Nonorganic sleep disorders: Types, Epidemiology, Diagnostic Criteria and

Etiology- Nonorganic insomnia, Nonorganic hypersomnia, Nonorganic disorder of

the sleep-wake schedule, Sleepwalking, Sleep terrors, Nightmares.- MAHIMA

ELECTROPHYSIOLOGY OF SLEEP
Sleep is made up of two physiological states: non-rapid eye movement (NREM) sleep and rapid
eye movement (REM) sleep. In NREM sleep, which is composed of stages 1 through 4, most
physiological functions are markedly lower than in wakefulness. REM sleep is a qualitatively
diϱerent kind of sleep, characterized by a high level of brain activity and physiological activity
levels similar to those in wakefulness. About 90 minutes after sleep onset, NREM yields to the
erst REM episode of the night. This REM latency of 90 minutes is a consistent ending in normal
adults; shortening of REM latency frequently occurs with such disorders as narcolepsy and
depressive disorders.

In normal persons, NREM sleep is a peaceful state relative to waking. The pulse rate is typically
slowed five to ten beats a minute below the level of restful waking and is very regular. The
deepest portions of NREM sleep—stages 3 and 4—are sometimes associated with unusual
arousal characteristics. When persons are aroused 30 minutes to 1 hour after sleep
onset—usually in slow-wave sleep—they are disoriented, and their thinking is disorganized.
Brief arousals from slow-wave sleep are also associated with amnesia for events that occur
during the arousal. The disorganization during arousal from stage 3 or stage 4 may result in
specific problems, including enuresis, somnambulism, and stage 4 nightmares or night terrors.
By young adulthood, the distribution of sleep stages is as follows: NREM (75 percent)Stage 1: 5
percent Stage 2: 45 percent Stage 3: 12 percent Stage 4: 13 percent REM (25 percent) This
distribution remains relatively constant into old age, although a reduction occurs in both
slow-wave sleep and REM sleep in older persons.
The EEG recordings show typi- cal features of sleep which is broadly divided into two broadly
different phases:
1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye
movement sleep), active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or
orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1
to 4. As the person falls asleep, the person first passes through these stages of NREM-sleep.
Stage 1, NREM-sleep is the fi rst and the ligh test stage of sleep characterised by an absence of
alpha- waves, and low voltage, predominantly theta activity.

Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two
typical EEG changes:
i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a charac teristic waxing and wan- ing amplitude.

ii. K-complexes: High voltage spikes present in- termittently.

Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec.
Stage 4, NREM-sleep shows predominant δ-activity in EEG.
● NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is
characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1
NREM-sleep. One of the most characteristic features of the REM-sleep is presence of
REM or rapid (conjugate) eye move ments. The other features include generalised mus
cular atony, penile erection, autonomic hyperac tivity (increase in pulse rate, respiratory
rate and blood pressure), and movements of small muscle groups, occurring intermi-
ttently. Although it is a light stage of sleep, arousal is difficult.

The important time periods of the various sleep stages are summarised below:
1. In an 8 hour sleep, usually 6-6½ hours are spent in the NREM-sleep while 1½-2 hours are in
the REM-sleep.
2. Out of 6-6½ hours NREM-sleep period, only about 70-80 minutes are spent in Stage 4 sleep.
3. The maximum Stage 4 sleep occurs in the fi one-third of the night. In the later part, the REM-
sleep follows the Stage 3 NREM-sleep directly.
4. The REM-sleep occurs maximally in the last one-third of the night. The REM-sleep occurs
regularly after every 90-100 minutes, with pro- gressive lengthening of each REM period. The fi
rst REM period typically lasts for less than 10 minutes. Usually, there are 4-5 REM periods in
the whole night of sleep.
5. A younger person may typically need more sleep. The usual sleep duration in newborn
children is 16-18 hours/day, with nearly 8-10 hours spent in the REM-sleep. As the age
advances, the sleep duration tends to reduce.
TYPES OF SLEEP DISORDERS
Dyssomnias : primarily psychogenic conditions in which the predominant disturbance is in
amount, quality, or timing of sleep due to emotional causes.

