Sleep-and related disorders

DR. Muland Roger

psychiatrist
.

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 Outline
1) Introduction
2) Sleep physiology
3) Classifications of sleep disorders
4) Clinical features
5) Diagnostic criteria
6) Management
7) References:

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Introduction
 Sleep is a physiologically recurring state of rest characterized by relative

suspension of consciousness and In action of voluntary muscles.

 It is regulated by the circadian rhythm and usually consists of 4–5 sleep cycles

 That include three stages of non-rapid eye movement sleep (NREM sleep)

 And one stage of rapid eye movement sleep(REM sleep).

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Cont’d
 Sleep disorders can be grouped Into primary disorders (i.e., due to an
Intrinsic disorder of the sleep-wake cycle)

 And secondary disorders (i.e., due to an underlying medical condition).

 Primary sleep disorders are further divided

Into dyssomnias and parasomnias.

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 Cont’d
 Symptoms include difficulty falling asleep, difficulty remaining asleep, or
abnormal behavior during sleep.
 Environmental factors (e.g., long working hours, Irregular sleep
schedules, alcohol consumption) can also lead to sleep loss.
 Symptoms include excessive daytime sleepiness , and cognitive
impairment.
 Failure to sleep impairs thought processes, mood regulation, and a host of
normal physiologic functions.

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Sleep physiology
 Normal sleep cycle:
 Sleep latency: the length of time required to fall asleep
 Sleep stages:
 A full night's rest typically consists of 4–5 sleep cycles of 90–120
minutes each.
 Every cycle consists of 3 NREM sleep stages and one REM sleep stage
with the percentage of REM sleep gradually increasing as the night
progresses.

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Sleep physiology
Circadian rhythm:
 Definition: a 24-hour cycle of biophysical changes that regulate sleep patterns,
feeding, patterns
hormone production(e.g., release of melatonin, prolactin, ACTH, norepinephrine),
and body temperature.
 Regulation of sleep: decrease In light is detected by photosensitive melanopsin-
containing retinal ganglion cells (mRGCs) → retinohypothalamic tract
(RHT) stimulation → norepinephrine release from the suprachiasmatic
nucleus of the hypothalamus → melatonin release from the pineal gland → sleep
Induction

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8
Cont’d
 Characteristics of Sleep from Infancy to Old Age
Total sleep time decreases.
REM percentage decreases.
Stages 3 and 4 tend to vanish.
 Neurotransmitters of Sleep
Serotonin: Increased during sleep; initiates sleep.
Acetylcholine: Increased during sleep; linked to REM sleep.
Norepinephrine: Decreased during sleep; linked to REM sleep
Dopamine: Increased toward end of sleep; linked to arousal and
wakefulness.
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Chemical Effects on Sleep
 Tryptophan : Increases total sleep time
 Dopamine agonist : produce arousal.
 Dopamine antagonist : decrease arousal, produce sleep
 Benzodiazepines : suppress stage 4 , when used chronically Increase sleep
latency
 Alcohol intoxication : suppresses REM
 Barbituates intoxication : suppresses REM
 Alcohol withdrawal : REM rebound
 Barbituates withdrawal : REM rebound
 Major depression : shortened REM latency , Increased REM time.

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Classification of sleep disorders
 Dyssomnias:

DEFINITION :
A group of primary sleeping disorders characterized by difficulty
falling/staying asleep or hypersomnia (excessive daytime sleepiness)

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Cont’d
Types of dyssomnias:  Narcolepsy
 Circadian rhythm sleep-wake  Central sleep apnea (CSA)
disorder  Obstructive sleep apnea (OSA)
 Delayed sleep phase disorder
 Advanced sleep phase disorder
 Jet lag disorder
 Shift-work disorder
 Non-24 hour sleep-wake disorder
 Insomnia disorder
 Hypersomnolence disorder
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 Parasomnias:

Definition:
A group of primary sleeping disorders characterized by abnormal behaviors
or experiences that occur while falling asleep, during sleep, or while
waking up

