Sleep Disorders

By
Dr. Yasmin Othman
 What is Sleep?
• One third of human life spent in sleep.
• Sleep is a basic human need and is essential for good
health, good quality of life and performing well during
the day.
• It is a behavioural phenomenon as it include postures,
closed eyes, relative immobility and impaired response
to external stimulation.
• While the physiological criteria of sleep is the stages of
sleep (the activities of the brain) (Chokroverty, 2001).
• Sleep research began when EEG able to read the stages
of sleep.
 Circadian Rhythm
• Circadian rhythm refers to biological rhythm or
biological clock which has a cycle length of about
24 hours. It regulates body temperature, activity
levels (DSM-1V-TR, 2004).
• Wakefulness and sleepiness is a result of the rise
and fall of the body temperature, by controlling
the variations of body temperature, it means
circadian rhythm influences the sleep-wake cycle
Body temperature related to sleep cycle
http://science.education.nih.gov/supplements/nih3/sleep/guide/info-
sleep.htm
National Institute of Health. US
The location of circadian rhythm is in the
suprachiasmatic nuclues
source: http://www.health-choices-for-life.com/science_of_sleep.html
 How Many Hours of Sleep Human Need

• The amount of sleep each person needs varies

and it depends on many factors such as age
and health (ASA, 1997)
• Infants generally require about 16 hours
• Teenagers require about 9 hours sleep.
• For most adults, 7 to 8 hours of sleep a night
seem to be the best amount of sleep
 Stages of Sleep
• Sleep is divided into five stages: stages 1, 2, 3,
4 (non-REM) and REM
• Each sleep cycle lasts about 90 to 110 minutes
• Stages 1 to 4 are gradual descent into ‘deep
sleep’.
 Stages of Sleep
• When each cycle follows through less time is
spent in deep sleep. Nearly all deep sleep
obtained in the 1st 4 hours of sleep.
• The fifth stage of sleep is REM. The main
characteristic in this stage is the eyes of the
sleeper begin to move in a rapid and jerky
manner.
• This is also the stage which people experience
dream (WHO, 1997).
Sleep Stage Cycle
Sleep Stages
Source: National Library of Medicine (USA, 2007).
PSG: Sleep Stages

Dr. Yasmin Othman Mydin

 Epidemiology of Sleep Disorders
• Sleep disorders are one of the most common
complaints in the mental and general health.
• 30-40% of adults population suffer sleep
problems.
• More women and elderly experience sleep
problems
 Theory of Insomnia
• Psychobiological theory suggest that life
events may precipitate physiologic and
psychological arousal which leads to insomnia.
 Assessment
• Psychiatric and medical history
• Details on sleep problems such as screening
questions, sleep history, sleep diary,
investigation (polysomnography)
• Polysomnography is used to diagnose various
sleep disorders.
Polysomnography Test: Records the physiological
changes while asleep, such as brain, eye
movements, breathing, muscle activity.
 Polysomnography Scores
The score consist of:

• Sleep efficiency: number of minutes divided in

bed divided by number of minutes of sleep
• Sleep stages
• Breathing irregularities
• Arousal: sudden shift of brain wave activities due
to abnormal breathing, noise, body movements
 Sleep Disorders
• Insomnia
• Hypersomnia
• Narcolepsy
• Circadian Rhythm Disorder or Sleep-wake
Cycle Disorder
• Parasomnias
• Sleep apnea
 Insomnia
• Insomnia is the most common sleep disorder
experienced by individuals
• Insomnia refers to poor sleep or not having
adequate sleep and it interferes with daytime
functioning
• Classification of insomnia
• 1. Transient (less than a week)
• 2. Short-term (more than a week, but less than a
month)
• 3. Long-term (more than a month)
 Symptoms of Insomnia
• Difficulty falling asleep
• Difficulty staying asleep
• Early awakening at the end of the sleep period
• Consistently non-restorative or poor sleep
• Feeling physically or mentally tired during the
day
 Insomnia
• Transient insomnia may occur during one
experiences problems such as personal, illnesses,
death among family member or friends,
relationship problems or stress at work.
• Insomnia in clinical practice is secondary to other
illnesses, such as physical pain or due to mental
illness such as depression or anxiety.
• Insomnia is more common among women and
elderly
 Assessment of Insomnia
• Diagnosis by interviewing the patient,
knowing the:
• nature of sleep pattern
• daytime functioning
• screen for psychiatric and medical conditions
• use of caffeine or drugs
 Assessment of Insomnia
According to ICD-10
• Complaints of all the symptoms of insomnia
• The sleep has been disturbed at least 3 days a week, at
least a month
• Preoccupation with the lack of sleep and show
excessive concern over this day and night (psycho-
physiological)
• The sleep problem cause distress and interferes with
daily functioning
• No evidence of neurological or medical condition or
substance abuse, or medication
 Sleep Hygiene Model

• The do’s and don’ts of good sleep

• Sleep hygiene- specific behaviours are
conducive to or incompatible with sleep
• Behaviours such as : consumption of caffeine,
alcohol, smoking, heavy meals close to
bedtime
• Modifying the behaviours may alleviate
insomnia
Stimulus control model of Insomnia; By Bootzin

• Based on behavioural principal; sleep linked

with conditioned response to the stimuli of
sleep environment.
• When the sleep related stimuli is paired with
other activities such as such as studying,
working and being awake .
• Sleep environment will be associated with
wakefulness, arousal and this can elicit the
response of sleep.
 3P Theory of Insomnia (Spielman)

• First fully articulated model and widely accepted.

