SLEEP DISORDERS

DR. VIDYA MOHAN KRITHIKANAND

DEPARTMENT OF PSYCHIATRY
KMCH INSTITUTE OF HEALTH SCIENCES AND RESEARCH
 DEFINITION - SLEEP

“A naturally-occurring, reversible,
periodic and recurring state in which
consciousness and muscular activity
is temporarily suspended or
diminished, and responsiveness to
outside stimuli is reduced”
 Sleep - Architecture

• Normal sleep architecture

constitutes two distinct stages
 Rapid-eye-movement
(REM)
 Non-REM (NREM)
• Polysomnography
measures stages of sleep and
wakefulness
 Electroencephalography • NREM sleep accounts for 75% to
records brain activity 80%
 Electromyography • REM sleep accounts for 20% to
records muscle tone 25%
 Electro-oculography • Each NREM-REM cycle lasts
records eye movements approximately 90-120 minutes1
 Sleep - Architecture
Sleep cycle recurs 3 to 7 times
NREM Duration of the stages varies with age
Lasts for 70 to 100 minutes
REM
First episode lasts 5 minutes
Increases in subsequent cycles

Shallow NREM Stage 1

Lasts 30 seconds to 5 minutes

Deeper NREM Stage 3-4

Lasts 30 to 45 minutes

Deeper NREM Stage 2

Lasts 5 to 25 minutes
 Sleep – Physiological
Changes
Physiology Wakefulness NREM sleep REM sleep

Normal sinus
Heart rate Bradycardia tachy
rhythm
Blood pressure Normal Decreased Variable
Cardiac output Normal Decreased Decreases further
Variable; apnoeas
Respiratory rate Normal Decreased
may occur
Cerebral blood flow Moderate Variable Markedly increased

Thermoregulation Mild Moderate Absent

Gastric acid
Normal Variable Variable
secretion

hokroverty S. Overview of sleep & sleep disorders. Indian J Med Res. 2010;131:126-40.
 Sleep - Functions
 The biological function of sleep remains the
greatest mystery of all times
 Sleep has the following functions
 Restorative
 Conservative
 Adaptive
 Thermoregulatory
 Memory consolidation

Chokroverty S. Overview of sleep & sleep disorders. Indian J Med Res. 2010;131:126-40.
Sleep – How much is normally essential?

 Significant individual and night-to-night variability

 One needs a sufficient amount of sleep
 To feel alert and refreshed
 To avoid falling asleep unintentionally during the
waking hours
 Most young adults need 7-8 hours of sleep1

Age Duration of Sleep

Newborns 0 to 2 months 10 to 19 hours
2 months to 3 years 11 to 13 hours approximately
3 to 18 years 9 to 10 hours approximately2
Adults 7 to 8 hours1

1. Markov D, Goldman M. Normal Sleep and Circadian Rhythms: Neurobiologic Mechanisms Underlying Sleep and Wakefulness. Psychiatr Clin N Am.
2006;29:841–53.
2. Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Lippincott. Philadelphia, PA. 2010.
SLEEP DISORDERS
 Sleep Disorders – ICSD-2
Classification
Insomnias Adjustment (Acute) Insomnia
Sleep Related Behavioral Insomnia of Childhood
Breathing Disorders
Psychophysiological Insomnia
Hypersomnias of
Central Origin Paradoxical Insomnia
Circadian Rhythm Idiopathic Insomnia
Disorders Inadequate Sleep Hygiene
Parasomnias Insomnia Due to Mental Disorder
Sleep Related Insomnia Due to Medical Condition
Movement Disorders
Insomnia Due to Drug/Substance
Isolated Symptoms
Insomnia Not Due to Substance or Known
Other Sleep Physiological Condition, Unspecified
Disorders
Physiological (Organic) Insomnia, Unspecified

Schutte-Rodin S, Broch L, Buysse D, et al. Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults. J Clin Sleep Med.
2008;4(5):487-504.
PARASOMNIAS
INSOMNIA
 INSOMNIA

