Sleep Disorders As Outlined by Outlined As Disorders Sleep of Classification N the Ribe the Features and Symptoms of Each Disorder

NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 9781284189490_CH02_Endee.indd 13

© Agsandrew/Shutterstock limit-setting disorder sleep hygiene sleep log sleep diary paradoxical insomnia idiopathic insomnia psychophysiological chronic insomniadisorder insomnia International Classification Association ofSleep Pickwickian syndrome KEY TERMS LEARNING OBJECTIVES Chapter Summary SleepOther Disorders Movement Disorders Sleep-Related Parasomnias Disorders Sleep–Wake Rhythm Circadian Central Disorders of Hypersomnolence Disorders Breathing Sleep-Related Insomnia Disorders Sleep of Classification Disorders Sleep of History CHAPTER OUTLINE 2. 3. 4. 1. insomnia NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC of SleepDisorders (ICSD) (ASDC) Disorders Centers NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC

Disc Desc AASM. the Lear disorders. sleep of history abrief Discuss disorders. uss the social and personal impact of specific specific of impact personal and social the uss n the classification of sleep disorders as outlined by outlined as disorders sleep of classification n the ribe the features and symptoms of each disorder. each of symptoms and features the ribe © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOTFORSALEORDISTRIBUTION. LLC, anAscendLearning © Jones&Bartlett Learning NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC oxygen desaturation hypopnea obstructive apnea obstructive sleep sleep-related breathing biofeedback self-control techniques sleep restriction light therapy group therapy insomnia short-term behavioral insomnia Sleep Disorders Sleep apnea (OSA) disorders disorder of childhood CHAPTER 2 NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC late-onset central congenital central obesity hypoventilation complex sleepapnea treatment-emergent primary sleepapnea primary central high-altitude periodic Cheyne–Stokes breathing hypocapnia hypercapnia continuous positiveairway central apnea central sleepapnea(CSA) sudden infantdeath excessive daytime upper-airway resistance respiratory effort–related respiratory disturbance apnea–hypopnea retrognathia micrognathia paradoxical breathing EEG arousal hypothalamic dysfunction hypoventilation with syndrome (CCHS) alveolar hypoventilation syndrome (OHS) central sleepapnea of infancy sleep apnea breathing pressure (CPAP) syndrome sleepiness (EDS) syndrome arousal (RERA) index (RDI) index (AHI) NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC actigraphy circadian rhythm sleep– circadian rhythm sleep insufficient hypersomnia Kleine-Levin syndrome periodic hypersomnolence recurrent hypersomnia idiopathic hypersomnia narcolepsy typeII sleep-onset REM hypnopompic hypnagogic narcolepsy typeI microsleep automatic behavior narcolepsy tetrad hypnagogic hallucinations sleep paralysis cataplexy narcolepsy maintenance of multiple sleeplatency bi-level therapy adenoidectomy tonsillectomy positional therapy CPAP therapy catathrenia sleep-related groaning primary snoring snoring idiopathic centralalveolar alveolar hypoventilation wake disorder (CRSWD) syndrome period (SOREMP) wakefulness test test (MSLT) hypoventilation

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delayed sleep–wake somniloquy which defined scoring techniques for sleep studies for © Jones & Bartlettphase disorder Learning, LLCsleep-related movement © Jones & Bartlett Learning, LLC the next 40 years. NOT FOR SALEadvanced OR sleep–wake DISTRIBUTION disorders NOT FOR SALE OR DISTRIBUTION phase disorder restless legs In 1970, Dement started the first sleep-disorders irregular sleep–wake syndrome (RLS) lab, which provided all-night evaluations of patients rhythm disorder periodic limb movement with sleep complaints; within 5 years there were free-running circadian disorder (PLMD) four more sleep centers