SOMATOFORM DISORDERS

Somatization Disorder

INTRODUCTION

Somatoform disorders are characterized by physical symptoms suggesting medical disease

but without demonstrable organic pathology or a known pathophysiological mechanism to
account for them.

They are classified as mental disorders because pathophysiological processes are not
demonstrable or understandable by existing laboratory procedures, and there is either
evidence or strong presumption that psychological factors are the major cause of the
symptoms.

It is now well documented that a large proportion of clients in general medical

outpatient clinics and private medical offices do not have organic disease requiring medical
treatment. It is likely that many of these clients have somatoform disorders, but they do not
perceive themselves as having a psychiatric problem and thus do not seek treatment from
psychiatrists.

DEFINTION

The somatoform disorders are characterised by repeated presentation with physical symptoms
which do not have any adequate physical basis (and are not explained by the presence of
other psychiatric disorders), and a persistent request for investigations and treatment despite
repeated assurances by the treating doctors.

These disorders are divided into following categories:

• Somatization disorder

• Hypochondriasis

• Somatoform autonomic dysfunction

• Persistent somatoform pain disorder

Somatization Disorder

Somatization disorder is a chronic syndrome of multiple somatic symptoms that cannot be

explained medically and are associated with psychosocial distress and long-term seeking of
assistance from health-care professionals. Symptoms can represent virtually any organ
system but commonly are expressed as neurological, gastrointestinal, psychosexual, or
cardiopulmonary disorders. Onset of the disorder is usually in adolescence or early adulthood
and is more common in women than in men. The disorder usually runs a fluctuating course,
with periods of remission and exacerbation.
Pain Disorder

The essential feature of pain disorder is severe and prolonged pain that causes clinically
significant distress or impairment in social, occupational, or other important areas of
functioning (APA, 2000). This diagnosis is made when psychological factors have been
judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain,
even when the physical examination reveals pathology that is associated with the pain.

Hypochondriasis

Hypochondriasis is an unrealistic preoccupation with the fear of having a serious illness. The
DSM-IV-TR suggests that this fear arises out of an unrealistic interpretation of physical signs
and symptoms. Occasionally medical disease may be present, but in the hypochondriacal
individual, the symptoms are grossly disproportionate to the degree of pathology. Individuals
with hypochondriasis often have a long history of “doctor shopping” and are convinced that
they are not receiving the proper care.

Conversion Disorder

Conversion disorder is a loss of or change in body function resulting from a psychological

conflict, the physical symptoms of which cannot be explained by any known medical disorder
or pathophysiological mechanism. The most common conversion symptoms are those that
suggest neurological disease such as paralysis, aphonia, seizures, coordination disturbance,
akinesia, dyskinesia, blindness, tunnel vision, anosmia, anesthesia, and paresthesia. Body

Dysmorphic Disorder

This disorder, formerly called dysmorphophobia, is characterized by the exaggerated belief

that the body is deformed or defective in some specific way. The most common complaints
involve imagined or slight flaws of the face or head, such as thinning hair, acne, wrinkles,
scars, vascular markings, facial swelling or asymmetry, or excessive facial hair (APA, 2000).

PREDISPOSING FACTORS TO SOMATOFORM DISORDERS

1. Physiological

a. Genetic. Studies have shown an increased incidence of somatization disorder, conversion

disorder, and hypochondriasis in first-degree relatives, implying a possible inheritable
predisposition (Sadock & Sadock, 2007; Soares & Grossman, 2007; Yutzy, 2003).

b. Biochemical. Decreased levels of serotonin and endorphins may play a role in the etiology
of pain disorder.

2. Psychosocial
a. Psychodynamic. Some psycho dynamicists view hypochondriasis as an ego defense
mechanism. They hypothesize that physical complaints are the expression of low self-esteem
and feelings of worthlessness and that the individual believes it is easier to feel something is
wrong with the body than to feel something is wrong with the self.

