non-organic sleep disorder.ppt

Normal Sleep
Normal sleep is divided into non–rapid eye movement
(NREM) and rapid eye movement (REM) sleep.
The stages of sleep are stage I (light sleep), stage II, stages
III and IV (deep or delta-wave sleep), and REM sleep; NREM
sleep comprises stages I-IV.
Sleep is an active process that cycles at an ultradian rhythm
of about 90 minutes.
Waking usually transitions into NREM sleep. REM follows
NREM sleep and occurs 4-5 times during a normal 8- to 9-
hour sleep period.
The first REM period of the night may be less than 10
minutes in duration, while the last may exceed 60 minutes.

Stages of Sleep
Stage 1
Stage 1 sleep, or drowsiness, is often described as first in
the sequence
The eyes are closed during Stage 1 sleep, but if aroused
from it, a person may feel as if he or she has not slept. Stage
1 may last for five to 10 minutes.
Stage 2
Stage 2 is a period of light sleep during which spontaneous
periods of muscle tone mixed with periods of muscle
relaxation occur. Muscle tone of this kind can be seen in
other stages of sleep as a reaction to auditory stimuli.
The heart rate slows, and body temperature decreases. At
this point, the body prepares to enter deep sleep

Stages of Sleep
Stages 3 and 4
These are deep sleep stages, with Stage 4 being more
intense than Stage 3. These stages are known as slow-
wave, or delta sleep.
Non-REM Sleep
The period of non-REM sleep (NREM) lasts from 90 to 120
minutes, each stage lasting anywhere from 5 to 15 minutes.
A normal sleep cycle has this pattern: waking, stage 1, 2, 3,
4, 3, 2, REM.
Usually, REM sleep occurs 90 minutes after sleep onset.

Stage 5, REM
REM sleep is distinguishable from NREM sleep by changes
in physiological states, including its characteristic rapid eye
movements.
In normal REM sleep, heart rate and respiration speed up
and become erratic, while the face, fingers, and legs may
twitch.
Intense dreaming occurs during REM sleep as a result of
heightened cerebral activity, but paralysis occurs
simultaneously in the major voluntary muscle groups,
including the submental muscles (muscles of the chin and
neck).
It is sometimes called paradoxical sleep.
The first period of REM typically lasts 10 minutes, with each
recurring REM stage lengthening, and the final one lasting
an hour.

Factors that Affect Sleep Stage
and the Sleep
The sleep cycle is variable, influenced by several
agents.
Generally, sleep disorders affect the quality,
duration, and onset of sleep.
Sleep deprivation, frequently changing sleep
schedule, stress, and environment all affect the
progression of the sleep cycle.
Rapid eye movement latency (the time it takes a
person to achieve REM sleep) may be affected by
a sleep disorder like narcolepsy.
Psychological conditions like depression shorten
the duration of rapid eye movement. Also,
treatment for psychiatric conditions often positively
affects sleep, typically inducing some desired
change in sleep habit.

Sleep in infants
Infants have an overall greater total sleep time
than any other age group; their sleep time can be
divided into multiple periods. In newborns, the total
sleep duration in a day can be 14-16 hours.
REM sleep in infants represents a larger
percentage of the total sleep at the expense of
stages III and IV.
Until age 3-4 months, newborns transition from
wake into REM sleep. Thereafter, wake begins to
transition directly into NREM.

Sleep in adults
In adults, sleep of 8-8.4 hours is considered fully restorative.
Stage I usually accounts for 5-10% of total sleep time. Stage
II occurs throughout the sleep period and represents 40-50%
of total sleep time.
They are distinguished from each other only by the
percentage of delta activity and represent up to 20% of total
sleep time. REM represents 20-25% of total sleep time

Sleep in elderly persons
In elderly persons, the time spent in stages III and IV sleep
decreases by 10–15% and the time in stage II increases by
5% compared to young adults, representing an overall
decrease in total sleep duration.
Latency to fall asleep and the number and duration of
overnight arousal periods increase..
Sleep fragmentation results from the increase in overnight
arousals and may be exacerbated by the increasing number
of geriatric medical conditions, including sleep apnea,
musculoskeletal disorders, and cardiopulmonary disease

NON-ORGANIC SLEEP
DISORDERS
If the sleep disorder is one of the major complaints
and is perceived as a condition in itself, the
present code should be used along with other
pertinent diagnoses describing the
psychopathology and pathophysiology involved in
a given case.
This category includes only those sleep disorders
in which emotional causes are considered to be a
primary factor, and which are not due to
identifiable physical disorders classified
elsewhere.

