Sleep disorder

Common Sleeping Problems Find out how you can get a good night's sleep.

Sleep is a reversible state during which the individual's voluntary functions are suspended but the involuntary functions, such as circulation and respiration, are uninterrupted; the sleeping subject assumes a characteristic posture with relative immobility and decreased responses to external stimuli.

The sleep state can be divided into nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep is divided into four stages based on electroencephalographic criteria. The first REM in a normal adult occurs 60–90 min after sleep onset, and there are usually four or five NREM-REM cycles, each lasting for 90–110 min. Most dreams occur during REM sleep. The sleep-wake pattern for humans follows a circadian rhythm. An average adult needs approximately 7–8 hours of sleep, but elderly people have frequent awakenings.

Clinical disorders

Sleep disorders are classified as dyssom-nias (intrinsic, extrinsic, or circadian rhythm disorders), para-somnias, and disorders associated with medical, psychiatric, and neurological illnesses. Obstructive sleep apnea syndrome, narcolepsy, psychophysiological and idiopathic insomnia, and restless legs syndrome are examples of intrinsic sleep disorders. Extrinsic sleep disorders include inadequate sleep hygiene, insufficient sleep syndrome, and hypnotic-, stimulant-, and alcohol-dependent sleep disorders. Circadian-rhythm disorders include jet lag and shift-work sleep disorders.

Parasomnias are characterized by abnormal movements or behavior intruding into sleep (for example, sleep walking, sleep terrors, sleep talking, nightmares, sleep paralysis, tooth grinding, and bed wetting).

Excessive daytime sleepiness, insomnia (sleeplessness), and abnormal movements and behavior during sleep are the major sleep complaints. An individual with insomnia may have difficulty initiating or maintaining sleep; repeated awakenings or early morning awakenings; or daytime fatigue and impairment of performance. Individuals with hypersomnia complain of excessive daytime sleepiness. Circadian-rhythm sleep disorders may be associated with either insomnia or hypersomnia.

There are two forms of sleep apnea. In central apnea, both the airflow at the mouth and nose and the effort by the diaphragm decrease. In obstructive apnea, the airflow stops but the effort by the diaphragm continues. Obstructive sleep apnea syndrome is common in middle-aged and elderly obese men.

Narcoleptic sleep attacks usually begin in individuals between the ages of 15 and 25. Narcolepsy is characterized by an irresistible desire to sleep, and the attacks may last 15–30 min. Other symptoms may include fearful dreams or feeling of loss of power at sleep onset or offset. Narcolepsy cannot be cured.

The restless legs syndrome occurs during middle age and is characterized by intense disagreeable feelings in the legs at rest and repose with compulsion to move the legs to get relief. Most individuals with this problem also have periodic limb movements in sleep.

The most common cause of insomnia is psychiatric or psy-chophysiologic disorder (for example, depression, anxiety, or stress), but other causes include medical disorders or pain. Early morning awakening is characteristic of depression.

Diagnosis and treatment

Overnight polysomnography involves recording of brain waves, muscle activities, eye movements, heart activity, airflow at the nose and mouth, respiratory effort, and oxygen saturation. Polysomnography is needed for individuals with excessive daytime sleepiness, narcolepsy, parasomnias, restless legs-period limb movements, and nocturnal seizures. The multiple sleep latency test is important in documenting pathologic sleepiness and diagnosing narcolepsy; it records brain waves, muscle activities, eye movements, and heart activity.

Treatment of obstructive sleep apnea syndrome consists of avoidance of sedatives or alcohol consumption, weight loss, and use of continuous positive airway pressure which will open the upper airway passage. Narcolepsy is treated by stimulants and short naps. Cataplexy is treated with tricyclics. Chronic insomnia can best be treated by sleep hygiene and behavioral modification. Most parasomnias do not require special treatment; however, psychotherapy may be helpful in some cases. Circadian-rhythm disorders may be treated by bright light and chronotherapy. See also Biological clocks; Sleep and dreaming.

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The ability to fall asleep, stay asleep, and wake up are all considered inalienable rights. We should neither stuporously wander about our houses nor suddenly decide to jump off our beds into imaginary swimming pools. The child's prayer, ‘Now I lay me down to sleep’, epitomizes the fond hope that sleep is a safe passage across a sea of unconsciousness undisturbed by life-threatening deficits in vital physiological processes. Still, it should have come as no surprise that a system as complicated and differentiated as the brain mechanisms underlying sleep and dreaming would have its own intrinsic propensity for dysfunction and disorder as well as its amazing capacity as a health-conveying operation. And the normal variation in sleep propensity, sleep depth, sleep length, and sleep stage distribution is already proof that such mundane events as excessive daytime sleepiness, or its converse, excessive night-time wakefulness (insomnia) should be viewed at least in part as expressions of extremes of normal physiology.

Yet even the most sophisticated and perspicacious sleep scientists were unprepared for the discovery that breathing sometimes stopped or was blocked in sleep (as it is in sleep apnea) or the recognition that all of the symptoms of the compelling need to sleep (as seen in narcolepsy) could be explained as abnormalities of sleep neurophysiology. More surprising still were the twin discoveries that sleepwalking, sleep-talking, and bedwetting had little to do with dreaming but that a previously unrecognized process, the REM sleep behaviour disorder, was not only dream enactment but the harbinger of degenerative disease of brain motor control systems!

