By: Reashnaa A/P Loganathan

Yunisa Meutia Putri

Zahra Fitrianti

Preseptor: R.M. Haryadi Karyono, dr., SpKJ.

 TIDUR FISIOLOGIS

 Merupakan mekanisme pelepasan kelelahan jasmani
dan mental.
 Bagian dari circadian
 Tidur dibagi menjadi 2 tipe:
1. Rapid Eye Movement (REM)
2. Non Rapid Eye Movement (NREM)


 PERANAN
NEUROTRANSMITTER

 Serotonergik
 Noradrenergik
 Kholinergik
 Histaminergik
 Hormon
 KLASIFIKASI
Gangguan Tidur

DSM V
1. Insomnia Disorder
2. Hypersomnolence disorder
3. Narcolepsy
4. Breathing-related sleep Disorders :
o Obstructive Sleep Apnea Hypopnea
o Central Sleep Apnea
o Idiopathic central sleep apnea
o Cheyne-Stokes breathing
o Central sleep apnea comorbid with opioid use
o Sleep-Related Hypoventilation
 DSM V

5. Circardian Rhythm Sleep-Wake Disorders :
o Delayed sleep phase type
o Advanced sleep phase type
o Irregular sleep-awake type
o Non-24-hour sleep-awake type
o Shift work type
o Unspecified type
6. Parasomnias
7. Non-rapid eye movement sleep arousal disorders :
o Sleepingwalking type
o Sleep terror type
8. Nightmare disorder
9. Rapid eye movement sleep behavior disorder
10. Restless legs syndrome
11. Substance / Medication –Induced sleep disorder
ICSD-2

ICSD-2

ICSD-2

ICSD-2

ICSD-2

ICSD-2

 ICD-1 0
Diagnostic Criteria for Nonorganic Sleep
Disorders

Nonorganic Insomnia
A. The individual complains of di iculty falling asleep,
difficulty maintaining sleep, or nonrefreshing sleep.
B. The sleep disturbance occurs at least 3 times a week for at
least 1 month.
C. The sleep disturbance results in marked personal distress
or interference with personal functioning in daily living.
D. There is no known causative organic factor, such as a
neurological or other medical condition, psychoactive
substance use
disorder, or a medication.
 
Nonorganic Hypersomnia
A. The individual complains of excessive daytime sleepiness or sleep
attacks or of prolonged transition to the fully aroused state upon
awakening (sleep drunkenness), which is not accounted for by an
inadequate amount of sleep.
This sleep disturbance occurs nearly every day for at least 1 month or
recurrently for shorter periods of time and causes either marked
distress or interference with personal functioning in daily living.
C. There are no auxiliary symptoms of narcolepsy (cataplexy, sleep
paralysis, hypnagogic hallucinations) and no clinical evidence for
sleep apnea (nocturnal breath cessation, typical intermittent snorting
sounds, etc.).
D. There is no known causative organic factor, such as a neurological
or other medical condition, psychoactive substance use disorder, or a
medication.
 
Nonorganic Disorder of the Sleep-Wake Schedule
A. The individual's sleep-wake pattern is out of synchrony with
the desired sleep-wake schedule, as imposed by societal demands
and shared by most people in the individual's environment.
As a result of disturbance of the sleep-wake schedule, the
individual experiences insomnia during the major sleep period or
hypersomnia during the waking period, nearly every day for at
least 1 month or recurrently for shorter periods of time.
C. The unsatisfactory quantity, quality, and timing of sleep causes
either marked personal distress or interference with personal
functioning in daily living.
D. There is no known causative organic factor such as a
neurological or other medical condition, psychoactive substance
use disorder, or a medication.
 
Sleepwalking (Somnambulism)
A. The predominant symptom is repeated (two or more) episodes of
rising from bed, usually during the first third of nocturnal sleep, and
walking about for between several minutes and half an hour.
B. During an episode, the individual has a blank, staring face, is
relatively unresponsive to the e orts of others to influence the event or
to communicate with him or her, and can be awakened only with
considerable difficulty.
C. Upon awakening (either from an episode or the next morning), the
individual has amnesia for the episode.
D. Within several minutes of awakening from the episode, there is no
impairment of mental activity or behavior, although there may
initially be a short period of some confusion and disorientation.
E. There is no evidence of an organic mental disorder, such as
dementia, or a physical disorder, such as epilepsy.
 
Sleep Terrors (Night Terrors)
A. Repeated (two or more) episodes in which the individual gets
up from sleep with a panicky scream and intense anxiety, body
motility, and autonomic hyperactivity (such as tachycardia, heart
pounding, rapid breathing, and sweating).
B. The episodes occur mainly during the first third of sleep.
C. The duration of the episode is less than 1 0 minutes.
D. If others try to comfort the individual during the episode, there
is a lack of response followed by disorientation and preservative
movements.
E. The individual has limited recall of the event.
There is no known causative organic factor, such as neurological or
other medical condition, psychoactive substance use disorder, or a
medication.
 
