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Home , Bruxism, Hypersomnia, Jet lag, Narcolepsy, Nightmare, Sleepwalking

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Sleep disorders — a doctor’s disorders are common and can potentially be dangerous.

Insomnia is the most common, and often of difficulty in initiating or maintaining frustrating, sleep-related complaint doc- sleep, or of non-restorative sleep. tors have to deal with. Up to one-third of Physicians often judge sleep according to the population suffers from a sleep disor- duration alone, while ignoring the sleep der at some time in their life. quality. can be a primary problem, or it can be secondary to medical or psychiatric disor- ders or to and of Physicians often judge abuse. Insomnia can also be caused by psychophysiological factors such as . sleep according to Sedative- drugs are often pre- duration alone, while JANUS scribed for the treatment of insomnia. It i g n o ring the sleep PRETORIUS is, however, necessary to understand the MB ChB, MMed (Psych) of insomnia before quality. Principal treating it symptomatically as sympto- Specialist and matic treatment often removes the impe- Senior Lecturer tus to diagnose and relieve underlying Department of CLASSIFICATION AND DIFFER- causes.Treating the primary condition University of the Free often relieves the insomnia, and sympto- ENTIAL DIAGNOSIS OF SLEEP State and matic treatment can be avoided. It is DISORDERS Psychiatric Complex therefore important to make an appropri- DSM IV classifies sleep disorders into of the Free State ate diagnosis and ask a few screening Bloemfontein three categories: questions to all patients complaining of • primary sleep disorders Janus Pretorius' acad- insomnia, poor quality of sleep or exces- • sleep disorders related to other mental emic interests include sive daytime sleepiness. Screening ques- disorders disorders, tions in combination with a physical work- • sleep disorders related to general med- forensic psychiatry up and sleep laboratory studies, when and . ical conditions or substances. indicated, should enable the clinician to Primary sleep disorders are presumed to refine the diagnosis to a specific sleep dis- arise from endogenous abnormalities in order and to plan an appropriate manage- sleep-wake generating or timing mecha- ment strategy.Treatment options include nisms, often complicated by factors of behaviour changes, addressing underlying conditioning. stressors, and pharmacological interven- tions. The International Classification of Sleep Disorders (ICSD) (Table I) is, however, the most advanced nosology available.The DEFINITIONS RELATING TO are disorders of sleep and INSOMNIA , whereby sufferers have diffi- According to the Diagnostic and Statistical culty in initiating or maintaining sleep, or Manual of Mental Disorders IV (DSM IV), may sleep excessively. The insomnia is associated with complaints are disorders of transition from one sleep about the quantity, quality or timing of stage to another, arousal, or partial sleep. Insomnia should be present at least arousal. General medical psychiatric dis- 3 times a week over a period of at least orders are not primarily disorders of one month. Patients can complain either sleep, but are frequently associated with

138 C M E M a r ch 2003 Vol.21 No.3 MAIN TOPIC it. Medical-psychiatric disorders DSM III category of primary sors (see ‘Adjustment sleep disor- and drugs associated with sleep insomnia. The onset is usually der’ below). The patient complains problems are summarised in Table associated with tension and fre- of difficulty in initiating and main- II. Parasomnias are mentioned quently follows an adjustment taining sleep or of non-restorative only briefly as these patients do precipitated by stres- sleep for at least one month. not normally present with com- plaints of insomnia, poor quality of sleep or . Table I. The International Classification of Sleep Disorders (ICSD) DYSSOMNIAS Intrinsic sleep disorders Dyssomnias These disorders originate within or Intrinsic sleep disorders (excludes general medical and mental are caused by some conditions in disorders) the body. However, they exclude Extrinsic sleep disorders (includes /-related causes, general mental and medical condi- poor sleep , emotional, and -related causes) tions such as major , sleep disorders and gastro- Parasomnias oesophageal reflux which are clas- Arousal disorders sified under a separate heading in Sleep-wake transition disorders the ICSD. Drug-related sleep dis- Parasomnias usually associated with REM sleep orders are classified under dyssom- nias as extrinsic sleep disorders. Sleep disorders associated with medical-psychiatric disorders (Table II) Psychophysiological insomnia Associated with mental disorders Associated with neurological disorders Psychophysiological insomnia is Associated with other medical disorders the most common sleep disorder, and the sleep disorder in the ICSD Adapted from Kaplan HI, Sadock BJ. Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md: Williams & Wilkins, 1996. that most closely resembles the