Parasomnias : abnormal episodic events occuring during sleep; in childhood these are related
mainly to the child’s development, while in adulthood these are predominantly psychogenic.

ICD-10 classification

DYSSOMNIAS
Non-organic insomnia
Non-organic hypersomnia
Non-organic disorders of the sleep-wake schedule

PARASOMNIAS
Somnambulism ( sleep walking )
Sleep terrors ( night terrors )
Nightmares
Sleep-Wake Rhythm
Without external clues, the natural body clock follows a 25-hour cycle. The influence of external
factors—such as the light-dark cycle, daily routines, meal periods, and other external
synchronizers—entrain persons to the 24-hour clock. Sleep is also influenced by biological
rhythms. Within a 24-hour period, adults sleep once, sometimes twice. This rhythm is not present
at birth but develops over the ϧrst 2 years of life. Some women exhibit sleep pattern changes
during the phases of the menstrual cycle. Naps taken at diϱerent times of the day diϱer greatly in
their proportions of REM and NREM sleep. In a normal nighttime sleeper, a nap taken in the
morning or at noon includes a great deal of REM sleep, whereas a nap taken in the afternoon or
the early evening has much less REM sleep. A circadian cycle apparently affeects the tendency
to have REM sleep.
INSOMNIA DISORDER
Insomnia is defined as difficulty initiating or maintaining sleep. It is the most common sleep
complaint and may be transient or persistent. Population surveys show a 1-year prevalence rate
of 30 to 45 percent in adults. As DSM-5 defines insomnia disorder as dissatisfaction with sleep
quantity or quality associated with one or more of the following symptoms: difficulty initiating
sleep, difficulty maintaining sleep with frequent awakenings or problems returning to sleep, and
early morning awakening with inability to return to sleep.
Insomnia is very common, with nearly 15-30% of general population complaining of a period of
insomnia per year requiring treatment. It is required for diagnosis that sleep disturbance occurs at
least three times a week for at least 1 month, and that it causes either marked distress or
interferes with social and occupational functioning.
Descriptively, insomnia can be categorized in terms of how it aϱects sleep (e.g., sleep- onset
insomnia, sleep-maintenance insomnia, or early-morning awakening). Insomnia can also be
classiϧed according to its duration (e.g., transient, short term, and long term).
● Persistent insomnia is composed of a fairly common group of conditions in which the
problem is diϫculty falling asleep or remaining asleep. This insomnia involves two
sometimes separable, but often intertwined, problems: somatized tension and anxiety and
a conditioned associative response. Patients often have no clear complaint other than
insomnia. They may not experience anxiety per se but discharge the anxiety through
physiological channels; they may complain chiefly of apprehensive feelings or
ruminative thoughts that appear to keep them from falling asleep.
● Sleep state misperception (also known as subjective insomnia) is characterized by a
dissociation between the patient’s experience of sleeping and the objective polygraphic
measures of sleep. The ultimate cause of this dissociation is not yet understood, although
it appears to be a specific case of a general phenomenon seen in many areas of medicine.
Sleep state misperception is diagnosed when a patient complains of diϫculty initiating or
maintaining sleep and no objective evidence of sleep disruption is found.
● Psychophysiological insomnia typically presents as a primary complaint of difficulty in
going to sleep. A patient may describe this as having gone on for years and usually denies
that it is associated with stressful periods in his or her life. Objects associated with sleep
(e.g., the bed, the bedroom) likewise become conditioned stimuli that evoke insomnia.
Thus, psychophysiological insomnia is sometimes called conditioned insomnia.