There are three major kinds of sleep problems and each can be understood through sleep physiology:

1. Difficulty falling asleep (which is caused by excessively strong or inadequately suppressed brain drives toward waking) — the classic example is insomnia.
2. Difficulty staying awake (caused by excessively strong or inadequately suppressed brain drives toward sleep). The classic example is narcolepsy.
3. Abnormal movements that occur as the depth of sleep varies over the course of the night. For example, the movement-generating centres of the brain can sometimes become active without the brain's consciousness-generating arousal systems becoming simultaneously activated to waking levels. The classic example is sleepwalking.

The sleep apnea syndromes are an ambiguous but critically important class of sleep disorder with characteristics of all three categories. Victims of this life-threatening tendency to stop breathing when they fall asleep — and then to choke when they make compensatory efforts to wake up and breathe again — may be insomniac (because their bodies will literally not allow them to go to sleep) ; they may have excessive sleepiness by day (because they are chronically sleep deprived) ; and their laboured efforts to breathe while asleep can be seen as a form of chronic abnormal sleep movement, which, in the long term, may prove to be much more physiologically harmful than other sorts of abnormal sleep movements such as sleepwalking.

Sleep apnea sufferers are usually overweight (which makes breathing more difficult as the airway closes normally — causing snoring — at sleep onset) and male (which deprives them of the unexplained protection of sleep breathing afforded by female sex hormones). But they also just exaggerate the surprising normal tendency of men to have long pauses in their breathing efforts, especially during NREM sleep but also in REM. As their oxygen hunger increases and their brain alarm clock arouses them, they make a gasping effort to gulp air, at which point their flaccid, fat-compressed airway closes and they move even closer to self-strangulation. Because treatment is now quite effective it is crucial that any person suspected of having sleep apnea consult a physician or a sleep disorders centre.

Narcolepsy is a rare but instructive illness with four defining attributes: (i) excessive daytime sleepiness and irresistible attacks of sleep; (ii) the sudden loss of postural muscle tone (called cataplexy, often leading to total collapse; (iii) the occurrence of frightening dream hallucinations at sleep onset and upon awakening; and (iv) the persistence of REM sleep motor paralysis, also on arousal from sleep.

All of these symptoms are manifestations of a genetically-determined failure to inhibit REM sleep physiology, which most of us can do quite easily, especially during waking. Like new-borns, many adult narcoleptic patients have prolonged REM sleep bouts at sleep onset. Effective treatment is achieved using drugs that potentiate the brain chemicals responsible for effective waking, and/or suppression of the brain chemicals responsible for REM sleep.

Insomnia is by far the most prevalent disorder of sleep. It is also the most problematic to manage, because none of the myriad sedative drugs available for its relief is a physiological sleep inducer or enhancer. For this reason all of the effective sedatives have one or more defects: undesirable side-effects, diminished efficacy with prolonged use, or a worsening of symptoms upon withdrawal.

Because so much insomnia is psychologically and behaviourally driven, effective treatment should always include attention to such factors as (i) regular, early times of retirement; (ii) elimination of the commonly abused anti-sleep ingestants tobacco and alcohol; (iii) a review of daytime work and interpersonal concerns with special attention to identifying and eliminating the sources of nocturnal rumination and anxiety; (iv) the prescription of sleep-enhancing aerobic exercise; and (v) instruction in systematic body relaxation techniques.

This naturalistic approach to insomnia does not deny its sometimes strong physiological basis, which may demand pharmacological adjuncts, but it is cautious and conservative in warning against the undue expectation and the unacceptable risks of uncritical sedative treatment.

The REM sleep behaviour disorder is easily distinguished from ordinary sleepwalking. Sleepwalking is a self-limited and usually harmless problem of adolescence and early adulthood that occurs in NREM sleep and disappears when that sleep stage declines in the fourth decade. By contrast, the REM sleep behaviour disorder usually begins at that age or later, and reflects the dangerous and prognostically grave failure to inhibit the motor commands of REM sleep that are normally experienced as only the illusion of movement during dreaming.

Early degeneration of the brain (and especially Parkinson's disease) is heralded by REM sleep behaviour disorder, but it has also recently been reported to arise in younger subjects who have been treated for depression with drugs that specifically potentiate serotonin, one of the chemicals that the brain uses to energize itself in waking and to influence the excitability of the motor system in all of its states.

The study of sleep disorders is still a young, rapidly-developing field at the interface of neurology, psychiatry, and internal medicine. Its inventory of disorders, its methods of investigation, and its approaches to treatment can all be expected to change rapidly in the next few decades.

— J. Allan Hobson

See also body clock; sleep; snoring.

Definition

Sleep disorders are a group of syndromes characterized by disturbance in the individual's amount of sleep, quality or timing of sleep, or in behaviors or physiological conditions associated with sleep.

Description

Although sleep is a basic behavior in animals as well as humans, researchers still do not completely understand all of its functions in maintaining health. Since 1975, however, laboratory studies on human volunteers have yielded information about the different types of sleep. Researchers have learned about the cyclical patterns of different types of sleep and their relationships to breathing, heart rate, brain waves, and other physical functions. These measurements are obtained by a technique called polysomnography. There are about 70 different sleep disorders. To qualify for the diagnosis of sleep disorder, the condition must be a persistent problem, cause the patient significant emotional distress, and interfere with his or her social, academic, or occupational functioning.