The psychodynamic theory of conversion disorder proposes that emotions associated

with a traumatic event that the individual cannot express because of moral or ethical
unacceptability are “converted” into physical symptoms. The unacceptable emotions are
repressed and converted to a somatic hysterical symptom that is symbolic in some way of the
original emotional trauma.

b. Family Dynamics. Some families have difficulty expressing emotions openly and resolving
conflicts verbally. When this occurs, the child may become ill, and a shift in focus is made
from the open conflict to the child’s illness, leaving unresolved the underlying issues that the
family cannot confront openly. Thus, somatization by the child brings some stability to the
family, as harmony replaces discord and the child’s welfare becomes the common concern.
The child in turn receives positive reinforcement for the illness.

c. Sociocultural/Familial Factors. Somatic complaints are often reinforced when the sick role
relieves the individual from the need to deal with a stressful situation, whether it be within
society or within the family. When the sick person is allowed to avoid stressful obligations
and postpone unwelcome challenges, is excused from troublesome duties, or becomes the
prominent focus of attention because of the illness, positive reinforcement virtually
guarantees repetition of the response.

d. Past Experience with Physical Illness. Personal experience, or the experience of close
family members, with serious or life-threatening illness can predispose an individual to
hypochondriasis. Once an individual has experienced a threat to biological integrity, he or she
may develop a fear of recurrence. The fear of recurring illness generates an exaggerated
response to minor physical changes, leading to hypochondriacal behaviors.

e. Cultural and Environmental Factors. Some cultures and religions carry implicit sanctions
against verbalizing or directly expressing emotional states, thereby indirectly encouraging
“more acceptable” somatic behaviors. Cross cultural studies have shown that the somatization
symptoms associated with depression are relatively similar, but the “cognitive” or emotional
symptoms such as guilt are predominantly seen in Western societies. In Middle Eastern and
Asian cultures, depression is almost exclusively manifested by somatic or vegetative
symptoms.

Environmental influences may be significant in the predisposition to somatization disorder.

Some studies have suggested that a tendency toward somatization appears to be more
common in individuals who have low socioeconomic, occupational, and educational status.

In ICD-10, somatoform disorders are divided into the following categories.

Somatisation disorder is characterised by the following clinical features:

1. Multiple somatic symptoms in the absence of any physical disorder.

2. The symptoms are recurrent and chronic (of many years duration, usually); at least 2 year
duration is needed for diagnosis.

3. The symptoms are vague, presented in a dramatic manner, and involve multiple organ
systems. The common symptoms include gastrointestinal (abdominal pain, beltching, nausea,
vomiting, regurgitation), abnormal skin sensations (numbness, soreness, itching, tingling,
burning), and sexual and menstrual complaints (menorrhagia, dysmenorrhoea, dyspareunia).

4. There is frequent change of treating physicians.

5. Persistent refusal to accept the advice or reassurance of several doctors that there is no
physical explanation for the symptoms.

6. Some degree of impairment of social and family functioning attributable to the nature of
the symptoms and resulting behaviour.

7. Presence of conversion symptoms is common.

SYMPTOMATOLOGY (SUBJECTIVE AND OBJECTIVE DATA)

1. Any physical symptom for which there is no organic basis but for which evidence exists
for the implication of psychological factors.

2. Depressed mood is common.

3. Loss or alteration in physical functioning, with no organic basis. Examples include the
following:

a. Blindness or tunnel vision

b. Paralysis

c. Anosmia (inability to smell)

d. Aphonia (inability to speak)

e. Seizures

f. Coordination disturbances

g. Pseudocyesis (false pregnancy)

h. Akinesia or dyskinesia

i. Anesthesia or paresthesia
 4. “La belle indifference”—a relative lack of concern regarding the severity of the symptoms
just described (e.g., a person is suddenly blind but shows little anxiety over the situation).

5. “Doctor shopping”

6. Excessive use of analgesics

7. Requests for surgery

8. Assumption of an invalid role

9. Impairment in social or occupational functioning because of preoccupation with physical

complaints

10. Psychosexual dysfunction (impotence, dyspareunia [painful coitus], sexual indifference)

11. Excessive dysmenorrhea

12. Excessive preoccupation with physical defect that is out of proportion to the actual
condition

Treatment

The treatment is often difficult. It mainly consists of:

1. Supportive psychotherapy: The treatment of choice is usually supportive psychotherapy.

The first step is to enlist the patient in the therapeutic alliance by establishing a rapport. It is
useful to demonstrate the link between psychosocial conflict(s) and somatic symptoms, if it is
apparent. In chronic cases, ‘symptom reduction’ rather than ‘complete cure’ might be a
reasonable goal.