Table II. Medical and psychiatric causes of insomnia

General medical disorders Psychiatric disorders Medication and substances of abuse Cardiopulmonary Adjustment disorders Coronary or pulmonary (stress related) Use or withdrawal insufficiency Post-traumatic stress disorder Sedative-hypnotic Congestive Generalised Tolerance or withdrawal Chronic obstructive pulmonary disorder Major depression Stimulating — Bipolar SSRIs Nocturnal cardiac ischaemia Theophylline Sleep apnoea* Pain related Chronic pain Fibromyositis Other Endocrine and neurological Beta-blockers Sleep-related Beta- Thyroid hormone Parkinson's disease Oral contraceptives Hyperthyroidism Steroids Other Toxins (mercury, bismuth, lead) Gastro-oesophageal reflux disease Peptic ulcer disease

*See ‘Intrinsic sleep disorders’. SSRIs — selective reuptake inhibitors.

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Increased physiological or psycho- agonists, , benzo- lifelong sleep difficulties beginning logical arousal during the night diazepines (especially ) in childhood. and negative conditioning for sleep and have been shown are frequently evident. Decreased to improve symptoms. This condi- functioning during wakefulness is tion and periodic limb movement Narcolepsy is a neurological disor- also present. These patients expe- disorder are more common in der of unknown aetiology charac- rience a sense of frustration con- older patients. Iron supplements terised by excessive daytime sleepi- cerning their inability to sleep. The have proved to be effective in ness associated with harder they try to sleep the more patients with serum ferritin levels (episodes of abrupt decrease in difficult it becomes. below 50 µg/dl. Pregnant women muscle tone) and other REM sleep or patients on antidepressants phenomena such as sleep Behaviour treatment modalities complaining of insomnia should (temporary inability to talk or include moving to another , also be asked about restless legs. move while asleep or awak- using the bed for sleep and sexual SSRIs have also been associated ening) and hypnagogic hallucina- activity only, and relaxation train- with RLS. tions (occurring in the transition ing. These behaviour modalities from wakefulness to sleep or when are the first line of treatment, but dozing). Only a minority of can be combined with a hypnotic patients experience all four of the agent if necessary. Idiopathic insomnia above symptoms. Cataleptic attacks can consist of either brief, Sleep state misperception is a lifelong inability to obtain adequate almost imperceptible weakness of Sleep state misperception is a dis- isolated muscle groups (loss of order in which the patient com- sleep. Some defect grip, jaw drop, head drop) or sud- plains of insomnia without objec- in the neurological den paralysis of almost all skeletal tive evidence (sleep studies or muscles. These attacks are fre- observation) of sleep disturbance. control of the sleep- quently triggered by intense emo- These patients are overly con- wake system proba - tions or sexual arousal. cerned about the effects of dimin- ished sleep. Reassurance and bly explains the The onset of narcolepsy usually attempts to identify underlying c o n d i t i o n . occurs during the second decade psychological concerns are fre- of life, with excessive daytime quently unsuccessful. Hypnotic sleepiness preceding the other use should be limited as the risk Periodic limb movement disor- symptoms by several years.The for dependence may be high. der (nocturnal myoclonus) diagnosis is confirmed by polysomnographic studies indicat- This disorder is characterised by ing the presence of sleep-onset periodic episodes of repetitive, REM periods (decreased sleep Restless legs syndrome (RLS) is stereotyped limb movements that latency) and hypersomnolence dur- experienced as a discomfort in the occur during sleep. These patients ing daytime. legs which is relieved by moving or are unaware of the limb move- stimulating the legs. This feeling is ments and complain of either There is no cure for narcolepsy but commonly described as a crawling, interrupted sleep or excessive day- it can be managed with tingling or prickling sensation. The time sleepiness. Bed partners medications such as dextroamphet- symptoms tend to increase later in should be questioned about exces- amine and . Drug the day or evening. Patients report sive leg movements during sleep. holidays are recommended to min- difficulty in falling asleep as they The diagnosis can also be con- imise development of tolerance. have to keep on moving their legs firmed by polysomnographic stud- However, abuse potential of these to relieve the uneasy sensations. ies. drugs remains a concern. Getting up and walking around, is a newly registered taking a hot shower or rubbing the Idiopathic insomnia novel, wake-promoting agent for legs may provide some relief. Idiopathic insomnia is a lifelong the treatment of narcolepsy. It has Pharmacotherapy needs to be inability to obtain adequate sleep. a mechanism of action similar to explored and individualised Some defect in the neurological that of sympathomimetics that dif- because of differing responses. control of the sleep-wake system fers from and Various drugs such as dopaminer- probably explains the condition. amphetamine-like stimulants. gic agents (carbidopa/levodopa), This condition is characterised by