N i ghtmares
The individual wakes from nocturnal sleep or naps with detailed and vivid
recall or intensely frightening dreams, usually involving threats to survival,
security, or self-esteem. The awakening may occur during any part of the sleep
period, but typically during the second half.
Upon awakening from the frightening dreams, the individual rapidly becomes
oriented and alert.
The dream experience itself and the disturbance of sleep resulting from the
awakenings associated with the episodes cause
marked distress to the individual.
There is no known causative organic factor, such as neurological or other
medical condition, psychoactive substance use
disorder, or a medication.
Other Nonorganic Sleep Disorders Nonorganic Sleep Disorder, Unspecified
INSOMNIA DISORDER

Definition : difculty initiating or maintaining sleep.

It is the most common sleep complaint and may be transient

or persistent.
Population surveys show a 1 -year prevalence rate of 30 to 45
percent in adults.

 insomnia can be categorized in terms of how it affects

sleep sleep-onset insomnia, sleep-maintenance insomnia,
or early-morning awakening
 Insomnia can also be classified according to its duration
transient, short term, long term
 Treating Insomnia

PharmacologicalTreatment :
benzodiazepines, zolpidem, eszopiclone (Lunesta), zaleplon
(Sonata), and other hypnotics.

sleep medications should not be prescribed for more than 2

weeks because tolerance and withdrawal may result.
Cognitive-behavioral therapy (CBT) :
universal sleep hygiene, stimulus control therapy, sleep
restriction therapy, relaxation therapies, and bio feedback.
HYPERSOMNOLENCE
DISORDER

Excessive sleepiness (hypersomnolence) is a serious,
debilitat ing, potentially life-threatening noncomm
icable condition.

Sleepiness can be a consequence of

(1) insuficient sleep
(2) basic neurologic dysfunction in brain systems
regulating sleep,
(3) disrupted sleep, or
(4) the phase of an individual's circadian rhythm.
 
 Sleepiness adversely affects attention, concentration,
mem ory, and higher-order cognitive processes.
 Serious results of sleepiness include failure at school,
loss of employment, motor vehicle accidents, and
industrial disasters.
 Primary hypersomnia is diagnosed when no other
cause can be found for excessive somnolence
occurring for at least 1 month.
 Types of Hypersomnia

• Kleine-Levin Syndrome.
• Menstrual-Related Hypersomnia.
• Idiopathic Hypersomnia.
• Behaviorally Induced Insufficient Sleep Syndrome.
Hypersomnia Due to a Medical Condition.
• Hypersomnia Due to Drug or Substance Use.
 Treating Hypersomnia

• extending and regularizing the sleep period
• Sleepiness arises from narcolepsy, medical
conditions, or idiopathic hypersomnia, it is usually
managed pharmacologically
• Symptoms are managed with either the wake-
promoting substance modafinil (Provigil; first-line
treatment)
• traditional psychostimulants such as amphetamines
and their derivatives (if modafinil fails)
 NARCOLEPSY

• characterized by excessive sleepiness
• sleep attacks of narcolepsy represent episodes of
irresistible sleepiness, leading to perhaps 10 to 20
minutes of sleep, after which the patient feels
refreshed, at least briefly.
• occur at inappropriate times (e.g., while eating,
talking, or driving and during sex).
 
The classic form of narcolepsy (narcolepsy with
cataplexy ) is characterized by
(1) excessive day time sleepiness,
(2) cataplexy,
(3) sleep paralysis, and
(4) hypnagogic hallucinations.
 Treating Narcolepsy

 regimen of forced naps at a regular time of day
occasionally helps patients with narcolepsy
 Modafinil, an α1-adrenergic receptor agonist, to
reduce the number of sleep attacks and to improve
psychomotor performance in narcolepsy.
 BREATHING-RELATED SLEEP
DISORDERS

 includes conditions ranging from upper airway
resistance syndrome to severe obstructive sleep
apnea.
 Obstructive Sleep Apnea
Hypopnea

 characterized by repetitive collapse or partial
collapse of the upper airway during sleep.
 During an obstructive apnea episode, respiratory
effort continues but airflow ceases due to loss of
airway patency. A reduction in breathing for at least
1 0 seconds is termed hypopnea.
 Predisposing factors for OSA include :
male, reaching middle age, being obese, and having
micrognathia, retrognathia, nasopharyngeal
abnormalities, hypothyroidism, and acromegaly.
 Diagnosis

 Clinical features associated with OSA hypopnea :
excessive sleepiness, snoring, obesity, restless sleep,
nocturnal awakenings with choking or gasping for breath,
morning dry mouth, morning headaches, and heavy
nocturnal sweating.

 Obstructive apnea and hypopnea episodes can occur in

any state of sleep but are more typical during REM sleep,
non-rapid-eye-movement (NREM) stage 1, and NREM
stage 2 sleep.
 Treatment

 weight loss
 surgical intervention
 positive airway pressure, and oral appliances.
 Central Sleep Apnea

 results om periodic failure of CNS mechanisms that
stimulate breathing.
 absence of breathing due to lack of respiratory effort.
 It is a disorder of ventilatory control in which
repeated episodes of apneas and hypopneas occur in
a periodic or intermittent pattern during sleep
caused by variability in respiratory effort.
 