2. Behaviour modification: After rapport is established, attempts at modifying behaviour are

made, for example, not focusing on the symptoms per se, and positively reinforcing normal
functioning.

3. Relaxation therapy, with graded physical exercises.

4. Drug therapy: Antidepressants and/or benzodiazepines can be given on a short-term basis

for associated depression and/or anxiety. Benzodiazepines should be used with great caution,
as the risk of dependence and misuse is high in these patients.

HYPOCHONDRIASIS (HYPOCHONDRIACAL DISORDER)

Hypochondriasis is defined as a persistent preoccupation with a fear (or belief) of having one
(or more) serious disease(s), based on person’s own interpretation of normal body function or
a minor physical abnormality.

The other important features of hypochondriasis are:

1. Complete physical examination and investigations do not show presence of any significant
abnormality.

2. The fear or belief persists despite assurance to the contrary by showing normal reports to
the patient.

3. The fear or belief is not a delusion but is instead an example of an overvalued idea. The
patient may agree regarding the possibility of his exaggerating the graveness of situation, at
that time.

4. A preoccupation with medical terms and syndromes is quite common. The patient tends to
change the physician frequently, in order to get investigated again. The usual age of onset is
in the late third decade. The course is usually chronic with remissions and relapses. Obsessive
personality traits and narcissistic personality features are frequently seen, in addition to
associated anxiety and depression.

Aetiology

The cause of hypochondriasis is not known. The important theories are mentioned below:

1. Psychodynamic Theory

Hypochondriasis is believed to be based on a narcissistic personality, caused by a

narcissistic libido. Here other parts of body become erotogenic zones, which act as
substitutes for genitals. Hypochondriacally focused organs symbolise the genitals. It must be
remembered that this is only a theoretical psychodynamic construct.

2. As a Symptom of Depression

Hypochondriacal symptoms are commonly present in major depression. In fact, according to

some, hypochondriasis is almost always a part of another psychiatric syndrome, most
commonly a mood disorder. Thus, hypochondriasis has been visualised as a masked
depression or depressive equivalent, though not everyone agrees with this view. Treatment
The treatment of hypochondriasis is often difficult. It basically consists of:
1. Supportive psychotherapy

3. Treatment of associated or underlying depression and/or anxiety, if present.

PERSISTENT SOMATOFORM PAIN DISORDER

It was previously called as psychogenic pain disorder. In this disorder, persistent, severe and
distressing pain is the main feature which is, either grossly in excess of what is expected
from the physical findings, or inconsistent with the anatomical distribution of nervous
system. Preoccupation with pain is common. There is often a precipitating stressful event
and secondary gain may be present. Repeated change of physicians (doctor-shopping) is
common. The affected person often assumes a ‘sick-role’ or an ‘invalid-role’. Abuse and
dependence of analgesics and minor tranquilisers is common, particularly when the course is
chronic. This disorder is more common in females, with an onset in the third or fourth
decade of life.

Treatment

1. The patients usually refuse psychiatric intervention; therefore treatment is often managed
by the treating physician.

2. Drug therapy should be avoided if possible as the risk of iatrogenic drug abuse is quite
high.

3. In the absence of other modes of successful treatment, a supportive relationship with a

physician will prevent doctor-shopping and provide relief.

Other Somatoform Disorders

In ICD-10, this category includes other somatoform disorders not classified in the previous
four categories, e.g. ‘globus hystericus’, psychogenic torticollis, psychogenic pruritus,
psychogenic dysmenorrhoea, teeth-grinding.

CONVERSION DISORDER

It is characterised by the following clinical features:

1. Presence of symptoms or deficits affecting motor or sensory function, suggesting a

medical or neurological disorder.

2. Sudden onset

3. Development of symptoms usually in the presence of a significant psychosocial

stressor(s).

4. A clear temporal relationship between stressor and development or exacerbation of symp

toms.