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 Types of parasomnias

NREM-related parasomnia:
A group of parasomnias characterized by repeated episodes of brief but
incomplete awakenings that typically occur during the first third of sleep ,
Which includes:
1) Sleep walking disorder
2) Sleep terror disorder

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Cont’d
REM-related parasomnias:
A group of parasomnias characterized by a dissociation between REM
sleep and the awake state.
 Nightmare disorder
 REM sleep behavior disorder
 Recurrent isolated sleep paralysis
 Restlessness leg syndrome ( RLS)

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Common features of circadian rhythm sleep-
wake disorders
 Insomnia
 Excessive daytime somnolence
 Irritability
 Frequent waking during abnormal hours
 Headaches and impaired concentration
Delayed sleep phase disorder:
Definition: a sleep-wake disorder characterized by a recurrent delay in
sleep onset and waking times.
Risk factors: puberty, use of stimulants (e.g., caffeine), Irregular sleep.

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Treatment:
Phototherapy in the morning
 Melatonin receptor agonist (e.g., ramelteon, administered at night)
 Chronotherapy.

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Advanced sleep phase disorder:
Definition: a sleep-wake disorder characterized by earlier than desired sleep
onset and awakening times. Advanced sleep phase occurs when the
circadian rhythm cycle shifts forward. Therefore , the sleepiness cycle moves
earlier.
Individuals with this pattern of advanced sleep phase are sometimes called
early birds or larks.
Risk factor: associated with older age.
Treatment:
 Reassurance
 Phototherapy in the evening.

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Irregular sleep- wake type
The irregular sleep-wake pattern occurs when the circadian sleep-wake
rhythm is absent or pathologically diminished .
The sleep –wake pattern temporally disorganized and the timing of
sleep and wakefulness is unpredictable .
Individuals with this condition have a healthy amount of sleep 24
hours. , However it’s fragmented into three or more episodes that occur
irregularly .
There are symptoms of insomnia at night and excessive sleepiness the
day.

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Shift-work disorder:
Definition: a sleep-wake disorder characterized by misaligned circadian
rhythm due to nightly working hours and sleep deprivation
Risk factors: shifts > 16 hours and/or rotating day/ night shifts maybe
present particular difficulties .
Treatment:
 Modafinil If severe, mechanism of action is unknown , selective , and
weak dopamine reuptake Inhibitors and indirectly activates the release
of orexin neuropeptides and histamine from the lateral hypothalamus and
tubero-mammillary nucleus.
 Bright light therapy at night to adapt to work shift.

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Insomnia disorder
Definition: a dissatisfying quantity or quality of sleep that leads to some form
of daytime dysfunction
Etiology: complex and not fully understood
Predisposing factors include:
 A chronic state of cognitive and physiological hyperarousal.
 Medical comorbidities, including mood and anxiety disorders.
 Precipitating (acutely triggering) factors: e.g., stressful events (acute or
chronic)
 Perpetuating factors: e.g., poor sleep hygiene

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 Insomnia disorder
Persons with Insomnia primarily have difficulty falling asleep,
Difficulty staying asleep, or trouble waking early with an inability to fall
back to sleep, Sufficient to Impair their social and occupational
functioning.

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Diagnostic Criteria
A. A predominant complaint of dissatisfaction with sleep quantity or quality,
associated with one (or more) of the following symptoms:
1. Difficulty Initiating sleep.
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems
returning to sleep after awakenings.
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in
social, occupational, educational, academic, behavioral, or other important areas of
functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
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E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The Insomnia is not better explained by and does not occur
exclusively during the course of another sleep-wake disorder
G. The Insomnia is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
H. Coexisting mental disorders and medical conditions do not
adequately explain the predominant complaint of insomnia

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Cont’d
Different manifestations of insomnia can occur at different times of the
sleep period.
Sleep- onset insomnia (or initial insomnia) involves difficulty initiating
sleep at bedtime. Sleep maintenance insomnia (or middle insomnia)
involves frequent or prolonged awakenings throughout the night. Late
insomnia involves early-morning awakening with an inability to return
to sleep.
Impairment in cognitive performance may include difficulties with
attention, concentration and memory, and performing complex manual
skills.