There are five stages of human sleep. Four stages have non-rapid eye movement (NREM) sleep, with unique brain wave patterns and physical changes occurring. Dreaming occurs in the fifth stage, during rapid eye movement (REM) sleep.

• Stage one NREM sleep. This stage occurs while a child is falling asleep. It represents about 5 percent of sleep time.
• Stage two NREM sleep. In this stage, (the beginning of "true" sleep), the child's electroencephalogram (EEG) will show distinctive waveforms called sleep spindles and K complexes. About 50 percent of sleep time is stage two NREM sleep.
• Stages three and four NREM sleep. Also called delta or slow wave sleep, these are the deepest levels of human sleep and represent 10 to 20 percent of sleep time. They usually occur during the first 30 to 50 percent of the sleeping period.
• REM sleep. REM sleep accounts for 20 to 25 percent of total sleep time. It usually begins about 90 minutes after the child falls asleep. It alternates with NREM sleep about every hour and a half throughout the night. REM periods increase in length over the course of the night.

Sleep cycles vary with a person's age. Children and adolescents have longer periods of stage three and stage four NREM sleep than do middle aged or elderly adults. Because of this difference, the doctor needs to consider the individual's age when evaluating a sleep disorder. Total REM sleep also declines with age.

The average length of nighttime sleep varies among individuals. Most people sleep between seven and nine hours a night. This population average appears to be constant throughout the world. In temperate climates, however, people often notice that sleep time varies with the seasons. It is not unusual for people in North America and Europe to sleep about 40 minutes longer per night during the winter. Infants can regularly sleep up to 16 hours a day. The total amount of sleep declines as the infant gets older. Teenagers may actually need more sleep than slightly younger children and often sleep nine or more hours a day.

Sleep disorders are classified based on what causes them. Primary sleep disorders are distinguished as those that are not caused by other mental disorders, prescription medications, substance abuse, or medical conditions. The two major categories of primary sleep disorders are the dyssomnias and the parasomnias.

Dyssomnias

Dyssomnias are primary sleep disorders in which the patient suffers from changes in the amount, restfulness, and timing of sleep. The most important dyssomnia is primary insomnia, which is defined as difficulty that lasts for at least one month in falling asleep or remaining asleep. Primary insomnia can be caused by many things, including a traumatic event related to sleep or bedtime, and it is often associated with increased physical or psychological arousal at night. Children who experience primary insomnia may develop anxiety related to not being able to sleep. The child may come to associate all sleep-related things (their bed, bedtime, etc.) with frustration, making the problem worse. The child may then becomes more stressed about not sleeping.

Hypersomnia is a condition marked by excessive sleepiness during normal waking hours. The individual has either lengthy episodes of daytime sleep or episodes of daytime sleep on a daily basis even though he or she is sleeping normally at night. In some cases, people with primary hypersomnia have difficulty waking in the morning and may appear confused or angry. This condition is sometimes called sleep drunkenness and is more common in males.

The number of people with primary hypersomnia is unknown, although 5 to 10 percent of patients in sleep disorder clinics have the disorder. Primary hypersomnia usually affects young adults between the ages of 15 and 30.

Kleine-Levin syndrome is a recurrent form of hypersomnia that usually starts in late teen years. Doctors do not know the cause of this syndrome. It is marked by excessive drowsiness and for short spells, maybe two to three days, the person sleeps 18 to 20 hours per day, overeats, and is highly irritable. Males are three or four times more likely than females to have the syndrome.

PARASOMNIAS. Parasomnias are primary sleep disorders in which the individual's behavior is affected by specific sleep stages or transitions between sleeping and waking. They are sometimes described as disorders of physiological arousal during sleep.

Nightmare disorder is a parasomnia in which the child is repeatedly awakened from sleep by frightening dreams and is fully alert on awakening. The actual rate of occurrence of nightmare disorder is unknown. Approximately 10 to 50 percent of children between three and five years old have nightmares, as do many older children. The nightmares occur during REM sleep, usually in the second half of the night. The child is usually able to remember the content of the nightmare and may be afraid to go back to sleep. More females than males have this disorder, but it is not known whether the sex difference reflects a difference in occurrence or a difference in reporting. Nightmare disorder is most likely to occur in children under severe or traumatic stress.

Sleep terror disorder is a parasomnia in which the child awakens screaming or crying. The child also has physical signs of arousal, like sweating and shaking. Sleep terror is sometimes referred to as pavor nocturnus. Unlike nightmares, sleep terrors typically occur in stage three or stage four NREM sleep during the first third of the night. The child may be confused or disoriented for several minutes and cannot recall the content of the dream. He or she may fall asleep again and not remember the episode the next morning. Sleep terror disorder is most common in children four to 12 years old and is usually outgrown in adolescence. It affects about 3 percent of children. In children, more males than females have the disorder.

Sleepwalking disorder, which is sometimes called somnambulism, occurs when the child is capable of complex movements during sleep, including walking. Like sleep terror disorder, sleepwalking occurs during stage three and stage four NREM sleep during the first part of the night. If the child is awakened during a sleepwalking episode, he or she may be disoriented and have no memory of the behavior. In addition to walking around, individuals with sleepwalking disorder have been reported to eat, use the bathroom, unlock doors, or talk to others. It is estimated that 10 to 30 percent of children have at least one episode of sleepwalking. However, only 1 to 5 percent meet the criteria for sleepwalking disorder. The disorder is most common in children eight to 12 years old.

