Sleep Disorders

Part 2

by
Dr.Perjan Hashim Taha
Assistant Professor
5th Stage

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 Primary Sleep Disorders

not caused by another mental disorder, a physical

condition, or a substance but, rather, are caused
by an abnormal sleep-wake mechanism and
often by conditioning.
The two main primary sleep disorders are
1-Dyssomnias and 2-Parasomnias.

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 Insomnia
• Difficulty initiating or maintaining sleep or non
restorative sleep for at least 1 mo

• Its persistent problem for 3 days/ week for 1

mo

• Females more
• Elderly more
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 Insomnia
• Cause impairment in social, occupational and other
important areas of functioning
• Does not occur during a course of another mental
disorder (MDD, GAD, Delirium, …)
• Does not occur during the course of narcolepsy,
breathing related sleep dis, circadian rhythm sleep
dis, or a parasomnia
• Not due to the direct physiological effect of a
substance (drug of abuse, or medication) or a GMC.

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 Treatment of insomnia
Non pharmacological measures
1. Sleep hygiene
2. CT
3. Stimulus control therapy
4. Sleep restriction
5. Muscle relaxation

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 Treatment of insomnia
Pharmacological treatment
Hypnotics
1. Used if insomnia is sever
2. For short period
3. Intermittent (5 nights with dr and 2 without)
4. Not more than 4 wk to avoid tolerance and to
avoid rebound insomnia which occur after
stopping

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 Treatment of insomnia
Pharmacological treatment
Hypnotics
1. Benzodiazepines
2. Z drugs
3. Chloral hydrate
4. Sedating antidepressants e.g. trazadone used
for insomnia secondary to SSRI use

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 Intrinsic causes of insomnia
Sleep Apnea Syndrome:
1. Obstructive sleep apnea syndrome
Called pickwickian syndrome
Repetitive air way obstruction 
Decreased O2 saturation  snoring
Day somnolense
- Over wt. males 1-2%

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 Intrinsic causes of insomnia
Sleep Apnea Syndrome:
2. Central sleep apnea syndrome
Decreased ventilation effort during sleep
à Snoring

Elderly

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 Intrinsic causes of insomnia
Sleep Apnea Syndrome:
Inv.: Polysomnography
Treatment:
Decrease wt.,
decrease alcohol, avoid sedatives
CPAP
Surgical: nasal reconstruction, tonsilectomy

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 Intrinsic causes of insomnia
Periodic limb movement disorder PLMD:
Called sleep myoclonus
Occur in NREM sleep
In > 60 yr old
Reported by bed partner
Inv.: polysomnography
R: reassurance, clonazepam

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 Intrinsic causes of insomnia
Restless legs syndrome (Ekbom’s syndrome):
Unpleasant painful sensation in legs on sleep
onset
Idiopathic or familiar
Increased by caffeine or stress
10% in general population
M=F elderly

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 Intrinsic causes of insomnia
Restless legs syndrome (Ekbom’s syndrome):
• Associated with: pregnancy, uremia, R.arthritis,
Iron deficiency anemia, hypothyroidism, DM,
Parkinson disease, drug related.
• Inv.: H, exam., Polysomnography.
• R: walking or stimulation of legs (rubbing,
squeezing, hot showers, ointment)
clonazepam

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 Extrinsic causes of insomnia
• Inadequate sleep hygiene
• Environmental sleep disorder
Disturbing environmental stimuli: heat, cold,
noise, light, movement of bed partner, danger,
allergies, hospitalization.

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 Extrinsic causes of insomnia
• Altitude insomnia:
Occur in high altitudes due to decreased O2
With fatigue, decreased appetite
25% if 2000 m above sea level
In most individuals above 4000 m

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 Extrinsic causes of insomnia
• Limited setting sleep disorder:
By inadequate enforcement of bed time by
caregiver
5-10 % children
• Nocturnal eating drinking disorder:
5 % of children
Inability to sleep without eating or drinking

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 Primary Hypersomnia
• Excessive sleepiness for at least 1 mo
Either -prolonged night sleep episodes or
-daytime sleep episodes

• Recurrent: if period > 3days a week

• 3-5%
• Is leading cause of road traffic accident

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 Primary Hypersomnia
• Cause impairment in social, occupational and other
important areas of functioning
• Does not occur during a course of another mental
disorder (MDD, GAD, Delirium, …)
• Does not occur during the course of narcolepsy,
breathing related sleep dis, circadian rhythm sleep
dis, or a parasomnia
• Not due to the direct physiological effect of a
substance (drug of abuse, or medication) or a GMC.

