Kousar Ishaq

Khizra Khan
Adeela Majeed
Asia yasmeen
 SLEEP
 condition of body and mind which typically recurs for
several hours every night, in which the nervous system is
inactive, the eyes closed, the postural muscles relaxed,
and consciousness practically suspended.

 Sleep is a state where awareness to environmental stimuli is

reduced.

 Basic human drive regulated by two biological process

• Sleep/wake homeostasis

Drive to sleep that increases the longer we are awake

• Circadian rhythm

Internal clock in our brain that regulates when we feel

sleepy and when we alert
WHY DO WE NEED SLEEP?

Biochemical function

Neurological function

Physiological function

Psychological function

Normal sleep--- 7.5hrs to 8.5hrs in young adults

Phases of sleep
sleep

Non-
REM
REM

Light Deep
Sleep Sleep

Stage 1 Stage 2 Stage 3 Stage 4

14-25 Hz
8-13 Hz

4-7 Hz

0.5-3 Hz
Sleep-wake disorders
• Patient present with sleep-wake complaints of dissatisfaction regarding
Quality,
Timing
Amount of sleep
• Distress and impairment.

• “In DSM-IV, we might have diagnosed someone as having insomnia due

to depression or heart failure. But in DSM-5, we are asking clinicians to
specify the sleep disorder and to list co-occurring disorders.

• DSM-5 also distinguishes narcolepsy, which is now known to be

associated with hypocretin deficiency, from other forms of
hypersomnolence.
• Primary insomnia to insomnia

• Division of breathing related disorders.

• Subtypes of circadian rhythm sleep-wake disorders have been expanded ,

whereas the jet lag type has been removed.

• The use of DSM-IV “not otherwise specified” diagnoses has been reduced by
designating rapid eye movement sleep behavior disorder and restless legs
syndrome as independent disorders. In DSM-IV, both were included under
dyssomnia not otherwise specified.
 INSOMNIA
780.52(G47.00)
Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying
asleep.
Diagnostic criteria:
 predominant complaint of dissatisfaction with sleep quantity or quality, asssociated
with one(or more) of the following symptoms:
Difficulty initiating sleep
Difficulty maintaining sleep
Early morning awakening with inability to return to sleep.

 3 nights per week

 Present for at least 3 months.
 Sleep difficulty occurs despite adequate opportunity for sleep

 Coexisting medical condition and mental disorders do not adequately explain the
predominant complaint of insomnia
Specify If:
 With non-sleep disorders mental comorbidity
 With other medical comorbidity
 With other sleep disorder
 Episodic
 Persistent
 Recurrent
Diagnostic Features:
 Different manifestation of insomnia can occur at different time of the
sleep period
Sleep onset insomnia (initial insomnia)
Sleep maintenance insomnia (middle insomnia)
Late insomnia
 Non restorative sleep (poor sleep quality)
 Other specified or unspecified insomnia is made when there is a Complain
of non restorative sleep in isolation (absence or difficulty initiating and/or
marinating sleep)
Associated Features:
 Maladaptive sleep habits
 Daytime complaints and symptoms
 Napping
 Excessive attention and efforts to sleep
 Insomnia can be situational, persistent or recurrent.

