B4. Sleep-Wake Disorders

Sleeping Disorders

Group of disorders that involve dissatisfaction regarding the quality, timing, and amount of sleep which results in daytime distress and impairment

Dyssomnia

Characterized by problems in amount, quantity, or timing of sleep

Parasomnia

Abnormal behaviors or physiological events that occur during sleep

Stage 1 (N1): Light Sleep

Stage of wakefulness to sleep

Stage 2 (N2): Deep Sleep

Stage with sleep spindles and k-complexes that comprises 50% of sleep

Stage 3 (N3): Deeper Sleep

Slow wave sleep that is also the deepest level of sleep

Stage 4 (N4): REM Sleep

Stage where majority of dreams occur (20-25% of total sleep)

Insomnia Disorder

Sleeping disorder mostly about bad sleep quantity, quality, or timing where the individual has a hard time initiating or maintaining sleep or has early-morning awakenings with the inability to return to sleep

With non-sleep disorder mental comorbidity

With other medical comorbidity

With other sleep disorder

Episodic (At least 1 month but less than 3 months)

Persistent (3 months)

Recurrent (2 or more episodes in a year)

Specifiers of Insomnia Disorder

Other specified insomnia disorder

What should be the diagnosis for acute and short-term insomnia (Symptoms lasting less than 3 months?)

Rebound Insomnia

Sleeping disorder where sleep problems keep reappearing but sometimes worse

Hypersomnolence Disorder

Excessive sleepiness despite sleeping for at least 7 hours with recurrent periods or lapses into sleep within the same day and difficulty being awake after abrupt awakening

With mental disorder

With medical condition

With another sleep disorder

Acute (Less than 1 month)

Subacute (1-3 months)

Persistent (More than 3 months)

Mild (1-2 days a week of sleepiness)

Moderate (3-4 days a week)

Severe (5-7 days a week)

Specifiers of Hypersomnolence Disorder

Narcolepsy

Sleeping disorder with recurrent periods of an irresponsible need to sleep, lapsing into sleep, or napping occurring within the same day usually with cataplexy, hypocretin deficiency, or rapid eye movement sleep latency ≤15 minutes on a multiple sleep latency test

Without cataplexy but with hypocretin deficiency

With cataplexy but without hypocretin deficiency

Autosomal dominant cerebellar ataxia, deafness, and narcolepsy, & Narcolepsy secondary to another medical condition

Mild: Less than once a week cataplexy, 1-2 a day need for naps, less disturbed nocturnal sleep

Moderate: Cataplexy once daily or every few days, multiple naps daily, disturbed nocturnal sleep

Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepiness, and disturbed nocturnal sleep

Specifiers of Narcolepsy

At least 3 times per week for at least 3 months

How long should symptoms of Insomnia Disorder, Hypersomnolence Disorder, and Narcolepsy last?

Obstructive Sleep Apnea Hypopnea

Central Sleep Apnea

Sleep-Related Hypoventilation

Breathing-Related Sleep Disorders

Obstructive Sleep Apnea Hypopnea

Sleeping disorder with either:

1. least 4 obstructive apneas or hypopneas per hour sleep with either:

• Nocturnal breathing disturbances or;

• Excessive daytime sleepiness

2. 15 or more obstructive apneas or hypopneas from a polysomnography

Mild (<15)

Moderate (15-30)

Severe (>30)

Specifiers of Obstructive Sleep Apnea Hypopnea

Central Sleep Apnea

Sleep disorder with evidence of polysomnography of 5 or more central apneas per hour of sleep

Idiopathic central sleep apnea (Apneas and Hypopneas caused by variability in respiratory effort but with no airway obstruction)

Cheyne-Stokes breathing (Pattern of periodic crescendo-decrescendo variation in tidal volume causing sleep distrubances)

Central sleep apnea comorbid with opioid use

Specifiers of Central Sleep Apnea

Idiopathic Central Sleep Apnea

Sleep disorder with apneas and hypopneas caused by variability in respiratory effort but without evidence of airway obstruction

Chyne-Strokes Breathing

Sleep disorder with an abnormal pattern of breathing characterized by progressive, deeper, and sometimes faster breathing, followed by a gradual decrease, results in a temporary stop in breathing called an apnea

Sleep-Related Hypoventilation

Sleeping disorder with polysomnography that demonstrates episodes of decreased respiration associated with elevated carbon dioxide levels

Idiopathic hypoventilation (Not attributable to any medical condition)

Congenital central alveolar hypoventilation (Rare where the individual has a perinatal period with shallow breathing, or cyanosis and apnea during sleep)

Comorbid sleep-related hypoventilation (Consequence of a medical condition)

Specifiers of Sleep-Related Hypoventilation

Circadian Rhythm Sleep-Wake Disorders

Sleeping disorder with mismatch between the individual's internal sleep-wake cycle and the desired or required sleep-wake schedule

Delayed sleep phase type: Delayed sleeping time and awakening time (Specify if familial or overlapping with a non-24 hour sleep-wake type)

Advanced sleep phase type: Advanced sleeping time and awakening time (Specify if familial or overlapping with non-24 hour sleep-wake type)

Irregular sleep-wake type (Timing of sleep and wake is variable throughout 24 hours)

Non-24-hour sleep-wake type: Not synchronized with the 24-hour environment with a daily drift of sleeping and awakening time

Shift work type: Due to working schedule

Episodic (1 month but less than 2 months)

Persistent (3 months or longer)

Recurrent (2 or more episodes in a year)

Specifiers of Circadian Rhythm Sleep-Wake Disorders

Non-rapid Eye Movement Disorders

Rapid-eye Movement Sleep Behavior Disorder

Parasomnias

Non–Rapid Eye Movement Sleep Arousal Disorders

Sleep disorder with incomplete awakening from sleep through either sleepwalking or sleep terrors, usually occurring during the first third of the major sleep episode. They can’t remember the dream (Amnesia for episodes)

Sleepwalking type (With sleep-related eating & With sleep-related sexual behavior/sexsomnia)

Sleep terror type

Specifiers of Non–Rapid Eye Movement Sleep Arousal Disorders

Nightmare Disorder

Sleeping Disorder repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that generally occur during the second half of the major sleep episode. The individual usually becomes oriented and alert upon awakening and remembers the dreams

During sleep onset

With associated non-sleep disorder

With associated other medical condition

With associated other sleep disorder

Acute (1 month or less),

Subacute (More than 1 month, less than 3 months

Persistent (>6 months)

Mild (Less than 1 episode per week on average)

Moderate (One or more episodes per week but less than nightly)

Severe (Episodes nightly)

Specifiers of Nightmare Disorder

REM Sleep Behavior Disorder

Sleeping disorder with repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors during REM sleep and occur 90 minutes after sleep onset. Upon awakening, the individual is alert and oriented

Restless Legs Behavior

An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations with specific characteristics related to rest, movement, and time of day.

Urges begin or worsens during rest or inactivity, is partially or totally relieved by movement, and is worse in the evening than day or can only occur at night

3 times per week for at least 3 months

How long should symptoms of Restless Legs Behavior last?