Sleep-Wake Disorders
Classification of sleep-wake disorders:
Insomnia: a common sleep disorder that can make it hard to fall asleep or stay asleep
Hypersomnolence disorder: a condition in which you feel extreme daytime sleepiness despite getting sleep that should be adequate (or more than adequate)
Narcolepsy: a chronic neurological disorder that affects the brain's ability to control sleep-wake cycles
Circadian rhythm sleep-wake disorders: are a family of sleep disorders which affect the timing of sleep
Delayed sleep phase type
Advanced sleep phase type
Irregular sleep wake type
Non 24-hour sleep wake type
Shift work type
Jet lag disorder
Social jet lag disorder
Parasomnias: a category of sleep disorders that involve abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep
Non-REM sleep arousal disorder
Nightmare disorder
REM sleep behaviour disorder
Restless legs syndrome
Substance/medication induced sleep disorder
Insomnia
Diagnosing insomnia:
Is primarily by clinical evaluation through a thorough:
Sleep history
Medical history
Substance use
Psychiatric history
Instruments which are helpful in the evaluation and differential diagnosis of insomnia include:
Self-administered questionnaires
At-home sleep logs
Symptom checklists
Psychological screening tests
Bed partner interviews
PSG and daytime MSLT are NOT indicated in the routine evaluation of chronic insomnia, including insomnia due to psychiatric or neuropsychiatric disorders
Insomnia diagnostic criteria:
A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
Difficulty initiating/maintaining sleep
Inability to return to sleep
Sleep disturbance causes clinically significant distress/impairment
The sleep difficulty occurs at least 3 nights per week, present for at least 3 months, despite adequate opportunity for sleep
Insomnia prevalence:
One-third of adults report insomnia symptoms
33% to 50% have symptoms
10% to 15% experience associated daytime impairments
5% to 10% experience specific insomnia disorders
More prevalent complaint among females than males, with a gender ratio of 1.44:1
40%–50% of individuals with insomnia also present with a comorbid mental disorder
50%-75% of individuals with insomnia also present with psychiatric and chronic pain disorders
Insomnia Development and Course:
Onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood
In women, new-onset insomnia may occur during menopause and persist even after other symptoms (e.g., hot flashes) have resolved
The course of insomnia may also be episodic, with recurrent episodes of sleep difficulties associated with the occurrence of stressful events
Risk factors for insomnia:
Increasing age
Female sex
Health problems
Persistent pain
Cardiac or respiratory failure
Chronic inflammatory conditions—such as arthritis, connective tissue disorders, inflammatory bowel disease
Chronic infection—such as hepatitis, HIV infection
Mental health problems (relationship between insomnia and psychiatric conditions appear bidirectional)
Depression
Anxiety
Bipolar disorder
Personality disorders—such as narcissistic and borderline
Medications that can disturb sleep
Antidepressants—such as selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors
Adrenergic agonists—such as salbutamol, terbutaline, dexamphetamine, methylphenidate
Corticosteroids
Opioids
Personal factors
Family history of insomnia from a young age
Tendency to anxiety or perfectionism
Lifestyle factors
Excess stimulant or substance use—such as caffeine, energy drinks, nicotine
Shift work or long working hours with little recovery time between shifts
Unemployment
Lower socio-economic status
Chronic insomnia:
Chronic insomnia is defined as difficulty getting to sleep at least 3 nights a week for the past 3 months and is distressed by their sleep symptoms (as opposed to acute or transient insomnia, which may last days to weeks)
Chronic insomnia persists even when lifestyle factors adversely affecting sleep are addressed
Chronic insomnia is the most prevalent sleep disorder in the general population
Chronicity rates range from 45% to 75% for follow-ups of 1–7 years
Factors to address in chronic insomnia:
Anxiety around sleep
Maladaptive behaviours around sleep
Fear of further disruption of sleep
Predisposing dispositions
Comorbidities
Pharmacological options, but consider hypnotics as a short term measure
Refer to specialist if there are ongoing symptoms despite the above measures
Treatment goals in chronic insomnia:
Regardless of the therapy type, primary treatment goals are to:
Improve sleep quality and quantity
Improve insomnia related daytime impairments