A complaint of difficulty
initiating/maintaining sleep, or
waking up too early, or sleep that is
chronically non-restorative/poor in
quality
 Sleep difficulty occurs despite
adequate opportunity/circumstances
for sleep
 Insomnia – Prevalence
 In industrialised nations, approximately one-third
to one-fourth of the population report problems
with sleep disturbance at some point in their lives
 Approximately 10 per cent suffer from persistent
insomnia
 Chronic insomnia does not usually resolve on its
own; with a study showing an average chronicity
of 10 years at the initial assessment
 Insomnia presents more frequently as a co-morbid
illness than as primary insomnia
 Chronic insomnia tends to be unremitting,
disabling, expensive, and may pose a risk for
additional medical/ psychiatric disorders

Pigeon WR. Diagnosis, prevalence, pathways, consequences & treatment of insomnia. Indian J Med Res. 2010;131:321-32.
Consequences of Sleep Deprivation
and Disruption

Sleep Deprivation and Disruption

Excessive Daytime Sleepiness

Cognitive/Executive Deficits of Performance Cardio-metabolic

Function Deficits Errors/Accuracy High blood
Attention/ pressure Appetite
Concentration regulation

Decreased Quality of Life and Increased

Morbidity/Mortality
 Effects of Sleep Deprivation
• Irritability
• Cognitive impairment
• Increased heart rate
• Memory lapses or loss
• Impaired moral variability
• Risk of heart disease
judgement
• Severe yawning
• Hallucinations
• Symptoms similar to • Decreased reaction
ADHD time and accuracy
• Tremors
• Aches

Impaired
immune
system

Other:
Risk of • Growth suppression
Diabetes Type • Risk of obesity
2 • Decreased temperature
INSOMNIA-
MANAGEMENT
 Management of sleep disorders is a multi-
pronged approach, involving non-
pharmacological strategies and
pharmacological interventions1,
 Non-pharmacological strategies (Cognitive
behavioural intervention)
• Stimulus control instructions
• Relaxation training
• Sleep restriction therapy
• Sleep hygiene
• Cognitive therapy

Pharmacotherapy
 Insomnia – Management
Stimulus control Relaxation training
• Includes
instructions Progressive muscle relaxation
 Sleep on the bed only when
sleepy Slow abdominal breathing
 Use the bed only to sleep Autogenic training
 If unable to fall asleep within 15- Guided imagery
20 minutes, go out of the
bedroom and try to engage in • The specific technique should be
relaxing activities such as light demonstrated by the clinician
reading unrelated to work. and the rationale explained
 Go back to bed only when ready
to sleep or feeling sleepy • Patient should practice the
 If still unable to sleep, repeat the technique at home, maybe with
above step as often as necessary the help of a video explaining the
 Always wake up at the same time same
each and every morning • Patient should use the technique
 Use an alarm clock, if necessary only after a moderate level of
skill is developed which may take
a few weeks
Yang CM, Spielman AJ, Glovinsky P. Nonpharmacologic strategies in the management of insomnia. Psychiatr Clin North Am. 2006;29(4):895-919.
 Insomnia – Management

Sleep Restriction Therapy

 Information has to be taken from a sleep log
maintained for at least 1 week
 Sleep time has to be maintained at the average
total sleep time from the log with a minimum of
5 hours

Yang CM, Spielman AJ, Glovinsky P. Nonpharmacologic strategies in the management of insomnia. Psychiatr Clin North Am. 2006;29(4):895-919.
SLEEP HYGIENE
 Get regular
 Sleep when sleepy
 Get up & try again
 Avoid caffeine/ nicotine/ alcohol
 Bed is for sleeping
 No naps
 Sleep rituals
 No clock watching
 Exercise
 Eat right
 The right space
 Maintain day time routine
 Insomnia – Management
Cognitive Therapy
Discuss patient’s beliefs and approaches
to sleep and sleep problems
Dysfunctional beliefs and attitude scales
are used for evaluation
Involve patient in assessing and
disproving the dysfunctional beliefs
with accurate information and rationale

Yang CM, Spielman AJ, Glovinsky P. Nonpharmacologic strategies in the management of insomnia. Psychiatr Clin North Am. 2006;29(4):895-919.
Insomnia – Management
Pharmacotherapy
Drugs commonly used in the treatment of
insomnia
• Sedating antidepressants
• Sedating antihistamines
• Benzodiazepines
• Nonbenzodiazepine hypnotics1
 For many years, benzodiazepines remained the mainline
therapy for insomnia, until the advent of newer non-
benzodiazepine group of drugs
 Prolonged use of benzodiazepine is associated with tolerance
and dependence unlike newer nonbenzodiazepines2