• 3Ps contributing factors for insomnia, stress-diathesis
model
1. Predisposing- genetic, physiological or psychological-
2.Precipitating- stressful life events , play a role that can
result in acute insomnia . May diminish over time
3. Perpetuating-strategies one adopts to compensate
sleep loss, the tendency to extend sleep opportunity.
The chances is more time spent awake than sleeping
during the given sleep period
 Social Factors: Life Events

• Personal
• Family
• Marriage
• Death
• Work
• Finance
• Social
• Legal matters
 Life events as stressors

• One or more life events may be experienced at

one time.
• Major or minor events - ‘in the eye of the
beholder’
• Depending on how one perceives the events and
the coping skills
• When stress is not managed well, it challenges
the physiological and psychological well-being,
arousal of either of these 2 factors may cause
sleep difficulties
 Lifestyle

• Caffeine- 4-5 cups (about 500mg) in a day may

cause sleep difficulties (Epson& Mardon, 2007)

• Consumption close to bedtime- increase wakefulness (WHO, 1997)

• Sensitivity to caffeine varies from one individual
to another
• Delays the sleep onset and decreases the quality
of deep sleep
• Habitual consumption in daytime in a regular
sleep-wake cycle was found not to affect sleep.
 Continued

• Alcohol-has sedative affect , may help to fall

asleep , but may cause fragmented sleep and
awakenings
• Nicotine- a stimulant makes the mind alert
and increases energy, this arousal interrupts
the sleep onset.
• Smoking 20 cigarettes in a day or more is
associated with sleep difficulties
 Treatment of Insomnia
• Pharmacological and non-pharmacological
• Non-pharmacological: Cognitive and
behavioural
 Cognitive Therapy
• Identify the negative thoughts
• Change the belief system (the negative thoughts)
rationalize to gain positive thoughts)
• E.g., Anxiety of not having enough sleep
• A- light sleep
• B- I am deprived of sleep, I am not sleeping well
(misperceive)
• C- anxiety
• D- light sleepers do get adequate sleep, I am
functioning well in daytime
• E- reduce anxiety and improved sleep
 Behavioural Therapy
• Sleep hygiene
• Stimulus control therapy
• Progressive muscle relaxation
• Relaxation breathing technique
 Sleep Hygiene and Stimulus Control
Rules (DSM-IV-TR-2004)
• Go to bed only when sleepy
• Do not remain in bed for more than 20-30 minutes if
you can’t sleep
• Wake up at the same time each day
• Avoid looking at the bedroom clock
• Avoid caffeine, alcohol and tobacco close to bedtime
• Exercise in the morning or afternoon
• Eat a light snack before going to sleep
• Prepare sleeping environment for optimal
temperature, sound and darkness
• Do not use the bed for other activities than to sleep
• Do not nap during the day
 Hypersomnia
• The characteristics of hypersomnia are excessive
daytime sleepiness and sleep attacks, many cases
are secondary to sleep deprivation.
• Genetic cause may be involved and can also be
caused by infectious disease such as
mononucleosis or chronic fatigue syndrome.
• Excessive sleepiness should be treated quickly
and comprehensively as it could result in
dangerous situation such as accidents.
 Suggestions to Manage Hypersomnia
• There is no effective treatment for
hypersomnia.
• Nevertheless, there are management
strategies such as:
• Caffeine (either pill or caffeinated drinks) can
be used while attending important occasions.
But this stimulant must be used with caution
as it may have effect on subsequent sleep.
 Narcolepsy Sleep Disorder
• Narcolepsy is sudden extreme sleepiness,
cataplexy (sudden brief episodes of paralysis
with loss of muscle tones) is the key feature.
• In Narcolepsy, the sleep attacks are irresistible
while hypersomnia the sleep attacks occur less
frequently each day, and easier to resist.
Individuals with narcolepsy will fall asleep in
inappropriate circumstances such as while
standing and during physical activities.
Dr. Yasmin Othman Mydin, USIM YEAR 6
 Narcolepsy

