Sleep-Wake Disorders

[Pages:16]Sleep-Wake Disorders

page 390-422 starts w/ Circadian Rhythm Sleep-Wake Disorder

All info is either from DSM-5 (diagnostic/assessment) or our Text (treatments) -for the unspecified/specified

I consulted the stated disorder (ie insomnia for "Other Specified Insomnia Disorder") However I did not research this section, so it would be good to take a look at the assessment and treatment of the stated disorder, and compare

It seems like those are quite up in the air depending on symptoms presented

Sleep Wake Disorders

Breathing Related Sleep Disorders

Disorder

Circadian Rhythm Sleep-Wake Disorders Code: 307.45

(DSM-5 pp. 391-8)

Codes Subtypes Assessment

Treatment

Delayed sleep phase type G47.21

Advanced sleep phase type G47.22

Irregular Sleep-Wake type G47.23

Non-24-hour sleep-wake type G47.24

Shift Work type G47.26 Unspecified type G47.20

Sleep Diary Actigraphy (wrist-

sleep/wake detector) Diagnosis Unclear-

Biomarkers (Salivary dim light melatonin onset) Sequential Measurement of phase markers (melatonin) (primarily for Non-24 hour sleep-wake type)

Sleep log associated with chronobiology (resetting daily life schedule)

Behavior modification Techniques

Interventions: psychoeducation, light therapy (increasing melatonin), restrictions on alcohol/caffeine, sleep hygiene rules

(Kress & Paylo, 2015, p. 504)

Sleep Wake Disorders

Parasomnias

Disorder

Non-Rapid Eye Movement Sleep Arousal Disorders

Nightmare Disorder

Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome

Codes

Assessment

Sleepwalking type 307.46 (F51.3)

Sleep Terror type 307.6 (F51.4)

Polysomnography and audiovisual monitoring to document episodes

307.47 (F51.5)

Polysomnography

327.42 (G47.52) 333.94 (G25.81)

Medical evaluation Polysomnography

Self-Report, History of episodes, Immobilization Test, serum ferritin level test (iron in body), Polysomnography

Treatment

Children-family therapy, increased emotional connection

Adults Interventions: reduce deep sleep through medication, behavior changes, counseling to consider options

Cognitive Behavioral Therapy Interventions Image Rehearsal Therapy, Lucid dreaming therapy, Exposure, Relaxation and Rescripting Therapy (EERT)

Medications (melatonin, clonazepam)

For mild case: Self-directed activities during onset of sensation (read, stretch, massage)

For Severe case: medication (low-dose dopamine agonists)

Last resort: Anticonvulsants, Opiods

(Kress & Paylo, 2015, pp. 505-6)

Sleep Wake Disorders Parasomnias (continued)

Disorder

Substance/MedicationInduced Sleep Disorder

Assessment

Medical evaluation/ consultation, Electroencephalographic sleep profile, All night Polysomnography, Multiple Sleep Latency Test, 2 Week Sleep Diary, Actigraphy, Drug Screening

Treatment

Consult with medical doctor, psychiatrist

Cognitive Behavioral Therapy, Behavioral therapy

Psychoeducation, sleep hygiene rules, relaxation techniques, sleep restrictions, cognitive techniques

Other Specified Insomnia Disorder

Unspecified Insomnia Disorder

Polysomnography, Quantitative electroencephalographic analysis

Polysomnography, Quantitative electroencephalographic analysis

Cognitive Behavioral Therapy, Behavioral therapy

Psychoeducation, sleep hygiene rules, relaxation techniques, sleep restrictions, cognitive techniques

Cognitive Behavioral Therapy, Behavioral therapy

Psychoeducation, sleep hygiene rules, relaxation techniques, sleep restrictions, cognitive techniques

Other Specified

Medical evaluation/ consultation,

Hypersomnolence Disorder

Multiple sleep latency test, Nocturnal polysomnography

Cognitive Behavioral Therapy, Behavior therapy, psychopharmacotherapy

Sleep Wake Disorders Parasomnias (continued)

Disorder

Unspecified Hypersomnolence Disorder

Assessment

Medical evaluation/ consultation, Multiple sleep latency test, Nocturnal polysomnography

Treatment

Cognitive Behavioral Therapy, Behavior therapy,

psychopharmacotherapy

Other Specified SleepWake Disorder

Medical evaluation/ consultation, Biological validators, Polysomography

Treatment Depends on presenting symptoms Cognitive Behavioral Therapy,

Behavioral therapy, medications, oral applications, ventilators Psychoeducation, sleep hygiene rules, relaxation techniques, sleep restrictions, cognitive techniques

