Sleep wake disorder

diagnostic criteria 307.42

Quality , timing and amount of sleep not upto the required amount
Either independent or co morbid with other conditions
Risk factor for depression
• Sleep disorders (or sleep-wake disorders) involve problems with the
quality, timing, and amount of sleep, which result in daytime distress
and impairment in functioning.
• Sleep-wake disorders often occur along with medical conditions or
other mental health conditions, such as depression, anxiety, or
cognitive disorders.
characteristics of sleep disorders
• Difficulty initiating sleep
• Difficulty maintaining sleep
• Risk factors - mental illness
• Multidimensional approach -coexisting medical and neurological
approach
• may or may not be after a conflict or crisis that the person has
undergone
coexisting clinical conditions are the rule,
not an exception
• Breathing related sleep disorders
• Disorder of the heart and lungs ( heart failure , congestive disease )
• Neurogenerative disorders – alzheimers
• Disorders of muskoskeletal system .
• Bipolar and schizophrenic disorders
• The disorders get worsened before ,during sleep or after getting up
from sleep
• The dreams and nightmares often exacerbate these conditions
•
some of the sleeping disorders
• Insomnia disorder
• Hypersomnolence disorder
• Narcolepsy
• Breathing related disorder
• Circadian rhythm sleep related disorders
• Restless legs syndrome
• Substance/medication induced disorder
•
 Five most common sleep disorders
• Insomnia. Inability to fall asleep and maintain sleep
• Sleep Apnea. Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops
and starts. If you snore loudly and feel tired even after a full night's sleep, you might have sleep
apnea. The main types of sleep apnea are: Obstructive sleep apnea, the more common form that
occurs when throat muscles relax.
• Narcolepsy - a condition characterized by an extreme tendency to fall asleep whenever in relaxing
surroundings
• Restless Legs Syndrome. Restless legs syndrome (RLS) is a condition that causes an uncontrollable
urge to move your legs, usually because of an uncomfortable sensation. It typically happens in the
evening or nighttime hours when you're sitting or lying down. Moving eases the unpleasant feeling
temporarily.
• REM Sleep Behavior Disorder Rapid eye movement (REM) sleep behavior disorder is a sleep disorder
in which you physically act out vivid, often unpleasant dreams with vocal sounds and sudden, often
violent arm and leg movements during REM sleep — sometimes called dream-enacting behavior
Insomnia disorder – diagnostic criteria
• A -Complaint of Dissatisfaction with sleep quality or quantity
• Difficulty initiating sleep at bedtime ( without caregiver attention )
• Difficulty maintaining sleep –frequent awakenings with inability to
return to sleep
• Early morning awakening with inability to return to sleep
• involves significant daytime impairments as well as night time
difficulties -Fatigue ,day time sleepiness
• Impairment with cognitive functioning .attention .memory and
concentration
Insomnia disorder
• B Causes clinically significant distress or impairment in social,
educational, academic, behavioral or other area of functioning
• C occurs at least 3 nights in a week
• D It is present for at least three months
• E occurs despite adequate opportunity for sleep
• F Not explained by or does not occur during another sleep disorder
• G not attributable due to another substance
• Coexisting mental condition do not explain the complaint of insomnia
Diagnostic features
• Difficulty maintaining sleep (most common symptom)
• early morning awakening with difficulty going back to sleep
• Sleep latency greater than 20 -30 minutes
• Occupational impairments
 Common causes of chronic insomnia
• Stress. Concerns about work, school, health, finances or family
• making it difficult to sleep.