NON-ORGANIC SLEEP
DISORDERS
Dyssomnias : primarily psychogenic
conditions in which the predominant
disturbance is in amount, quality, or timing
of sleep due to emotional causes.
Parasomnias : abnormal episodic events
occuring during sleep; in childhood these
are related mainly to the child’s
development, while in adulthood these are
predominantly psychogenic.

NON-ORGANIC SLEEP DISORDERS
( ICD-10 Classification)
DYSSOMNIAS
Non-organic insomnia
Non-organic hypersomnia
Non-organic disorders of the sleep-
wake schedule
PARASOMNIAS
Somnambulism ( sleep walking )
Sleep terrors ( night terrors )
Nightmares

Insomnia
DIAGNOSTIC GUIDELINES
A condition of unsatisfactory quantity and/or
quality of sleep, which persists for a considerable
period of time, including difficulty falling asleep,
difficulty staying asleep, or early final wakening.
Sleep disturbance has occurred atleast three
times per week for atleast 1 month.
Sleep disturbance causes marked distress or
interferes with ordinary activities.
Preoccupation with sleeplessness and excessive
concern over its consequences at night or day

Insomnia
DIAGNOSIS
Insomnia is a common symptom of other mental
disorders, if it does not dominate the clinical
picture, the diagnosis should be limited to that of
underlying mental or physical disorder.
The presence of other psychiatric symptoms such
as depression, anxiety, obsession does not
invalidate the diagnosis of insomnia, provided it is
the primary complaint.

ASSESSMENT
Assessment begins with the documentation of a
complete sleep history and an evaluation of the
patient's sleep hygiene. A medical history is
obtained and an examination performed to
determine if underlying medical or psychiatric
conditions are present.
Formal testing for sleep disorder is noninvasive
and includes overnight polysomnography and
multiple sleep latency testing (MSLT).

DIAGNOSTIC APPROACH TO INSOMNIA
•Sleep history Include
? Hours of sleep
? Sleep & awakening
time
? Sleep position
? Type of bed & pillow
? Eating habits
? Alcohol/ Smoking
habit
Any chronic
medical condition
Discuss sleep patterns
with partner
Medications ?
Family history of
sleep disorders
Any psychiatric illness
Any symptom of daytime sleepiness,
excessive snoring, apnea, or BMI >35
yes
Referral for
Polysomnograhy

Treatment
Insomnia due to depression or anxiety
would include treatment of those
underlying disorders.
Along with the specific therapy directed at
a specific sleep condition, general
symptomatic therapy is provided.
This may include good sleep hygiene,
behavioral therapy, and often medications.

Treatment
contd…
Sleep Hygiene
Sleep hygiene refers to activities or practices that either promote
sleep or hinder it. People with insomnia, may be very susceptible to
poor sleep hygiene. Good sleep hygiene practices include:
Standard wake-up time
Eliminate nicotine, caffeine, alcohol, and other stimulants
Avoiding Napping
Exercise
Regular exercise can promote sleep quality and duration. However,
exercising immediately before bedtime can have a stimulant effect
on the body and should be avoided.
Limit activities in bed
People suffering from insomnia should avoid working in bed, such
as balancing the checkbook, studying, making phone calls, and
other distractions, like watching television or listening to the radio..

Treatment
contd…
Avoid food and drink before bed
Eating a late dinner or snacking before going to bed can
activate the digestive system and cause arousal and should be
avoided.
Ensure an adequate sleep environment
Temperature and lighting should be controlled to make the
bedroom conducive to falling asleep. Isolation from loud noise
Worry time
It can be very helpful to set aside a period of time at night to
review the day and to make plans for the next day. The goal is
to avoid doing these things while trying to fall asleep.
Relaxation therapy
Relaxation therapy and stress reduction methods may consist
of a variety of techniques, including progressive relaxation
(perhaps with audio tapes), meditation, and biofeedback.

Treatment
contd…
Sleep restriction and stimulus control
Sleep restriction therapy is used to limit the amount of time
spent in bed to time actually sleeping. Being in the bed while
awake causes increased anxiety and prohibits sleep.
Therefore, in sleep restriction therapy, a person is
encouraged to get out of bed if sleep is not possible. Also,
sleep restriction therapy uses stimulus control to promote
consolidated and restful sleep after sleep onset. ( Bootzin et.al.
1992).