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Recently, low levels of hypocretin, patient’s life as sleep apnoea is sleep disorders discussed in this a newly identified , associated with cardiovascular dis- article. were described in the cerebrospinal ease fatalities. fluid of patients with narcolepsy. Adjustment sleep disorder Continuous positive airway pres- The role of hypocretins in nar- This commonly occurring condi- sure (CPAP) or bi-level positive colepsy is intriguing but unclear at tion is caused by emotional stres- airway pressure (BiPAP) are used this stage. sors or change of environment, to pneumatically maintain an open which results in an anxiety-mediat- airway during sleep. These meth- Obstructive sleep apnoea syn- ed insomnia. The condition is nor- ods are generally well accepted by drome mally self-limiting and remits once patients. In patients who have Obstructive sleep apnoea syn- the stressors have been removed or identifiable anatomical abnormali- drome is characterised by repetitive are adjusted to. ties, orthognatic surgery appears to episodes of upper airway obstruc- be an excellent treatment option. tion that occur during sleep. This Various drug therapy trials for is usually associated with reduction sleep apnoea are currently being Stimulant-, alcohol- of blood oxygen saturation. conducted. Obstructive apnoea results from a and hypnotic-relat - collapse of the upper airways, Recurrent ed sleep disorder despite a continuous effort to This disorder is relatively rare but needs to be ruled breathe. The obstruction is is most common among male ado- released when the patient is briefly out in patients lescents.Periodic hypersomnia aroused or wakes up completely. and excessive eating are its major complaining of Obstructive sleep apnoea is often features. i n s o m n i a . associated with overweight, middle- aged men, but can occur at any age and also in women.These patients The patient suffering from this Sleep disorder related to med- present with excessive daytime syndrome takes long unrefreshing ication and substances of a buse sleepiness. Loud , morning preceded by long periods of Stimulant-, alcohol- and hypnotic- headaches and poor sexual func- drowsiness. It differs from nar- related sleep disorder needs to be tioning are often present. Other colepsy in that daytime sleepiness ruled out in patients complaining important symptoms are prolonged is more continuous. of insomnia (Table II). Short- but unrefreshing naps, periods of Extrinsic sleep disorders term co-prescription of sedative- disorientation and automatic can alleviate insomnia behaviour. Up to 50% of patients The causes of the disorders arise aggravated by stimulating antide- who have essential outside the body and include a pressants.Tolerance to or with- have obstructive sleep apnoea. wide variety of contributing fac- tors, including drugs, environment drawal from sedative-hypnotics is The diagnosis is confirmed by and stressors. often associated with insomnia. polysomnographic investigations Abrupt withdrawal should be indicating cessation of both nasal Insufficient sleep syndrome avoided as it can lead to interrupt- and oral airflow for longer than 10 Many patients limit sleep time ed sleep. seconds more than 30 times during unintentionally to less than that Circadian rhythm sleep disor- a seven-hour sleep period. necessary for normal day-to-day ders functioning, perhaps owing to a Symptoms of hypersomnia, poor Adults have an intrinsic body clock lack of understanding of his/her concentration, and per- which regulates a complex series of sleep requirement. sonality changes overlap to some rhythms, including sleep and wake- fulness, and cognitive abili- extent with major depression. Inadequate Prescribing a sedating antidepres- ty. This endogenous clock is also This category entails bad or irregu- sant can aggravate sleep apnoea influenced by alternation of light lar sleep habits and sleep-incom- and increases the patient's risk of and darkness. patible behaviours. Insomnia complications. Sleep apnoea results from behaviours that Jet lag, shift-work sleep disorder, therefore needs to be considered in increase arousal. Poor sleep delayed and advanced sleep phase the differential diagnosis of depres- hygiene is also responsible for syndromes and some of the chron- sion. A timely diagnosis can save a maintaining some of the other ic insomnias are caused by a tem-