 Idiopathic CSA.
 Cheyne-Stokes Breathing.
 CSA Comorbid with Opioid Use.
 CSA Due to High Altitude.
 CSA Due to Medical Condition that Is Not Cheyne
Stokes.
 CSA Due to Drug or Substance Use.
 Primary Sleep Apnea of Infancy.
 Sleep-Related
Hypoventilation

 Idiopathic Hypoventilation.
 CIRCADIAN RHYTHM
SLEEP DISORDERS

 a wide range of conditions involving a misalignment
between desired and actual sleep periods.
 Mismatched circadian clock and desired schedules can
arise from improper phase relationships between the two,
travel across time zones, or dysfunctions in the basic
biological rhythm.
 DSM-5 lists six types of circadian rhythm sleep disorders:
delayed sleep phase type, advanced sleep phase type,
irregular sleep wake type, non-24-hour sleep-wake type,
shift work type, and unspecified type.
 Jet lag type and "due to a medical condition" are not
included in DSM-5 but are included in other classi ca tion
systems such as ICSD-2.
 
Delayed Sleep Phase Type
occurs when the biological clock runs slower than 24
hours or is shifted later than the desired schedule.

more alert in the evening and early nighttime, stay up

later, and are more tired in the morning. These
individuals are commonly referred to as night owls.
 
Advanced Sleep Phase Type
circadian rhythm cycle is shifted earlier.

sleepiness cycle is advanced with respect to clock time.

drowsy in the evening, want to retire to bed earlier,

awaken earlier, and are more alert in the early morning.
Individuals with this pattern of advanced sleep phase
are sometimes called early birds or larks .
 
Irregular Sleep-Wake Type
circadian sleep wake rhythm is absent or pathologically
diminished.

the sleep-wake pattern is temporally disorganized, and

the timing of sleep and wakefulness is unpredictable.

symptoms of insomnia at night and excessive sleepiness

during the day. Long daytime naps and inappropriate
nocturnal wakefulness occur.
 PARASOMNIAS


 collection of sleep disorders characterized by
physiological or behavioral phenomena that occur
during or are potentiated by sleep.
 
N REM Sleep Arousal Disorders
 Sleepwalking.
 Sleepwalking.
Parasomnias Usually Associated with REM Sleep
 REM Sleep Behavior Disorder (Including Parasom nia Overlap Disorder
and Status Dissociatus).
 Recurrent Isolated Sleep Paralysis.
 Nightmare Disorder.
Other Parasomnias
 Sleep Enuresis.
 Sleep-Related Groaning (Catathrenia).
 Sleep-Related Hallucinations.
 Parasomnia Due to Drug or Substance Use and Para somnia Due to
Medical Conditions.
 ISOLATED SYMPTOMS, APPARENTLY NORMAL
VARIANTS, AND UNRESOLVED ISSUES


 Long Sleeper
sleep 10 to 12 hours
 Short Sleeper
less than 5 hours of sleep per 24-hour period
 Snoring
 Sleep Talking
 Sleep Starts (Hypnic Jerk)
 Benign Sleep Myoclonus of Infancy
 Hypnagogic Foot Tremor and Alternating Leg Muscle
Activation during Sleep
 Propriospinal Myoclonus at Sleep Onset
 Excessive Fragmentary Myoclonus
 TOOLS IN SLEEP MEDICINE


 Clinical Interview
 Polysomnography
 Multiple Sleep Latency Test
 Maintenance of Wakefulness Test
 Actigraphy
 Home Sleep Testing
PENATALAKSANAAN
UMUM

 Pendekatan hubungan antara pasien
 Konseling dan psikoterapi
 Sleep hygiene
 Pendekatan farmakologi
 Nonspecific Measures to
Induce Sleep (Sleep Hygiene)
1.Arise at the same time daily. 
2.Limit daily in-bed time to the usual amount present before the sleep
disturbance.
3.Discontinue central nervous system (CNS)-acting drugs (caffeine, nicotine,
alcohol, stimulants).
4.Avoid daytime naps (except when sleep chart shows they induce better
night sleep).
5.Establish physical fitness by means of a graded program of vigorous
exercise early in the day.
6.Avoid evening stimulation; substitute radio or relaxed reading for
television.
7.Try very hot, 20-minute, body-temperature-raising bath soaks near
bedtime.
8.Eat at regular times daily; avoid large meals near bedtime.
9.Practice evening relaxation routines, such as progressive muscle relaxation
or meditation.
10.Maintain comfortable sleeping conditions.
 
Dysomnia is commonly treated with:
 benzodiazepines, zolpidem, zaleplon (Sonata), and
other hypnotics. Hypnotic drugs should be used
with care.
 Over-the-counter sleep aids have limited
effectiveness.
 Long-acting sleep medications (e.g., flurazepam
[Dalmane], quazepam [Doral]) are best for middle-
of-the-night insomnia; short-acting drugs (e.g.,
zolpidem, triazolam [Halcion] ) are useful for
persons who have difficulty falling asleep.
THANK YOU