Other specific outcome indicators for sleep generally include measures of:
Wake time after sleep onset (WASO)
Sleep onset latency (SOL)
Number of awakenings
Sleep time or sleep efficiency
Formation of a positive and clear association between the bed and sleeping
Improvement of sleep related psychological distress
Ideally, regardless of the therapy type, clinical reassessment should occur every few weeks and/or monthly until the insomnia appears stable or resolved, and then every 6 months, as the relapse rate for insomnia is high
When a single treatment or combination of treatments has been ineffective, other behavioral therapies, pharmacological therapies, combined therapies, or reevaluation for occult comorbid disorders should be considered
Treatment of chronic insomnia:
Cognitive Behavioural Therapy for insomnia (CBT-I) is first line treatment for patients with chronic insomnia
Effect of CBT-I is similar to usage of hypnotics for chronic insomnia however whilst hypnotics effects wear off once treatment stops, CBT-I has ongoing effects
Medications may be used as an adjunct to CBT-I, but their long term effectiveness and safety have not been well assessed
Other treatment involves incorporating sleep restriction, stimulus control, relaxation strategies, and sleep hygiene measures
Combined therapy shows no consistent advantage or disadvantage over CBT-I alone
Psychological and behavioral therapies:
Psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia
Initial approaches to treatment should include at least one behavioral intervention:
Stimulus control therapy: designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration and worry. The objectives of stimulus control therapy are for the patient to form a positive and clear association between the bed and sleep and to establish a stable sleep-wake schedule
Relaxation therapy: eg progressive muscle relaxation, guided imagery or abdominal breathing is designed to lower somatic and cognitive arousal states which interfere with sleep
Sleep restriction: initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive
Paradoxical intention: is a specific cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. The objective is to eliminate a patient’s anxiety about sleep performance
Biofeedback therapy: trains the patient to control some physiologic variable through visual or auditory feedback. The objective is to reduce somatic arousal
CBT-I: combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy. Seeks to change the patient’s overvalued beliefs and unrealistic expectations about sleep; uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects
Multicomponent therapy (without cognitive therapy)
Although all patients with chronic insomnia should adhere to rules of good sleep hygiene, there is insufficient evidence to indicate that sleep hygiene alone is effective in the treatment of chronic insomnia. It should be used in combination with other therapies
5 components of CBT-i:
Cognitive therapy
Aims to identify, challenge and replace dysfunctional beliefs and attitudes about sleep and insomnia. Such misconceptions may include unrealistic expectations of sleep, fear of missing out on sleep, and overestimation of the consequences of poor sleep.
Stimulus control
Behavioural instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associate bed with other stimulating activities. Such instructions include avoiding non sleep activities in the bedroom; going to bed only when sleepy; and leaving the bedroom when unable to sleep for 15–20 minutes, returning to bed only when sleepy.
Sleep restriction
Behavioural instructions to limit time in bed to match perceived sleep duration in order to increase sleep drive and further reduce time awake in bed. Time allowed in bed is initially restricted to the average time perceived as sleep per night and then adjusted to ensure sleep efficiency remains greater than 85%.
Sleep hygiene
General recommendations relating to environmental factors, physiologic factors, behaviour and habits that promote sound sleep. Specific instructions include advice on control of the bedroom environment, including avoiding visual access to a clock; regular sleep scheduling and avoiding daytime naps; and limiting alcohol, caffeine and nicotine intake, especially before bed.
Relaxation
Any relaxation technique that the patient finds effective can be used to limit cognitive arousal and reduce muscular tension to facilitate sleep. Specific techniques that may be effective include meditation, mindfulness, progressive muscle relaxation, guided imagery and breathing techniques.