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poral discrepancy of the body clock in relation to environmental Table III. Assessment of sleeping problem requirements. • Is there difficulty falling asleep or early morning awakening? Some individuals, especially the •For how long does the person sleep? Is it adequate? elderly, suffer from advanced sleep • Does the sleeping problem affect functioning during the day? phase syndrome (excessive sleepi- • Does the person sleep during the day? ness in the evening and undesired • Does the person take excessive amounts of caffeine or other stimu- lants? early morning waking). Delayed • Is there an associated medical condition? sleep phase syndrome is more •What medication does the person take? common in adolescents (sleep- • Is there an underlying psychiatric disorder? onset insomnia and difficulty wak- •What psychological or social stresses are there? ing in the morning). From Wilson D. Psychiatry and primary health care. In: Baumann SE, ed. APractical Guide for Health Care Workers in Southern Africa. Kenwyn: Juta, 1998. PARASOMNIAS These can be marked by unusual Table IV. Sleep hygiene (behaviour and environmen- or bizarre behaviour. , tal factors that promote good sleep) sleep terrors, , sleep •Keep regular sleeping hours and sudden death syn- •Go to bed only when feeling sleepy drome in infants are some exam- •Avoid bright light before ples of parasomnias. •Avoid stimulants for six hours before going to bed (caffeine) •Avoid nicotine, especially near bedtime •Use the bed for sleeping only MANAGEMENT •Avoid near bedtime Insomnia should be addressed to • Don’t eat a heavy meal before bedtime or go to bed hungry • Get out of bed when unable to fall asleep within 30 minutes avoid functional impairment and •Avoid alcohol near bedtime the possible increased risk of devel- • Block excessive noise with white noise oping anxiety and depressive ill- Compiled from Lippman S, Mazour I, Shahab H. Insomnia: therapeutic approach. South Med J 2001; 94: (suppl nesses. Management includes 1): 15 - 24. obtaining a proper history from patients experiencing difficulties Table V. Classification of insomnia in terms of dura- with sleep or staying awake (Table tion and probable causes in each group III). Identifying behaviour that can interfere with sleep (poor sleep Transient insomnia — lasting a few days • Jet lag hygiene) needs special attention • Change in sleeping environment Treatment usually not needed (Table IV). Underlying psychiatric •Acute stress } conditions (Table II) need to be ruled out. Information about Short-term insomnia duration of the problem can also • Stress that doesn’t resolve within a few days, such as divorce, bankruptcy — may require short-term symptomatic treatment lead the clinician towards an appropriate diagnosis (Table V). Long-term insomnia Medical and psychiatric condi- •Psychiatric disorder tions, as well as intrinsic sleep dis- •Associated drug use/abuse/withdrawal/associated medical disor- orders, need to be ruled out in der long-term insomnia. Information • Intrinsic sleep disorders about excessive leg movements, snoring and breathing problems should be obtained from bed part- to bed, sleep duration and time of electroencephalographic and elec- ners. A physical examination and waking up during the night and tromyographic activity, measure- appropriate laboratory investiga- final time of waking up. Daytime ment of eye movements, oxygen tions to rule out possible underly- naps should also be recorded. saturation, limb movements, air- ing medical problems need to be Although subjective, the log sum- flow and chest and abdominal undertaken. Keeping of sleep logs marises the patient’s perception of movement. These studies are indi- can provide valuable information. the quality and quantity of sleep. cated in long-term insomnia with These should record time of going an unidentified cause or in treat- Polysomnographic studies combine