in business. In 1975, the rhythm periodic limb movements Association of Sleep Disorders Centers (ASDC) non–24-hour sleep–wake© Jones &in Bartlettsleep Learning, LLC © Jones & Bartlett was Learning, LLC rhythm disorder NOT FORPLM SALE index OR DISTRIBUTIONdeveloped, which is now knownNOT as theFOR American SALE OR DISTRIBUTION shift work disorder sleep-related leg cramps Academy of Sleep Medicine (AASM). Its sleep center jet lag disorder bruxism accreditation went into effect 2 years later in 1977. By parasomnia sleep-related bruxism the early 1990s, several professional sleep societies had confusional arousal rhythmic masticatory sleepwalking muscle activity developed, including the ASDC, Clinical Sleep Society, somnambulism© Jones & Bartlett Learning,sleep-related LLCrhythmic Association© of JonesProfessional & Bartlett Sleep Societies, Learning, American LLC sleepNOT terror FOR SALE OR DISTRIBUTIONmovement disorder Board of SleepNOT Medicine, FOR SALEand National OR DISTRIBUTIONSleep Founda- night terror body rocking tion. The American Academy of Sleep Medicine was sleep-related eating disorder head banging known as the Clinical Sleep Society from 1984 to 1986 REM-related parasomnias myoclonus REM sleep behavior benign sleep myoclonus and the American Sleep Disorders Association from disorder (RBD) of infancy 1987 to 1998; in 1999 it became the American Academy © Jones & isomorphismBartlett Learning, LLCpropriospinal myoclonus © Jonesof Sleep & Medicine.Bartlett Learning, LLC recurrent isolated at sleep onset NOT FOR SALE OR DISTRIBUTION NOT FORIn 1990, SALE the AASM OR DISTRIBUTION developed the first edition of the sleep paralysis excessive fragmentary International Classification of Sleep Disorders (ICSD), nightmare myoclonus (EFM) posttraumatic stress hypnagogic foot tremor which categorized and described all known sleep dis- disorder (PTSD) alternating leg muscle orders. A second edition of the ICSD was published in exploding head syndrome activation 2005 (ICSD-2), and the third edition was published in sleep-related hallucinations© Jonessleep & Bartlettstart Learning, LLC2014 (ICSD-3). The information© Jones in this chapter& Bartlett reflects Learning, LLC nocturnal enuresis hypnic jerk the updated definitions and classifications of sleep dis- bedwetting NOT FORenvironmental SALE OR sleep DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sleep enuresis disorder orders found in the third edition. sleep talking Classification of Sleep Disorders History of Sleep Disorders © Jones & Bartlett Learning, LLC The following© Jonespages categorize & Bartlett sleep Learning,disorders as out-LLC 3 SinceNOT the beginningFOR SALE of time, OR humans DISTRIBUTION have been fasci- lined in theNOT third editionFOR ofSALE the ICSD OR: DISTRIBUTION nated with sleep. Many early writings discuss sleep and 1. Insomnia sleep disorders in a variety of ways. In 1836, Charles a. Chronic insomnia disorder Dickens published a series of papers called the “Posthu- b. Short-term insomnia disorder mous Papers of the Pickwick Club.”1 In these writings, c. Other insomnia disorders he describes a boy named Joe who was overweight and © Jones & Bartlett Learning, LLC © Jones &d. Bartlett Isolated symptomsLearning, and LLC normal variants extremely tired, and who snored heavily. A drawing of 2. NOT FOR SALEthe boy ORshows DISTRIBUTION an obese young man with a short, fat NOT FOR Sleep-reSALE latedOR breathingDISTRIBUTION disorders a. neck. From this, the term Pickwickian syndrome was Obstructive sleep apnea disorders i. coined; although it is not used today, the symptoms Obstructive sleep apnea, adult ii. have many similarities with the sleep disorder called Obstructive sleep apnea, pediatric b. obesity hypoventilation© Jonessyndrome &. Bartlett Learning, LLC Central sleep apnea© syndromeJones & Bartlett Learning, LLC Pioneering sleep researchers in the 1950s and 1960s i. Central sleep apnea with Cheyne– such