1. Carson S, McDonagh MS, Thakurta S, Yen PY. Drug Class Review: Newer Drugs for Insomnia: Final Report Update 2. Oregon Health & Science
University. Accessed February 4, 2011 and available at http://www.ncbi.nlm.nih.gov/pubmed/21089248.
2. Ramakrishnan K, Scheid DC. Treatment options for insomnia. Am Fam Physician. 2007;76(4):517-26.
NARCOLEPSY
NARCOLEPSY

 Excessive sleepiness + auxiliary

symptoms that represent the intrusion
of aspects of REM sleep into the waking
state.
 Sleep attacks -irresistible, 10-20 min of
sleep, refreshed.
 Abnormality of REM inhibiting
mechanism
 Inappropriate times ex-while eating,
talking, driving
MANAGEMENT

INVESTIGATIONS:
 Polysomnography-sleep onset REM period
 Multiple sleep latency Test (MSLT) - is the
diagnostic technique. It provides patient 4-6
nap opportunities at 2 hour intervals though
out the day.

TREATMENT:
 Forced naps
 Psychostimulants
 Modafinil
 REM suppressants
Circadian Rhythm Sleep Disorders

 Asynchrony between an individual’s

internal circadian biological clock & the
desired sleep wake cycle.
 Endogenous clock -24-hour period -
circadian rhythm.
 Synchronized by external time cues
(“zeitgebers”) such as the light–dark
cycle, which serves as the major
external time cue in humans.
 Delayed sleep phase syndrome:

 reported sleep onset and wake times -

later than desired
 actual sleep times - same clock hours
daily
 Essentially normal all-night
polysomnography except for delayed
sleep onset.
 They are active in evening and early
night & tired in morning, referred to as
night “Owls”.
MANAGEMENT
 Rescheduling regimen (Chronotherapy)
bedtimes are successively delayed.
 Bright-light phototherapy during the
morning hours also show promise in these
patients. Light is usually administered in
doses of 2,500 lux for a period of 2 hours
per day
 In DSPS adequate physiological dose (0.3
mg) of melatonin, small enough not to
cause sleepiness, is given 7 hours prior to
the patient’s regular (late) sleep onset time.
Advanced Sleep Phase
Syndrome
 early birds or “larks”
Rapid Time-Zone Change
(Jet Lag) Syndrome
 Travel across several time zones. Traveling
east advances the sleep-wake cycle and is
typically more difficult than traveling west
(which delays the cycle).
 ‘Owls’ difficult to adjust toward east travel.
‘Larks’ difficult to adjust toward west travel.
 Jet lag may be associated with difficulty
initiating or maintaining sleep or with daytime
sleepiness, impaired performance, and
gastrointestinal disturbance after rapid
transmeridian flights
 > 50 Years - vulnerable
 Healthy individuals - 1—2 time zones
changes per day. Natural adjustment to 8 hr
translocation takes 4 days.
 Transient, typically lasting 2 to 14 days.
 Depends: number of time zones crossed,
the direction of travel, and the traveler’s age
and phase-shifting capacity.
 Travelers who spend more time outdoors
reportedly adapt more quickly than those
who remain in hotel rooms, presumably due
to bright (outdoor) light exposure.
SLEEP WALKING
(SOMNAMBULISM)
 Sleepwalking is a disorder that occurs when a person walks
or does another activity while they are still asleep.
 They roam around the house ~ They are difficult to wake ~
Engage in routine activities ~ Talking is also common,
although what they say might not make any
 Inherited
 TREATMENTS ~ Medication ~ Relaxation. ~ Anticipatory
Awakenings ~ Waking the child or person approximately 15-
20 minutes before the usual time of an event, and then
keeping them awake through the time during which the
episodes usually occur..
 Prevention ~ Limit stress ~ Meditate or do relaxation
exercises. ~ Avoid getting too tired, and try to prevent
insomnia, because this can trigger a sleep walking episode.
~ Avoid or minimize stress, anxiety, and conflict
THANK YOU