142 C M E M a r ch 2003 Vol.21 No.3 MAIN TOPIC ment-resistant cases. Multiple sleep Table VI. Drugs commonly prescribed for insomnia latency tests are also indicated in this group if narcolepsy is suspect- Novel non- Sedating antidepressants ed. TREATMENT RECOMMEN- Nefazodone DATIONS Benzodiazepines The best results are usually achieved by employing more than one component in the manage- ment plan. Compiled from Lippman S, Mazour I, Shahab H. Insomnia: therapeutic approach. South Med J 2001; 94: 866 - Non-pharmacological measures 873. These are quite effective and should always be regarded as the the lowest effective dose should be first line of management. Skills used to minimise side-effects, FURTHER READING obtained through these measures rebound insomnia and tolerance. Diagnostic and Statistical Manual of may have long-term benefits for Mental Disorders, 4th ed. Washington, Sleep experts suggest that sedative- the patient. Moderate intensity DC: American Psychiatric Association, hypnotic drugs be used for a maxi- exercise should be promoted and 1997. mum of several weeks. Short-term has been reported to improve self- Kaplan HI, Sadock BJ. Comprehensive insomnia should be treated for no Textbook of Psychiatry, 6th ed. rated sleep quality and sleep dura- more than three weeks, while long- Baltimore, Md: Williams & Wilkins, 1996. tion in elderly patients. term insomnia should be treated Wilson D. Psychiatry and primary health care. In: Baumann SE, ed. APractical The main psychological therapies intermittently whenever possible. Guide for Health Care Workers in that have been studied include Chronic treatment can be one Southern Africa. Kenwyn: Juta, 1998. sleep hygiene training, relaxation night in three for up to four Stahl SM. Essential therapies, stimulus control therapy, months at a time. : Neuroscientific sleep restriction therapy and para- Basis and Practical Application, 2nd ed. Advantages of the non-benzodi- Cambridge: Cambridge University Press, doxical intention. The principle of azepines include a lower risk of 2000. sleep hygiene is to promote condi- rebound insomnia, dependence, tions and behaviour that enhance withdrawal symptoms and loss of effective sleep (Table IV). efficacy over time. Relaxation procedures have been IN A NUTSHELL employed with varying success There are numerous antidepres- Sleep disorders can present with rates. Procedures such as progres- sants with sedative-hypnotic prop- insomnia, poor quality of sleep or sive muscle relaxation are designed erties (Table VI). They are advised excessive daytime sleepiness. to alleviate somatic and cognitive for managing insomnia in patients One-third of the population suf- arousal. Attention-focusing proce- with depression, a history of sub- fers from sleep disorders at some dures target cognitive arousal stance abuse or where the need for time in their life. through imagery training, medita- } extended treatment duration exists. An attempt should be made to tion, and thought-stopping. Tricyclic antidepressants are effec- diagnose and treat or relieve Paradoxical intention addresses the tive for inducing sleep and improv- underlying causes of insomnia. conditioned inability to sleep. ing sleep continuity. Low-dose tra- Symptomatic treatment is warrant- zodone can be combined with ed if underlying causes do not Pharmacological measures respond to treatment sufficiently. sleep-disrupting psychotropic Established medications for the drugs such as SSRIs. Symptomatic treatment should be symptomatic treatment of insom- time limited and preferably given nia include non- Antihistamines are effective for intermittently. hypnotics, benzodiazepines and managing mild insomnia but next- Non-pharmacological measures sedating antidepressants or occa- day sedation and anticholinergic should be regarded as part of sional histaminic drugs. The non- effects may be problematic. first-line management. Patients benzodiazepines are rapidly with treatment-resistant and long- becoming the first-line treatment term insomnia of unidentified cause should be referred. for insomnia. Short-term use of

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