• Stressful life events or trauma — such as the death or illness of a
loved one, divorce, or a job loss
• Sexual abuse or assault
• Physical /emotional abuse
prevalence
• One third of adults report insomnia symptoms
• 10-15 % report daytime impairments
• Most prevalent of all sleep disorders
• Female to male -1.44:1
• Most often observed as a co morbid disorder –nearly half present a
comorbid disorder
Development and course
• First episode in young adulthood
• Some cases has a late life onset .menopause or helath related
conditions
• Situational persistent or recurrent – may last a few days or weeks
associated with life events - conditioned arousal -
• High chronicity – 45 -70 % .1-7 years with high variability
• Related to age -More in midlife and older adults
•
Risk factors
• Precipitation events –war , riots natural disasters ,illness
• Repressing emotions , high anxiety persons
• Environmental – noise pollution .
• Genetic
• poor health practices caffeine
 Two major categories
• Dyssomnia - amount or quality of sleep a patient sleep too little, too
much or at the wrong time but sleep is normal
• Parasomnia – quantity, quality and timing are normal but something
abnormal occurs during sleep
sleep as other functions s
• Withdrawl from reality
• A space for enactment of inner wishes ,fulfillment
• Sleep as defense mechanism to cope with life’ issues
hypersomnalence - excessive sleep
diagnostic features
• Extended nocturnal sleep or involuntary daytime sleep
• Deteriorated quality of wakefulness but fall sleep quickly
• Impairment of alertness at sleep wake transition
• Sleep inertia – impairment of attention at sleep drunkenness -reduced vigilance
,noticing things ,registering of details
• Sleep is no restorative in nature –unrefreshing
• Have daytime naps everyday
• Disorientation in time and place
• happens in high attention situations
•
Hypersomnalence disorder -diagnostic
criteria
• Self reported excessive sleepiness despite a main sleeping period
lasting 8 hours with one of the following – recurrent sleep within
same day – prolonged sleep of more than 9 hours – difficulty being
awake after fully awakening
• Three times a week for three months
• Accompanied by distress or impairment in cognitive functioning
• Doesn’t occur with other sleep disorders
• Not due to drugs or medication
• Coexisting disorders do not explain the issue
• Mild – difficulty maintain alertness for 1-2 days a week
• Mild for 3-4 days a week
• Severe –more than five days a week
• Progressive course –in extreme cases lasts upto 20 hours
• Average nighttime sleep duration in 9.5 hours
• Early adolescence or late adulthood appearance
•
•
Risk factors
• Environmental –addictions may increase it – viral infections –
• Genetic factors not known
Differential diagnosis
• Symptoms of excessive sleepiness occur regardless of normal
sleep duration- an average of 9-10 hours per day suggests
hypersomnelence – persists for decades
• Different from long sleep due to fatigue and tiredness
• as different from hypersomnalnece disorder circadian sleep
disorders by characterized by excessive day time sleepiness
• Linked with depressive , bipolar disorders
Parasomnias -Non rapid eye movement sleep
arousal disorders –diagnostic features
• Recurrent episodes of incomplete awakening from sleep ,occurring during first third of major sleep episode
accompanied by either of the following –sleepwalking or sleep terror
• 1 Sleepwalking -repeated episodes of rising from bed during sleep and walking around .has blank staring
face.
• Unresponsive to communicate to others
• Can be awakened with great difficulty

• 2 sleep terror recurrent episodes of terror arousals from sleep starting with a panicky scream.intense fear
and sign of intense arousal with physical reactions like tachycardia ,sweating
• B no dream imagery is recalled. Only a single visual scene is recalled .
• C amnesia is present
• Distress in social , occupational situations .
• Not attributable to substance abuse
• Co existing conditions do no explain the episode of sleepwalking or sleep terror
• REM stands for rapid eye movement. During REM sleep, your eyes
move around rapidly in a range of directions, but don't send any
visual information to your brain. That doesn't happen during non-REM
sleep. First comes non-REM sleep, followed by a shorter period of
REM sleep, and then the cycle starts over again.
• NREM sleep disorder and REM sleep disorder – one occurs during
ist stage of sleep disorder but the other late in the third stage .late
at night
• Incomplete arousal during sleep . first third of major sleep episode -1-10min
• Eyes are typically open
• Sleepwalking –repeated episodes of complex motor behavior –rising from bed and walking
about . Occurs during first third of night.