Prevalence:
More in females than in males with the ratio of 1.44:1

Onset:
More common in young adults
Differential diagnosis:
 Normal sleep variation
 Situational/acute insomnia
 Delayed sleep phase and shift work types of circadian rhythm sleep-wake
disorder.
 Restless leg syndrome
 Breathing related sleep disorders
 Narcolepsy
 Parasomnias
 Substance/medication- induced sleep disorder, insomnia type
 Case 1
A 42-year-old woman, is referred to the sleep disorders center with a
complaint of chronic, severe insomnia affecting her daytime functioning.
The single mother of three teenage boys, she first experienced insomnia
eight years ago when bankruptcy threatened her small business.
Medication History: she has taken Temazepam, Zolpidem, and Zaleplon, as
well as several antidepressants..
Review of Sleep Pattern: she tries to go to bed around 11:00 PM. She usually
falls asleep in less than 15 minutes, but occasionally it seems to take her
hours to fall asleep. She wakes up three to four times per night, and at least
one of these awakenings lasts two to three hours.
Physical Examination.
referred to a sleep center
Treatment: sleep hygiene improvements: decrease caffeine intake; avoid
sleeping late in the morning at all costs; a relaxation course (using
meditation). cognitive therapy After six months, sleep improved, An as-
needed hypnotic was prescribed for her Follow-up: One year later, she
reported that her life was much improved.. A second follow-up conducted
five years after initial treatment showed she was sleeping normally without
the use of hypnotics.
 Case 2
A 40 year old schoolteacher complains of inability to sleep well for more than 2
years. She regularly goes to bed at 10 pm but is unable to sleep until 1 am. She
experiences about 3-5 awakenings every night and with each awakening
requires about 30 minutes to fall asleep again. She also experiences daytime
fatigue and is unable to concentrate in her work.
As bedtime approaches, she becomes very tense and worries about the
prospect of another sleepless night. “Sleep has become a real frustration. Every
night, when I lie in bed, I have to try very hard to sleep. I keep watching the
clock”.
She does not take any sleeping pills and has no symptoms of depression. There
is no marital conflict. On further questioning, she surprising admits that she
sleeps well while on vacations and relatives houses.
Stimulus control therapy
Cognitive behavioral therapy
Relaxation course was given to her
Hypersomnolence Disorder
Hypersomnolence is characterized by recurrent episodes of excessive daytime
sleepiness or prolonged nighttime sleep

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 period of sleep or lapses into sleep within a same day.
A prolonged main sleep episode of more than 9 hours per day that is non
restorative ( i.e., unrefreshing)
Difficulty being fully awake after abrupt awakening.

 Occurs at least 3 times per week, for at least 3 months

Specify if:
 With mental disorder
 With medical condition
 With other sleep disorder
 Acute (less than 1 month)
 Subacute (1-3 months)
duration
 Persistent (more than 3 months)
 Mild
 Moderate
severity
 Severe
Diagnostic Features:
 Hyper somnolence is a broad diagnostic term and includes symptoms of
excessive quantity
 Deteriorated quality of wakefulness
 Sleep inertia (sleep drunkenness)
 Difficulty waking up in morning
 Daytime naps (lasting 1 hour or more)
 Unintentional sleep episode
Associated features :
 Non restorative sleep
 Sleep inertia
 Short naps

Prevalence
 Equal frequency in males and females

Age onset
 Late adolescence and early adulthood
 Mean age at onset 17-24
Diagnostic markers:
Nocturnal polysomnography
Increased amount of slow wave sleep
Sleep efficiency is greater
REM sleep is normal
Normal to increased sleep continuity

Differential diagnosis
 Normative variation in sleep
 Poor sleep quality and fatigue
 Breathing related sleep disorders
 Circadian rhythm sleep-wake disorders
 Parasomnias
 Other mental disorders
 Case 1
A 32-year-old C woman came to us with complaints of excessive daytime sleepiness (EDS).
She had no problems with her sleep or general health until two years before, when she
began to experience excessive daytime fatigue. Her condition progressed and at the time
of presentation she was able to sleep for extended periods of time (up to two to three days
at a stretch) and still be hypersomnolent in the day. On questioning, she denied cataplexy,
hypnagogic hallucinations or sleep paralysis.. During her initial diagnostic work-up for
fatigue, she was found to have a mildly elevated TSH level. She was started on thyroxine,
but her symptoms persisted (in spite of TSH value subsequently returning to normal). She
stopped driving because she had found herself in the wrong lane on occasion and not sure
how she got there. She is married with two children and there is no family history of
excessive daytime sleepiness. There was no change in her appetite. However, she stated
she would drink about 12 cans of caffeinated soft drinks per day. She smokes half a pack of
cigarettes a day, but does not take alcohol or any recreational drugs. Her medications
included diphenhydramine for allergic rhinitis.
Physical examination was unremarkable, except that the patient appeared sleepy and
yawned several times during the interview.
Based on the clinical picture as well as the polysomnographic findings, a diagnosis of PH
was made. Treatment was initiated with methylphenidate 10 mg b.i.d and pemoline 18.5
mg t.i.d. At the prescribed doses, she was not able to stay alert and would take up to 150
mg of each of these. She subsequently developed edema of the hands and feet, for which
she discontinued methylphenidate. Due to the safety concerns regarding pemoline, she
stopped taking this drug. At the moment, the patient is doing relatively well on modafinil
100 mg b.i.d and methamphetamine 10 mg t.i.d and can manage some household work in
the daytime. She has switched to cetirizine for her seasonal allergy.
 Case 2
A 36-year-old widower who sought help at a sleep disorders center after reading about excessive daytime
sleepiness (EDS) in the newspaper.

