Sleep Disorders

False: middle-aged overweight males who snore loudly is a risk factor

True or False: Smoking is a risk factor for breathing related sleep disorders

False- The incident rate is higher among the elderly

True or False: The incidence rate of insomnia is higher among adolescents

True

True or False: Women are affected more than men in regards to insomnia

1. arousal disorders 2. sleep-wake transition disorders 3. parasomnia associated with REM sleep 4. other parasomnias 5. other parasomnias not otherwise stated

Parasomnia is classified into subtypes which are?

circadian rhythm sleep disorder - part of dyssomnia

Patients with this have abnormal sleep-wake patterns, leading to excessive daytime sleepiness and impairment in social or occupational functioning

*A. fluoxetine* B. agomelatine C. melatonin D. hypnotics

Pharmacological management of circadian rhythm sleep disorders includes all of the following except: A. fluoxetine B. agomelatine C. melatonin D. hypnotics

1. First line (Hydroxyzine, Mirtazapine, Agomelatine) 2. Second line (Zopiclone, Zolpidem CR) 3. Benzodiazepines (Alprazolam, Clonazepam, Lorazepam, Diazepam)

Pharmacological management of insomnia includes?

A. Modafinil B. SSRIs C. Benzodiazepines D. Zopiclone *E. Both A and B are correct*

Pharmacological management of narcolepsy includes: A. Modafinil B. SSRIs C. Benzodiazepines D. Zopiclone E. Both A and B are correct

True

True or False: Concentrations of hypocretin-1 and hypocretin-2 are reduced in narcoleptic patients

False: There is a 1:1 ratio of M:F who experience narcolepsy spells

True or False: Narcolepsy occurs more commonly in woman than in men

False: Narcolepsy occurs most common between the ages of 10-20 years old

True or False: Narcolepsy occurs most commonly between the ages of 50-60 years old

random eye movement (REM) and non-random eye movement (NREM) sleep disorders

Sleep compromises of period or NREM and REM sleep alernating through the night; the deepest stages of NREM occur in the first part of the night, and episodes of REM sleep are longer as the night progresses

breathing related sleep disroder- part of dyssomnia

Breathing disturbances which can occur during sleep including apnea and hypopnea

False: Nightmares are common especially among children between the ages of 5-6 years old

True or False: Nightmares are common in children 2-3 years of age

Hyroxyzine (Atarax)- first line for insomnia

- Anti-histamine - Main SE: drowsiness in the morning

Zolpidem CR (Stilnox CR)- second line for insomnia

- Half life: 2-3 hours (non-CR form), longer in CR form - High risk of dependence - Associate with less day time sedation

Zopiclone (Imovane)- second line for insomnia

- Half life: 6 hours - Main SE: metallic taste

Alprazolam (Xanax)- benzo used for insomnia

- Indication: anxiolytic use - Half life: ~11 hours

Clonazepam- benzo used for insomnia

- Indication: anxiolytics use and REM-movement disorder - Half life: ~25 hours

Benzodiazepines

- Insomnia tx - Should only be used for short periods not more than 2 weeks - Prevent dependence

Lorazepam (Ativan)- benzo used for insomnia

- Intramuscular form: calm patient with acute agitation - Half life: ~10 hours

Agomelatine (Valdoxan)- first line for insomnia

- Novel antidepressant targeting melatonin receptors to regulate sleep-wake cycle - Main SE: giddiness

Diazepam (Valium)- benzo used for insomnia

- Per-rectum use: epilepsy - Half life: ~30 hours

Mirtazapine (Remeron)- first line for insomnia

- Sedative antidepressant - Main SE: weight gain

Kleine-Levin Syndrome- part of dyssomnia

- aka sleeping beauty syndrome - rare in prevalence - largely affects male adolescent

*A. anorexia nervosa* B. poor sleep hygiene C. environmental D. adjustment E. altitude F. substace-related G. circadian rhythm disorders

All of the following are *extrinsic causes* of insomnia except: A. anorexia nervosa B. poor sleep hygiene C. environmental D. adjustment E. altitude F. substace-related G. circadian rhythm disorders

A. idiopathic/primary insomnia B. sleep apnea syndrome *C. altitude* D. periodic limb movement disorder, restless leg syndrome E. restless leg syndrome

