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Sleep DisordersAuthor: Roy H Lubit, MD, PhD, AssistantClinical Professor, Mount Sinai School ofMedicine; Clinical Faculty, Department of Child

Psychiatry, New York ni!ersity School ofMedicine; Pri!ate PracticeCoauthor(s): Curley L Bonds II, MD, Ad"unctAssociate Professor and Chair, Department ofPsychiatry and #uman $eha!ior, Charles Drew

ni!ersity of Medicine and Science; AssociateClinical Professor, Department of Psychiatry and$io%eha!ioral Sciences, ni!ersity of California at&os An'eles; Mi hael A Lu ia, MD, !AASM, (wner)C*(, Pulmonary, Aller'y and SleepMedicine, Sierra Pulmonary and Sleep Consultants,

&&CContri%utor +nformation and Disclosures

pdated May -., -//0

Introdu tion

Ba "#roundSleep disorders are amon' the most commonclinical pro%lems encountered in medicine and

psychiatry1 Sleep pro%lems can %e primary or resultfrom a !ariety of psychiatric and medicalconditions1 +nade2uate or nonrestorati!e sleep canmarkedly impair a patient3s 2uality of life1 .

Primary sleep disorders result from an endo'enousdistur%ance in sleep4wake 'eneratin' or timin'mechanisms, often complicated %y %eha!ioralconditionin'1 Primary sleep disordersare su%di!ided into parasomnias and dyssomnias1Parasomnias are unusual e5periences or %eha!iorsdurin' sleep and include sleep terror disorder andsleepwalkin' 6which occur durin' Sta'e 7 sleep8and ni'htmare disorder 6which occurs durin' 9*Msleep81 Dyssomnias are characteri:ed %ya%normalities in the amount, 2uality, or timin' ofsleep1 hese include primary insomnia andhypersomnia, narcolepsy , %reathin'4related sleepdisorder 6ie, sleep apnea8, and circadian rhythmsleep disorder 1

Assessin' if a sleep disorder is primary orsecondary is important1 At times, assessin' ifan5iety and depression are causin' sleep pro%lemsor if the an5iety and depression are secondary to a

primary sleep pro%lem is difficult1 See Medscape3sAn5iety Disorders and Depression 9esourceCenters1

Primary insomnia is the 'eneral term for difficultyin initiatin' or maintainin' sleep1 $ecause sleepre2uirements !ary from indi!idual to indi!idual,insomnia is considered clinically si'nificant when a

patient percei!es the loss of sleep as a pro%lem1+nsomnia may %e characteri:ed further as acute6transient8 or chronic1

Pathophysiolo#yRapid eye $o%e$ent and nonrapid eye$o%e$ent

Sleep is di!ided into - cate'ories, rapid eyemo!ement 69*M8 and nonrapid eye mo!ement6N9*M81 *ach of these sleep states is associatedwith distinct central ner!ous system acti!ity1

N9*M sleep is further di!ided into 7 pro'ressi!ecate'ories, termed sta'es .47 sleep1 he arousalthreshold rises with each sta'e of sleep, with sta'e7 6delta8 %ein' the sleep state from which a personis least a%le to %e aroused, characteri:ed %y hi'h4amplitude slow wa!es1

9*M sleep is characteri:ed %y muscle atonia,episodic 9*Ms, and low4amplitude fast wa!es onelectroencephalo'ram 6**


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he pineal 'land secretes less melatonin whene5posed to %ri'ht li'ht; therefore, the le!el of thischemical is lowest durin' the daytime hours ofwakefulness1

Multiple neurotransmitters are thou'ht to play arole in sleep1 hese include serotonin from the

dorsal raphe nucleus, norepinephrine contained inneurons with cell %odies in the locus ceruleus, andacetylcholine from the pontine reticular formation1Dopamine, on the other hand, is associated withwakefulness1

A%normalities in the delicate %alance of all of thesechemical messen'er systems may disrupt !arious

physiolo'ic, %iolo'ic, %eha!ioral, and **< parameters responsi%le for 9*M 6ie, acti!e8 sleepand N9*M 6slow4wa!e8 sleep1

!re uen y

nited States

Appro5imately one third of all Americans ha!esleep disorders at some point in their li!es1Appro5imately -/47/> of adults report difficultysleepin' at some point each year1 Appro5imately.?> of adults consider the pro%lem to %e serious1Sleep disorders are a common reason for patient!isits throu'hout medicine1 Appro5imately onethird of adults ha!e insufficient sleep syndrome1

wenty percent of adults report chronic insomnia1

Mortality*Morbidity Chronic insomnia is associated with an

increased risk of depression andaccompanyin' dan'er of suicide, an5iety,e5cess disa%ility, reduced 2uality of life, andincreased use of health care resources1

+nsufficient sleep can result in industrial andmotor !ehicle crashes, somatic symptoms,co'niti!e dysfunction, depression, anddecrements in daytime work performanceowin' to fati'ue or sleepiness1

Se+ Primary insomnia is more common in

women, with a female4to4male ratio of @ -1#ormonal !ariations durin' the menstrualcycle or durin' menopause may causedisruptions in sleep1