Unspecified Sleep-Wake Disorder

Medical evaluation/ consultation, Biological validators, Polysomography

Treatment Depends on presenting symptoms Cognitive Behavioral Therapy,

Behavioral therapy, medications, oral applications, ventilators Psychoeducation, sleep hygiene rules, relaxation techniques, sleep restrictions, cognitive techniques

(Kress & Paylo, 2015, pp. 361-73)

Sleep-Wake Disorders: Diagnostic Criteria: Circadian Rhythm Sleep-Wake Disorders

Circadian Rhythm SleepWake Disorders

(DSM-5 pp.391-8)

1. Delayed Sleep Phase Type

Code: 307.45 (G47.21)

2. Advanced Sleep Phase Type

Code: 307.45 (G47.22)

3. Irregular SleepWake Type

4. Non-24 Hour Sleep-Wake Type

5. Shift Work Type

Code: 307.45 (G47.23)

Code: 307.45 (G47.24)

Code: 307.45 (G47.26)

Recurrent Pattern + History of delay in timing of

of Sleep disruption major sleep pd.(usually 2+ hrs.)

compared to desired sleep/wake

Excessive

sleepiness,

+ Lasts 3+ months

insomnia, or both

time

Causes distress or impairment in social occupational, & other functioning

+Difficulty waking in the morning (morning confusion)

+Excessive early day sleepiness

Common features +history of mental disorder/concurrent mental disorder

+Psychophysiological insomnia

Differential Diagnosis: Normative variations in Sleep

Other Sleep Disorders

+Sleep-wake times several hours earlier than desired

+History of advance in timing of major sleep pd. (usually 2+ hrs.) compared to desired sleep/wake time

+Early morning insomnia

+Excessive daytime sleepiness

+"morning types" biomarkers occur 2-4 hr. earlier than normal

+use of drugs to combat sleepwake time may lead to substance abuse

+Onset late adulthood +Familial +Symptom severity increases with age +varies according to lifestyle and lifespan

Differential Diagnosis: Other Sleep Disorders

Depressive and Bipolar Disorders

+history of insomnia at night

+excessive sleepiness/napping in the day

+No major sleep pd.

+Fragmented sleep into at least 3 pds. in 24 hrs.

+Commonly linked to neurodegenerative disorders (major neurocognitive disorder, neurodevelopmental disorders)

+Linked to limited environmental light exposure

Differential Diagnosis: Normative variations in sleep

Other medical conditions and mental disorders

+Pattern of sleep-wake cycles not synchronized to 24 hr. environment

+Consistent daily drift of sleep-wake times.

+pds of insomnia, excessive sleepiness or both altering with asymptomatic pds.

+Common among the visually impaired (50% prevalence)

+based on history of individual working out of 8AM-6PM daylight schedule on a regular basis

+Insomnia during major sleep pd.

and/ or +Excessive sleepiness during major awake pd. associated with a shift work schedule

+In sighted individuals often due to lack of light and structured activity

+May effect travelers frequently flying across time zones

+Associated with traumatic brain injury

+May effect those with rotating shifts

Differential Diagnosis: Circadian Rhythm Sleep-Wake Disorders

Depressive Disorders

+Common in 50+

Differential Diagnosis: Normative Variations in Sleep with Shift Work

R/O: Other Sleep Disorders

Sleep-Wake Disorders: Diagnostic Criteria: Parasomnias

Parasomnias

(DSM-5 pp. 399422)

Abnormal behavioral, experiential or physiological events occurring w/ sleep/specific sleep stages/sleepwake transitions

Most common

NREM Sleep Behavior Disorder

REM Sleep Behavior Disorder

Non-Rapid Eye Movement (NREM) Sleep Arousal Disorders

Sleepwalking type Code: 307.46(F51.3)

Sleep terror type Code: 307.46 (F51.4)

+Repeated occurrence of incomplete arousals can be brief up to 10 mins. or up to 1 hr. in first 3rd of sleeping episode

+eyes are typically open

Sleepwalking +repeated episodes of complex motor behavior initiated during sleep +Episodes begin during NREM +reduced alertness +blank stare +unresponsive to communication +limited recall afterward +initial confusion immediately following +return to full cognitive function afterwards

Sleep Terrors +Repeated occurrence of sudden awakening from sleep +Often begins w/ scream/cry +Automatic arousal +Intense fear, compulsion to escape +Automatic arousal (rapid breathing, sweating, etc.) +Unresponsiveness to others efforts to comfort

Non-Rapid Eye Movement (NREM) Sleep Arousal Disorders

(Continued)

+No or little dream imagery (single scene)