as Nathaniel Kleitman,NOT FOR William SALE Dement, OR and DISTRIBUTION oth- Stokes breathingNOT FOR SALE OR DISTRIBUTION ers identified different stages of sleep and were able to ii. Central sleep apnea due to a medical recognize specific patterns of these stages throughout disorder without Cheyne–Stokes the night. Along with the development of new tech- breathing iii. nologies© Jones designed & Bartlett to read and Learning, record physiological LLC © JonesCentral &slee Bartlettp apnea due Learning, to high-altitude LLC activities,NOT FOR this gave SALE way to OR the DISTRIBUTIONdevelopment of the field NOTperiodic FOR breathingSALE OR DISTRIBUTION of sleep disorders. In 1961, the Sleep Research Society iv. Central sleep apnea due to a medication began informally with such sleep pioneers as Doctors or substance William Dement, Allan Rechtschaffen, Nathaniel v. Primary central sleep apnea Kleitman, Michel Jouvet, and Eugene Aserinsky. In vi. Primary central sleep apnea of infancy vii. © Jones & 1968,Bartlett Rechtschaffen Learning, and LLCDr. Anthony Kales produced © Jones & BartlettPrimary Learning, central sleep LLC apnea of A Manual of Standardized Technology Techniques and prematurity NOT FOR SALE OR DISTRIBUTION 2 NOT FOR SALE OR DISTRIBUTION Scoring Systems for Sleep Stages of Human Patients, viii. Treatment-emergent central sleep apnea

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c. d. © Jones & Bartlett Sleep-relatedLearning, hypoventilationLLC disorders © Jones & BartlettIsolated symptomsLearning, and LLC normal variants i. Obesity hypoventilation syndrome i. Sleep talking NOT FOR SALE ORii. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Congenital central alveolar hypoventila- 6. Sleep-related movement disorders tion syndrome a. Restless legs syndrome iii. Late-onset central hypoventilation with b. Periodic limb movement disorder hypothalamic dysfunction c. Sleep-related leg cramps iv. Idiopat© hicJones central & alveolar Bartlett Learning, LLC d. Sleep-related bruxism© Jones & Bartlett Learning, LLC hypoventilationNOT FOR SALE OR DISTRIBUTIONe. Sleep-related rhythmicNOT movementFOR SALE disorder OR DISTRIBUTION v. Sleep-related hypoventilation due to a f. Benign sleep myoclonus of infancy medication or substance g. Propriospinal myoclonus at sleep onset vi. Sleep-related hypoventilation due to a h. Sleep-related movement disorder due to a medical disorder medical disorder © Jonesd. Sleep-re & Bartlettlated hypoxemia Learning, disorder LLC i. Sleep-re© Joneslated & movement Bartlett disorder Learning, due to LLC a NOTe. FORIsolat edSALE symptoms OR DISTRIBUTIONand normal variants medicationNOT FOR or SALE substance OR DISTRIBUTION i. Snoring j. Sleep-related movement disorder, ii. Catathrenia unspecified k. 3. Central disorders of hypersomnolence Isolated symptoms and normal variants a. Narcolepsy type I © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC b. Narcolepsy type II Insomnia NOT FOR SALE c.OR Idiopat DISTRIBUTIONhic hypersomnia NOT FOR SALE OR DISTRIBUTION d. Kleine-Levin syndrome Insomnia can be defined as a complaint of a lack of e. Hypersomnia due to a medical disorder sleep or of nonrestorative sleep and can occur in all age f. Hypersomnia due to a medication or groups. The ICSD-3 defines insomnia as “persistent difficulty with sleep initiation, duration, consolida- substance© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC g. Hypersomnia associated with a psychiatric tion, or quality that occurs despite adequate opportu- disorder NOT FOR SALE OR DISTRIBUTIONnity and circumstances for sleep,NOT and FOR results SALE in some OR DISTRIBUTION 3 h. Insufficient sleep syndrome form of daytime impairment.” Daytime impairments may include daytime sleepiness, reduced motivation, 4. Circadian rhythm sleep–wake disorders impaired memory or concentration, irritability, behav- a. Delayed sleep–wake phase disorder ioral issues such as