Treatment
contd….
Medications
Current pharmacological therapy may
include
Medications with sedative effects.
Antidepressants.
Benzodiazepines.

Treatment
contd….
Antihistamines:
They are associated with drowsiness. Unfortunately,
they also tend to cause decreased memory and
concentration, dry mouth, morning sickness, blurred
vision, extended sedation, and constipation.
They are generally not recommended for the treatment
of insomnia that is severe enough to require attention of
a physician. And they should be avoided, especially, in
cases of chronic insomnia.

Treatment
contd….
Antidepressants.
Many antidepressants have sedative side effects.
These side effects may be utilized in patients with
depression and insomnia. In fact, many widely
used antidepressants, like fluoxetine, actually
regulate sleep onset and duration for those who
take them.
Generally, they are used to treat the depression
causing insomnia; the side effect of causing
drowsiness is used to an advantage in helping
with the insomnia.

Treatment
contd….
Benzodiazepines
Benzodiazepines have been the most popularly prescribed
hypnotic (sleeping pill) for some time. Longer-acting
benzodiazepines cause a lot of carry-over morning sedation,
and shorter-acting benzodiazepines cause a higher
incidence of rebound insomnia after discontinuation.
There is a risk for developing drug dependency with long-
term use in some patients. Benzodiazepines can cause
fatigue, dizziness, confusion, falls, and blurred vision,
especially in older people. Operating a motor vehicle or
heavy machinery may be hazardous when using this type of
medication.
There are new drugs such as zaleplon and zolpidem which
interact with one of the benzodiazepine receptors on cells
that induce sleep. These two drugs are increasingly being
used to treat insomnia because of their rapid onset,
decreased residual effect the next morning, and low number
and severity of side effects. (Lavoisy J, Zivkovic B 1992 )

Hypersomnia is defined as a condition of either excessive
daytime sleepiness and sleep attacks (not accounted for by
an inadequate amount of sleep) or prolonged transition to
the fully aroused state upon awakening.
Disturbance lasting for more than 1 month or recurrently for
shorter period of time causing marked distress or interferes
with ordinary activities.
In the absence of an organic factor for the occurrence of
hypersomnia, this condition is usually associated with mental
disorders.
In the absence of auxillary symptoms of narcolepsy or
clinical evidence of sleep apnoea.

contd…
Nonorganic hypersomnia can be primary or
associated with a number of psychiatric disorders
such as reaction to severe stress or adjustment
disorders, affective disorders, other functional
disorders, tolerance to or withdrawal of CNS-
stimulating substances and chronic use of CNS-
sedating substances.
Diagnostic procedures comprise case history and
symptom evaluation, sleep-specific and
supplementary investigations.

Treatment
Therapy of hypersomnia involves : psychological and pharmacological
treatment
Psychological
Changes in behavior (for example avoiding night work and social
activities that delay bed time) and diet may offer some relief.
Patients should avoid alcohol and caffeine.
Pharmacological :
Stimulants, such as amphetamine, methylphenidate, and modafinil,
may be prescribed to treat hypersomnia
Dosage of stimulants is based on individual need. Modafinil is given
as a single morning dose of 200 or 400 mg ( Basset et al 1996 ),
Methylphenidate 20 to 60 mg/day, ephedrine 25 mg, amphetamine
10 to 20 mg, dextroamphetamine 5 to 10 mg.
Other drugs used to treat hypersomnia include, antidepressants,
and monoamine oxidase inhibitors.

Nonorganic disorder of the sleep-
wake schedule
A lack of synchrony between the sleep-wake schedule and
the desired sleep-wake schedule for the individual's
environment,
Resulting in a complaint of either insomnia during major
sleep period or hypersomnia during the waking period are
experienced nearly every day for at least 1 month or
recurrently for shorter period of time.
Sleep disturbance causes marked distress or interferes with
ordinary activities.

Common Circadian Rhythm Disorders
Jet Lag or Rapid Time Zone Change Syndrome: This syndrome
consists of symptoms including excessive sleepiness and a lack of
daytime alertness in people who travel across time zones.
Shift Work Sleep Disorder: This sleep disorder affects people who
frequently rotate shifts or work at night
Delayed Sleep Phase Syndrome (DSPS): This is a disorder of
sleep timing. People with DSPS tend to fall asleep at very late times
and have difficulty waking up in time for work, school, or social
engagements.
Advanced Sleep Phase Syndrome: Advanced sleep phase
syndrome is a disorder in which the major sleep episode is
advanced in relation to the desired clock time. This syndrome
results in symptoms of evening sleepiness, an early sleep onset,
and waking up earlier than desired.
Non 24-Hour Sleep Wake Disorder: Non 24-hour sleep wake
disorder is a condition in which an individual has a normal sleep
pattern but lives in a 25-hour day. Throughout time the person's
sleep cycle will be affected by inconsistent insomnia that occurs at
different times each night. People will sometimes fall asleep at a
later time and wake up later, and sometimes fall asleep at an earlier
time and wake up earlier.