History of Previous Illness: he has needed to nap 2-3 times per day since he was about 17 years old, despite
typically sleeping about 8 hours per night.

Past Medical History: Blood tests assessing thyroid and other endocrine functions, and evaluations for allergies
and psychological health, have not produced significant findings.

Treatment History: A psychotherapy trial 2 years ago did not uncover a cause for Raymond “laziness.”

Family History: Raymond’s father has suffered from lifelong excessive sleepiness, and a cousin has been
diagnosed with narcolepsy.

Review of Sleep Patterns: he sleeps about 8 hours per night, but is often disturbed by short awakenings.
Although he awakens for the day refreshed, within 1-3 hours he becomes sleepy. For the remainder of the day,
he rarely feels adequately refreshed and alert

Evaluation and Diagnosis: Following the intake interview, he was evaluated by polysomnography (PSG) and the
multiple sleep latency test (MSLT). PSG revealed a sleep-onset REM episode immediately upon falling asleep,
frequent awakenings, and excessive amounts of stage 1 sleep. The MSLT results, on the day following his PSG,
showed a mean sleep latency of 4.6 minutes and 3 sleep-onset REM periods.

Treatment and Follow-up; Modafinil was titrated up to 400 mg qAM with little effect. He was switched to
methylphenidate, and the dose was gradually increased to 20 mg TID. He reported improved wakefulness that
lasted about 2.5 hours post-dosing, followed by a more profound sleepiness before he could take his next dose.
A trial of extended-release methylphenidate was initiated, and he was gradually increased to 40 mg qAM. Once
stabilized on this dose, he maintained adequate but incomplete alertness throughout the day.
Narcolepsy
 Narcolepsy is a neurological disorder characterized by the brains inability to
control sleep/wakefulness cycle.
 Sleep attacks

Diagnostic criteria:
A. Irrepressible need to sleep, lapsing into sleep, or napping occurring within the
same day.
 at least 3 times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, occurring at least a few times per month

2. Hypocretin deficiency

3. Nocturnal sleep polysomnography (PSG) showing rapid eye movement (REM)

sleep latency of 15 minutes or less, or a multiple sleep latency test (MSLT) showing a
mean sleep latency of 8 minutes or less and more than 2 sleep onset rapid eye
movement periods (SOREMPs).
Specifiers
 Narcolepsy without cataplexy but with hypocretin deficiency
 Narcolepsy with cataplexy but without hypocretin deficiency
 Autosomal dominant cerebral ataxia deafness and narcolepsy
 Autosomal dominant narcolepsy, obesity, and type 2 diabetes
 Narcolepsy secondary to another medical condition
 Mild
 Moderate Severity

 Severe
Associated features
 Excessive day time sleepiness
 Sleep paralysis
 Cataplexy
 Hallucination
Hypnopompic (waking from sleep)
Hypnogogic (sleep onset)
 Disturbed nocturnal sleep
 Obesity is common

Prevalence
 In both gender with possibly a slight male preponderance

age onset
 Children and adolescents / young adults
 15-25 30-35
Diagnostic markers:
Polysomnography / MSLT
CSF hypocretin-1 immunoreactivity

