4.4 Sleep Disorders - Page-by-Page Notes

Page 1

Learning Objectives

• Describe the symptoms and treatments of insomnia.
• Recognize the symptoms of several parasomnias.
• Describe the symptoms and treatments for sleep apnea.
• Recognize risk factors associated with sudden infant death syndrome (SIDS) and steps to prevent it.
• Describe the symptoms and treatments for narcolepsy.

Overview and epidemiology

• Disturbances in sleep are common across populations. Depending on population and disorder studied, between 30% and 50% of people experience a sleep disorder at some point in life. Key references include Bixler, Kales, Soldatos, Kaels, & Healey (1979); Hossain & Shapiro (2002); Ohayon (1997, 2002); Ohayon & Roth (2002).
• This section covers several sleep disorders and treatment options.

Insomnia

• Definition: A consistent difficulty in falling or staying asleep. Individuals may experience long delays before falling asleep and may wake multiple times at night with difficulty returning to sleep.
• Diagnostic criterion (as stated): Symptoms occur for at least three nights per week for at least one month. ext{Insomnia criterion}: ext{symptoms }
  ightarrow 3 ext{ nights/week} imes 1 ext{ month}
• Psychological cycle: Increased anxiety about inability to sleep leads to higher arousal, which further reduces sleep onset probability (a self-perpetuating cycle).
• Associated features: Chronic insomnia is often linked with overtiredness and may be associated with depression.
• Contributing factors: Age, drug use, exercise, mental status, and bedtime routines.
• Treatment approaches (multi-faceted):
  • Reduce stimulant use (e.g., caffeine) and increase daytime physical activity.
  • Use of over-the-counter (OTC) or prescribed sleep medications sparingly due to dependence and potential alteration of sleep architecture; this can increase insomnia over time.
  • Seek professional treatment if insomnia persists and affects quality of life.
  • Psychotherapy options include cognitive-behavioral therapy (CBT).
• Cognitive-Behavioral Therapy (CBT) for insomnia: Focuses on cognitive processes and problem behaviors; treatment often includes stress management and changes in behaviors that contribute to insomnia (e.g., spending more time awake in bed).
  • CBT has been demonstrated to be effective in treating insomnia (Savard, Simard, Ivers, & Morin, 2005; Williams, Roth, Vatthauer, & McCrae, 2013).

Practical takeaway (contextual guidance)

• CBT-based approaches are preferred for long-term relief and reducing dependence on medications.
• Consider a multi-component strategy (sleep restriction, stimulus control, relaxation training, cognitive therapy) rather than relying solely on medications.

Everyday connection (tips for healthy sleep)

• For college students and others under stress, aim for the recommended sleep duration and consistent schedule.
• Tips include:
  • Stick to a sleep schedule, even on weekends.
  • Avoid stimulating activity for at least an hour before bed (including bright light from screens).
  • Exercise daily.
  • Avoid naps.
  • Keep bedroom temperature between $60^{\circ}\mathrm{F}$ and $67^{\circ}\mathrm{F}$.
  • Avoid alcohol, cigarettes, caffeine, and heavy meals before bed (alcohol disrupts REM sleep and can cause awakenings; heavy meals can cause gastric distress and awakenings).
  • If you cannot fall asleep, leave the bed and engage in a quiet activity until sleepy again (reassociate the bed with sleep).
  • Train the bed to be a cue for sleep, not for studying, eating, or watching TV.

Page 2

Paragraph overview: Insomnia continued and CBT evidence

• The text reiterates affordability and risks of self-treatment with sleep medications and emphasizes seeking professional treatment if insomnia persists.
• It underscores CBT as an evidence-based treatment option with demonstrated efficacy (Savard et al., 2005; Williams et al., 2013).

Everyday connection (expanded tips)

• The section provides practical strategies to support healthy sleep patterns and reduce insomnia symptoms through behavioral changes and sleep hygiene.

Page 3

Parasomnias: definition and examples

• Parasomnias are a group of sleep disorders characterized by unwanted, disruptive motor activity or experiences during sleep. They can occur in either REM or NREM sleep.
• Examples include sleepwalking (somnambulism), restless leg syndrome, and night terrors (Mahowald & Schenck, 2000).