Demographics

In the United States, 20 to 25 percent of children have some kind of sleep problem. Nightmares are believed to occur in about 30 percent of children, usually in younger children. Sleepwalking occurs more than once in about 25 to 30 percent of children. The most common age group to experience sleepwalking is children under 10. Insomnia is reported to occur in approximately 23 percent of children. Many other sleep disorders occur less frequently but are still a problem for many children.

Causes and Symptoms

The causes of sleep disorders vary depending on the disorder. Many times, stress, anxiety, or other factors are found to be the cause. Often the underlying cause of the sleep disorder is never found.

The most important symptoms of sleep disorders are insomnia and sleepiness during waking hours. Insomnia is by far the more common of the two symptoms. It covers a number of different patterns of sleep disturbance. These patterns include inability to fall asleep at bedtime, repeated awakening during the night, and/or inability to go back to sleep once awakened.

When to Call the Doctor

If a child does not seem to be getting enough sleep at night or the child wakes frequently or seems tired frequently during the day, it may be helpful to consult a doctor.

Diagnosis

Diagnosis of sleep disorders usually requires a psychological history as well as a medical history. Physical examinations are not usually revealing. The patient's sex and age are useful starting points in assessing the problem. The doctor may also talk to other family members in order to obtain information about the patient's symptoms. The family's observations are particularly important for evaluating sleepwalking, kicking in bed, snoring loudly, or other behaviors that the patient cannot remember.

Psychological Testing

The doctor may use psychological tests or inventories to evaluate insomnia because it is frequently associated with mood or affective disorders. The Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the Beck Depression Inventory, and the Zung Depression Scale are the tests most commonly used in evaluating this symptom.

Laboratory Studies

If the doctor is considering breathing-related sleep disorders, myoclonus, or narcolepsy as possible diagnoses, he or she may ask the patient to be tested in a sleep laboratory or at home with portable instruments.

POLYSOMNOGRAPHY. Polysomnography can be used to help diagnose sleep disorders as well as conduct research into sleep. In some cases the patient is tested in a special sleep laboratory. The advantage of this testing is the availability and expertise of trained technologists, but it is expensive. Since 2001, however, portable equipment is available for home recording of certain specific physiological functions.

MULTIPLE SLEEP LATENCY TEST (MSLT). The multiple sleep latency test (MSLT) is frequently used to measure the severity of the patient's daytime sleepiness. The test measures sleep latency (the speed with which the patient falls asleep) during a series of planned naps during the day. The test also measures the amount of REM sleep that occurs. Two or more episodes of REM sleep under these conditions indicates narcolepsy. This test can also be used to help diagnose primary hypersomnia.

REPEATED TEST OF SUSTAINED WAKEFULNESS (RTSW). The repeated test of sustained wakefulness (RTSW) measures sleep latency by challenging the patient's ability to stay awake. In the RTSW, the patient is placed in a quiet room with dim lighting and is asked to stay awake. As with the MSLT, the testing pattern is repeated at intervals during the day.

Treatment

Treatment for a sleep disorder depends on what is causing the disorder. For example, if major depression is the cause of insomnia, then treatment of the depression with antidepressants or psychological counseling should resolve the insomnia. The use of antidepressants in minors is a matter of debate. In October 2003, the United States Food and Drug Administration issued an advisory indicating that children being treated with selective serotonin re-uptake inhibitor antidepressants (SSRIs) for major depressive illness may be at higher risk for committing suicide. A similar warning was issued in the United Kingdom. Parents and physicians must weigh the benefits and risks of prescribing these medications for children on an individual basis.

Medications

Medications for sleep disorders are generally not recommended for use by children. In most cases medications are the treatment of last resort. If children with sleep terror disorder or sleepwalking are treated with medication, then they may be given benzodiazepines because this type of medication suppresses stage three and stage four NREM sleep.

Psychotherapy

Psychotherapy is recommended for patients with sleep disorders associated with other mental disorders. In many cases the patient's scores on the Beck or Zung inventories will suggest the appropriate direction of treatment.

Sleep Preparation

Children with sleep disorders such as insomnia may benefit from a regular pattern of pre-bedtime rituals designed to help the child relax and prepare for bed. Fluid intake should usually be limited in the hours before bed to reduce the need to get out of bed and use the toilet. Children should generally not be given caffeine in the evening, as it may make it harder for them to fall asleep. Children with nightmare disorder may benefit from limits on television or movies. Violent scenes or frightening science fiction stories appear to influence the frequency and intensity of children's nightmares.

Alternative Treatment

Some alternative approaches may be effective in treating insomnia caused by anxiety or emotional stress. For some people, meditation practice, breathing exercises, and yoga can break the vicious cycle of sleeplessness, worry about inability to sleep, and further sleeplessness. Yoga can help some people to relax muscular tension in a direct fashion. The breathing exercises and meditation can keep some patients from obsessing about sleep.

Homeopathic practitioners recommend that people with chronic insomnia see a professional homeopath. They do, however, prescribe specific remedies for at-home treatment of temporary insomnia: Nux vomica for alcohol or substance-related insomnia, Ignatia for insomnia caused by grief, Arsenicum for insomnia caused by fear or anxiety, and Passiflora for insomnia related to mental stress.