5. Patient does not intentionally produce the symptoms.

6. There is usually a ‘secondary gain’ (though not required by ICD-10 for diagnosis).

7. Detailed physical examination and investigations do not reveal any abnormality that can
explain the symptoms adequately.

8. The symptom may have a ‘symbolic’ relationship with the stressor/conflict. There can be
two different types of disturbances in conversion disorder; motor and sensory. Autonomic
nervous system is typically not involved, except when the voluntary musculature is involved,
e.g. vomiting, globus hystericus.

In ICD-10, conversion disorder is subsumed under ‘dissociative disorders of movement and

sensation’, a subtype under ‘dissociative (conversion) disorders’. It is further classified in to
dissociative motor disorders, dissociative anaesthesia and sensory loss, and dissociative
convulsions.

SOMATOFORM AUTONOMIC DYSFUNCTION

According to ICD-10, in this disorder, symptoms are presented by the patient as if they were
due to a physical disorder of an organ system that is predominantly under autonomic control,
e.g. heart and cardio vascular system (such as palpitations), upper gastro intestinal tract (such
as aerophagy, hiccough), lower gastrointestinal tract (such as flatulence, irritable bowel),
respiratory system (such as hyperventilation), genitourinary system (such as dysuria), or
other organ systems.

There is preoccupation with, and distress regarding, the possibility of a serious (but often
unspecified) disorder of the particular organ system.

Physical examination and investigations do not however show presence of any significant
abnormality. The preoccupation persists despite repeated assurances and explanations.

Treatment

The treatment consists of:

1. Supportive psychotherapy

2. Drug treatment: The symptoms of anxiety and/or depression usually respond to short-term
use of benzodiazepines and antidepressants.

SLEEP DISORDERS
Sleep is a naturally recurring state of mind and body, characterized by altered consciousness,
relatively inhibited sensory activity, reduced muscle activity and inhibition of nearly all
voluntary muscles during rapid eye movement sleep, and reduced interactions with
surroundings.

Sleep occurs in repeating periods, in which the body alternates between two distinct
modes: REM sleep and non-REM sleep. Although REM stands for "rapid eye movement",
this mode of sleep has many other aspects, including virtual paralysis of the body. A well-
known feature of sleep is the dream, an experience typically recounted in narrative form,
which resembles waking life while in progress, but which usually can later be distinguished
as fantasy.

The amount of sleep a person needs depends on many factors, including age. In general:

 Infants (ages 0-3 months) require 14-17 hours a day.

  Infants (ages 4-11 months) require 12-15 hours a day
 Toddlers (ages 1-2 years) require about 11-14 hours a day.
 Pre-school children (ages 3-5) require 10-13 hours a day.
 School-age children (ages 6-13) require 9-11 hours a day.
 Teenagers (ages 14-17) need about 8-10 hours each day.
 Most adults need 7 to 9 hours a night for the best amount of sleep, although some people
may need as few as 6 hours or as many as 10 hours of sleep each day.
 Older adults (ages 65 and older) need 7-8 hours of sleep each day.
 Women in the first 3 months of pregnancy often need several more hours of sleep than
usual.

Sleep is divided into two broad types: non-rapid eye movement (non-REM or NREM) sleep
and rapid eye movement (REM) sleep. Non-REM and REM sleep are so different that
physiologists identify them as distinct behavioral states. Non-REM sleep occurs first and
after a transitional period is called slow-wave sleep or deep sleep. During this phase, body
temperature and heart rate fall, and the brain uses less energy. REM sleep, also known as
paradoxical sleep, represents a smaller portion of total sleep time. It is the main occasion
for dreams (or nightmares), and is associated with desynchronized and fast brain waves, eye
movements, loss of muscle tone, and suspension of homeostasis.
The sleep cycle of alternate NREM and REM sleep takes an average of 90 minutes, occurring
4–6 times in a good night's sleep. [12][14] The American Academy of Sleep Medicine (AASM)
divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep
or slow-wave sleep. The whole period normally proceeds in the order: N1 → N2 → N3 →
N2 → REM. REM sleep occurs as a person returns to stage 2 or 1 from a deep sleep. [2] There
is a greater amount of deep sleep (stage N3) earlier in the night, while the proportion of REM
sleep increases in the two cycles just before natural awakening.