Sleepwalking (Somnambulism)

• Behavioral scope: Sleepwalkers may engage in complex behaviors ranging from wandering to driving. They often have their eyes open but are unresponsive to communication.
• Timing: Most often occurs during slow-wave sleep but can occur at other times during the night in some individuals.
• Treatment history and current understanding: Historically, pharmacotherapies from benzodiazepines to antidepressants have been used, but the success rate is questionable. Notably, Guilleminault et al. (2005) found benzodiazepines did not alleviate sleepwalking generally. However, among patients with sleep-related breathing problems, effective treatment of breathing problems markedly reduced sleepwalking.
• Illustrative case (DIG DEEPER): The Falater case (January 16, 1997) describes a man who, after a day of work-related stress and evening duties, murdered his wife during a sleep-related episode; he reported no recollection. He had a history of regular sleepwalking in childhood and violent behavior during sleepwalking in the past. He was convicted of first-degree murder in 1999; researchers note the possibility of homicidal sleepwalking in some sleep disorders, though this remains a controversial and debated area (Cartwright, 2004; Mahowald et al.; Pressman, 2007).

REM Sleep Behavior Disorder (RBD)

• Phenomenon: In RBD, the normal REM sleep paralysis is absent, leading to high physical activity during REM sleep (e.g., kicking, punching, scratching, yelling) and actions that may injure the sleeper or bed partner. There is typically no memory of these events upon waking.
• Clinical significance: RBD is associated with several neurodegenerative diseases, particularly Parkinson’s disease; it may serve as an early marker for neurodegenerative processes.
• Treatment: Clonazepam (an anti-anxiety sedative) is commonly used, often in combination with melatonin. Safety measures are implemented to modify the sleeping environment to reduce risk of injury (Arnulf, 2012; Zangini et al., 2011).

Page 4

Additional parasomnias: Restless Legs and Night Terrors

• Restless Leg Syndrome (RLS): Characterized by uncomfortable sensations in the legs during periods of inactivity or when attempting to fall asleep. Movement relieves symptoms, which can disrupt the ability to fall or stay asleep. RLS is associated with several medical conditions, including chronic kidney disease and diabetes. Treatments include benzodiazepines, opiates, and anticonvulsants (Restless Legs Syndrome Foundation, n.d.).
• Night Terrors: Involve a sense of panic with screams and attempts to escape. The sufferer often appears awake but has no memory of the episode. Consoling is typically ineffective. These events occur during NREM sleep, and most individuals return to sleep shortly after. Treatment is generally unnecessary unless there is an underlying medical or psychological condition contributing to night terrors (Mayo Clinic, n.d.).

Page 5

Sleep Apnea

• Definition: Repeated episodes during which a sleeper’s breathing stops for 10–20 seconds or longer, often accompanied by brief arousals. Sufferers may be unaware of sleep disruptions, but they report fatigue.
• Prevalence and risk factors: Sleep apnea is more common in overweight individuals and is often associated with loud snoring. It can exacerbate cardiovascular disease (Sánchez-de-la Torre, Campos-Rodriguez, & Barbé, 2012).
• Types:
  • Obstructive sleep apnea (OSA): airway blockage during sleep prevents air from reaching the lungs.
  • Central sleep apnea: brain signal disruption regulates breathing, causing periods of interrupted breathing (White, 2005).
• Treatment: The most common treatment is continuous positive airway pressure (CPAP). A CPAP device uses a mask and a pump to deliver air and keep airways open, effective for mild to severe cases (McDaid et al., 2009). Newer approaches are explored due to compliance issues; expiratory positive airway pressure (EPAP) devices have shown promise in double-blind trials (Berry, Kryger, & Massie, 2011).
• Figure reference: Typical CPAP setup and headgear illustration (Figure 4.13) is described in the text.

Page 6

SIDS: Sudden Infant Death Syndrome

• Definition: An infant stops breathing during sleep and dies. Highest risk is in infants under 12 months, with boys at higher risk than girls.
• Risk factors: Premature birth, exposure to tobacco smoke in the home, and hyperthermia. Brain structure and function differences have been observed in infants who die from SIDS (Berkowitz, 2012; Mage & Donner, 2006; Thach, 2005).
• Public health guidance (Safe Sleep practices): Recommending back-sleep position, removing suffocation hazards from the crib (blankets, pillows, padded bumpers), avoiding head caps to prevent overheating, and ensuring a smoke-free home. These recommendations have contributed to decreasing SIDS incidence (Mitchell, 2009; Task Force on SIDS, 2011).
• Campaigns: The Safe to Sleep campaign educates caregivers about reducing SIDS risk and is supported in part by the National Institute of Child Health and Human Development (Figure 4.14 reference).