Pharmacological treatment:
Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible
For patients with primary insomnia (psychophysiologic, idiopathic or paradoxical ICSD-2 subtypes), when pharmacologic treatment is utilised alone or in combination therapy, the recommended general sequence of medication trials is:
Short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon eg zolpidem, eszopiclone, zaleplon, temazepam
Alternate short-intermediate acting BzRAs or ramelteon if the initial agent has been unsuccessful
Sedating antidepressants especially when used in conjunction with treating comorbid depression/anxiety eg trazodone, amitriptyline, doxepin, and mirtazapine
Combined BzRA or ramelteon and sedating antidepressant
Other sedating agents eg anti-epilepsy medications (gabapentin, tiagabine) and atypical antipsychotics (quetiapine and olanzapine)
These medications may only be suitable for patients with comorbid insomnia who may benefit from the primary action of these drugs as well as from the sedating effect
OTC antihistamine or antihistamine/analgesic type drugs (“sleep aids”) as well as herbal and nutritional substances (eg valerian and melatonin) are NOT recommended in the treatment of chronic insomnia due to the relative lack of efficacy and safety data
Older approved drugs for insomnia including barbiturates, barbiturate-type drugs and chloral hydrate are NOT recommended for the treatment of insomnia
Hypersomnolence
Hypersomnolence Disorder Diagnostic Criteria:
Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
Recurrent periods of sleep or lapses into sleep within the same day
A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing)
Difficulty being fully awake after abrupt awakening
The hypersomnolence occurs at least 3 times per week, for at least 3 months
Not explained by other sleep disorders
Hypersomnolence Disorder Prevalence:
It is estimated that about 1% of the European and U.S. general population has episodes of sleep inertia (temporary disorientation/low mood after waking)
Hypersomnolence occurs with relatively equal frequency in males and females
Hypersomnolence Disorder Development and Course:
Hypersomnolence has a progressive onset
Symptoms begin between ages 15 and 25 years, with a gradual progression over weeks to months
For most individuals, the course is then persistent and stable, unless treatment is initiated
Narcolepsy
Narcolepsy Diagnostic criteria:
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
The presence of at least one of the following:
Episodes of cataplexy (muscle weakness), defined as either (a) or (b), occurring at least a few times per month:
(a) In individuals with CHRONIC long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking
(b) In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers
Hypocretin deficiency (type I)
PSG showing latency to REM-sleep of < 15 minutes or MSLT (multi-sleep latency test) showing mean sleep latency <= 8 minutes and 2 or more sleep-onset REM periods
Narcolepsy Prevalence:
0.02%–0.04% of the general population in most countries
Slight male predilection
Narcolepsy Development and Course:
Onset is typically in children and adolescents/young adults but rarely in older adults
Two peaks of onset are suggested, at ages 15–25 years and ages 30–35 years
Onset can be abrupt or progressive (over years)
In 90% of cases, the first symptom to manifest is sleepiness or increased sleep, followed by cataplexy (sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, or terror)
Circadian Rhythm Sleep-Wake Disorders Subtypes:
Delayed sleep phase type
A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time
Prevalence 0.17% of population, 7% of adolescence
Course is persistent, lasting longer than 3 months, with intermittent exacerbations throughout adulthood. Although age at onset is variable, symptoms begin typically in adolescence and early adulthood and persist for several months to years before diagnosis is established
Advanced sleep phase type
A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times
Prevalence: approximately 1% in middle age adults. Sleep-wake times and circadian phase advance in older individuals, probably accounting for increased prevalence in this population
Onset is usually in late adulthood. In the familial form, onset can be earlier
The course is typically persistent, lasting more than 3 months, but the severity may increase depending on work and social schedules
Irregular sleep wake type
A temporally disorganized sleep-wake pattern, such that the timing of sleep and wake periods is variable throughout the 24-hour period
Prevalence unknown
Course is persistent
Age at onset is variable, but the disorder is more common in older adults
Non-24-hour sleep wake type
A pattern of sleep-wake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times
Prevalence is unclear, but the disorder appears rare in sighted individuals. The prevalence in blind individuals is estimated to be 50%