Differential diagnosis
 Other hypersomnia
 Sleep deprivation and insufficient nocturnal sleep
 Sleep apnea syndromes
 Major depressive disorder
 Conversion disorder
 ADHD or other behavioral problems
 Seizures
 Chorea and movement disorders
 Schizophrenia
Case 1
A 14-year-old girl was referred to Sleep and Epilepsy Unit for excessive daytime
sleepiness, impaired nocturnal sleep, binge eating and weight gain, over the last
year. After being diagnosed with a NT1 the patient was treated with modafinil and
sodium oxybate. She was hospitalized for psychotic symptoms after starting NT1
treatment. Withdrawal of the narcolepsy treatment and initiation of haloperidol 1
mg/day (the only antipsychotic treatment she could tolerate) improved the
delusions, hallucinations and dysphoria but worsened the narcolepsy symptoms.
Polysomnography showed fragmented nocturnal sleep and five sleep REM onset
periods in MSLT. Undetectable level of hypocretine in the cerebrospinal fluid were
found. MRI and CT-scan were normal. Diagnostic Interview for Genetic Studies
Adapted for Narcolepsy (DIGSAN) questionnaire confirmed that patient presented
a dual diagnostic NT1 and psychotic symptoms. The last sleep follow-up while on
psychopharmacological treatment, showed an increased sleep efficiency index.
She currently has severe somnolence, obesity, and partial cataplectic attacks
along with normal mood, academic failure and social isolation.
Case 2
Mr. A, an 18-year-old man, presented to psychiatry outpatient services with excessive daytime
sleepiness of approximately 1.5 years’ duration. When the chronology of symptoms was evaluated, it
was evident that about 1.5 years before presentation, the patient had an episode of high -grade fever
(101–103F) and was empirically treated for typhoid and malaria. Within a week of the fever episode
while on antibiotics and antimalarial medications, he started experiencing excessive daytime
sleepiness (EDS), i.e., despite good sleep at night, he started sleeping for 5 to 6 hours during the
daytime, with total sleep duration/day being 15 to 16 hours/day. If not woken, he would continue to
sleep for 19 to 20 hours/day. Initially, family members attributed his sleepiness to weakness from the
fever and medications and did not consider it important. Because of continued EDS, the patient was
unable to study, and this led to academic decline. He would often attempt to keep himself awake but
would fall asleep between activities like studying, watching television, eating, etc. About three months
after developing EDS, he started to notice that whenever he would laugh out loud or get angry, he
would experience a sudden feeling of generalized body weakness, especially in the upper part of his
body, along with ptosis of both eyes and flexion of the head. In addition, he would have a sudden
bending of his knees, leading to imbalance if he was standing, and would also have difficulty speaking.
At times, he could not control his posture and would fall. He often would drop things during these
episodes. This entire phenomenon would last for 8 to 10 seconds after the particular emotional
reaction, following which he would have complete recovery within 10 to 15 minutes without any
deficits.. During the same time, while the patient would fall asleep, he could see an unknown boy
standing near him that others could not see. He would describe it as visualizing an unknown boy
touching his chin in gray-color film with open eyes in clear consciousness along with normal
visualization of his family members. While experiencing these hallucinations, the patient would not be
able to move his limbs or speak; such episodes of inability to move his limbs or speak would last for 5
to 10 minutes. The same phenomenon would at the time also be experienced while he was coming out
of sleep.. He was started on tablet methylphenidate 5mg/day, which later was increased to 10mg/day.
The patient and family members were informed about the disorder. After one month of
methylphenidate therapy, he resumed his studies. He has remained symptom free for the last two
years since starting methylphenidate.
Breathing- Related Sleep
Disorder
Obstructive sleep apnea hypopnea
Central sleep apnea
Sleep related hypoventilation
Obstructive sleep apnea
hypopnea
 Diagnostic criteria:
A. either 1 or 2

1. at least 5 obstructive apneas or hypopneas per hour of sleep and either of the
following sleep symptoms:

a. Nocturnal breathing disturbances

b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities

to sleep

2. 15 or more obstructive apneas and/or hypopneas per hour of sleep

Specifier :
Mild: Apnea hypopnea index is less than 15.

Moderate: Apnea hypopnea Index is 15-30.

