Decreased sleep efficiency is present, with fra'mented unrestful sleep and fre2uent wakin' durin' the ni'ht1 Middle insomnia may %e associated with medical illness, pain syndromes, or depression1 +n terminal insomnia, also referred to as early mornin' wakenin', patients consistently wake up earlier than needed1

Mortality*Morbidity
Chronic insomnia is associated with an increased risk of depression and accompanyin' dan'er of suicide, an5iety, e5cess disa%ility, reduced 2uality of life, and increased use of health care resources1 +nsufficient sleep can result in industrial and motor !ehicle crashes, somatic symptoms, co'niti!e dysfunction, depression, and decrements in daytime work performance owin' to fati'ue or sleepiness1

Se+
Primary insomnia is more common in

;his symptom is fre2uently associated with Slowed reaction time ma"or depression1 Aei'ht 'ain Alterations of the sleep4wake cycle may %e a si'n of circadian rhythm distur%ances, Causes such as those caused %y "et la' and shift work1 ;he ma"or causes of insomnia may %e di!ided into medical conditions, psycholo'ical conditions, and #ypersomnia, or e5cessi!e daytime sleepiness, is often attri%uta%le to on'oin' en!ironmental pro%lems1 sleep depri!ation or poor 2uality sleep for Medical conditions reasons ran'in' from sleep apnea to Cardiac conditions include ischemia su%stance a%use or medical pro%lems1 and con'esti!e heart failure1 +n delayed sleep phase syndrome, the Neurolo'ic conditions include patient is una%le to fall asleep until !ery stroke, de'enerati!e conditions, early mornin'1 As time pro'resses, the onset dementia, peripheral ner!e dama'e, of sleep %ecomes pro'ressi!ely delayed1 myoclonic "erks, restless le' Sleepwalkin', also called somnam%ulism, syndrome, hypnic "erk, and central refers to episodes of comple5 %eha!iors sleep apnea1 durin' N9*M sleep 6sta'es @ and 78 of *ndocrine conditions affectin' sleep which the patient is amnestic afterward1 are related to hyperthyroidism, Ni'htmares are repeated awakenin's from menopause, the menstrual cycle, sleep caused %y !i!id and distressin' recall pre'nancy, and hypo'onadism in of dreams1 Ni'htmares usually occur durin' elderly men1 the second half of the sleep period1 pon Pulmonary conditions include wakenin' from the dream, the person chronic o%structi!e pulmonary rapidly reorients to time and place1 disease, asthma, central al!eolar Ni'ht terrors are recurrent episodes of hypo!entilation 6the (ndine curse8, a%rupt awakenin' from sleep characteri:ed and o%structi!e sleep apnea %y a panicky scream, with intense fear and syndrome 6associated with snorin'81 autonomic arousal1 ;he indi!idual usually <astrointestinal conditions include has no recall of the details of the e!ent and 'astroesopha'eal reflu5 disease1 is unresponsi!e durin' the episode1 Ni'ht #ematolo'ical conditions include terrors occur durin' the first third of the paro5ysmal nocturnal ni'ht, durin' sta'es @ and 7 of N9*M hemo'lo%inuria, which is a rare, sleep1 ac2uired, hemolytic anemia ;he %ed partner of patients who snore may associated with %rownish4red pro!ide a history of snorin'1 Such a history mornin' urine1 may help identify whether a patient Su%stances that may result in e5periences o%structi!e sleep apnea1 insomnia include stimulants, opioids, caffeine, and alcohol, or, Physi al withdrawal from any of these also may cause insomnia1 #ypertension 6can %e caused %y sleep Medications implicated in insomnia apnea8 include decon'estants, Distur%ed coordination 6caused %y sleep corticosteroids, and %ronchodilators1 depri!ation8 (ther conditions include fe!er, pain, Drowsiness and infection1 Poor concentration Psychiatric conditions, $ear in mind that the

ma"or psychiatric conditions now are known to ha!e a %iolo'ical %asis and constitute a su%set of medical conditions1 Depression may cause alterations in 9*M sleep1 As many as 7/> of people with depression ha!e insomnia1 Posttraumatic stress disorder 6P;SD8 can produce !i!id and terrifyin' ni'htmares1 An5iety disorders predispose to insomnia1 ;he most common of these are 'enerali:ed an5iety disorder, panic disorder, and an5iety disorders not otherwise specified1 ;hou'ht disorders and misperception of sleep state are other potential states that cause insomnia1

Psychotropic medications, such as antidepressants, may interfere with normal 9*M sleep patterns1 9e%ound insomnia from %en:odia:epines or other hypnotic a'ents is common1 *n!ironmental pro%lems Stressful or life4threatenin' e!ents 6e', %erea!ement, P;SD8 may cause insomnia1 Shift work may distur% the sleep cycle, as mi'ht "et la' or chan'es in altitude1 Sleep depri!ation may occur as a result of an o!erly warm sleepin' en!ironment, en!ironmental noise, or fre2uent intrusions 6such as in an intensi!e care unit settin'81

