Embed Size (px)
DESCRIPTION
General Approach to Classification of Sleep Disorders. Dr. Ahmet U. Demir. ICSD-II (2005) Aims. In 2002 the American Academy of Sleep Medicine, set up a committee to revise once again the classification of sleep disorders. - PowerPoint PPT Presentation
Citation preview
General Approach to Classification of Sleep
DisordersDr Ahmet U Demir
ICSD-II (2005) Aimsbull In 2002 the American Academy of Sleep Medicine set up abull committee to revise once again the classification of sleep disordersbull bull Under the direction of Dr Peter Hauri the committee has proposed abull more pragmatic classification based on current clinical concepts ofbull the grouping of sleep disordersbull bull The goals of ICSD-2 arebull 1 To describe all currently recognized sleep and arousal disordersbull and to base the description on scientific and clinical evidencebull 2 To present the sleep and arousal disorders in an overall structurebull that is rational and scientifically validbull 3 To render the sleep and arousal disorders as compatible withbull ICD-9 and ICD-10 as possiblebull bull Based on the thought express above ICSD-2 sorts the sleepbull disorders into the following eight categories
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Insomnia
bull Insomnia is a symptom of perceived
bull reduction in the quantity or quality of sleep
bull and is not a single clinical entity
bull bull However certain causes of chronic
bull insomnia are believed to be due to intrinsic
bull disturbances of brain function
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
ICSD-II (2005) Aimsbull In 2002 the American Academy of Sleep Medicine set up abull committee to revise once again the classification of sleep disordersbull bull Under the direction of Dr Peter Hauri the committee has proposed abull more pragmatic classification based on current clinical concepts ofbull the grouping of sleep disordersbull bull The goals of ICSD-2 arebull 1 To describe all currently recognized sleep and arousal disordersbull and to base the description on scientific and clinical evidencebull 2 To present the sleep and arousal disorders in an overall structurebull that is rational and scientifically validbull 3 To render the sleep and arousal disorders as compatible withbull ICD-9 and ICD-10 as possiblebull bull Based on the thought express above ICSD-2 sorts the sleepbull disorders into the following eight categories
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Insomnia
bull Insomnia is a symptom of perceived
bull reduction in the quantity or quality of sleep
bull and is not a single clinical entity
bull bull However certain causes of chronic
bull insomnia are believed to be due to intrinsic
bull disturbances of brain function
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Insomnia
bull Insomnia is a symptom of perceived
bull reduction in the quantity or quality of sleep
bull and is not a single clinical entity
bull bull However certain causes of chronic
bull insomnia are believed to be due to intrinsic
bull disturbances of brain function
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Insomnia
bull Insomnia is a symptom of perceived
bull reduction in the quantity or quality of sleep
bull and is not a single clinical entity
bull bull However certain causes of chronic
bull insomnia are believed to be due to intrinsic
bull disturbances of brain function
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Insomnia
bull Insomnia is a symptom of perceived
bull reduction in the quantity or quality of sleep
bull and is not a single clinical entity
bull bull However certain causes of chronic
bull insomnia are believed to be due to intrinsic
bull disturbances of brain function
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
General Criteria for Insomnia ICSD-2 ( 2005)
bull A A complaint for difficulty initiating sleep difficultybull maintaining sleep or waking up too early or sleep that isbull chronically nonrestorative or poor in quality In children the sleepbull difficulty is often reported by the caretaker and may consist ofbull observed bedtime resistance or inability to sleep independentlybull bull B The above sleep difficulty occurs despite adequate opportunitybull and circumstances for sleepbull bull C At least one of the following forms of daytime impairmentbull related to the nighttime sleep difficulty is reported by the patientbull bull i Fatigue or malaisebull bull ii Attention concentration or memory impairmentbull bull iii Social or vocational dysfunction or poor school performancebull bull iv Mood disturbance or irritabilitybull bull v Daytime sleepinessbull bull vi Motivation energy or initiative reductionbull bull vii Proneness for errors or accidents at work or while drivingbull bull viii Tension headaches or gastrointestinal symptoms
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Adjustment Insomnia (Acute Insomnia)