Severe: Apnea hypopnea index is greater than 30

Diagnostic features:
Apnea --------total absence of air flow
Hypopnea -------reduction in air flow
Low level of oxygen
Reduction in breathing of at least 10 seconds
2 missed breaths in children
Greater electroencephalographic arousal

Associated features
Heart burn
Morning headaches
Dry mouth
erectile dysfunction
Reduced libido
hypertension
 Prevalence
1-2% of children
2-15% of middle Age
20% of older

Diagnostic markers:
Polysomnography
Imaging procedures cardiac testing
Validated sleep measures (MSLT)
Differential diagnosis:
 Primary snoring and other sleep disorder
 Insomnia disorder
 Panic attacks
 ADHD
 Substance/medication- induced insomnia or hypersomnia
Case 1
J.B. is a 61-year-old man who is a busy physician and has had type 2 diabetes for 11
years. He suffers from gastroesophageal reflux disease daily and has moderate
depression. For 11 years, he has maintained a weight of 210–220 lb (BMI of 31 kg/m2),
and he does not have hypertension or hypercholesterolemia. J.B. has no other known
diabetes complications. He uses a low-carbohydrate meal plan and a bicycle exercise
program. However, he snores and reports being excessively sleepy all the time.
J.B. has no family history of diabetes or sleep apnea. During the past year, he has not
been able to get his plasma glucose levels to < 200 mg/dl. His hemoglobin A1c (A1C)
has been 7.5% (lab norm) on the past two visits. The patient denies polyuria or
nocturia. He is in bed for ∼ 8 hours per night. His wife does not complain about his
nighttime snoring, but she describes herself as a heavy sleeper.
The bed partner is often the first to complain of sleep apnea. In this case, J.B.'s wife is
not bothered. However, fellow physicians who travel with J.B. on medical mission trips
joke and complain about his snoring and gasping. J.B. now requests a private room for
these trips to avoid the complaints. He did not share this information with his diabetes
care team.
J.B. is excessively sleepy, yet he sleeps ∼ 8 hours nightly. Colleagues and family who
sleep in adjacent rooms have told him that he snores and gasps throughout the night.
Published research demonstrates that 50% of men with type 2 diabetes have sleep
apnea. These factors are sufficient to suspect sleep apnea and inquire further.
CPAP therapy is the gold standard sleep apnea treatment.
Medication
Case 2
Nathan, a 40-year-old lawyer, was referred to the sleep disorders center with the chief
complaints of chronic fatigue and exhaustion. A routine workup for fatigue was negative.
History of Present Illness: Nathan reported a 10-year history of long working hours and
lack of personal activities, such as exercise and vacation, in pursuit of a promising law
career and hopes of making partner. During this time, Nathan had developed a habit of
snacking to stay awake during late nights at work. Coupled with the lack of exercise,
Nathan gradually gained 95 pounds. His current weight is 278 pounds (height = 69 inches;
BMI = 41.05).
Nathan described increased fatigue throughout the previous 6 years. Recently, this has
become “an embarrassment” as he occasionally falls asleep in important meetings.
Nathan previously attempted to restart an exercise program but reports he simply lacked
the energy. Friends describe him as “burned out.”
Medication History: Previous treatment with the stimulant Modafinil was not effective.
Family History: Father snores heavily.
Review of Sleep Pattern: Nathan has a normal sleep schedule (11:30 PM – 7:00 AM) and
reports he sleeps soundly. However, he arises from bed un-refreshed and occasionally
awakens during the night gasping for air. Presence of snoring could not be confirmed by
interview because Nathan sleeps alone and has no recent bed partners.
Evaluation and Diagnosis: Nathan spent a night in a sleep lab. He fell asleep almost
instantly and slept soundly for about 3.5 hours. However, his AHI was 49 with O2
saturation frequently dipping into the low 80s.
Treatment and Follow-up: Nathan was prescribed nightly CPAP at 13 cm H2O.
Diagnostic criteria
5 0r more central apneas per hour of sleep
Not better explained by another current sleep disorder

Subtypes
• Idiopathic central sleep apnea
Repeated episodes of apneas and hypopneas caused by variabilty in respiratory
effort but without evidence of air way obstruction.
• Cheyne-stokes breathing
Periodic crescendo- decrescendo variation in tidal volume that results in apneas
and hypopneas at a frequency of 5 events per hour.
Increased gain of ventilatory control system (High loop gain) PaCO2 Level
And instability in ventilation ( periodic breathing)
Central sleep apnea comorbid with opioid use
• Effects of opioid on the respiratory rhythm generators in the medulla as well as the
hypoxic versus hypercapnic respiratory drive .