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Clinical features

 Difficulty falling asleep, maintaining sleep, or early morning

awakening
 Non-refreshing sleep
 Impaired daytime functioning
 Fatigue
 Cognitive impairment
 Mood disturbance
 Difficulty with social, academic, or occupational functioning.

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Potential health consequences

 Development of mood disorders and increased risk of suicide

 Workplace injuries
 Reduced quality of life.

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Clinical assessment:

• Sleep-related symptoms
• Inquire about sleeping habits and bedtime routine.
• Determine symptom onset, triggers, and interventions already tried.
• Identify nighttime symptoms and assess their frequency and pattern.
• Ask about daytime impaired functioning and/or sleepiness.

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 Cont’d
Medical and psychiatric history should include:
 Comorbid conditions and associated symptoms that could interfere with sleep.
 Medication use (prescription and over-the-counter) and the time at which
medications are taken .
 Alcohol consumption, use of stimulants .
 Occupation, school, and working hours.

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Cont’d
Physical exam:
Check BMI, neck circumference, and airway to evaluate for obstructive sleep
apnea( OSA.)
Sleep difficulties in childhood can result from conditioning factors (e.g., a child
who does not learn to fall asleep or return to sleep without the presence of a
parent) or from the absence of consistent sleep schedules and bedtime routines.

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Management
All patients should Provide sleep hygiene education.
Optimize management of comorbid conditions.

Short-term Insomnia:
Address triggers, the precipitating factors.
 Start a brief course of pharmacotherapy for insomnia.

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Cont’d
Chronic insomnia:
First line: multicomponent cognitive behavioral therapy for insomnia (CBT-I)
If CBT-I is not successful:
Reassess the diagnosis (e.g., consider other sleep-wake disorders),
comorbidities, and exacerbating factors.
Consider pharmacotherapy for select patients; use a shared decision-
making strategy. Refer to a sleep specialist.

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Nonpharmacological management
 Treatment of insomnia should be individualized based on the nature and
severity of symptoms and should occur after other causes have been
considered, diagnosed, and treated.
 Nonpharmacologic treatments for insomnia are considered effective if they
decrease sleep onset latency or increase total sleep time by 30 minutes.
 Most treatment studies use patient-reported sleep diaries to measure
outcome.
 Criteria used include total sleep time, sleep-onset latency, and number of
nocturnal awakenings.

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Pharmacotherapy for insomnia
The evidence supporting the benefits of pharmacotherapy for
treating insomnia is relatively weak overall.
Some examples of commonly used drugs include:
 Melatonin , ramelteon
 Z-Drugs ( eszopiclone , Zalepton , Zolpidem )
 Benzodiazepines ( preferably short- acting benzodiazepines like triazolam )
 Suvorexant ( orexin antagonist )

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Cont’d

 Sleep-maintenance insomnia:

Z-drugs (eszopiclone, zolpidem), doxepin, suvorexant

 Early-morning awakening: doxepin, suvorexant
 Older adults (> 65 years old): doxepin, melatonin, ramelteon
 Comorbid depression: doxepin, mirtazapine, trazodone
• Pregnancy: doxylamine, diphenhydramine.

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Cont’d

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Hypersomnolence disorder
Etiology:
 Genetic (may be autosomal dominant)
 Head trauma
 Viral infections (e.g., HIV)
Classification:
 Acute: < 3 months
 Chronic: ≥ 3 months

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Cont’d

Hypersomnolence disorder includes symptoms of excessive quantity of

sleep (e.g., extended nocturnal sleep or long naps), sleepiness, and sleep
Inertia
(i.e., a period of impaired performance and reduced vigilance following
awakening from the regular sleep episode or from a nap)

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Diagnostic Criteria
A. Self-reported excessive sleepiness (hyper somnolence) despite a
main sleep period lasting at least 7 hours, with at least one of the
following symptoms:
1. Recurrent periods of sleep or lapses into sleep within the same day.
2. A prolonged main sleep episode of more than 9 hours per day that is
nonrestorative
3. Difficulty being fully awake after abrupt awakening.