aggression, and proneness toward b. Advanced sleep–wake phase disorder © Jones & Bartlett Learning, LLC errors. The© ICSD-2 Jones identified & Bartlett several Learning, different types LLC c. Irregular sleep–wake rhythm NOT FOR SALE OR DISTRIBUTION of insomnia.NOT The ICSD-3FOR SALE consolidates OR DISTRIBUTIONthese types and d. Non–24-hour sleep–wake rhythm disorder groups them into the categories of chronic and short- e. Shift work disorder term insomnia. f. Jet lag disorder g. Circadian rhythm sleep–wake disorder not Chronic Insomnia Disorder © Jones & Bartlett otherwiseLearning, specified LLC © Jones & Bartlett Learning, LLC Chronic insomnia disorder is associated with sleep NOT FOR SALE5. ParasomniOR DISTRIBUTIONas NOT FOR SALE OR DISTRIBUTION a. NREM-related parasomnias disturbances and daytime symptoms as previously i. Disorders of arousal from NREM sleep described that occur at least three times a week for at least ii. Confusional arousals 3 months. There are several clinical subtypes defined and iii. Sleepwalking described below. iv. Sleep© ter Jonesrors & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Psychophysiological Insomnia v. Sleep-reNOTlated FOR eating SALE disorder OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Psychophysiological insomnia b. REM-related parasomnias is caused by excessive i. REM sleep behavior disorder focus and anxiety about sleep, learned sleep-prevention ii. Recurrent isolated sleep paralysis habits, and a heightened level of arousal. The subject iii. Nightmare disorder typically has no difficulty falling asleep when sleep is not © Jones & Bartlett Learning, LLC planned or ©when Jones outside & ofBartlett their usual Learning, sleep setting, LLC but c. Other parasomnias sleep onset is difficult to achieve at the normal bedtime NOT FORi. ExplodingSALE OR head DISTRIBUTION syndrome NOT FOR SALE OR DISTRIBUTION and during planned naps. ii. Sleep-related hallucinations iii. Sleep enuresis Idiopathic Insomnia iv. Parasomnia due to a medical disorder v. © Jones & Bartlett Learning,Parasomni LLCa due to a medication or © JonesPerhaps & theBartlett most detrimental Learning, and LLC debilitating form of insomnia is idiopathic insomnia. Idiopathic insom- NOT FOR SALE OR DISTRIBUTIONsubstance NOT FOR SALE OR DISTRIBUTION vi. Parasomnia, unspecified nia, also termed lifelong insomnia, is first identified at

9781284189490_CH02_Endee.indd 15 17/12/19 10:11 PM 16 CHAPTER 2 Sleep Disorders

© Jones &infancy Bartlett or early Learning, childhood LLC and persists throughout the © JonesA sleep & Bartlett diary can Learning, help patients LLCsee abnormalities in patient’s life. There appears to be no external cause for NOTtheir FOR own SALE sleep habits,OR DISTRIBUTION such as irregular or inconsistent NOT FOR SALEthis insomnia, OR DISTRIBUTION although genetic and congenital aberra- bedtimes or daytime naps that may affect their sleep tions are suspected. schedules at night. Clinicians can use a patient’s sleep diary to point out some of these inconsistencies or poor Paradoxical Insomnia sleep habits. They can also use the sleep study report Formerly termed sleep© stateJones misperception & Bartlett, paradoxical Learning, LLCto demonstrate to the patient© the Jones discrepancy & Bartlett between Learning, LLC insomnia consists of theNOT subject’s FOR complaint SALE OR of insomnia DISTRIBUTION actual sleep and perceived sleep.NOT FOR SALE OR DISTRIBUTION without any actual evidence of insomnia. Many times in Inadequate Sleep Hygiene the sleep lab, a patient will report that he or she remained awake all night, even though the technician was able to The termsleep hygiene refers to habits that are determine by viewing the electroencephalograms (EEGs) healthy for one’s sleep. Therefore, inadequate sleep that© sleep Jones was achieved. & Bartlett In some Learning, cases, the patientLLC may hygiene is a© set Jones of habits & or Bartlett practices Learning,that