+Amnesia for episode

+Significant stress and impairment of functioning

+Not due to drug use/ Medication

+Mental and Medical disorders do not explain episodes

Sleep Related Eating Disorder +eating w/ amnesia ranging from no-full awareness

Sleep Related sexual behavior (sexsomnia) +Arising from sleep and participating in sexual activity w/ no conscious awareness

Common in children

+link w/ major depressive episodes and obsessivecompulsive disorder

Non-Rapid Eye Movement (NREM) Sleep Arousal Disorders

(Continued)

Differential Diagnosis: Nightmare Disorder

Breathing-Related Sleep Disorders

REM Sleep Behavior Disorder

Parasomnia Overlap Syndrome

Sleep-Related Seizures

Alcohol-Induced Blackouts

Dissociative Amnesia, w/ Dissociative Fugue

Malingering or other voluntary behavior occuring during wakefulness

Medication-Induced Complex Behaviors

Night Eating Syndrome

Nightmare Disorder

Code: 307.47 (F51.5)

Rapid Eye Movement (REM) Sleep Behavior Disorder

Code: 327.42 (G47.52)

Restless Leg Syndrome

Code: 333.94 (G25.81)

+Repeated occurrences of dream imagery involving extreme negative emotions +well remembered +Alert after dream episode +Significant distress or impairment in functioning

Replicative Nightmares -occur after a traumatic experience

Differential Diagnosis: Sleep Terror Disorder

REM Sleep behavior Disorder

Bereavement

Narcolepsy

Nocturnal Seizures

Breathing-Related Sleep Disorders

Panic Disorder

Sleep-Related Dissociative Disorders

Medication or Substance Abuse

+Repeated episodes of arousal during sleep

+Vocal and/or complex motor behaviors in response to threats "dream enacting behaviors"

+Motor behaviors can be violent

+Happen in REM sleep (90 mins into sleep onset)

+Awaken alert and NOT confused/disoriented

+Causes significant distress and/or impairment of functioning

+Present in 30% of narcoleptics

Differential Diagnosis: Other Parasomnias

Nocturnal Seizures

Obstructive Sleep Apnea

Other Specified Dissociative Disorder

Malingering

+desire to move the legs or arms due to uncomfortable feelings

+Urge to move -worsens during rest -is relieved by movement -worse in evening

+3x/week +At least 3 months

+Causes significant distress and/or impairment of functioning

Differential Diagnosis: Substance Intoxication or withdrawal

Delirium

Other Sleep Disorders

Sleep Disorder due to another medical condition

Sleep-Wake Disorders: Diagnostic Criteria: Parasomnias

Substance/ MedicationInduced Sleep Disorder (DSM-5 pp 417-8)

Code: 780.52 (G47.00)

Prominent/severe disturbance in sleep -develop during/after intoxication or -after withdrawal

and -Substance is capable of sleep disturbance

+Sleep disorders are ruled out

+does not occur during delirium

+Symptoms cause significant distress

or Impairment of functioning

Differential Diagnosis: Substance intoxication or withdrawal

Delirium

Other Sleep Disorders

Sleep Disorder due to another medical condition

1.Alcohol (291.82)

+often occurs with insomnia type

+Extremely disrupted sleep

First half of night +Immediate/ short lived sedative effect

+increased intensity of REM sleep (vivid dreams- alcohol withdrawal delirium)

Second half of night +Restlessness

+can aggravate breathing-related sleep disorder

+fragmented sleep can last for weeks/years in chronic alcohol users

2.Caffeine (292.85)

+produces insomnia +signs of withdrawal = daytime sleepiness

3.Cannabis (292.85)

4. Opiods (292.85)

+may shorten sleep latency

+enhances slow wave sleep /sleep inducing

+Chronic users develop tolerance to sleep effects

+ Withdrawal signs sleep difficulties and unpleasant dreams -may last for weeks

-Increase in sleepiness and sleep depth

-W/ chronic use tolerance develops and insomnia

-Respiratory depressant effects worsen sleep apnea

5. Sedative, hypnotic, or anxiolytic (292.85)

6.Amphetamine (or other stimulant) (292.85)

+Similar to Opiods

+Increases sleepiness

+Decreases wakefulness

+W/ chronic use tolerance develops and insomnia

+Daytime sleepiness

+Insomnia during intoxication

+Excessive Sleepiness during withdrawal

+MDMA -restlessness and disturbed sleep within 48 hrs.

-frequent use is connected with anxiety, depression, steep disturbances even during pds. of non use

7. Tobacco (292.85)

8. Other (or unknown) Substance (292.5)

+Insomnia

+Decreased slowwave sleep

+Reduction of sleep efficiency

+Increased daytime sleepiness

+Withdrawal -impaired sleep

+Heavy smokers may awake at night due to cravings

+Medications affecting central. and/or automatic nervous systems may cause sleep disturbances

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