There are several types of sleep disorders known. The ASDC (Association for Sleep
Disorders Centre) has done a lot of work in classifying the various sleep disorders and their
classification has been adapted for use both by DSM-IV-TR and ICD-10. The sleep disorders
are known as non-organic sleep disorders in ICD-10.

The various sleep disorders are divided in 2 subtypes:

I. Dyssomnias

1. Insomnia

2. Hypersomnia

3. Disorders of sleep-wake schedule.

II. Parasomnias

1. Stage 4 sleep disorders

2. Other sleep disorders.

DYSSOMNIAS
Dyssomnias are sleep disorders that are characterised by disturbances in the amount, quality
or timing of sleep. These are the commonest disorders of sleep.

Insomnia

Insomnia is also known as the Disorder of Initiation and/or Maintenance of Sleep (DIMS).
Insomnia means one or more of the following:

1. Difficulty in initiating sleep (going-off to sleep).

2. Difficulty in maintaining sleep (remaining asleep).

This can include both:

a. Frequent awakenings during the night, and

b. Early morning awakening.

3. Non-restorative sleep where despite an adequate duration of sleep, there is a feeling of not
having rested fully (poor quality sleep). Insomnia is very common, with nearly 15-30% of
general population complaining of a period of insomnia per year requiring treatment. It is
required for diagnosis that sleep disturbance occurs at least three times a week for at least 1
month, and that it causes either marked distress or interferes with social and occupational
functioning.

Aetiology

The common causes of insomnia are listed in Table 11.2 A person suffering from insomnia
should be differentiated from a short-sleeper, who needs less than 6 hours of sleep per night
and has no symptoms or dysfunction. A short-sleeper does not need any treatment.

Table 11.2: Common Causes of Insomnia

1. Medical illnesses

i. Any painful or uncomfortable condition

ii. Heart diseases

iii. Respiratory diseases

iv. Rheumatic and musculo-skeletal disease

v. Old age

vi. Brain stem or hypothalamic lesions

vii. Delirium

viii. PMS (Periodic movements in sleep)

2. Alcohol and drug use

i. Drug or alcohol withdrawal syndrome

ii. Delirium tremens

iii. Amphetamine or other stimulants, e.g. caffeine

iv. Chronic alcoholism

3. Current medication, e.g. fluoxetine, steroids, theophylline, propranolol

4. Psychiatric disorders

i. Mania (may not complain of decrease in sleep, as there is often a decreased need for
sleep)

ii. Major depression (difficulty in maintenance of sleep is more prominent, although

difficulty in initiating sleep is also present)

iii. Dysthymia (difficulty in initiating sleep is characteristic)

iv. Anxiety disorder (difficulty in initiating sleep is common)

v. Stressful life situation (may cause temporary insomnia).

5. Idiopathic insomnia

HYPERSOMNIA

Hypersomnia is also known as Disorder of excessive somnolence (DOES). Hypersomnia

means one or more of the following:

1. Excessive day time sleepiness.

2. ‘Sleep attacks’ during day time (falling asleep unintentionally).

3. ‘Sleep drunkenness’ (person needs much more time to awaken; and during this period is
confused or disoriented).

Aetiology

The common causes of hypersomnia are listed in Table 11.4. A person suffering from
hypersomnia should be differentiated from a long-sleeper, who needs more than 9 hours of
sleep per night and has no symptoms or dysfunction. A long- sleeper does not need any
treatment.

A few important causes of hypersomnia are discussed below:

1. Narcolepsy This is a disorder characterised by excessive daytime sleepiness, often

disturbed night-time sleep and disturbances in the REM-sleep. The hallmark of this
 disorder is decreased REM latency, i.e. decreased latent period before the fi rst REM
period occurs. Normal REM latency is 90-100 minutes.