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Cont’d

B. The hyper somnolence occurs at least three times per week, for at least 3
months.
C. The hyper somnolence is accompanied by significant distress or impairment
in cognitive, social, occupational, or other important areas of functioning.
D. The hyper somnolence is not better explained by and does not occur
exclusively during the course of another sleep disorder.
E. The hyper somnolence is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain the
predominant complaint of hyper somnolence.

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 Clinical features
 Excessive sleep (with decreased sleep quality)
 Difficulty awakening from sleep
 Sleep inertia (impaired alertness or excessive fatigue after waking)
 Automatic behaviors (with no memory of the episode after waking)
Treatment:
 Regularly scheduled naps.
 First-line therapy: modafinil or methylphenidate
 Second-line therapy: atomoxetine.

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Parasomnias
Definition: a NREM-related parasomnia characterized by walking or performing
other activities during the first third of the sleep cycle
Risk factors:
Sleep deprivation
Irregular sleep schedules
Stress or fatigue
Obstructive sleep apnea
Nocturnal seizures
Fever
Drugs (e.g., benzodiazepines, z-drugs, antidepressants, antipsychotics, β-blockers)

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Diagnostic Criteria
A. Recurrent episodes of incomplete awakening from sleep, usually
occurring during the first third of the major sleep episode, accompanied by
either one of the following:
1. Sleepwalking: Repeated episodes of rising from bed during sleep and
walking about. While sleepwalking, the individual has a blank, staring
face; is relatively unresponsive to the efforts of others to communicate
with him or her; and can be awakened only with great difficulty.

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Cont’d
2. Sleep terrors: Recurrent episodes of abrupt terror arousals from
sleep, usually beginning with a panicky scream.
There is intense fear and signs of autonomic arousal, such as mydriasis,
tachycardia, rapid breathing, and sweating, during each episode.
There is relative unresponsiveness to efforts of others to comfort the
individual during the episodes.

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B. No or little (e.g., only a single visual scene) dream imagery is recalled.
C. Amnesia for the episodes is present.
D. The episodes cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a
substance
F. Coexisting mental disorders and medical conditions do not explain
the episodes of sleepwalking or sleep terrors.

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Cont’d
 SLEEPWALKING. Sleepwalking, in its classic form, as the name implies, is a
condition in which an individual arises from bed and ambulates without fully
awakening.
 Sleepwalking episodes may range from sitting up and attempting to walk to
conducting an involved sequence of semi purposeful actions. The sleepwalker
can often successfully interact with the environment (e.g., avoiding tripping
over objects).
 In individual who is sleepwalking is difficult to awaken. Once awake, the
sleepwalker will usually appear confused. It is best to gently attempt to lead
sleepwalkers back to bed rather than to attempt to awaken them by grabbing,
shaking, or shouting.
 Nightly to weekly sleepwalking episodes associated with physical injury to the
patient and others are considered severe. There are “specialized” forms of
sleepwalking 47
Clinical features:
 Recurrent episodes during the first third of the sleep cycle, including sitting up,
walking, or eating.
 Blank stare and difficulty arousing patient during the episode
 Followed by amnesia of the event.
Treatment
 Education and reassurance.
 Ensuring safe sleep environment to reduce the risk of physical harm or
wandering outdoors.
 In refractory cases, benzodiazepines.

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Narcolepsy
 Narcolepsy is a neurological disorder of the sleep-wake cycle
characterized by excessive daytime sleepiness
 People with narcolepsy have an overwhelming desire to sleep and may
suddenly fall asleep, even if it is not appropriate to do so. Also, they
may experience cataplexy, apoplexy can range from transient weakness
in the knees to total paralysis while the patient is fully conscious.
 Usually, the patient is unable to speak and may fall to the floor.
 Sleep paralysis and hypnagogic (or hypnopompic) hallucinations may
occur. Primary narcolepsy type 1 may manifest with cataplexy and/or
orexin deficiency. Patients with type 2 primary narcolepsy have normal
orexin levels. Secondary narcolepsy can occur as a result of
brain damage or genetic syndromes.
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Etiology
 Primary narcolepsy
 Narcolepsy type 1
 Loss of lateral hypothalamic neurons, which produce hypocretin-
1 and hypocretin-2.
 Genetic predisposition
 Narcolepsy type 1 is strongly associated with a variation of the HLA-
DQB1 gene called HLA-DQB1
 Positive family history increases the risk
 Environmental factors: e.g., streptococcal pharyngitis, exposure
to H1N1 influenza vaccine Pandemrix.
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Cont’d
Narcolepsy type 2 :
 Idiopathic
 No changes in orexin levels
Secondary narcolepsy:
 Cerebral damage (e.g., tumor, stroke, inflammation,
vascular malformation)
 Genetic syndromes (e.g., Niemann-Pick disease type C and Prader-Willi
syndrome)