Melatonin has also been used as an alternative treatment for sleep disorders. Melatonin is produced in the body by the pineal gland at the base of the brain. This substance is thought to be related to the body's circadian rhythms.

Practitioners of traditional Chinese medicine usually treat insomnia as a symptom of excess yang energy. Cinnabar is recommended for chronic nightmares. Either magnetic magnetite or "dragon bones" is recommended for insomnia associated with hysteria or fear. If the insomnia appears to be associated with excess yang energy arising from the liver, the practitioner will give the patient oyster shells. Acupuncture treatments can help bring about balance and facilitate sleep.

Dietary changes such as eliminating stimulant foods (coffee, cola, chocolate) and late-night meals or snacks can be effective in treating some sleep disorders. Nutritional supplementation with magnesium, as well as botanical medicines that calm the nervous system, can also be helpful. Among the botanical remedies that may be effective for sleep disorders are valerian (Valeriana officinalis), passionflower (Passiflora incarnata), and skullcap (Scutellaria lateriflora).

Prognosis

The prognosis depends on the specific disorder. Children usually outgrow sleep disorders. Patients with Kleine-Levin syndrome usually get better around age 40. The prognosis for sleep disorders related to many other conditions depends on successful treatment of the underlying problem. The prognosis for primary sleep disorders is affected by many things, including the patient's age, sex, occupation, personality characteristics, family circumstances, neighborhood environment, and similar factors.

Prevention

There is no known way to prevent sleep disorders, although having a good, regular, sleep schedule with a nighttime ritual intended to reduce stress may help.

Parental Concerns

Children who do not get enough sleep, or do not get good quality sleep, may seem irritable or uncooperative during the day. Lack of sleep reduces the ability to concentrate and decreases mental functioning, so children who are not getting enough good sleep at night may have poor concentration skills and poor academic performance.

Resources

Books

Kryger, Meir H., Thomas Roth, William C. Dement, eds. Principles and Practice of Sleep Medicine, 3rd ed. Philadelphia: Saunders, 2000.

Reite, Martin, John Ruddy, and Kim Nagel. Concise Guide to Evaluation and Management of Sleep Disorders, 3rd ed. Washington, DC: American Psychiatric Publishing, 2002.

Organizations

National Sleep Foundation. 1522 K Street, NW, Suite 500, Washington, DC 20005. Web site: www.sleepfoundation.org.

[Article by: Tish Davidson, A.M. Rebecca J. Frey, PhD]

Conditions characterized by a disruption in normal sleeping patterns which may be the result of serious medical conditions, including breathing difficulties or thyroid disorders, or external factors such as stress or substance abuse. Manifestations include insomnia, sleep apnea, and narcolepsy.

It has been suggested that Sleeping disorders in truck drivers be merged into this article or section. (Discuss) Proposed since April 2011.

Sleep disorder
Classification and external resources
ICD-10	F51, G47
ICD-9	307.4, 327, 780.5
DiseasesDB	26877
eMedicine	med/609
MeSH	D012893

A sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning. Polysomnography is a test commonly ordered for some sleep disorders.

Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a person suffers from difficulty in sleeping with no obvious cause, it is referred to as insomnia.^[1] In addition, sleep disorders may also cause sufferers to sleep excessively, a condition known as hypersomnia. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.

Contents 1 Common disorders 2 Types 3 General principles of treatment 4 Sleep medicine 5 See also 6 References 7 External links

Common disorders

The most common sleep disorders include:

• Primary insomnia: Chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms.
• Bruxism: Involuntarily grinding or clenching of the teeth while sleeping.
• Delayed sleep phase syndrome (DSPS): inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. (Other such disorders are advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome (Non-24), and irregular sleep wake rhythm, all much less common than DSPS, as well as the transient jet lag and shift work sleep disorder.)
• Hypopnea syndrome: Abnormally shallow breathing or slow respiratory rate while sleeping.
• Narcolepsy: Excessive daytime sleepiness (EDS) often culminating in falling asleep spontaneously but unwillingly at inappropriate times.
• Cataplexy: a sudden weakness in the motor muscles that can result in collapse to the floor.
• Night terror: Pavor nocturnus, sleep terror disorder: abrupt awakening from sleep with behavior consistent with terror.
• Parasomnias: Disruptive sleep-related events involving inappropriate actions during sleep; sleep walking and night-terrors are examples.
• Periodic limb movement disorder (PLMD): Sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. See also Hypnic jerk, which is not a disorder.
• Rapid eye movement behavior disorder (RBD): Acting out violent or dramatic dreams while in REM sleep (REM sleep disorder or RSD)
• Restless legs syndrome (RLS): An irresistible urge to move legs. RLS sufferers often also have PLMD.
• Situational circadian rhythm sleep disorders: shift work sleep disorder (SWSD) and jet lag.
• Sleep apnea, and mostly obstructive sleep apnea: Obstruction of the airway during sleep, causing lack of sufficient deep sleep; often accompanied by snoring. Other forms of sleep apnea are less common. The air is blocked from entering into the lungs, causing the individual to unconsciously gasp for air. The individual will pause for an average of ten seconds in order to breathe. This is commonly found in overweight, middle-aged men but is also found in people who have suffered from stroke.^{[citation needed]}
• Sleep paralysis: is characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of narcolepsy.
• Sleepwalking or somnambulism: Engaging in activities that are normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject.
• Nocturia: A frequent need to get up and go to the bathroom to urinate at night. It differs from Enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties.^[2]
• Somniphobia: a dread of sleep.