(%structi!e sleep apnea is more common inmen 67>8 than in women 6-1=>81

A#e +ncreasin' a'e predisposes to sleep

disorders 6=> in persons a'ed @/4=/ y and@/> in those a'ed =/ y or older81

People who are elderly e5perience adecrease in total sleep time, with morefre2uent awakenin's durin' the ni'ht1

People who are elderly ha!e a hi'herincidence of 'eneral medical conditions and

are more likely to %e takin' medicationsthat cause sleep disruption1

Clini al

History+nsomnia may present as decreased sleep efficiencyor decreased total hours of sleep, with someassociated decrease in producti!ity or well4%ein'1

Sleep 2uality is more important than the totalnum%er of hours slept %ecause sleep re2uirements!ary from person to person1 Compare the totalnum%er of hours slept with each indi!idual3slifelon' normal ni'ht sleep time1

+nitial insomnia is characteri:ed %ydifficulty fallin' asleep, with increasedsleep latency 6time %etween 'oin' to %edand fallin' asleep81 +nitial insomnia isfre2uently related to an5iety disorders1

Middle insomnia refers to difficultymaintainin' sleep1 Decreased sleepefficiency is present, with fra'mentedunrestful sleep and fre2uent wakin' durin'the ni'ht1 Middle insomnia may %eassociated with medical illness, painsyndromes, or depression1

+n terminal insomnia, also referred to asearly mornin' wakenin', patientsconsistently wake up earlier than needed1


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his symptom is fre2uently associated withma"or depression1

Alterations of the sleep4wake cycle may %ea si'n of circadian rhythm distur%ances,such as those caused %y "et la' and shiftwork1

#ypersomnia, or e5cessi!e daytimesleepiness, is often attri%uta%le to on'oin'sleep depri!ation or poor 2uality sleep forreasons ran'in' from sleep apnea tosu%stance a%use or medical pro%lems1

+n delayed sleep phase syndrome, the patient is una%le to fall asleep until !eryearly mornin'1 As time pro'resses, the onsetof sleep %ecomes pro'ressi!ely delayed1

Sleepwalkin', also called somnam%ulism,refers to episodes of comple5 %eha!iors

durin' N9*M sleep 6sta'es @ and 78 ofwhich the patient is amnestic afterward1

Ni'htmares are repeated awakenin's fromsleep caused %y !i!id and distressin' recallof dreams1 Ni'htmares usually occur durin'the second half of the sleep period1 ponwakenin' from the dream, the personrapidly reorients to time and place1

Ni'ht terrors are recurrent episodes ofa%rupt awakenin' from sleep characteri:ed

%y a panicky scream, with intense fear andautonomic arousal1 he indi!idual usuallyhas no recall of the details of the e!ent andis unresponsi!e durin' the episode1 Ni'htterrors occur durin' the first third of theni'ht, durin' sta'es @ and 7 of N9*Msleep1

he %ed partner of patients who snore may pro!ide a history of snorin'1 Such a historymay help identify whether a patiente5periences o%structi!e sleep apnea1

Physi al #ypertension 6can %e caused %y sleep

apnea8 Distur%ed coordination 6caused %y sleep

depri!ation8 Drowsiness Poor concentration

Slowed reaction time ei'ht 'ain

Causeshe ma"or causes of insomnia may %e di!ided into

medical conditions, psycholo'ical conditions, anden!ironmental pro%lems1 Medical conditions

Cardiac conditions include ischemiaand con'esti!e heart failure1

Neurolo'ic conditions includestroke, de'enerati!e conditions,dementia, peripheral ner!e dama'e,myoclonic "erks, restless le'syndrome, hypnic "erk, and centralsleep apnea1

*ndocrine conditions affectin' sleepare related to hyperthyroidism,menopause, the menstrual cycle,

pre'nancy, and hypo'onadism inelderly men1

Pulmonary conditions includechronic o%structi!e pulmonarydisease, asthma, central al!eolarhypo!entilation 6the (ndine curse8,and o%structi!e sleep apnea

syndrome 6associated with snorin'81


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ma"or psychiatric conditions now are knownto ha!e a %iolo'ical %asis and constitute asu%set of medical conditions1

Depression may cause alterations in9*M sleep1 As many as 7/> of

people with depression ha!e

insomnia1 Posttraumatic stress disorder 6P SD8can produce !i!id and terrifyin'ni'htmares1

An5iety disorders predispose toinsomnia1 he most common ofthese are 'enerali:ed an5ietydisorder, panic disorder, and an5ietydisorders not otherwise specified1

hou'ht disorders andmisperception of sleep state are

other potential states that causeinsomnia1

Psychotropic medications, such asantidepressants, may interfere withnormal 9*M sleep patterns1

9e%ound insomnia from %en:odia:epines or other hypnotica'ents is common1

*n!ironmental pro%lems Stressful or life4threatenin' e!ents

6e', %erea!ement, P SD8 may causeinsomnia1

Shift work may distur% the sleepcycle, as mi'ht "et la' or chan'es inaltitude1

Sleep depri!ation may occur as aresult of an o!erly warm sleepin'en!ironment, en!ironmental noise,or fre2uent intrusions 6such as in anintensi!e care unit settin'81

Re eren es.1 Bammit < , einer , Damato N, et al1 Euality of life in people with insomnia1 Sleep 1 May

. .000;-- Suppl - S@?04 =1 GMedlineH1

-1 Morin CM, IalliJres A,


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