TREATMENT
Circadian rhythm disorders are treated based on the kind of
disorder that is present. The goal of treatment is to fit a
persons sleep pattern into a schedule that can allow the
person to meet the demands of a desired lifestyle.
Therapy usually combines proper sleep hygiene techniques
and external stimulus therapy such as bright light therapy or
chronotherapy.
Chronotherapy is a behavioral technique in which bedtime is
systematically delayed, which follows the natural tendency of
human biology. Bedtime is delayed by 3 hour increments each
day, establishing a 27-hour day. The procedure is maintained
until the desired bedtime is reached, (say 11 p.m.) when the
normal 24-hour day is then established. (Piazza c et.al. 1998)
Bright light therapy takes total control of light and dark
exposure across the whole day. The patient uses bright light
exposure early in the morning and avoids light in the evening.
This should produce a phase advance. Two hours (upon rising
in the early morning) in front of a light box that emits 2500 lux
will usually produce and increase in alertness in one week.
( fetveit a et.al. 2005 )

TREATMENT
CONTD….
Melatonin
Melatonin is a natural hormone produced by a gland in the brain at
night (when it is dark). Melatonin levels in the body are low during
daylight hours and high during the night.
Melatonin supplements, may be used to enhance the natural sleep
process and for resetting the body's internal time clock when
traveling through different time zones.
Melatonin supplements have been reported to be useful in treating
jet lag and sleep-onset insomnia in elderly persons with melatonin
deficiency. However, melatonin supplements have not been
approved by the FDA; therefore, it is not clear as to how much
melatonin is safe and effective.
Melatonin Receptor Stimulant
Rozerem, a melatonin receptor stimulant, is also available to treat
circadian rhythm disorders, but requires a doctor's prescription.
Rozerem is used to promote the onset of sleep and help normalize
circadian rhythm disorders. It works differently than melatonin
supplements as it is not melatonin, but a stimulator of melatonin
receptors in the brain. Rozerem is approved by the FDA for treating
insomnia characterized by difficulty falling asleep.

TREATMENT
contd…
Other Medications Used to Treat Circadian Rhythm
Benzodiazepines. Short-acting benzodiazepines, such
as alprazolam, are often chosen in the early treatment of
a circadian rhythm disorder and are used in conjunction
with behavioral therapy.
Long-term use of these medications is not
recommended due to potential side effects, such as the
rebound phenomenon (the original problem returns at a
higher level), and the risk of developing a dependence
on these drugs.
Non benzodiazepine Hypnotics: These medications,
such as zolpidem, zaleplon, are gaining popularity
because they do not have a significant effect on the
regular sleep cycle and are not associated with the
rebound phenomenon seen with benzodiazepines.
Zolpidem and zaleplon are good short-term options for
treating sleep problems.

A state of altered consciousness in which
phenomena of sleep and wakefulness are
combined.
During a sleepwalking episode the individual
arises from bed, usually during the first third of
nocturnal sleep, and walks about, exhibiting low
levels of awareness, reactivity, and motor skill.
Upon awakening, there is usually no recall of the
event.
Some cases of autonomic (independently
functioning) behavior that occur with sleepwalking
involve dressing and even eating.

Treatment and Management
Treatment for sleepwalking is often unnecessary,
especially if episodes are infrequent and
uncomplicated. Safety issues are of prime
importance to someone who sleepwalks and to
others who are involved with managing the
condition. The following measures are usually
recommended:
1. Locate the bedroom on the main floor, if possible.
2. Lock the windows and cover them with large, heavy drapes.
3. Keep the floor clear of harmful objects.
4. Remove any hazardous materials and sharp objects from
the room and secure them in the house.
5. Stay on the first floor when visiting others and when
sleeping at a hotel.

Treatment and Management contd..
Medication may be used in cases where episodes are
violent, injurious, frequent, or disruptive. Therapy usually
consists of either a benzodiazepine, such as Diazepam or
Alprazolam, or a tricyclic antidepressant. (schenk c,et.al. 1983).
Biofeedback and hypnosis have also been used effectively
with individual sleepwalking patients.