Types

• Dyssomnias - A broad category of sleep disorders characterized by either hypersomnolence or insomnia. The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm. MeSH
  • Insomnia: Insomnia is often a symptom of a mood disorder (i.e., emotional stress, anxiety, depression) or underlying health condition (i.e., asthma, diabetes, heart disease, pregnancy or neurological conditions). ^[3]
  • Narcolepsy: A chronic neurological disorder (or dyssomnia), which is caused by the brain's inability to control sleep and wakefulness.^[4]
  • Sleep Disordered Breathing (SDB), including (non exhaustive):
    • Several types of Sleep apnea
    • Snoring
    • Upper airway resistance syndrome
  • Restless leg syndrome
  • Periodic limb movement disorder
  • Hypersomnia
    • Recurrent hypersomnia - including Kleine-Levin syndrome
    • Posttraumatic hypersomnia
    • "Healthy" hypersomnia
  • Circadian rhythm sleep disorders
    • Delayed sleep phase syndrome
    • Advanced sleep phase syndrome
    • Non-24-hour sleep-wake syndrome
  • Parasomnias - A category of sleep disorders that involve abnormal and unnatural movements, behaviors, emotions, perceptions, and dreams in connection with sleep.
  • REM sleep behaviour disorder
  • Sleep terror (or Pavor nocturnus)- Characterized by a sudden arousal from deep sleep with a scream or cry, accompanied by some behavioral manifestations of intense fear.^[5]
  • Sleepwalking (or somnambulism)
  • Bruxism (Tooth-grinding)
  • Bedwetting or sleep enuresis.
  • Sleep talking (or somniloquy)
  • Sleep sex (or sexsomnia)
  • Exploding head syndrome - Waking up in the night hearing loud noises.
• Medical or Psychiatric Conditions that may produce sleep disorders
  • Psychosis (such as Schizophrenia)
  • Mood disorders
    • Depression
    • Anxiety
  • Panic
  • Alcoholism
• Sleeping sickness - a parasitic disease which can be transmitted by the Tsetse fly.

General principles of treatment

Pediatric polysomnography

Treatments for sleep disorders generally can be grouped into four categories:

• Behavioral and psychotherapeutic treatment

• Rehabilitation and management

• Medication

• Other somatic treatment

None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a specific treatment depends on the patient's diagnosis, medical and psychiatric history, and preferences, as well as the expertise of the treating clinician. Often, behavioral/psychotherapeutic and pharmacological approaches are not incompatible and can effectively be combined to maximize therapeutic benefits. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.

Medications and somatic treatments may provide the most rapid symptomatic relief from some sleep disturbances. Some disorders, such as narcolepsy, are best treated pharmacologically. Others, such as chronic and primary insomnia, may be more amenable to behavioral interventions, with more durable results.

Chronic sleep disorders in childhood, which affect some 70% of children with developmental or psychological disorders, are under-reported and under-treated. Sleep-phase disruption is also common among adolescents, whose school schedules are often incompatible with their natural circadian rhythm. Effective treatment begins with careful diagnosis using sleep diaries and perhaps sleep studies. Modifications in sleep hygiene may resolve the problem, but medical treatment is often warranted.^[6]

Special equipment may be required for treatment of several disorders such as obstructive apnea, the circadian rhythm disorders and bruxism. In these cases, when severe, an acceptance of living with the disorder, however well managed, is often necessary.

Some sleep disorders have been found to compromise glucose metabolism.^[7]

Sleep medicine

Main article: Sleep medicine

Normison (temazepam) is a benzodiazepine commonly prescribed for insomnia and other sleep disorders.^[8]

Due to rapidly increasing knowledge about sleep in the 20th century, including the discovery of REM sleep and sleep apnea, the medical importance of sleep was recognized. The medical community began paying more attention than previously to primary sleep disorders, such as sleep apnea, as well as the role and quality of sleep in other conditions. By the 1970s in the USA, clinics and laboratories devoted to the study of sleep and sleep disorders had been founded, and a need for standards arose.

Sleep Medicine is now a recognized subspecialty within internal medicine, family medicine, pediatrics, otolaryngology, psychiatry and neurology in the United States. Certification in Sleep Medicine shows that the specialist:

"has demonstrated expertise in the diagnosis and management of clinical conditions that occur during sleep, that disturb sleep, or that are affected by disturbances in the wake-sleep cycle. This specialist is skilled in the analysis and interpretation of comprehensive polysomnography, and well-versed in emerging research and management of a sleep laboratory."^[9]

Competence in sleep medicine requires an understanding of a myriad of very diverse disorders, many of which present with similar symptoms such as excessive daytime sleepiness, which, in the absence of volitional sleep deprivation, "is almost inevitably caused by an identifiable and treatable sleep disorder", such as sleep apnea, narcolepsy, idiopathic central nervous system (CNS) hypersomnia, Kleine-Levin syndrome, menstrual-related hypersomnia, idiopathic recurrent stupor, or circadian rhythm disturbances.^[10] Another common complaint is insomnia, a set of symptoms which can have a great many different causes, physical and mental. Management in the varying situations differs greatly and cannot be undertaken without a correct diagnosis.