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DIAGNOSTIC CRETERIA
A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or
napping occurring within the same day. These must have been occurring at least
three times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times
per month:
2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-
1 immunoreactivity values
3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep
latency less than or equal to 15 minutes, or a multiple sleep latency test showing a
mean sleep latency less than or equal to 8 minutes and two or more sleep-onset
REM periods.
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Clinical features
 Excessive daytime sleepiness (EDS)
 Abnormal REM sleep
Cataplexy
Sleep paralysis
 Sleep hallucinations
Hypnagogic hallucinations
Hypnopompic hallucinations
 Automatic behavior

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MANAGEMENT
First-line medications:
 Modafinil: a nonamphetamine CNS stimulant
 Solriamfetol: selective dopamine and norepinephrine reuptake inhibitor
that promotes wakefulness
 Pitolisant: highly selective H3receptor antagonist/inverse agonist for the
treatment of EDS and cataplexy
 Nighttime sodium oxybate: a sodium salt of gamma hydroxybutyric acid
Second-line medications :
 Armodafinil
 Dextroamphetamine
 Methylphenidate

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Sleep terror disorder
Definition: a NREM-related parasomnia that occurs during the N3 sleep
stage (slow-wave sleep), characterized by episodes of sleep terror
Epidemiology:
Discrete episodes of sleep terrors are relatively common in children (∼
20% of children and ∼ 2% of adults), but the disorder is rare.
Etiology: unknown; presumed to be genetic (family history)

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Risk factors
 Stress or fatigue
 Fever
 Sleep deprivation
 Obstructive sleep apnea ( OSA)
 Nocturnal seizures
 Drugs (e.g., lithium)

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Cont’d

 Sleep terrors involve sudden arousal with intense fearfulness.

 They usually begin with a piercing scream or cry and are
accompanied by behavioral manifestations of intense anxiety
bordering on panic.
 An individual experiencing a sleep terror sits up in bed, is
unresponsive to stimuli, and, if awakened, is confused or disoriented.
Vocalizations may occur, but they usually are incoherent.

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Clinical features
 Screaming or crying suddenly upon awakening, usually in the first part of
the night (rarely during daytime naps)
 Intense fear and agitation
 Tachypnea, diaphoresis, tachycardia during episodes.
 Difficulty arousing patients during episodes
 Patients usually return to sleep after the episode.
 Typically no recollection of the arousal episode (unlike with nightmare
disorder)

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Treatment
 Education and reassurance (disorder usually self-limited)
 Removal of dangerous objects from bedroom to reduce risk of self-
injury
 In refractory cases, benzodiazepines

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Nightmare disorder
Nightmares are frightening or terrifying dreams. Sometimes called
dream anxiety attacks, they produce sympathetic activation and
ultimately awaken the dreamer.
Epidemiology:
Prevalence: most common in early adulthood; occurs in 2–5% of the
adult population
Sex: female > male ♀ > ♂
Risk factors: post-traumatic stress disorder (PTSD)

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 Clinical features
 Recurrent frightening dreams during the second half of sleep cycle (middle of
the night or early in the morning)
 Patient remembers the dream after awakening (unlike in sleep terror disorder).
 Causes functional impairment or distress.
 Nightmares occur in REM sleep and usually evolve from a long, complicated
dream that becomes increasingly frightening.
 Frequent and distressing nightmares are sometimes responsible for insomnia
because the individual is afraid to sleep.
 Withdrawal from REM suppressant medications may induce nightmares, as well.
Finally, drug or alcohol abuse is associated with nightmares.