bull 1 Adjustment Insomnia (Acute Insomnia)bull bull 2 Psychophysiological Insomniabull bull 3 Paradoxical Insomniabull bull 4 Idiopathic Insomniabull bull 5 Insomnia Due to Mental Disorderbull bull 6 Inadequate Sleep Hygienebull bull 7 Behavioral Insomnia of Childhoodbull bull 8 Insomnia Due to Drug or Substancebull bull 9 Insomnia Due to Medical Conditionbull bull 10 Insomnia Not Due to Substance or Known Physiologicalbull Condition Unspecified (Nonorganic Insomnia NOS)bull bull 11 Physiological (Organic) Insomnia Unspecified
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Adjustment insomnia
Diagnostic Criteriabull A The patients symptoms meet the criteria for insomniabull B The sleep disturbance is temporally associated with an identifiablestressor that is psychological psychosocial interpersonal
environmental orphysical naturebull C The sleep disturbance is expected to resolve when the acute
stressorresolves or when the individual adapts to the stressorbull D The sleep disturbance lasts for less than three monthsbull E The sleep disturbance is not better explained by another current
sleepdisorder medical or neurological disorder mental disorder medication
use orsubstance use disorder
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Psychophysiological Insomnia
bull Alternate Names Learned insomnia conditioned insomnia functionallybull autonomous insomnia chronic insomnia primary insomnia chronic somatizedbull tension internal arousal without psychopathologybull bull Diagnostic Criteria bull bull AThe patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C The patient has evidence of conditioned sleep difficulty andor heightened arousal in bedbull as indicated by one or more of the followingbull bull i Excessive focus on and heightened anxiety about sleepbull bull ii Difficulty falling asleep in bed at the desired bedtime or during planned napsbull but no difficulty falling asleep during other monotonous activities when not intending tobull sleepbull bull iii Ability to sleep better away from home than at homebull bull iv Mental arousal in bed characterized either by intrusive thoughts or a perceivedbull inability to volitionally cease sleep-preventing mental activitybull bull v Heightened somatic tension in bed reflected by a perceived inability to relaxbull the body sufficiently to allow the onset of sleepbull bull D The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Paradoxical Insomniabull Alternate Names Sleep state misperception subjective insomnia pseudo-insomniabull subjective complaint of sleep initiation and maintenance difficulty without objectivebull findings insomnia without objective findings sleep hypochondriasis subjectivebull sleep complaintbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C One or more of the following criteria applybull bull i The patient reports a chronic pattern of little or no sleep most nights with rare nights during whichbull relatively normal amounts of sleep are obtainedbull bull ii Sleep-log data during one or more weeks of monitoring show an average sleep time well below publishedbull age-adjusted normative values often with no sleep at all indicated for several nights per week typically there is anbull absence of daytime naps following such nightsbull bull iii The patients show a consistent marked mismatch between objective findings from polysomnography orbull actigraphy and subjective sleep estimates derived either from self-report or a sleep diarybull bull D At least one of the following is observedbull bull i The patients reports constant or near constant awareness of environmental stimuli throughout most nightsbull bull ii The patient reports a pattern of conscious thoughts or rumination throughout most nights whilebull maintaining a recumbent posturebull bull E The daytime impairment reported is consistent with that reported by other insomnia subtypes but it is much lessbull severe than expected given the extreme level of sleep deprivation reported there is no report of intrusive daytime sleepbull episodes disorientation or serious mishaps due to marked loss of alertness or vigilance even following reportedlybull sleepless nightsbull bull F The reported sleep disturbance is not better explained by another sleep disorder medical or neurological disorderbull mental disorder medication use or substance use disorder
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Idiopathic Insomniabull bull Alternate Names Childhood-onset insomnia life-long insomniabull insomnia first evident during infancy or childhoodbull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The course of the disorder is chronic as indicated by each of
thebull followingbull bull i Onset during infancy or childhoodbull bull ii No identifiable precipitant or causebull bull iii Persistent course with no periods of sustained remissionbull bull C The sleep disturbance is not better explained by another sleepbull disorder medical or neurological disorder mental disorderbull medication use or substance use disorder
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Insomnia Due to Mental Disorder