Sleep dentistry (bruxism, snoring and sleep apnea), while not recognized as one of the nine dental specialties, qualifies for board-certification by the American Board of Dental Sleep Medicine (ABDSM). The resulting Diplomate status is recognized by the American Academy of Sleep Medicine (AASM), and these dentists are organized in the Academy of Dental Sleep Medicine (USA).^[11] The qualified dentists collaborate with sleep physicians at accredited sleep centers and can provide oral appliance therapy and upper airway surgery to treat or manage sleep-related breathing disorders.^[12]

In the UK, knowledge of sleep medicine and possibilities for diagnosis and treatment seem to lag. Guardian.co.uk quotes the director of the Imperial College Healthcare Sleep Centre: "One problem is that there has been relatively little training in sleep medicine in this country – certainly there is no structured training for sleep physicians."^[13] The Imperial College Healthcare site^[14] shows attention to obstructive sleep apnea syndrome (OSA) and very few other sleep disorders.

See also

• Chronotypes
• Environmental noise health effects
• International Classification of Sleep Disorders
• National Sleep Foundation
• Reversed vegetative symptoms
• Sleep hygiene
• Sundowning (dementia)
• White noise machine
• Sleep medicine
• Polysomnography
• Polysomnographic technician

References

1. ^ Hirshkowitz, Max (2004). "Chapter 10, Neuropsychiatric Aspects of Sleep and Sleep Disorders (pp 315-340)". In Stuart C. Yudofsky and Robert E. Hales, editors (Google Books preview includes entire chapter 10). Essentials of neuropsychiatry and clinical neurosciences (4 ed.). Arlington, Virginia, USA: American Psychiatric Publishing. ISBN 9781585620050. http://books.google.no/books?id=XKhu7yb3QtsC&pg=PA315&lpg=PA315&dq=%22Max+Hirshkowitz%22#v=onepage&q=%22Max%20Hirshkowitz%22&f=false. Retrieved 2009-12-06. "...insomnia is a symptom. It is neither a disease nor a specific condition. (from p. 322)" 
2. ^ www.sleepfoundation.org
3. ^ Melinda Smith, M.A., Lawrence Robinson, Robert Segal, M.A. (September 2011). Sleep Disorders and Sleeping Problems. http://helpguide.org/life/sleep_disorders.htm. 
4. ^ National Institute of Neurological Disorders and Stroke (June 27, 2011). NINDS Narcolepsy. http://www.ninds.nih.gov/disorders/narcolepsy/narcolepsy.htm. 
5. ^ Thorpy, Michael J. "PARASOMNIACS." The International Classification of Sleep Disorders: Diagnostic and Coding Manual. Rochester: American Sleep Disorders Association, 1990. Print.
6. ^ Ivanenko A and Massey C (October 1, 2006). "Assessment and Management of Sleep Disorders in Children". Psychiatric Times 23 (11). http://www.psychiatrictimes.com/sleep-disorders/article/10168/52051. 
7. ^ Keckeis M, Lattova Z, Maurovich-Horvat E, Beitinger PA, Birkmann S, Lauer CJ, Wetter TC, Wilde-Frenz J, Pollmächer T. (2010). Finkelstein, David. ed. "Impaired Glucose Tolerance in Sleep Disorders". PloS 1 3 (5): 9444. doi:10.1371/journal.pone.0009444. PMC 2830474. PMID 20209158. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2830474. 
8. ^ Dictionary | Definition of Temazepam
9. ^ "American Board of Medical Specialties : Recognized Physician Specialty and Subspecialty Certificates". http://www.abms.org/Who_We_Help/Physicians/specialties.aspx. Retrieved 2008-07-21. 
10. ^ Mahowald, M.W. (March 2000). "What is causing excessive daytime sleepiness?: evaluation to distinguish sleep deprivation from sleep disorders". Postgraduate Medicine 107 (3): 108–23. doi:10.3810/pgm.2000.03.932. PMID 10728139. Archived from the original on 2008-05-30. http://web.archive.org/web/20080530012343/http://www.postgradmed.com/issues/2000/03_00/mahowald.shtml. Retrieved 2008-07-27. 
11. ^ "About AADSM". Academy of Dental Sleep Medicine. 2008. http://aadsm.org/. Retrieved 2008-07-22. 
12. ^ "About the ADBSM". American Board of Dental Sleep Medicine. http://www.abdsm.org/. Retrieved 2008-07-22. 
13. ^ Wollenberg, Anne (July 28, 2008). "Time to wake up to sleep disorders". Guardian News and Media Limited. http://www.guardian.co.uk/commentisfree/2008/jul/28/health. Retrieved 2008-08-03. 
14. ^ "Sleep services". Imperial College Healthcare NHS Trust. 2008. http://www.imperial.nhs.uk/services/sleepservices/index.htm. Retrieved 2008-08-02. 