All of the following are *intrinsic causes* of insomania except: A. idiopathic/primary insomnia B. sleep apnea syndrome C. altitude D. periodic limb movement disorder E. restless leg syndrome

A. chronic pain B. pulmonary diseases C. neurological disorders *D. PCOS* E. endocrine disorder F. iron deficiency G. restless leg syndrome H. sleep apnea

All of the following are *medical disorders* associated with insomnia except: A. chronic pain B. pulmonary diseases C. neurological disorders D. PCOS E. endocrine disorder F. iron deficiency G. restless leg syndrome H. sleep apnea

A. schizophrenia B. somatoform disorder C. anorexia nervosa D. PTSD E. chronic pain disorders *F. bulimia* G. bipolar affective disorder H. depression I. generalized anxiety disorder

All of the following are *psychiatric disorders* associated with insomnia except: A. schizophrenia B. somatoform disorder C. anorexia nervosa D. PTSD E. chronic pain disorders F. bulimia G. bipolar affective disorder H. depression I. generalized anxiety disorder

A. time zone changes *B. depression* C. shift work (e.g., security guard) D. irregular sleep-wake patterns

All of the following are causes for circadian sleep rhythm disorders except: A. time zone changes B. depression C. shift work (e.g., security guard) D. irregular sleep-wake patterns

A. B12 deficiency B. iron deficiency *C. vitamin D deficiency* D. chronic renal disease E. parkinson disease

All of the following are causes of periodic limb movement disorder except? A. B12 deficiency B. iron deficiency C. vitamin D deficiency D. chronic renal disease E. parkinson disease

nightmares- part of parasomnia

Awakening from REM sleep to full consciousness with detailed dream recall ability

A. episodes of excessive sleepiness B. increased appetite C. episodes of sexual disinhibition and other comorbid psychiatric symptoms *D. all of the above*

Clinical features of Kleine-Levin Syndrome include: A. episodes of excessive sleepiness B. increased appetite C. episodes of sexual disinhibition and other comorbid psychiatric symptoms D. all of the above

A. apnea at least five times per hours for greater than a 10-second period as a result of upper airway obstruction B. episodes of sexual disinhibition and other comorbid psychiatric symptoms C. sleep is fragmented by short arousals following apnea and there is unrefreshed sleep D. all of the above is correct E. A & B are correct *F. A & C are correct*

Clinical features of breathing related sleep disorders include: A. apnea at least five times per hours for greater than a 10-second period as a result of upper airway obstruction B. episodes of sexual disinhibition and other comorbid psychiatric symptoms C. sleep is fragmented by short arousals following apnea and there is unrefreshed sleep D. all of the above is correct E. A & B are correct F. A & C are correct

A. complex and automatic behaviors (eg., wandering without purpose, attempting to dress or undress) B. occurs in the initial stages of sleep, usually 15-120 minutes after individual falls asleep C. usually able to get back to bed and continue with sleep after event has taken place D. usually do not recall exact incidents that happen E. appear to be disoriented and confused if awakened during somnambulism *F. all of the above are correct* G. both A & B are correct H. both A & D are correct

Clinical features of somnambulism (sleep-walking) include: A. complex and automatic behaviors (eg., wandering without purpose, attempting to dress or undress) B. occurs in the initial stages of sleep, usually 15-120 minutes after individual falls asleep C. usually able to get back to bed and continue with sleep after event has taken place D. usually do not recall exact incidents that happen E. appear to be disoriented and confused if awakened during somnambulism F. all of the above are correct G. both A & B are correct H. both A & D are correct

narcolepsy- dyssomnia category

Hypersomnia characterized by excessive daytime sleepiness and falling asleep at inappropriate times

- various stages of sleep - typical sleep cycle - sleep cycle changes with age - allow patients to gain insight into characteristics of the sleep issue they are seeking treatment for

Sleep education for insomnia includes?

- sleep education (stages of sleep, assist establishment of good sleep habits) - shift workers (advised to try and have regular sleep cycles, attempt to nap if necessary to compensate for the absolute number of sleep hours lost)

Non-pharmacolgical management of circadian rhythm sleep disorders includes?