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 Intrinsic causes of hypersomnia
• Narcolepsy
• Kleine levine syndrome
• Menstrual related

• Idiopathic hypersomnia
• Posttraumatic hypersomnia
• Sleep apnea syndrome

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 Extrinsic causes of hypersomnia
• Insufficient sleep syndrome

• Dependency (alcohol, hypnotics, opiate)

• Toxins (bismuth, mercury, cupper, CO, vit. A)

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 Other causes of hypersomnia
• Circadian rhythm disorder
• Medical disorders: neurological, inf.,
metabolic, endocrine
• Psychiatric dis.: Mood dis
• Medications: anticonvulsants, antiemetic's,
antidepressives, antiH.T., hypnotics,
antipsychotics, anxiolytics, antiparkinsonism,..)

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 Narcolepsy
• Irresistible attacks of unrefreshing sleep that
occurs daily / 3mo
• In unusual and dangerous situations

• Cataplexy: brief episodes of paralysis and loss

of m. tone, when intense emotions

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 Narcolepsy
• Recurrent intrusion of elements of REM into
the transition between sleep and wakefulness
• Hypnogogic or hypnopompic hallucination

• 10-20 yr. M=F

• Prevalence 5/10 000

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 Narcolepsy
psychological aspects of narcolepsy

• Strong emotions ppt. cataplexy

• Narcolepsy have emotional and social

difficulties

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 Narcolepsy treatment
• treat stresses
• Stimulants (dextroamphetamine,
methylphenidate)
• Modafinil (non-amphetamine stimulant)
• Clomipramine and newer antidepressants for
cataplexy

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 Klein Levin syndrome
• Very rare
• Somnolence + increased appetite
• For days or weeks

• By: hypothalamic or autoimmune cause

• R: lithium or anticonvulsants

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 Circadian rhythm sleep disorder
• Excessive sleepiness or insomnia due to
mismatch between sleep-wake schedule
required by person and his sleep-wake
schedule pattern.

• Lead to decrease conc. and accidents

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 Circadian rhythm sleep disorder
• Delayed sleep phase type: delayed sleep
(inability to sleep) so wake late
• Jet lag type: bec. Of repeated travel across more
than 1 time zone………..its most common
• Shift work type: bec. Of night shift work….is
common

• R: Modafinil Melatonin in jet lag syn

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 Parasomnias
• Abnormal behavior or physiological
events occurring during sleep
1. Night mares disorder
2. Sleep terror disorder
3. Sleep walking disorder
4. Parasomnias NOS

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 Night mares disorder
• Repeated awakening from sleep or naps
with detailed recall of frightening dreams

• Awake at 2nd half of sleep period

• On awake person is oriented and alert

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 Night mares disorder
• Awakening from the REM to full
consciousness with detailed dream recall

• Mostly in Children 5-6 yr

• Causes: frightening experience in day,

anxiety, PTSD, fever, psychotropic drugs

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 Sleep terror disorder
• Few hr.s after onset of sleep while in
stage 3-4 NREM  sit up and terrified
and is confused (hence the difference with night
mares)
• Marked increase HR & RR

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 Sleep terror disorder
• After few min.  the child slowly settle
and goes back to normal calm sleep

• There is little or no dream recall

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 Sleep terror disorder
• Less common
• S.t. familial

• R:
Regular routine and sleep hygiene
Treat the cause
Benzodiazepines and imipramine

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 Sleep walking (Somnambulism)
• Repeated episodes of rising from bed
during sleep and walking

• Occur during first 3rd of sleep

• Blank staring face cannot be awakened

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 Sleep walking (Somnambulism)
• Is an automatism during 3-4 stages of
NREM
• Mostly few sec-few min. Rarely hr.

• 5-12 yr mostly
• May be familial
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 Sleep walking (Somnambulism)
• On awakening patient has amnesia

• If awakened short period confusion,

disorientation  after several min. 
child then has no any impairment

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 Sleep walking (Somnambulism)
Treatment
• Reassurance
• Protect patient from harm
• Sleep hygiene
• Relaxation
• Avoid sleep deprivation
• Benzodiazepines and antidepressants

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 Other parasomnias
1.REM sleep behavior disorder
• Agitation and aggression at night
• If normal atonia of REM lost so
dreams also are recalled
• Elderly specially Parkinsonism
• R: clonazepam and Donepezil

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 Other parasomnias
2.Sleep paralysis
• Inability to make voluntary movements
on transition between sleep and
wakefulness

• Either at sleep onset (hypnogogic)

Or at awakening (hypnopompic)
• Extreme fear
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