are detri LLC- haveNOT had aFOR normal SALE sleep efficiency, OR DISTRIBUTION but still insists he mental to a NOTperson’s FOR sleep SALE or may ORcause DISTRIBUTION a person to or she did not sleep at all. This type of comment should sleep poorly. Sleep hygiene techniques are practices always be included in the technician’s notes because the that everyone should follow to fall asleep more eas- patient may have paradoxical insomnia. A useful tool for ily and stay asleep longer. Often a clinician finds that both the clinician and patient when facing paradoxical a person’s insomnia may be the result of bad habits. © Jones & insomniaBartlett is Learning,a sleep diary orLLC a sleep log, which is a self- © JonesIn this & case, Bartlett it is beneficial Learning, to educate LLC patients about NOT FOR SALEreport of OR sleep DISTRIBUTION habits over a period of time. Sleep diariesNOT proper FOR andSALE beneficial OR DISTRIBUTION sleep habits (see Figure 1-2). usually last at least 5 days and sometimes as long as a Following these habits can greatly improve one’s ability month. Figure 2-1 shows a sample sleep diary. to fall asleep and stay asleep.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC DayNOT Date FOR Time in SALETime OutOR TotalDISTRIBUTION Time Time Awake Total Sleep EstimaNOTted FORNote SALEs OR DISTRIBUTION Bed of Bed in Bed Asleep Time Time Sleep Efficiency 1 2 © Jones3 & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 4 NOT FOR5 SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 6 7 8 9 © Jones & Bartlett 10Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR11 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 12 13 14 15 16 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 17 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 18 19 20 21

© JonesTime & in BartlettBed: The final Learning, time of day the LLC subject got in bed to go to sleep. © Jones & Bartlett Learning, LLC Time Out of Bed: The time of day the subject got out of bed for the last time in the morning. NOT FORTo tal Ti SALEme in Bed: OR The DISTRIBUTIONtotal time in minutes the subject spent in bed duringNOT the night. FOR This SALE equals the OR Time DISTRIBUTION Out of Bed minus the Time in Bed. Time Asleep: The estimated time of day the subject fell asleep for the first time. Awake Time: The estimated time of day the subject awoke for the last time in the morning. To tal Sleep Time (TST): The estimated total amount of time the subject actually slept. Estimated Sleep Efficiency: This is calculated by dividing the TST by the Total Time in Bed. A sleep efficiency © Jones & Bartlett >90%Learning, is considered LLC normal. © Jones & Bartlett Learning, LLC NOT FOR SALE ORFIGURE DISTRIBUTION 2-1 Sleep diary. NOT FOR SALE OR DISTRIBUTION

9781284189490_CH02_Endee.indd 16 17/12/19 10:11 PM Insomnia 17

Behavioral Insomnia of Childhood © Jones & Bartlett Learning, LLC © Jonesrebound. & BartlettThe use of Learning, alcohol, sedatives, LLC and pain medications can increase the likelihood of sleep disturbances NOT FOR SALEAlso called OR limit-setting DISTRIBUTION disorder, behavioral insomnia NOT FOR SALE OR DISTRIBUTION of childhood is comparable to inadequate sleep hygiene resulting from obstructive respiratory events. These for children or infants. In addition to the sleep hygiene drugs relax the muscles, which can lead to the likeli- practices listed in the previous section, parents should hood of obstructions in the upper airway. consider other sleep hygiene practices that are specific Prescription and illegal drugs alike can cause sleep for children such as not© Jones putting toys& Bartlett or other distrac-Learning, LLCproblems, including insomnia.