1. sleep education 2. sleep hygiene 3. stimulus control 4. sleep restriction

Non-pharmeceutical insomnia management includes?

delayed sleep phase syndrome- part of circadian sleep rhythm disorders (part of dyssomnia)

Delayed onset of sleep (usually at 2am); total sleep time is normal

insomnia- dyssomnia category

Diagnosed when the main problem lies with difficulty in initiating or maintaining sleep

Dyssomnia

Disorder of the quantity or timing of sleep includes both insomnia (disturbance in the quantity or quality of sleep) and hypersomnia (excessive sleepiness-you don't like waking up)

advanced sleep phase syndrome- part of circadian sleep rhythm disorders (part of dyssomnia)

Early onset of sleep with resultant early morning awakening

SSRIs (e.g. fluoxetine)- pharmacological management of narcolepsy

Help suppress REM and reduce cataplexy

Modafinil (Provigil)- pharmacological management of narcolepsy

Helps reduce number of sleep attacks; better side effect profile than traditional psychostimulants

1. Dyssomnia 2. During sleep or during the transition between sleep and wakefulness 3. Sleep disorders related to another mental disorder 4. Other sleep disorders

How are sleep disorders classified?

Eliciting a detailed medical and psychiatric history from patient

How do you assess sleep disorders?

- weight loss - continuous positive pressure ventilation (CPAP) via face mask at night

How do you manage breathing related sleep disorders?

10-15 minutes

How long does a sleep terror episode normally last?

1. advanced sleep phase syndrome 2. delayed sleep phase syndrome

How many types of *circadian rhythm sleep disorders* are there, and what are they?

hypersomnia- dyssomnia category

Individuals suffering from this present with recurrent sleep attacks during the day, poor concentration and difficulties with transitioning from a rested state to full arousal and wakefulness

*A. sleep restriction* B. supportive therapy, sleep hygiene, psychoeducation, and reassurance C. protective measures (locking doors/windows, installing bars/frames to prevent falls) D. antidepressants (e.g., imipramine and paroxetine)

Management of somnambulism (sleep walking) includes all of the following except: A. sleep restriction B. supportive therapy, sleep hygiene, psychoeducation, and reassurance C. protective measures (locking doors/windows, installing bars/frames to prevent falls) D. antidepressants (e.g., imipramine and paroxetine)

periodic limb movement disorder

More common in elderly, pregnant women, patients with vertebral degenerative disorders

*A. decreased recall of dreams if woken; decreased complexity of dreams* B. increased recall of dreams if woken; increased complexity of dreams

Pick the one associated with NREM sleep and dreams: A. decreased recall of dreams if woken; decreased complexity of dreams B. increased recall of dreams if woken; increased complexity of dreams

*A. abolition of tendon reflexes; no penile erection* B. decreased muscle tone; occasional myoclonic jerks; penile erection or increased vaginal blood flow

Pick the one associated with NREM sleep and neuromuscular: A. abolition of tendon reflexes; no penile erection B. decreased muscle tone; occasional myoclonic jerks; penile erection or increased vaginal blood flow

A. thermoregulation stops; no shivering or sweating *B. thermoregulation preserved*

Pick the one associated with NREM sleep and pokibothermic condition: A. thermoregulation stops; no shivering or sweating B. thermoregulation preserved

A. increased sympathetic activity; increased transient runs of conjugate eye movements; increased HR; increased systolic BP; increased RR; increased cerebral blood flow *B. increased parasympathetic activity; bell phenomenon + few or no eye movement; decreased HR; decreased systolic BP; decreased RR; decreased cerebral blood flow*

Pick the one associated with NREM sleep and sympathetic/parasympathetic activity: A. increased sympathetic activity; increased transient runs of conjugate eye movements; increased HR; increased systolic BP; increased RR; increased cerebral blood flow B. increased parasympathetic activity; bell phenomenon + few or no eye movement; decreased HR; decreased systolic BP; decreased RR; decreased cerebral blood flow

A. decreased recall of dreams if woken; decreased complexity of dreams *B. increased recall of dreams if woken; increased complexity of dreams*

Pick the one associated with REM sleep and dreams: A. decreased recall of dreams if woken; decreased complexity of dreams B. increased recall of dreams if woken; increased complexity of dreams

A. abolition of tendon reflexes; no penile erection *B. decreased muscle tone; occasional myoclonic jerks; penile erection or increased vaginal blood flow*