bull bull Alternate Names Insomnia related to psychopathology psychiatric insomniabull insomnia due to depression insomnia due to anxiety disorderbull bull Diagnostic Criteriabull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present at least one monthbull bull C A mental disorder has been diagnosed according to standard criteria (iebull formal criteria as provided in the Diagnostic and Statistical Manual of Mentalbull Disorders- see Appendix B)bull bull D The insomnia is temporally associated with the mental disorder however inbull some cases insomnia may appear a few days or weeks before the emergence ofbull the underlying mental disorderbull bull E The insomnia is more prominent than that typically associated with thebull mental disorders as indicated by causing marked distress or constituting anbull independent focus of treatmentbull bull F The sleep disturbance is not better explained by another sleep disorderbull medical or neurological disorder medication use or substance use disorder
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Inadequate Sleep Hygienebull bull Alternate Names Poor sleep hygiene sleep hygiene abuse bad sleep habitsbull irregular sleep habits excessive napping sleep incompatible behaviors bull bull Diagnostic Criteria bull bull A The patientrsquos symptoms meet the criteria for insomniabull bull B The insomnia is present for at least one monthbull bull C Inadequate sleep hygiene practices are evident as indicated by the presence of at leastbull one of the followingbull bull i Improper sleep scheduling consisting of frequent daytime napping selectingbull highly variable bedtimes or rising times or spending excessive amounts of time in bedbull bull ii Routine use of products containing alcohol nicotine or caffeine especially inbull the period preceding bedtimebull bull iii Engagement in mentally stimulating physically activating or emotionallybull upsetting activities to close to bedtimebull bull iv Frequent use of the bed for activities other than sleep (eg television watchingbull reading studying snacking thinking planning)bull bull v Failure to maintain a comfortable sleeping environmentbull bull The sleep disturbance is not better explained by another sleep disorder medical orbull neurological disorder mental disorder medication use or substance use disorder
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Behavioral Insomnia of Childhoodbull bull Alternate Names Childhood insomnia limit-setting sleep disorder sleep-onsetbull association disorderbull bull Diagnostic Criteria bull bull A A childrsquos symptoms meet the criteria for insomnia based upon reports of parents or other adultbull caregiversbull bull B The child shows a pattern consistent with either the sleep-onset association or limit-setting typebull of insomnia described belowbull bull i Sleep-onset association type includes each of the followingbull bull 1 Falling asleep in an extended process that requires special conditionsbull bull 2 Sleep-onset associations are highly problematic or demandingbull bull 3 In the absence of the associated conditions sleep onset is significantly delayed or sleep isbull otherwise disruptedbull bull 4 Nighttime awakenings require caregiver intervention for the child to return to sleepbull bull ii Limit-setting type includes each of the followingbull bull 1 The individual has difficulty initiating or maintaining sleepbull bull 2 The individual stalls or refuses to go to bed at an appropriate time or refuses to return t o bedbull following a nighttime awakeningbull bull 3 The caregiver demonstrates insufficient or inappropriate limit setting to establish appropriatebull sleeping behavior in the childbull bull The sleep disturbance is not better explained by another sleep disorder medical or neurologicalbull disorder mental disorder or medication use
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Insomnia Due to Medical Condition
bull Alternate Names Sleep disorder due to a general medical condition medically based
bull insomnia organic insomnia insomnia due to a known organic conditionbull Diagnostic Criteria bull A The patientrsquos symptoms meet the criteria for insomniabull B The insomnia is present for at least one monthbull C The patient has a coexisting medical or physiologic condition known to disrupt
sleepbull D Insomnia is clearly associated with the medical or physiologic condition The
insomniabull began near the time of onset or with significant progression of the medical orbull physiologic condition and waxes and wanes with fluctuations in the severity of thisbull conditionbull The sleep disturbance is not better explained by another sleep disorder mental
disorderbull medication use or substance use disorder
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Physiologic (Organic) InsomniaUnspecified
bull bull This diagnosis is used for forms of insomnia that cannot be classifiedbull elsewhere but are suspected to be related to an underlying medical
disorderbull physiological state or substance used or exposure In some cases thisbull diagnosis may be assigned on a temporary basis when an insomnia
diagnosisbull seems appropriate but further evaluation is required to determine the