Re,eren es
.1 Bammit <C, Aeiner D, Damato N, et al1 Euality of life in people with insomnia1 Sleep1 May . .000;-- Suppl -,S@?04F=1 GMedlineH1 -1 Morin CM, IalliJres A, <uay $, +!ers #, Sa!ard D, MKrette C, et al1 Co'niti!e %eha!ioral therapy, sin'ly and com%ined with medication, for persistent insomnia, a randomi:ed controlled trial1 JAMA1 May -/ -//0;@/.6.08,-//=4.=1 GMedlineH1 @1 *lie 9, 9uther *, Farr +, Salinas *1 Sleep latency is shortened durin' 7 weeks of treatment with :aleplon, a no!el non%en:odia:epine hypnotic1 Baleplon Clinical Study <roup1 J Clin Psychiatry1 Au' .000;L/6F8,=@L4771 GMedlineH1 71 American Psychiatric Association1 Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision DSM!"#!TR$1 Aashin'ton, DC, American Psychiatric Association; -///1 =1 Anders ;F, *i%en &A1 Pediatric sleep disorders, a re!iew of the past ./ years1 J A% Acad Child Adolesc Psychiatry1 Dan .00?;@L6.8,04-/1 GMedlineH1 L1 $enca 9M, Ancoli4+srael S, Moldofsky #1 Special considerations in insomnia dia'nosis and mana'ement, depressed, elderly, and chronic pain populations1 J Clin Psychiatry1 -//7;L= Suppl F,-L4@=1 GMedlineH1 ?1 $ryant PA, ;rinder D, Curtis N1 Sick and tired, Does sleep ha!e a !ital role in the immune systemM1 &at Rev "%%unol1 Dun -//7;76L8,7=?4L?1 GMedlineH1 F1 Chen A, Cushida CA1 Nasal o%struction in sleep4disordered %reathin'1 'tolaryngol Clin &orth A%1 Dun -//@;@L6@8,7@?4L/1 GMedlineH1 01 Ford D*, Camerow D$1 *pidemiolo'ic study of sleep distur%ances and psychiatric disorders1 An opportunity for pre!entionM1 JAMA1 Sep .= .0F0;-L-6..8,.7?04F71 GMedlineH1

./1 <illin DC, $yerley AF1 Dru' therapy, ;he dia'nosis and mana'ement of insomnia1 & (ngl J Med1 Dan -= .00/;@--678,-@047F1 GMedlineH1 ..1 #auri PD, #ayes $, Sateia M, et al1 *ffecti!eness of a sleep disorders center, a 04month follow4up1 A% J Psychiatry1 May .0F-;.@06=8,LL@4L1 GMedlineH1 .-1 Caplan #+, Sadock $D, <re%% DA1 Normal sleep and sleep disorders1 +n, )aplan and Sadoc*+s Synopsis of Psychiatry1 ?th ed1 $altimore, Md, Ailliams N Ailkins; .007,L004?.L1 .@1 &am%er' &1 Promotin' ade2uate sleep finds a place on the pu%lic health a'enda1 JAMA1 May -L -//7;-0.6-/8,-7.=4?1 GMedlineH1 .71 &am%er' &1 Sleep4disordered %reathin' may spur %eha!ioral, learnin' pro%lems in children1 JAMA1 Dune -//?;-?;-0?6-78,-LF.4@1 GMedlineH1 .=1 &oewy D#, $lack D*1 *ffecti!e mana'ement of transient and chronic insomnia1 +n, C&S &e,s1 McMahon Pu%lishin' <roup, New York, NY; -///,.04--1 GFull ;e5tH1 .L1 No authors listed1 $eauty sleep for the heart1 -arv -eart .ett1 May -//7;.7608,?1 GMedlineH1 .?1 9ichert AC, $aran AS1 A re!iew of common sleep disorders1 C&S Spectr1 Fe% -//@;F6-8,./-401 GMedlineH1 .F1 Schuen DN, Millard S&1 *!aluation and treatment of sleep disorders in adolescents1 Adolesc Med1 (ct -///;..6@8,L/=4.L1 GMedlineH1 .01 Schwa% 9D1 Distur%ances of sleep in the intensi!e care unit1 Crit Care Clin1 (ct .007;./678,LF.4071 GMedlineH1 -/1 Ieasey SC1 Sedatin', not treatin' sleep apnea, hit N run in primary care1 J Clin Sleep Med1 (ct .= -//=;.678,@?-4@1 GMedlineH1 -.1 Borner D, <eisler P1 GDia'nostic Spectrum and Filtration Function of (utpatient Sleep ClinicsH1 Psychiatr Prax1 May -//@;@/6Suppl -8,.?@4.?=1 GMedlineH