• During episodes ,reduced alertness and responsiveness, a bank stare , no communication
• Limited recall if woken up during this period
• Sleep terror – precipitous awakening from sleep -begins with panicky scream or cry
• First major sleep episode –
• Intense fear .
• Only fragmentary images recalled
•
Associated features
• Begins with confusion
• Most behaviors are normal and routine behaviors-low complexity
• Bizarre behavior may follow
• Sleep related - eating behavior and sleep related sexual behavior
• In sleep terror compulsion to escape
• Most episodes last half an hour
• Inappropriate behavior –urinating , defecating
• Painful injuries appreciated later on waking up
• Is forced sex during sleepwalking considered assault
• Overwhelming dread.
• Behavior during the episode different .
• One episode per one night .
• high prevalence 10-30%
• NREM occurs during childhood and diminish with age .
• Genetic and physiological basis
• Positive family history
• Forensic basis –
• Eating during sleepwalking in women
• Sleepwalking in women in childhood but in males in adulthood
• The individual or family must report significant distress for a
diagnosis to be made
• Severity based on behavior rather than intensity or frequency
• In NREM sleep , no targeted behavior
•
• Unlike NREM , REM sleep disorders wake easily and early. report
vivid sequences. Have it later in the night.
• Breathing relate disorders known by snoring, breathing pauses
• In REM injury personal injury often happens
• Dissociative fugue rare and difficult to distinguish
•
•
Narcolepsy disorder
• A recurrent periods of irrepressible need to sleep or lapsing into
sleep in daytime
• Must be occurring for past three months
• Brief cataplexy – loss of muscle tone with maintained consciousness
• In children, or within some individuals sudden grimacing or jaw
opening episodes or tongue thrusting
• Hypocretin deficiency
Diagnostic features
• Daily sleepiness with three times a week for three months
• Loss of hypothalamic hypocretin cells ,causing hypocretin deficiency
• Cataplexy -brief episodes of (sec to min) of loss of muscle tone
precipated by emotions . typically laughing or joking .
• mostly Neck jaw arms or leg muscles show loss of muscle tone
•
Development and course
• onset in children and adolescents
• Association with obesity
• First symptoms with increased or decreased sleepiness ,then
cataplexy within a year .
• Inability to sleep and decreased attention through the day
• Aggression
• Pregnancy
• In charge of machinery
• Driving
• Social relations affected due to cataplexy
obstructive sleep apnea disorder
• Obstructive relative sleep disorders - sleep apnea hypopnea ,
central sleep apnea ,sleep related hypoventilation .
• Apnea refers to total absence of airflow
• Hypoapnea refers to reduction in airflow
• Reduction in breathing of 10 seconds in adults . Missing of two
breaths in children .
• Drop in oxygen saturation level of 3%
• EEG arousal
Diagnostic features
• Nocturnal breathing disturbances - Snoring ,gasping , breathing
pauses
• Daytime sleepiness
• fatigue , non restorative sleep
• Polysomnography measures more than five apeas or hypoeas
during per hour of sleep
• If more than 15 per hour of sleep then it is at a high risk level
Associated features
• Insomnia
• Heartburn
• Morning headaches
• Nocturia
• Dry mouth
• Erectile dysfunction
• Hypertension
• 1-2 % of children. 15 of adults . 20 % of people above 60
• Correlation with obesity
• Males ,older adults and ethnic groups .
•
 development and course
• Peaks in children 3- 8 years . Incomplete lymphoid tissue
• Insidious onset
• Peaks between 40 – 60 years
• Every 4-5 years the apnea -hypopnea index increases
differential diagnosis
• Gasping , choking symptoms
• Absence of cataplexy makes it different from narcoplexy
• In insomnia , absence of snoring . But may coexist
• Different from panic attacks
• ADHD – Has a correlation . May exist together
•
Comorbidity
• hypertension
• Diabetes
• Coronary arterial disease
• Parkinsons disease
• Moderate to severe Depression
•
Diagnosis
• Based on polysomnographic findings
• Measured by apneas and hyponeas per hour of sleep
• Severity marked by oxygen homeoglabin desaturation( when more
than 10 % of sleep time is spent at desaturation levels of less than
90%.