Course of non-24-hour sleep-wake type is persistent, with intermittent remission and exacerbations due to changes in work and social schedules throughout the lifespan. Age at onset is variable, depending on the onset of visual impairment
Jet lag disorder
The diagnostic criteria for JLD:
There is a complaint of insomnia or excessive daytime sleepiness associated with transmeridian jet travel across at least 2 time zones
There is associated impairment of daytime function, general malaise or somatic symptoms such as gastrointestinal disturbance within 1 to 2 days after travel
The sleep disturbance is not better explained by another current sleep disorder, medical or neurologic disorder, mental disorder, medication use, or substance use disorder
Shift work type
Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period associated with a shift work schedule (ie requiring unconventional work hours)
Prevalence is estimated to affect 5%–10% of the night worker population (16%–20% of the workforce). Prevalence rises with advancement into middle-age and beyond
More prevalent in individuals older than 50 years and typically worsens with the passage of time if the disruptive work hours persist
Parasomnias:
Non-REM sleep arousal disorders
Nightmare disorder
REM sleep behaviour disorder
Restless legs syndrome
Non-REM Sleep Arousal Disorders Diagnostic Criteria:
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:
Sleep walking/sleep terrors
No or little dream imagery is recalled
Amnesia for the episodes is present
Episodes cause significant distress
Non-REM Sleep Arousal Disorders Prevalence:
Isolated or infrequent NREM sleep arousal disorders are very common in the general population
From 10% to 30% of children have had at least one episode of sleepwalking, and 2%–3% sleepwalk often
The lifetime prevalence of sleepwalking in adults is 29.2%, with a past-year prevalence of sleepwalking of 3.6%
The prevalence of sleep terrors in the general population is unknown
Non-REM Sleep Arousal Disorders Development and Course:
Occur most commonly in childhood and diminish in frequency with increasing age
The onset of sleepwalking in adults with no prior history of sleepwalking as children should prompt a search for specific aetiologies, such as obstructive sleep apnea, nocturnal seizures, or effect of medication
Nightmare Disorder DIagnostic criteria:
Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams
On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert
Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Nightmare Disorder Prevalence:
Prevalence of nightmares increases through childhood into adolescence
Prevalence increases from ages 10 to 13 for both males and females but continues to increase to ages 20–29 for females (while decreasing for males), when it can be twice as high for females as for males
Prevalence decreases steadily with age for both sexes, but the gender difference remains
Among adults, prevalence of nightmares at least monthly is 6%, whereas prevalence for frequent nightmares is 1%–2%
REM Sleep Behaviour Disorder Diagnostic criteria:
Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors
These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps
Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented
REM Sleep Behaviour Disorder Prevalence:
Approximately 0.38%–0.5% in the general population
Prevalence in patients with psychiatric disorders may be greater, possibly related to medications prescribed for the psychiatric disorder
REM Sleep Behaviour Disorder Development and Course:
The onset may be gradual or rapid
The course is usually progressive
REM sleep behavior disorder associated with neurodegenerative disorders may improve as the underlying neurodegenerative disorder progresses
Overwhelmingly affects males older than 50 years, but increasingly this disorder is being identified in females and in younger individuals
Restless Legs Syndrome Diagnostic Criteria:
An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
The urge to move the legs begins or worsens during periods of rest or inactivity
The urge to move the legs is partially or totally relieved by movement
The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night
Occur at least 3 times per week and have persisted for at least 3 months
Accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning
Restless Legs Syndrome Prevalence:
Prevalence rates of RLS vary widely when broad criteria are utilized but range from 2% to 7.2% when more defined criteria are employed
Restless Legs Syndrome Development and Course:
The onset of RLS typically occurs in the second or third decade
Substance/medication Induced Sleep Disorder Diagnostic criteria:
A prominent and severe disturbance in sleep
The symptoms develop during or soon after substance intoxication or after withdrawal from or exposure to a medication