• Studies suggest that hypocretins (or orexins)

play a key role in narcolepsy. Most people who
have narcolepsy have decreased hypocretins.
• Loss of hypocretin results in inability to
regulate sleep.
 Assessment of Narcolepsy
• The differential diagnosis is from causes of
excessive sleepiness, occasional epilepsy,
schizophrenia or chronic fatigue syndrome.
• Sleep history, as the main assessment tool
• Epworth Sleepiness Scale (ESS)
 Treatment of narcolepsy
• Encourage to follow regular routine with
planned naps during the day
• Stress or fatigues may provoke cataplexy, try
to change lifestyle, minimize or manage the
stress
 Circadian Rhythm Disorder or Sleep-
wake Disorder
• This disorder is a result of lack of synchrony
between biological clock and the environment.
• It is characterized by excessive daytime
sleepiness, difficulty awakening in the early
morning and difficulty falling asleep at a ‘normal’
time at night.
• Specific type and causes:
1. Jet lag type-inappropriate sleep and wakefulness
relative to local time (change of place)
2. Shift work type-associated with night shift work
or frequently changing shift work
 Parasomnias
• A group of disorders characterized by disturbances of
either physiological processes or abnormal behaviour
related with sleep such as:
1. Nightmares-frightening dreams
2. Night terrors-mainly in children, awaken suddenly in
extreme state of panic
3. Sleepwalking-sleepers rise during sleep and wanders
about (Nairne, 2006)
4. Other parasomnia is REM sleep behaviour disorder
related dreams, behavioural release during sleep,
unconsciously acting out their dreams
• When dreaming occurs during Rapid Eye
Movement (REM) sleep in normal patients,
the brain blocks signals from being sent to the
muscles, in order to prevent us from acting
out dreams. In patients with RBD, signals from
the brain to muscles are not blocked during
REM sleep, allowing the sufferer to act out
dreams (which are often violent, horrific or
frightening in nature).
 Nightmares and night-terror disorder
• Nightmares: awakening from REM sleep to full
consciousness with detailed recall of dream,
peak at the age of 5 or 6 years, stimulated by
frightening experience during the day and
while experience anxiety.
• Night-terror disorder: less common than
nightmares, occur in stage 3-4 (non-REM),
scream and confused, little or no dream recall
 Sleepwalking Disorder
• Is characterized by the phenomena of both sleep
and wakefulness occur simultaneously.
• The individual gets out of bed and walks around
for about a few seconds to a few minutes, it
rarely last for an hour.
• The individual will have a low level of awareness,
less reaction to stimuli and poor motor skills, will
not respond when spoken and avoid eye
contacts.
• If woken up while sleepwalking, the individual
will be disoriented for a few minutes.
Sleepwalking

Dr. Yasmin Othman Mydin, USIM YEAR 6

 Suggestions to Manage for
Sleepwalking Disorder
• Most children will overcome sleepwalking as they
grow.
• Sleepwalkers should be protected by appropriate
locks on the doors and windows to prevent them
from leaving the house.
• It is safer for sleepwalkers to sleep on the ground
floor
• Sleepwalkers should avoid sleep deprivation or
shift work and avoid going to bed with full
bladder as the need to urinate at night will
increase the chance of sleepwalking
 Breathing Related Sleep Disorder or
Sleep Apnea
• In people who have sleep apnea (also referred
to as sleep-disordered breathing), breathing
briefly stops or becomes very shallow during
sleep. This is due to the blocking of the upper
airway, usually when the soft tissue of the
throat collapses partially or completely closes
the airway.
• Each pause in breathing typically lasts 10–120
seconds and may occur 20–30 times or more
each sleeping hour.
Sleep Apnea

Dr. Yasmin Othman Mydin, USIM YEAR 6

 Treatment of Sleep Apnea
• Prevalence is about 4% in male population,
typically among middle aged overweight
• It is sometimes alleviated by weight loss and
breathing air under positive pressure through
a face mask (continuous positive airway
pressure) [CPAP]
• Surgery may be effective
CPAP
 Effect of Sleep Deprivation on Health
• The main effects of sleep deprivation include
physical effects (sleepiness, fatigue,
hypertension) cognitive impairment
(deterioration of performance, attention and
motivation; diminishment of mental
concentration and intellectual capacity and
increase of the likelihood of accidents at work
and during driving) and mental health
complications.
 REFERENCES
• American Sleep Association. (1997). What is sleep? Retrieved
October 5, 2008, from http://en.wikipedia.org/wiki/American Sleep
Association.
• American Psychiatric Association. (2004). Diagnostic Statistical
Manual of Mental Disorders, 4th ed. Washington, D. C.
• Chokroverty S. (2001). Sleep and Sleep Disorders. Blackwell Science.
Berlin.
• Nairne, J. S. (2006). Psychology. Thomson Wadsworth. US.
• Gelder, M., Harrison, P., & Cowen, P. (2006).Psychiatry. Oxford
University Press,
• World Health Organization. (1997). Management of Mental
• Disorder. Treatment Protocol Project. Sydney: Wild and Woolley.