Pick the one associated with REM sleep and neuromuscular: A. abolition of tendon reflexes; no penile erection B. decreased muscle tone; occasional myoclonic jerks; penile erection or increased vaginal blood flow

*A. thermoregulation stops; no shivering or sweating* B. thermoregulation preserved

Pick the one associated with REM sleep and poikilothermic condition: A. thermoregulation stops; no shivering or sweating B. thermoregulation preserved

*A. increased sympathetic activity; increased transient runs of conjugate eye movements; increased HR; increased systolic BP; increased RR; increased cerebral blood flow* B. increased parasympathetic activity; bell phenomenon + few or no eye movement; decreased HR; decreased systolic BP; decreased RR; decreased cerebral blood flow

Pick the one associated with REM sleep and sympathetic/parasympathetic activity: A. increased sympathetic activity; increased transient runs of conjugate eye movements; increased HR; increased systolic BP; increased RR; increased cerebral blood flow B. increased parasympathetic activity; bell phenomenon + few or no eye movement; decreased HR; decreased systolic BP; decreased RR; decreased cerebral blood flow

Parasomnia

Problems during sleep or during the transition between sleep and wakefulness

period limb movement disorder

Repeated leg twitching during sleep that requires the investigation of B12 and ferritin levels

Is useful in all patients: - ensure sleep environment is familiar, comfortable, dark and quiet - ensure regular bedtime routines with consistent bedtime and waking up time - reinforce going to bed only when tired - avoid factors associated with insomnia including overexcitement, working out late at night, caffeine late in the day, excessive smoking and alcohol, excessive daytime sleeping, late meals prior to bedtime

Sleep hygiene for insomnia includes?

- must have high intrinsic motivation - reduce total time spent in bed - enable improvement in quality of sleep via consolidation

Sleep restriction for insomnia includes?

- individuals should go to sleep only when tired - get up and focus on relaxing activities before attempting to go to bed again if there are difficulties wth sleep

Stimulus control for insomnia includes?

sleep terrors (night terrors)- part of parasomnia

Sudden awakening during sleep with loud terrified screaming that is more common in male children who are confused and disoriented if awakened and are usually unable to recollect events in detail

A. cataplexy B. excessive sleepiness C. hypnagogic hallucinations D. sleep paralysis *E. all of the above*

The clinical features of narcolepsy include: A. cataplexy B. excessive sleepiness C. hypnagogic hallucinations D. sleep paralysis E. all of the above

- recurrent periods or sleep or lapses back to sleep even within the same day - prolonged sleep episodes of more than 9 hours that are not restorative - difficulties associated with being fully awake after abrupt awakening

The excessive sleepiness associated with hypersomnia is characterized by?

Kleine-Levin Syndrome- part of dyssomnia

This lasts for days or weeks with long intervals and the individual is free from attacks in between episodes

somnambulism (sleep-walking)

This parasomnic sleep disorder is prevalent among both children and adults

arousal disorder- part of parasomnia

This subtype includes: - confusional arousals - sleep terrors - sleep walking

parasomnia associated with REM sleep- part of parasomnia

This subtype includes: - nightmares - sleep paralysis

sleep-wake transition disorders- part of parasomnia

This subtype includes: - nocturnal leg cramps - sleep talking - rhythmic movement disorder

other parasomnia- part of parasomnia

This subtype includes: - sleep bruxism (teeth grinding) - sleep enuresis

1. Do you feel sleepy during the day? 2. Do you take routine naps during the day? 3. Do you find yourself having difficulties with concentration during the day?

What are some questions asked during the assessment regarding "daytime"?

1. Have you notices any change in your partner's sleeping habits? 2. Have you noticed that your partner has been snoring during his sleep? 3. Does your partner exhibit any abnormal movements (e.g., kicking) during sleep? 4. Have you ever been injured by these movements?

What are some questions asked during the assessment regarding "history from sleep partner"?

1. Could you describe to me a typical night of sleep (in terms of the number of hours you get, the quality of sleep, etc.) 2. Do you find yourself having difficulties with falling asleep? 3. Do you sleep well? Do you find yourself awake during the night? (what is the reason, is it because you need to go to the toilet) 4. Do you find yourself waking up much earlier in the morning?

What are some questions asked during the assessment regarding "nighttime"?