Sleep terrors [night terrors]
Diagnostic Guidelines
Nocturnal episodes of extreme terror and panic associated
with intense vocalization, motility, and high levels of
autonomic discharge.
The individual sits up or gets up, usually during the first third
of nocturnal sleep, with a panicky scream
Repeated episodes typically lasts 1-10 min
Recall of the event, if any, is very limited (usually to one or
two fragmentary mental images).
No evidence of a physical disorder e.g epilepsy, tumor.

Treatment:
Counseling and Psychotherapy
In many cases, comfort and reassurance are the only treatment
required. Psychotherapy or counseling may be appropriate in
some cases.
Sleep disorder clinics often are able to help people restore
normal sleeping patterns through various techniques. Night
terrors may also be treated with hypnosis and guided imagery
techniques. ( Ipsiroglu OS, Fatemi A, Werner I, et al 2002)
Pharmacotherapy
Benzodiazepine medications (such as diazepam) used at
bedtime will often reduce the incidence of night terrors; however,
medication is not usually recommended to treat this disorder. A
safe over-the-counter drug, Benadryl elixir (diphenhydramine),
given 1 hour before bedtime may reduce the incidence of night
terror.
DiMario FJ Jr, Emery ES (1987)

NIGHTMARES
The awakening from sleep with dream experience which is
very vivid and usually includes themes involving threats to
survival, security, or self-esteem. Awakening may occur at
any time but typically during the second half.
Upon awakening the individual rapidly becomes alert and
oriented.
The dream experiences itself or resulting sleep disturbance
cause marked distress to sleep, causes marked distress to
the individual.

NIGHTMARES
Pathophysiology
In older children and adults, 75% of sleep is non-
REM sleep, which consists of 4 stages. Most
dreaming occurs during REM sleep. REM sleep is
characterized by EEG activity similar to a wakeful
pattern ( Ipsiroglu OS, Fatemi A, Werner I, et al 2002)
Prevalence varies because of different diagnostic
criteria and different study populations. Some
studies estimate as many as 50% of children aged
3-6 years have nightmares that disturb both their
sleep and the parents' sleep .(Leung AK, Robson WL:
Nightmares. 1993 )

Treatment
Reassurance
Reassurance is the only treatment required for sporadic
nightmares. Although all stressors cannot be removed
from a child's life, parents can attempt to make bedtime a
safe and comfortable time.
Encourage parents to spend time reading, relaxing, and
talking with the child.
If the child has a recurring nightmare, to have the parents
encourage the child to imagine a good ending may help.

1. Dahl RE: The pharmacologic treatment of sleep
disorders. Psychiatr Clin North Am 1992 Mar; 15(1): 161-
78.
2. DiMario FJ Jr, Emery ES 3d: The natural history of night
terrors. Clin Pediatr (Phila) 1987 Oct; 26(10): 505-11.
3. Guilleminault C, Palombini L, Pelayo R, Chervin RD:
Sleepwalking and sleep terrors in prepubertal children:
what triggers them? Pediatrics 2003 Jan; 111(1): e17-25.
4. Ipsiroglu OS, Fatemi A, Werner I, et al: Self-reported
organic and nonorganic sleep problems in schoolchildren
aged 11 to 15 years in Vienna. J Adolesc Health 2002
Nov; 31(5): 436-42.
5. Siegel JM: Why we sleep. Sci Am 2003 Nov; 289(5): 92-
7.
6. Wise MS: Parasomnias in children. Pediatr Ann 1997 Jul;
26(7): 427-33
7. Fetveit A, Bjorvatn Bright-light treatment reduces
actigraphic-measured daytime sleep in nursing home
patients with dementia: a pilot study. 1: Am J Geriatr
Psychiatry. 2005 May;13(5):420-3
8. Piazza c et.al. Using chronotherapy to treat severe sleep
problems: a case study.
Am J Ment Retard. 1998, jan; 102(4);358.
REFERENCES :

9. Lavoisy J, Zivkovic B : Contribution of zolpidem in the
management of sleep disordersEncephale. 1992 Jul-
Aug;18(4):379-92.
10. Bootzin et.al. non-pharmacological treatment of insomnia. J Clin
Psych 1992, 53 (supp); 37-41.
11. Schenk c,et.al.(1983) ;Chronic behavioural therapy of REM
sleep disorders; Sleep 9, 293-308.

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