specificbull medical condition or toxin exposure responsible for the reported sleepbull difficulty This diagnosis can also be assigned when substance abuse orbull dependence-related insomnia is suspected but is yet to be confirmed In
otherbull cases this diagnosis may be assigned when an endogenous physiologicbull disorder or condition appears to contribute to the insomnia but the patientrsquosbull symptoms fail to meet the criteria for one of the other insomnia diagnoses
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Hypersomnias not related torespiratory issues
bull bull Certain disorders of excessive daytimebull somnolence are believed to be caused by intrinsicbull brain dysfunctionbull bull Narcolepsy recognized for over a century consistbull of excessive daytime sleepiness usually associatedbull with weakness of muscles with emotion (known asbull cataplexy) and the premature occurrence of rapidbull eye movement (REM) sleep In most instances thisbull appears to be due to dysfunction of the hypocretinbull (orexin) neurotransmitter system
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Hypersomnias not related torespiratory issues
bull bull Idiophatic hypersomnia is a similar but less well
bull defined disorder with hypersomnolence but nobull cataplexy and no disturbance in the timing ofbull REM sleepbull bull Recurrent hypersomnia is a very rare
disorderbull with periods of sleep lasting days to weeks
oftenbull associated with behavioral disturbances ( KLS)
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Hypersomnias not related torespiratory issues
bull bull Insufficient sleep syndrome is a major societal
bull problem in which voluntary sleep deprivation canbull result in impairment of alertness and cognitivebull abilitiesbull bull Medications and illicit drug use can causebull excessive daytime sleepinessbull bull Hypersomnia may also be due to medicalbull conditions such as Parkinsonrsquos disease andbull dementias
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Narcolepsy
bull Canine narcolepsy was first reported in the earlybull 1970sbull bull The term narcolepsy was first coined by
Glineanbull in 1880 to designate a pathologic conditionbull characterized by irresistible episodes of sleep ofbull short duration recurring at close intervals
( Gelineanbull 1880 Gaz Hop Paris)
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull Prevalence (002 to 018in US)bull (narcolepsy with cataplexy)bull bull In Finland0026 ( Hublin et
al1996)bull bull Great Britain France Czech
Republic and USbull 0013 to 0067 ( Dauvilliers et
al 2003 Mignot 1998)bull African Americans 002 ( Solomon
1945)bull bull Japan016 and 018(did not use
PSG tobull confirm the diagnosis) ( Honda et al
1979)bull bull Israel as low as 0002 ( Lavie and
Peled 1987)bull bull Southern Chinese (Hong Kong)
0034bull ( Yun-Kwok Wing et al 2002)
bull The prevalence of narcolepsybull without cataplexybull bull Unknown cases of narcolepsy
without cataplexybull represent 10 to 50 of the
narcoleptic populationbull (455 in Chang Gung hospital)bull ( Rosen et al 2003)bull bull Adult population 1 to 3 may have
unexplainedbull sleepiness and SoREM during MSLTbull bull Higher Prevalence in adolescents or
young adults bull Because of voluntary chronic sleep
deprivation
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
PSG Criteria and Findings
bull bull Short sleep latencybull bull Sleep-onset REM period occurs in aboutbull 50 of narcolepticsbull bull Increased frequency of arousalsbull bull Increased amounts of Stage 1 sleepbull bull If cataplexy is absent narcolepsy is difficultbull to diagnose in the presence of sleepbull fragmentation from other sleep disorders
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
MSLT Criteria for Narcolepsy
bull bull Mean sleep latency of less than 8 minutesbull bull 2 or more sleep-onset REM periodsbull (SOREMPs)bull bull No other sleep disorder that accounts for thebull findingsbull bull MSLT should be performed followingbull sufficiend nocturnal sleep (minimum 6bull hours)
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Clinical Features Cataplexy
bull bull Most often occurs with in a year of onsetbull bull Recurrent brief episodes of muscle weaknessbull triggered by laughter or at least two of thebull following anger surprise elation amusementbull bull One or more of the following symptoms kneesbull buckling weakness in legs jaw head and neckbull complete fall with no injurybull bull At least 5 episodes over lifetime
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Clinical Features Cataplexy
bull bull Most episodes are bilateralbull bull Consciousness is maintained at least at thebull beginning of the episodesbull bull Most episodes last less than 2 minutes( a fewbull seconds to several minutes)bull bull Twitches and jerks may occur particularly in
facebull (as prsquot is trying to fight the episode)bull bull Cataplexy may vary in pattern frequency andbull severity
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Associated Featuresbull Hypnagogic hallucinations
bull 1048766Are vival perceptual experience typicallybull occurring at sleep onsetbull 1048766Include visual tactile kinetic and