1. Have you sought help for your sleep problem? (e.g., psychiatrist, acupuncturist, traditional medicine practitioner) 2. Are you on any chronic long-term medications to help yourself fall asleep (e.g., sleeping pills)? 3. Where do you get these medications?

What are some questions asked during the assessment regarding "past management"?

1. daytime 2. nighttime 3. past management

What categories are covered during the assessment of sleep disorders?

A. kleine-levin syndrome B. circadian rhythm syndrome *C. obstructive sleep apnea* D. sleep-walking

What is a common cause of breathing related sleep disorders? A. kleine-levin syndrome B. circadian rhythm syndrome C. obstructive sleep apnea D. sleep-walking

- supportive therapy - sleep hygiene - psychoeducation - reassurance

What is proper management of sleep terrors?

- no specific treatment is usually requires - agents that help to suppress REM sleep can be used (like SSRIs but make this last resort especially in children)

What is the appropriate management of nightmares?

Vitamin B12 and iron tablets

What is the appropriate management of periodic limb movement disorder?

HLA-DR2

What is the candidate gene for narcolepsy?

Excessive sleepiness that occurs at least 3 times per week for the past 3 months that must have occurred despite adequate opportunities for rest

What is the diagnostic criteria for hypersomnia?

There must be sleep difficulties for at least 3 nights per week, for the past 3 months and those sleep difficulties must have occurred despite adequate opportunities for rest

What is the diagnostic criteria for insomnia?

Repeated episodes during which there is a need to fall back into sleep, or nap occasionally within the same day that must have occurred at least 3 times per week over the past 3 months

What is the diagnostic criteria for narcolepsy?

- stimulatory SSRIs (e.g., fluoxetine) - psychostimulants (can be used but usually only effect for a short period of time)

What is the management of Kleine-Levin Syndrome?

encourage regimen of regular naps in the daytime

What is/are the non-pharmacological management(s) of narcolepsy?

Obtaining a sleep history from a sleep partner

What might be a crucial aspect of your sleep disorder assessment?

- tachycardia - diaphoresis - mydriasis

What physiological changes occur during sleep terrors?

1. difficulties associated with initiation of sleep 2. difficulties with maintaining sleep 3. early morning awakening and inability to return back to sleep

What sleep difficulties are associated with insomnia?

1. nightmare disorder 2. sleep terror disorder 3. sleepwalking disorder 4. parasomnia not otherwise specified

What sleep disorders are included in the "during sleep or during the transition between sleep and wakefulness" category?

1. breathing related sleep disorder 2. circadian rhythm sleep disorder 3. narcolepsy 4. primary insomnia 5. primary hypersomnia 6. dyssomnia not otherwise specified

What sleep disorders are included in the dyssomnia category?

A. episodes of sudden bilateral loss of muscular tone with maintained consciousness precipitated by laughter/joking *B. recurrent periods of sleep or lapses back to sleep even within the same day* C. lack of hypocretin (a neuropeptide that regulates arousal, wakefulness, and appetite) D. REM sleep latency less than or equal to 15 minutes

Which of the following is not a symptoms that must be present in addition to the diagnostic criteria for narcolepsy? A. episodes of sudden bilateral loss of muscular tone with maintained consciousness precipitated by laughter/joking B. recurrent periods of sleep or lapses back to sleep even within the same day C. lack of hypocretin (a neuropeptide that regulates arousal, wakefulness, and appetite) D. REM sleep latency less than or equal to 15 minutes

A. drug effects (e.g., long acting benzos) B. poor sleep routines (e.g., playing online games all night) C. circadian rhythm sleep disorders D. chronic physical illness E. frequent parasomnia F. insufficient night-time rest G. Kleine-Levin syndrome H. insomnia I. obstructive sleep apnea J. psychiatric disorders *K. poor sex drive*

Which of the following is not included in the etiology of hypersomnia? A. drug effects (e.g., long acting benzos) B. poor sleep routines (e.g., playing online games all night) C. circadian rhythm sleep disorders D. chronic physical illness E. frequent parasomnia F. insufficient night-time rest G. Kleine-Levin syndrome H. narcolepsy I. obstructive sleep apnea (MCC of secondary hypersomnia) J. psychiatric disorders (e.g., melancholic depression) K. poor sex drive