•
Nightmare disorder –REM sleep
• A Repeated occurrences if extended, extremely dysphoric and well
remembered dreams that involve efforts to avoid threat to survival,
security, physical integrity and occurs during second half of sleep
• B on awakening, the individual became alert and oriented.
• C impairment in social, occupational and other areas of functioning
• Coexisting mental conditions do not explain the complaint of
dysphoric dream
Diagnostic features
• Nightmares are lengthy story like sequences of dream imagery that
seem real and incite fear, anxiety or dysphoric emotions
• Imminent danger or avoid negative emotions
• Traumatic situations
• Rapid REM disorder –second half of sleep disorder
• Rapid return of full awareness
Associated features
• Mild autonomic arousal
• Sweating , tachy cardia or tachyapnea
• Body movement and vocalization not present because of loss of
skeletal muscle tone
• Nightmares and suicide
• Increase from childhood to adolesence
• 1 out of 20 school going children
• Women have more nightmares than men 2:1
• Decrease with age
• Begins between 3-6
• Reaches peak between adolescence
• Cross cultural , race and gender
• Temperamental
• Environmental
• Genetic and physiological
• Parental and family attitude
• Sleep terror disorder- REM AND NREM
• Bereavement –loss and sadness unlike terror
• Narcolepsy –sleepiness and catalepsy
• Nocturnal seizures –rare
• Panic disorder –reported unlike nightmares
•
• heart disease
• Parkinsonism
• Schizophrenia , bipolar ,
• PTSD
• A separate nightmare disorder when independent attention
warranted
Sexual dysfunction disorders
• Are a heterogeneous group of disorders that are characterized by
clinically significant disturbance in a persons ability to respond
sexually or to experience sexual pleasure .
• Clinical judgements should be made depending upon whether sexual
difficulties are a result of inadequate sexual stimulation or
psychological trauma
• These cases may include but not limited to where a lack of
knowledge or awareness may prevent experience of arousal or
orgasm .
 Subtypes of sexual disorders
• Time of onset may indicate different etiologies and interventions
• Lifelong - presents sexual dysfunctions that are present from first sexual
experiences
• Acquired refers to those that are acquired after a period of normal sexual
experiences
• Generalized referred to sexual difficulties not limited by a partner,
situations or stimulations.
• Situational refers to difficulties that are present only in certain situations,
partners or stimulations
A number of factors must be considered

• Partner factors (partners sexual problems, health status)

• Relationship factors (poor communication, discrepancies in explaining
sexual needs)
• Individual vulnerability (body image disturbance, sexual emotional
abuse)
• Cultural or religious factors (inhibitions related to sexual activity)
• Medical factors relevant to prognosis.
• Sexual response has biological, genetic underpinnings.
• Can be experienced in an intrapersonal, interpersonal and cultural
context.
• Precise etiology is unknown in sexual disorders
• Diagnosis of Sexual dysfunction disorder requires ruling out problems
explained by a nonsexual mental disorder, substance use and abuse or
by relationship distress, partner violence
Sexual dysfunction disorders include
• Delayed ejaculation
• Erectile dysfunction
• Female organismic interest /arousal disorder
• Genito pelvic pain /penetration disorder
• Male hypoactive disorder
• Premature ejaculation
• Substance /medication induced sexual dysfunction
 Erectile disorder
• A - Atleast one or of the three situations must be experienced on all or
at least 75 to 100 percent of occasions of asexual activity with a partner
• Marked difficulty in obtaining an erection during sexual activity
• Marked difficulty in maintaining an erection
• Marked decease in erectile rigidity
• B- Have persisted for six months
• Is not explained by another mental disorder or relationship distress or
stressor
•
causative factors
• Low self esteem or self confidence
• Decrease sense of masculinity
• Depression and anxiety
• Post traumatic stress disorder
A case -study from jagriti refugee camp
• Vivek and Karni 28 and 25 year old
• Married in camp in 2006
• Have lived in camp from 1999
• Unable to consummate the marriage
• Erectile dysfunction disorder
• Environmental and psychological causes
Premature ejaculation disorder
• A persistent pattern of ejaculation during partnered sexual activity
within 1 minute following vaginal penetration and before the
individual wishes it .