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Diagnostic Criteria
A. Repeated occurrences of extended, extremely dysphoric, and well-
remembered dreams that usually involve efforts to avoid threats to survival,
security, or physical integrity and that generally occur during the second half of
the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes
oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
E. Coexisting mental disorders and medical conditions do not adequately
explain the predominant complaint of dysphoric dreams.
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Treatment
 Reassurance if the disorder is mild
 Imagery rehearsal therapy: involves modifying a recurrent nightmare
by writing it down and rehearsing new endings that make nightmares
less frightening when they occur again
 Antidepressants or prazosin if associated with PTSD

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REM sleep behavior disorder
Definition: a REM-related parasomnia characterized by dream enactment due to loss
of REM sleep atonia
RBD involves a failure of the patient to have atonia (sleep paralysis) during the REM
stage sleep. The result is that the patient enacts his or her dreams.
Risk factors:
 Narcolepsy
 Psychiatric medications (e.g., antidepressants)
 Neurodegenerative disorders (e.g., Parkinson disease, Lewy body dementia)

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Clinical features

 Physically acting out dreams during sleep (e.g., yelling, moving

limbs, walking, punching), sometimes leading to injury to self or
others
 Patient is alert and orientated after awakening, and remember the
dream.

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Treatment
 Remove dangerous objects from the bedroom to reduce risk of self-injury.
 If applicable, discontinue causative medications.
 Pharmacotherapy
A. Melatonin receptor agonist (first-line treatment)
B. Benzodiazepines (e.g., clonazepam)
 Other parasomnias:
A. Nocturnal enuresis
B. Restless leg syndrome.

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Sleep deprivation
Definition:
A state of inadequate quality and/or quantity of sleep
Etiology :
Environmental causes, e.g.: Substance use (e.g., alcohol, stimulants such
as caffeine, cocaine, amphetamines)
Sleeping circumstances (e.g., exposure to increased noise or light at night)

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Cont’d
Sleep disorders , e.g.: Dyssomnias include:
Delayed sleep phase disorder
Advanced sleep phase disorder
Central sleep apnea
Obstructive sleep apnea
Insomnia disorder
Parasomnias

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Cont’d
 Other medical conditions, including: Metabolic syndrome
 Acute and chronic pain
 Neurodegenerative diseases
 Psychiatric disorders (e.g., major depressive disorder, anxiety, bipolar
disorder.
Classification:
o Acute sleep deprivation: 1–2 days of reduced or no sleep
o Chronic sleep deprivation (sleep restriction): reduced sleep for months

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Clinical features
 Fatigue
 Excessive daytime sleepiness
 Cognitive impairment (e.g., poor focus, impaired memory, reduced
alertness)
 Mood disturbances (e.g., depressed mood)
 Lower self-reported quality of life

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Cont’d
Diagnostics:
 Assessment of quality and quantity of sleep
 Polysomnography.

Differential diagnosis:
 Hypersomnolence disorder
 Chronic fatigue syndrome

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Cont’d
Management:
 Treatment of underlying conditions (e.g., Obesity, sleep apnea, psychiatric
disorders)
 Behavioral modification
 Patient education
 Improvement of sleep hygiene (eliminate behavioral habits that adversely
affect sleep)
 In case other options fail: sedative-hypnotic drugs
 In case life circumstances can not be changed (e.g., shift work): use of
substances helping with wakefulness (e.g., caffeine)

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Complications
 Increased rates of accidents and injuries
 Increased rates of errors (e.g., doctors, pilots)
 Organ-related complications :
 Obesity, diabetes mellitus, and impaired glucose tolerance
 Cardiovascular diseases and hypertension.
 Anxiety and depressive disorders.

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References:
• Kaplan & Sadock's Synopsis of Psychiatry 12th Ed..pdf
• STEP 2 CK _Lecture Notes-2020 _Psychiatry.pdf
• DSM-5-TR-2022.pdf.
• Oxford hand book of psychiatry 3rd edition .
• AMBOSS

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Any comments & Question

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