In narcolepsy, REM-sleep usually occurs within 10 minutes of the onset of sleep. The
common age of onset is 15-25 years, with usually a stable course throughout life. The
prevalence rate of narcolepsy is about 4 per 10,000. The classical tetrad of symptoms is:

i. Sleep attacks (most common): The person is unable to resist a sleep attack or ‘nap’,
from which he or she awakens refreshed. These ‘attacks’ can occur during any time
of the day, even whilst driving. Usually, there is a gap of 2-3 hours between the two
attacks.
ii. Cataplexy: This is characterised by a loss of muscle tone in the various parts of
body, e.g. jaw drop, or paresis of all skeletal muscles of body resulting in a fall. This
may be precipitated by sudden emotion. The consciousness is usually clear and
memory is normal, unless sleep attacks supervene.
iii. Hypnagogic hallucinations: These are vivid perceptions, usually dream-like, which
occur at the onset of sleep and are associated with fearfulness. When these occur at
awakening, they are called hypnopompic hallucinations.
iv. Sleep paralysis (least common): This occurs either at awakening in the morning
(usually) or at sleep onset. The person is conscious but unable to move his body. The
episode may last from 30 seconds to a few minutes and may cause significant
distress.
Not all symptoms of the tetrad are present in one person. The other associated
symptoms are fugue states, blackouts and blurring of vision. Poly somnography
helps in making a diagnosis in doubtful cases, showing a decreased REM latency.
The treatment consists of forced naps at regular times in the day, stimulant
medication (such as amphetamines) or modafinil in some patients, and/ or
antidepressants (particularly when cataplexy is a prominent symptom).

2. Sleep Apnoea

This condition is characterised by presence of repeated episodes of apnoea during sleep. In

this context, apnoea is defined as the cessation of airflow at the nostrils (and mouth) for 10
seconds or longer.

 The apnoea can be of central type, obstructive type or mixed type.

 It is commoner in elderly and obese (Pickwickian syndrome).
 Typically, there are 5 or more apnoeic episodes per hour of sleep and the total
number of apnoeic episodes exceeds 30 during one night’s sleep. In severe cases, the
number of episodes may be in hundreds.
 The patients are usually not aware of the occurrence of apnoea. Instead, they
complain of an inability to stay awake in the day time and non-restorative sleep at
night.
 The bed partner may report of loud snoring, rest less sleep or of periodic absences of
breathing.
  The diagnosis can be established in doubtful cases using polysomnography, with the
respiratory tracings included.
 Sleep apnoea can be a dangerous condition.
 It can cause cardiac arrhythmias, pulmonary and systemic hypertension, and death.
 The treatment consists of avoidance of alcohol and depressant medications, use of
stimulants such as caffeine, regular exercises, losing excess weight, teaching correct
sleeping posture, and corrective procedures for obstructive sleep apnoea (e.g.
mechanical tongue retaining device).
 Very severe obstructive sleep apnoea may necessitate tracheostomy (functional only
at night), CPAP (continuous positive airway pressure) through nasal mesh, or even
pharyngoplasty.

3. Kleine-Levin Syndrome This is a rare syndrome characterised by:

1. Hypersomnia (always present), occurring recurrently for long periods of time.

2. Hyperphagia (usually present), with a voracious appetite.

3. Hypersexuality (associated at times), consisting of sexual disinhibition, masturba tory

activity, exhibitionism, and/or inappropriate sexual advances. The associated features
include apathy, irritable behaviour, confusion, social withdrawal, bizarre behaviour,
psychotic symptoms (such as delusions and hallucinations), and disorientation. One or
more of these symptoms may occur during the episode. EEG abnormalities, usually showing
intermittent nonspecific slowing, are common but are not diagnostic. A typical episode lasts
for one to several weeks, followed usually by a complete remission. The common age of
onset is the second decade of life. Apparently this disorder has a finite course with a large
majority of patients recovering completely before the fifth decade of life. The disorder is
almost always seen in males. No specific treatment is available but Lithium and occasionally
Carbamazepine have been reported to be successful.

Treatment

1. A thorough physical and psychiatric assessment.

2. Treatment of the underlying cause is the most important method.

3. Associated or underlying insomnia should be looked for and treated.

4. Withdrawal of current medication causing hypersomnia, especially depressant

medication.

5. Benzodiazepines at night may paradoxically decrease hypersomnia by correcting night

time insomnia.