External links

• Sleep Problems - information leaflet from mental health charity The Royal College of Psychiatrists
• List of sleeping disorders
• Sleep Disorders ePatient website

v d e Pathology of the nervous system, primarily CNS (G04–G47, 323–349) Inflammation Brain Encephalitis (Viral encephalitis, Herpesviral encephalitis) · Cavernous sinus thrombosis · Brain abscess (Amoebic) Spinal cord Myelitis: Poliomyelitis · Demyelinating disease (Transverse myelitis) · Tropical spastic paraparesis · Epidural abscess Both/either Encephalomyelitis (Acute disseminated) Meningoencephalitis Brain/ encephalopathy Degenerative Extrapyramidal and movement disorders Basal ganglia disease: Parkinsonism (PD, Postencephalitic, NMS) · PKAN · Tauopathy (PSP) · Striatonigral degeneration · Hemiballismus · HD · OA Dyskinesia: Dystonia (Status dystonicus, Spasmodic torticollis, Meige's, Blepharospasm) · Chorea (Choreoathetosis) · Myoclonus (Myoclonic epilepsy) · Akathesia Tremor (Essential tremor, Intention tremor) · Restless legs · Stiff person Dementia Tauopathy: Alzheimer's (Early-onset) · Frontotemporal dementia/Frontotemporal lobar degeneration (Pick's, Dementia with Lewy bodies) Multi-infarct dementia Mitochondrial disease Leigh's Demyelinating autoimmune (Multiple sclerosis, Neuromyelitis optica, Schilder's disease) · hereditary (Adrenoleukodystrophy, Alexander, Canavan, Krabbe, ML, PMD, VWM, MFC, CAMFAK syndrome) · Central pontine myelinolysis · Marchiafava-Bignami disease · Alpers' disease Episodic/ paroxysmal Seizure/epilepsy Focal · Generalised · Status epilepticus · Myoclonic epilepsy Headache Migraine (Familial hemiplegic) · Cluster · Tension Cerebrovascular TIA (Amaurosis fugax, Transient global amnesia) Stroke (MCA, ACA, PCA, Foville's, Millard-Gubler, Lateral medullary, Weber's, Lacunar stroke) Sleep disorders Insomnia · Hypersomnia · Sleep apnea (Obstructive, Ondine's curse) · Narcolepsy · Cataplexy · Kleine-Levin · Circadian rhythm sleep disorder (Advanced sleep phase disorder, Delayed sleep phase disorder, Non-24-hour sleep-wake disorder, Jet lag) CSF Intracranial hypertension (Hydrocephalus/NPH, Idiopathic intracranial hypertension) · Cerebral edema · Intracranial hypotension Other Brain herniation · Reye's · Hepatic encephalopathy · Toxic encephalopathy Spinal cord/ myelopathy Syringomyelia · Syringobulbia · Morvan's syndrome · Vascular myelopathy (Foix-Alajouanine syndrome) · Spinal cord compression Both/either Degenerative SA Friedreich's ataxia · Ataxia telangiectasia MND UMN only: PLS · PP · HSP LMN only: PMA · PBP (Fazio-Londe, Infantile progressive bulbar palsy) · Spinal muscular atrophies (SMA, SMARD1, SBMA, SMAX2, SMA-PCH) both: ALS M: CNS anat(n/s/m/p/4/e/b/d/c/a/f/l/g)/phys/devp noco(m/d/e/h/v/s)/cong/tumr, sysi/epon, injr proc, drug(N1A/2AB/C/3/4/7A/B/C/D)

v d e Psychophysiology: Sleep and sleep disorders (F51 and G47, 307.4 and 327) Sleep stages Rapid eye movement sleep · Non-rapid eye movement sleep · Slow-wave sleep Brain waves Alpha wave · Beta wave · Gamma wave · Delta wave · Theta rhythm · K-complex · Sleep spindle · Sensorimotor rhythm · Mu rhythm Sleep disorders Dyssomnia Insomnia · Narcolepsy · Sleep apnea (Obesity hypoventilation syndrome, Ondine's curse) · Hypersomnia · Kleine-Levin syndrome · Sleep state misperception Circadian rhythm sleep disorder Advanced sleep phase disorder · Delayed sleep phase disorder · Irregular sleep–wake rhythm · Non-24-hour sleep-wake disorder · Jet lag Parasomnia Catathrenia · Night terror · Sleepwalking · Somniloquy Other/ungrouped Night eating syndrome · Nocturia · Nocturnal myoclonus Benign phenomena Dream · Exploding head syndrome · False awakening · Hypnagogia/Sleep onset · Hypnic jerk · Lucid dream · Nightmare · Nocturnal emission · Nocturnal penile tumescence · Sleep paralysis · Somnolence Related topics Bed (Bunk bed, Four poster bed, Futon, Daybed, Hammock, Mattress, Sleeping bag) · Bed bug · Bedding · Bedroom · Bedtime · Bedtime toy · Bedtime story · Caffeine nap · Chronotype · Dream journal · Hypnopompic state · Lullaby · Sleep induction · Microsleep · Nap · Nightwear · Polyphasic sleep · Polysomnography · Power nap · Second wind · Siesta · Sleep and creativity · Sleep and learning · Sleep debt · Sleep deprivation · Sleep diary · Sleep inertia · Sleep medicine · Sleeping while on duty · Sleepover · Snoring · Excessive daytime sleepiness · ("Sleeping sickness", which is not a sleep disorder.) M: PSO/PSI mepr dsrd (o, p, m, p, a, d, s), sysi/epon, spvo proc(eval/thrp), drug(N5A/5B/5C/6A/6B/6D) M: CNS anat(n/s/m/p/4/e/b/d/c/a/f/l/g)/phys/devp noco(m/d/e/h/v/s)/cong/tumr, sysi/epon, injr proc, drug(N1A/2AB/C/3/4/7A/B/C/D)

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