auditorybull phenomenabull 1048766Recurrent hypnagogic hallucinations arebull experience by 40 to 80 of patients withbull narcolepsy with cataplexy
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Sleep paralysis
bull 1048766A transient generalized inability to move or
bull to speak during the transition between sleep
bull and wakefulness
bull 1048766Sleep paralysis is experienced by 40 to
bull 80 of narcoleptic patients
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Nocturnal sleep disruption
bull 1048766Occurs in approximately 50 of
bull narcoleptics
bull 1048766Most typically sleep-maintenance rather
bull than sleep-onset insomnia
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Memory lapses
bull 1048766Especially during automatic behavior
bull without awareness of sleepiness
bull 1048766It may show inappropriate activity and poor
bull adjustment to abrupt environmental
bull demands
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull Many of the symptoms of
bull narcolepsy can occur in any person
bull who is severe sleep deprived only
bull cataplexy is unique to narcolepsy
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Functions potentially interested byHypocretin containing neurons
bull 1048766FEEDING
bull 1048766BLOOD PRESSURE REGULATION
bull 1048766NEURO-ENDOCRINE REGULATION
bull 1048766THERMOREGULATION
bull 1048766SLEEP-WAKING CYCLE (effect on
bull arousal)
bull Peyron et al 1998
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Parasomnias
bull bull Parasomnias are undesirable physical phenomenabull that occur predominantly during sleepbull bull Arousal disorders comprising sleep-walkingbull sleep terrors and confusional arousals are abull spectrum of conditions in which a sudden arousalbull from slow-wave sleep is associated with abnormalbull behavior due to the patientrsquos inability to make abull rapid transition to complete wakefulness They arebull common in childhood but can persist or evenbull develop in adulthood and may be associated withbull potentially injurious behavior
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Parasomnias
bull bull Parasomnias usually associated with REM sleep includebull nightmares which are frightening dreams during REM sleepbull resulting in wakeningbull bull Sleep paralysisoccurign at sleep onset or on wakening is anbull inability to move from seconds to minutes It is believed to bebull due to the muscle atonia of REM sleep developingbull inappropriately and may occur both as a normal phenomenonbull and in patients with narcolepsybull bull REM sleep behavior disorder occurs when the normalbull muscle atonia of REM sleep is lost allowing the enactment ofbull dreams Patients flail their arms kick and vocalize frequentlybull resulting in injuries to themselves or their bed partners Thebull conditions occurs predominantly in older men and is oftenbull associated with neurodegenerative diseases especiallybull Parkinsonian syndromes
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Parasomnias
bull Other parasomnias (not state-related) include sleepbull enuresis the continued occurrence of bedwetting inbull children beyond the age when it normally ceasesbull bull Parasomnias related to a known psychiatric disorderbull include nocturnal panic attacks and nightmares in
posttraumaticbull stress disorderbull bull Parasomnias related to medical conditions includebull confusional behavior at night in patients with dementia
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
bull I Insomniasbull bull II Sleep Related Breathing Disordersbull bull III Hypersomnias of Central Origin Not Due to a Circadianbull Rhythm Sleep Disorder Sleep Related Breathing Disorder orbull Other Cause of Disturbed Nocturnal Sleepbull bull IV Circadian Rhythm Sleep Disordersbull bull V Parasomniasbull bull VI Sleep Related Movement Disordersbull bull VII Isolated Symptoms Apparently Normal Variants andbull Unresolved Issuesbull bull VIII Other Sleep Diorders
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Sleep-related movementdisorders
bull bull Restless legs syndrome is characterized by an overwhelmingbull urge to move the legs while sitting or lying and relief bybull movement It is a very common cause of insomnia It is oftenbull familial and appears to be due to central dopaminergicbull dysfunctionbull bull Periodic limb movements disorder is usually associated withbull rhythmic kicking of the legs during sleep But PLM may alsobull accompany other sleep disorders and may occasionally alonebull be a cause of insomnia or hypersomnina
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Sleep-related movementdisorders
bull Rhythmic movement disorder can occur during any stage
of sleep but is commonest during drowsiness It consist oflarge rhythmic movements usually of the axialmusculature and includes the conditions previously knownas body rocking and head bangingbull Bruxism (tooth grinding) may occur during any stage ofsleep and can result in jaw pain and damage to teeth
Sleep Paris Louvre
Sleep Paris Louvre