Psychophysiological insomnia often occurs in combination with other causes of
insomnia, including episodes of stress and anxiety disorders, delayed sleep phase
syndrome, and hypnotic drug use and withdrawal.
● Idiopathic insomnia typically starts early in life, sometimes at birth, and continues
throughout life. As the name implies, its cause is unknown; suspected causes include
neurochemical imbalance in brainstem reticular formation, impaired regulation of
brainstem sleep generators (e.g., raphe nuclei, locus ceruleus), or basal forebrain
dysfunction.
● Primary insomnia is diagnosed when the chief complaint is nonrestorative sleep or
difficulty in initiating or maintaining sleep, and the complaint continues for at least a
month (according to ICD-10, the disturbance must occur at least three times a week for a
month). The term primary indicates that the insomniaphysical or mental condition.
Primary insomnia is often characterized both by difficulty falling asleep and by repeated
awakening.
ETIOLOGY
One cause of insomnia, PMS ( periodic move- ments in sleep) needs further mention. PMS
actually consists of two different syndromes, which often occur together: 1. Periodic Limb
Movement Disorder (PLMD), and 2. ‘ Restless Legs’ Syndrome (RLS or Ekbom synd- rome).
TREATMENT
1. Universal Sleep Hygiene. A common finding is that a patient’s lifestyle leads to sleep
disturbance. This is usually phrased as inadequate sleep hygiene, referring to a problem
in following generally accepted practices to aid sleep. These include, for instance,
keeping regular hours of bedtime and arousal, avoiding excessive caffeine, not eating
heavy meals before bedtime, and getting adequate exercise. Many behaviors can interfere
with sleep and may do so by increasing nervous system arousal near bedtime or by
altering circadian rhythms. The focus of universal sleep hygiene is on modiϧable
 environmental and lifestyle components that may interfere with sleep, as well as
behaviors that may improve sleep.
2. Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) as a treatment modality uses a combination of
behavioral and cognitive techniques to overcome dysfunctional sleep behaviors,
misperceptions, and distorted, disruptive thoughts about sleep. Behavioral techniques
include universal sleep hygiene, stimulus control therapy, sleep restriction therapy,
relaxation therapies, and biofeedback.
3. Benzodiazepines may be used, either alone, e.g. in primary insomnia, or may be used
with the treatment of underlying physical or psychiatric disorder(s). The use of benzo dia
zepines should only be for short-term periods, not more than for 4-6 weeks at one time.
4. Stimulus Control Therapy. Stimulus control therapy is a deconditioning paradigm
developed by Richard Bootzin and colleagues at the University of Arizona. This
treatment aims to break the cycle of problems commonly associated with difficulty
initiating sleep. By attempting to undo conditioning that undermines sleep, stimulus
control therapy helps reduce both primary and reactive factors involved in insomnia. The
rules attempt to enhance stimulus cues for sleeping and diminish associations with
sleeplessness.
5. Sleep Restriction Therapy. Sleep restriction therapy is a strategy designed to increase
sleep efficiency by decreasing the amount of time spent awake while lying in bed.
Developed by Arthur Spielman, this therapy specifically targets those patients who lie
awake in bed unable to sleep.
6. Paradoxical Intention. This is a cognitive technique with conflicting evidence regarding
its efficacy. In clinical practice compliance is often a barrier, but it does work for a
limited number of patients. The theory is that performance anxiety interferes with sleep
onset. Thus, when the patient tries to stay awake for as long as possible rather than trying
to fall asleep, performance anxiety will be reduced and sleep latency will improve.