DISORDERS OF SLEEP-WAKE SCHEDULE

These are characterised by a disturbance in the timing of sleep. The person with this
disorder is not able to sleep when he wishes to, although at other times he is able to sleep
adequately. This is due to a mismatch between person’s circadian rhythm and the normal
sleep-wake schedule demanded by the environment.

Aetiology

The common causes of disorders of sleep-wake schedule are listed below:

1. ‘Jet lag’ or rapid change of time zone: This typically occurs during international flights
crossing many ‘time zones’. At the new place, the person’s internal time of sleep and the
sleep time of surroundings are different, leading to insomnia during the new sleep time and
somnolescence in the new daytime, thus causing impairment of functioning.

2. ‘Work-shift’ from day to night or vice-versa. 3. Unusual sleep phases: Some persons are
unable to sleep early. They typically sleep late at night and get up late in the morning. They
are called as ‘owls’. Others are similarly unable to remain awake at night. They typically
sleep early at night and get up early in the morning. They are called as ‘l arks’. Some others
have a longer-than 24 hour sleep-wake cycle (usually of 25 hours).

Treatment

No specific treatment is usually needed. Benzodiazepines may be needed for short-term

correction of insomnia. Changes in ‘work-shifts’ may be needed for persons with unusual
sleep phases. Exposure to sunlight during outdoor activity (instead of staying indoors) and
adopting the local (new) hours for sleeping (and working) can help in combating jet lag.

PARASOMNIAS

Parasomnias are dysfunctions or episodic nocturnal events occurring with sleep, sleep stages
or partial arousals. Most parasomnias are common in childhood though they may persist into
adulthood.

STAGE 4 SLEEP DISORDERS

These disorders occur during deep sleep, i.e. Stages 3 and 4 of NREM-sleep. The common

Stage 4 parasomnias are:

1. Sleep-walking (somnambulism): The patient carries out automatic motor activities that
range from simple to complex. He may leave the bed, walk about or leave the house.
Arousal is difficult and accidents may occur during sleep-walking.

2. Sleep-terrors or night terrors ( pavornocturnus): The patient suddenly gets up screaming

with autonomic arousal (tachycardia, sweating and hyperventilation). He may be difficult to
arouse and rarely recalls the episode on awakening. In contrast, nightmares (which occur
during REM sleep) are clearly remembered in the morning.

3. Sleep-related enuresis (bedwetting):

4. Bruxism (teeth-grinding): The patient has an involuntary and forceful grinding of teeth
during sleep. Though the bed partner reports loud sounds produced by grinding of teeth and
destruction of the tooth enamel is obvious, the patient remains completely unaware of the
episode(s).

5. Sleep-talking (somniloquy): The patient talks during stages 3 and 4 of sleep but does not
remember anything about it in the morning on awakening. These disorders are often co-
existent. As they occur during stage 4 (and 3) of NREM-sleep, they are more common
during the first one-third of the night (There is more NREM-sleep in the first third of the
night while the last third has more REM-sleep). Arousal is difficult and on waking-up, there
is a complete amnesia for the event(s).

Treatment

Since benzodiazepines suppress stage 4 of NREM sleep, a single dose at bedtime usually
provides relief from stage 4 parasomnias.

OTHER SLEEP DISORDERS

Nightmares (dream anxiety disorder) occur during the REM-sleep.

They are characterised by fearful dreams occurring most commonly in the last one-third of
night sleep.

The person wakes up very frightened and remembers the dream vividly. This is in contrast
to night terrors which occur early in the night, are a stage 4 NREM disorder, and are
characterised by complete amnesia. In both the conditions, the observer finds the person
frightened during the episode.

Other sleep disorders include nocturnal angina, nocturnal asthma, nocturnal seizures,
paroxysmal nocturnal haemoglobinuria, nocturnal head banging, and familial sleep
paralysis.

Treatment

There is no specific treatment. Treatment of the underlying condition is the most import ant
step. The treatment of nightmares is by suppression of REM sleep, e.g. by bedtime dose of a
benzodiazepine. However, on stopping the drug, a rebound increase in symptoms may
occur.