• Elevated pCO2 while awake

specify current severity

On the basis of :

 Frequency of breathing disturbance

 Oxygen desaturation
 and sleep fragmentation
Associated features:
• Sleepiness or insomnia
• Sleep fragmentation
• Awakening with dyspnea

Prevalence:
• More common among patients with heart failure (4.8 percent).
• Men compared with women (1.8 versus 0.2 percent).

Differential diagnosis:
• Other breathing related sleep disorders and sleep disorders
Case 1
A 29-year-old male presented to his primary care doctor with a one-month
history of fatigue. The patient is a shift worker and a truck driver, and he
found himself tired and yawning while working. He also complained of
occasional night time awakenings and snoring. The patient had not
previously been seen by his primary care doctor, as he had always been
healthy. A full physical examination and basic laboratory testing, including
complete blood count, thyroid stimulating hormone, complete metabolic
panel, lipid panel, and fasting blood sugar were normal. The patient had a
slightly high blood pressure of 130/79 with pulse of 76. He was overweight
with a BMI of 29. The patient was not on any medications and denied alcohol
or illicit drug use. After a full medical and mental health history was obtained
and appeared to be noncontributory, a sleep study was ordered.
CPAP was given
Sleep Related Hypoventilation
Diagnostic criteria:
• Decreased respiration with elevated CO2 levels
• Disturbance is not better explained by others

Specfier
• Idiopathic hypoventilation
• Congenital central alveolar
perinatal period with shallow breathing or cyanosis and apnea
during sleep
• Comorbid sleep related hypo ventilation
Severity
Depend on Degree of hypoxemia and hypercarbia
Hypoxemia (or hypoxaemia in British English)
• abnormally low level of oxygen in the blood.
• More specifically, it is oxygen deficiency in arterial blood.
Hypoxemia has many causes, often respiratory disorders, and can cause
tissue hypoxia as the blood is not supplying enough oxygen to the body.

Hypercapnia, also known as hypercarbia and CO2 retention,

• abnormally elevated carbon dioxide (CO 2) levels in the blood.
Associated Features
• Sleep related complaints
• Headaches
• Episodes of shallow breathing
• consequences of ventilatory insufficiency

Prevalence:
• Idiopathic sleep related hypoventilation is uncommon
• Congenital central hypoventilation is unknown but rare .
Diagnostic marker
• Polysomnography

Differential diagnosis
• Other medical conditions affecting ventilation
• Other breathing related sleep disorder
Article review
Objectives: The aim of this study was to compare sleep disturbances during
pregnancy in women with a lifetime diagnosis of major depressive disorder (MDD)
and controls and to determine whether the sub group of postpartum major
depression (PPMD) women exhibits a specific pattern of disturbances.
Study design: 217 women recruited in childbirth in the maternity participated in the
survey with 34 included in the MDD group. 17 among the MDD group were diagnosed
PPMD. Sleep characteristics of women were assessed before and during pregnancy
with self administered questionnaires and depressive symptoms after delivery were
screen with the hospital anxiety depression scale HAD). Diagnosis of depression was
performed according to DSMIV criteria during a semi-structured interview done by
phone.
Results: Women in the MDD group presented more difficulties in falling asleep (P =
0.030), nocturnal awakening (P = 0.021) and sleep deprivation (P = 0.048) during the
first trimester, more pain during sleep (P = 0.025) and shorter sleep duration (P =
0.012) during the second trimester than control women. They, moreover exhibited
more early awakening during the second (P = 0.037) and third (P = 0.013) trimesters
with more morning sleepiness during the first (P = 0.044) and second (P = 0.034)
trimesters of gestation. Among these sleep alterations several, particularly in the
second trimester, seemed to be associated with PPMD and not with MDD outside
postpartum.
Conclusions: This survey revealed greater sleep disturbances during
pregnancy in vulnerable women to MDD compared with control women.
Interestingly, several of these disturbances were selectively reported in the
sub group of PPMD only. These outcomes could provide biomarkers for a
better detection of high-risk of PPMD women and the development of more
specific strategies to improve sleep during pregnancy in order to better
prevent PPMD.