• Must be present for atleast six months and must be experienced on
75 to 100 activities
• Causes clinically significant distress in the man
• Not explained by a non sexual mental disorder or relationship
distress or a stressor .
Female sexual interest /Arousal disorder - similar
to male hypoactive sexual desire disorder
• A---- lack of sexual interest /arousal as manifested by three of the following
• Absent /reduced interest in sexual activity
• Absence of erotic thoughts or fantasies
• Reduced initiation of sexual activity and unreceptive to partners attempts to initiate
• Reduced /no excitement during sexual activity in all sexual encounters
• Absence / reduced sexual interest to any external or internal cues (written verbal or visual )
• Absence of genital or no genital sensations
• B- have persisted for six months
• C --Produce clinical distress in the individual
• D—the sexual dysfunction is not explained by a non sexual mental disorder

• Lifelong ,acquired , generalized or situational

• Mild moderate or severe
Female orgasmic disorder
• A Presence of following symptoms –in 75 -100 sexual activity
• Marked delay in orgasm or reduced intensity
• B above symptoms have persisted for six months
• C cause clinically significant distress
• D not explained by a non sexual mental disorder or consequence of
relationship distress –partner violence
• lifelong or acquired
• Generalized or situational
• Mild sever or moderate
Case study
• Joey a 28 year old computer professional .
• Very devoted to work and diligent .
• Began to wear skirts to office and came in women’s clothing
• Adopted a young girl 8 years old who called her mommy
• Announced he wants to have a sex change operation to have a woman’s body
• visited a psychiatrist , a plastic surgeon who was going to operate on her and
showed their letter of support. His operation was to be after three months .
• Wanted the whole office to support him .
• The problem came when he wanted to use the women’s wash room .the women in
the office didn’t agree to that .
• Would you allow that
Gender dysphoric disorder
• A strong desire to be of the other gender or an insistence that one is the
other gender
• Any strong incongruence between one experienced gender and primary /
secondary sexual characteristics
• A strong desire to get rid of one primary secondary sexual characteristics
• A strong desire to be treated as that of the other gender
• A strong conviction that one has the typical feelings and reactions of the
other gender
• There is a marked distress about this impairment social, occupational and
other areas of functioning
• Incongruence between assigned gender and experienced gender .
Discrepancy at the core of diagnosis .
• Evidence of distress
• Reject the male or female characteristics of sexuality .
• Cross gender identification in role playing .dreams or fantasies in a
intense manner
•
 To be diagnosed with gender dysphoria
• Feel they are the wrong sex. Feel persistently and strongly that they
are the wrong sex and feel a strong identification with the opposite
sex.
• Feel discomfort in their sexual being , identity .
• Physical attributes.
• Experience distress in thinking as a male/female .
• Experience anxiety.
• Genetics, hormonal influences during prenatal development, and
environmental factors may be involved. The onset of gender
dysphoria is often during early childhood. While the exact
mechanisms are unclear, we do know that when children are born,
they are assigned a sex-based upon their physical anatomy.
• According to prospective studies, the majority of children diagnosed
with gender dysphoria cease to desire to be the other sex by puberty,
with most growing up to identify as gay, lesbian, or bisexual, with or
without therapeutic intervention. If the dysphoria persists during
puberty, it is very likely permanent.