NON ORGANIC HYPERSOMNIA

Hypersomnia is defined as a condition of either excessive daytime sleepiness and sleep attacks
(not accounted for by an inadequate amount of sleep) or prolonged transition to the fully aroused
state upon awakening.
Disturbance lasting for more than 1 month or recurrently for shorter period of time causing
marked distress or interferes with ordinary activities.
In the absence of an organic factor for the occurrence of hypersomnia, this condition is usually
associated with mental disorders.
In the absence of auxillary symptoms of narcolepsy or clinical evidence of sleep apnoea.
Nonorganic hypersomnia can be primary or associated with a number of psychiatric disorders
such as reaction to severe stress or adjustment disorders, affective disorders, other functional
disorders, tolerance to or withdrawal of CNS-stimulating substances and chronic use of
CNS-sedating substances.

Although hypersomnia syndromes have been described for more than a century, starting with
narcolepsy,1 it is only in the last 30 years that modern sleep medicine has stressed the health and
economic impacts of falling asleep at any time. Hypersomnia syndromes affect a growing
proportion of the 15% to 30% of people suffering from sleep problems. Hypersomnia is present
in 4% to 6% of the general population,2 with a higher prevalence in men because of sleep apnea
syndromes, the main purveyor of excessive daytime sleepiness.3 In recent years, sleep medicine
has benefited from the impact of hypersomnia and is now in full development in industrialized
countries.
CAUSES
1. Narcolepsy This is a disorder characterised by excessive day- time sleepiness, often disturbed
night-time sleep and disturbances in the REM-sleep. The hallmark of this disorder is decreased
REM latency, i.e. decreased latent period before the fi mal REM latency is 90-100 minutes. In
narcolepsy, REM-sleep usually occurs within 10 minutes of the onset of sleep.
2. Sleep Apnoea This condition is characterised by presence of repeated episodes of apnoea
during sleep. In this context, apnoea is defi fl ow at the nos- trils (and mouth) for 10 seconds or
longer. The apnoea can be of central type, obstructive type or mixed type.
3. Kleine-Levin Syndrome This is a rare syndrome characterised by: 1. Hypersomnia (always
present), occurring recur- rently for long periods of time. 2. Hyperphagia (usually present), with
a vora cious appetite. 3. Hypersexuality (associated at times), con sis ting of sexual disinhibition,
masturba tory activity, exhi- bitionism, and/or inap pro priate sexual advances. The associated
features include apathy, irri table behaviour, confusion, social withdrawal, bizarre behaviour,
psychotic symptoms (such as delu sions and hallucinations), and disorientation.
Nonorganic disorder of the sleep-wake schedule
A lack of synchrony between the sleep-wake schedule and the desired sleep-wake schedule for
the individual's environment,

Resulting in a complaint of either insomnia during major sleep period or hypersomnia during the
waking period are experienced nearly every day for at least 1 month or recurrently for shorter
period of time.

Sleep disturbance causes marked distress or interferes with ordinary activities.

SONAMBULISM
A state of altered consciousness in which phenomena of sleep and wakefulness are combined.

During a sleepwalking episode the individual arises from bed, usually during the first third of
nocturnal sleep, and walks about, exhibiting low levels of awareness, reactivity, and motor skill.
Upon awakening, there is usually no recall of the event.

Some cases of autonomic (independently functioning) behavior that occur with sleepwalking
involve dressing and even eating.

Sleep terrors [night terrors]

Nocturnal episodes of extreme terror and panic associated with intense vocalization, motility, and
high levels of autonomic discharge.

The individual sits up or gets up, usually during the first third of nocturnal sleep, with a panicky
scream
Recall of the event, if any, is very limited (usually to one or two fragmentary mental images).

TREATMENT
Counseling and Psychotherapy
In many cases, comfort and reassurance are the only treatment required.
Night terrors may also be treated with hypnosis and guided imagery techniques.
Pharmacotherapy
Benzodiazepine medications used at bedtime will often reduce the incidence of night terrors.

NIGHTMARES

The awakening from sleep with dream experience which is very vivid and usually includes
themes involving threats to survival, security, or self-esteem. Awakening may occur at any time
but typically during the second half.

Upon awakening the individual rapidly becomes alert and oriented.

The dream experiences itself or resulting sleep disturbance cause marked distress to sleep, causes
marked distress to the individual.

Most dreaming occurs during REM sleep. REM sleep is characterized by EEG activity similar to
a wakeful pattern
Prevalence estimate varies, but as many as 50% of children aged 3-6 years have nightmares that
disturb both their sleep and the parents' sleep.
TREATMENT
Reassurance

Reassurance is the only treatment required for sporadic nightmares. Although all stressors cannot
be removed from a child's life, parents can attempt to make bedtime a safe and comfortable time.

Encourage parents to spend time reading, relaxing, and talking with the child.

If the child has a recurring nightmare, to have the parents encourage the child to imagine a good
ending may help.