Page 7

Narcolepsy: an overview

• Core features: Narcoleptics experience irresistible sleep attacks at inappropriate times. Attacks are often accompanied by cataplexy, a sudden loss of muscle tone or weakness that may progress to complete temporary paralysis of voluntary muscles. This phenomenon mirrors REM sleep paralysis and contributes to daytime impairment.
• REM-like features during attacks: During narcoleptic episodes, elements such as rapid eye movement, vivid dream-like experiences, or hallucinations can occur. About one third of individuals with narcolepsy experience such hallucinations during attacks (Chokroverty, 2010).
• Trigger factors: Narcoleptic episodes are often triggered by heightened arousal or stress.
• Impact of narcolepsy: Episodes last from one to several minutes or up to about 30 minutes and can interfere with work, school, and safety (e.g., driving, operating machinery).
• Current treatment landscape: Treated primarily with psychomotor stimulants (e.g., amphetamines) that promote increased neural activity. These drugs do not directly address hypocretin, a neuropeptide involved in wakefulness, which has been implicated in narcolepsy. This suggests potential for future therapies targeting the hypocretin system (Mignot, 2012; De la Herrán-Arita & Drucker-Colín, 2012; Han, 2012).
• Variability among sufferers: There is substantial variability in symptom presentation and treatment response among individuals.

Page 8

Narcolepsy: Case example and treatment nuances

• Case study (McCarty, 2010): A 50-year-old woman reported excessive daytime sleepiness for several years, including falling asleep at unsafe moments (while eating, socializing, driving). She also experienced transient hemibody weakness during emotional arousal. She was diagnosed with narcolepsy based on sleep testing. Initial attempts with stimulants alone were ineffective; combining a stimulant with an antidepressant yielded dramatic improvement, illustrating the heterogeneity of treatment responses in narcolepsy.
• Treatment implications: Successful management often requires multi-drug strategies tailored to the individual, addressing both daytime sleepiness and cataplexy-like symptoms when present. The evolving understanding of hypocretin deficiency informs ongoing development of targeted therapies.

Page 9

Summary of narcolepsy notes (final synthesis)

• Narcolepsy presents with irresistible sleep attacks, cataplexy, hypnagogic/hypnopompic hallucinations, and sleep paralysis. It is linked to hypocretin system dysfunction in parts of the brain.
• Management is multimodal and may combine stimulants with antidepressants or other agents to control daytime sleepiness and cataplexy, with ongoing research into hypocretin-targeted treatments.
• Case-based evidence (such as the 50-year-old woman) demonstrates the need for individualized treatment plans and careful monitoring of efficacy and tolerability.

Key Formulas and Numerical References

• Insomnia diagnostic criterion (as described):
  $ext{Insomnia: at least } 3 ext{ nights/week for } 1 ext{ month}.$
• Sleep duration guideline referenced in everyday tips:
  $7 \leq \text{hours of sleep per night} \leq 9.$
• Temperature guidance for a sleep-conducive environment:
  $60^{\circ}\mathrm{F} \leq T_{bed} \leq 67^{\circ}\mathrm{F}.$

References (as cited in the notes)

• Bixler, Kales, Soldatos, Kaels, & Healey (1979); Hossain & Shapiro (2002); Ohayon (1997, 2002); Ohayon & Roth (2002).
• Savard, Simard, Ivers, & Morin (2005); Williams, Roth, Vatthauer, & McCrae (2013).
• Guilleminault et al. (2005).
• Arnulf (2012); Zangini, Calandra-Buonaura, Grimaldi, & Cortelli (2011).
• McDaid et al. (2009); Berry, Kryger, & Massie (2011).
• Henry & Rosenthal (2013).
• Cartwright (2004); CNN (1999); Mahowald, Schenck, & Cramer Bornemann (2005); Pressman (2007).
• Thach (2005); Mage & Donner (2006); Berkowitz (2012).
• Mitchell (2009); Task Force on SIDS (2011).
• Chokroverty (2010); De la Herrán-Arita & Drucker-Colín (2012); Han (2012).
• Mignot (2012).

Note: The notes above reflect the content of the transcript provided, including case examples and clinical considerations discussed in the pages. Always refer to the original text for figures (e.g., Figure 4.13, 4.14) and full bibliographic details.