© MedicationsJones & Bartlettwith insom- Learning, LLC tions in the crib, allowingNOT the FOR child SALE to fall asleep OR DISTRIBUTION alone nia as a side effect include, butNOT are FORnot limited SALE to, theOR DISTRIBUTION rather than in a parent’s arms, or preventing the infant following: from becoming dependent on a bottle to initiate sleep. ■■ Beta blockers Although some of these actions may be appropriate at ■■ Corticosteroids certain developmental stages in infancy or early child- ■■ Adrenocorticotropic hormones hood,© Jonestheir persistence & Bartlett into older Learning, childhood LLC increases ■■ Monoamine© Jones oxidase & Bartlettinhibitors Learning, LLC theNOT likelihood FOR of SALEthe child OR having DISTRIBUTION difficulty initiating and ■■ DiphenylhydantoinNOT FOR SALE OR DISTRIBUTION maintaining sleep. A normal, healthy bedtime routine ■■ Calcium blockers for a child is recommended, such as reading for a short ■■ Alpha methyldopa period of time. ■■ Bronchodilators ■■ Stimulating tricyclics © Jones & InsomniaBartlett Due Learning, to a Mental LLC Disorder © Jones■■ Stimulants& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR■■ Thyroid SALE hormones OR DISTRIBUTION As its name implies, this insomnia is caused by a diag- ■■ nosed mental illness and persists for at least 1 month. Oral contraceptives ■■ Antimetabolites Common mental illnesses contributing to insomnia ■■ Decongestants include depression and anxiety disorders. Clinicians are ■■ Thiazides faced with the challenge© Jones of determining & Bartlett whether Learning, the LLC © Jones & Bartlett Learning, LLC mental illness is causingNOT the FOR insomnia SALE or if ORanother DISTRIBUTION type NOT FOR SALE OR DISTRIBUTION of insomnia is causing the mental illness. For example, Short-Term Insomnia Disorder a patient suffering from a chronic insomnia can expe- Also called adjustment insomnia or acute insomnia, rience depression as a result of the inability to sleep. short-term insomnia disorder is extremely common, Alternately, a person who is depressed will often experi- especially in today’s busy, high-stress culture. Almost ence© insomniaJones &as aBartlett symptom. Learning, LLC everyone experiences© Jones difficulty & Bartlett initiating Learning, or main- LLC NOT FOR SALE OR DISTRIBUTION taining sleepNOT for a FORnight or SALE two at ORsome DISTRIBUTION point in life. Insomnia Due to a Medical Condition Adjustment insomnia is often associated with a specific stressor that can include work, school, or marital stress; Various medical conditions have the potential to cause excitement; anticipation; financial hardship; illness; symptoms of insomnia, either short-term or long-term. and the death of a loved one or a natural disaster. The Some of the most common and persistent insomnia- diagnosis of short-term insomnia is used when the © Jones & causingBartlett medical Learning, conditions LLC include those associated © Jones & Bartlett Learning, LLC disturbance has been present for less than 3 months. with pain or discomfort. These are more common in the NOT FOR SALE OR DISTRIBUTION NOTAlthough FOR SALE adjustment OR DISTRIBUTIONinsomnia is common, it also elderly but can occur at any age. typically corrects itself when the stressor is relieved. Insomnia Due to a Drug or Substance If a college student experiences adjustment insomnia because of stress from upcoming final exams, for exam- Another form of insomnia© Jones is secondary & Bartlett to substance Learning, LLCple, the insomnia will likely be© corrected Jones when& Bartlett final Learning, LLC abuse or substance withdrawal. These substances most exams are completed. often include alcohol,NOT hypnotic FOR drugs, SALE sedatives, OR DISTRIBUTION stimu- NOT FOR SALE OR DISTRIBUTION lants, and opiates. Most drugs have the ability to alter Other Insomnia Disorder or create a disturbance in sleep in one form or another. This diagnosis is used sparingly for individuals who These disturbances can vary greatly, depending on the experience difficulty initiating or maintaining sleep but type of drug used and the amount, duration, and regu- © Jones & Bartlett Learning, LLC do not meet© the Jones full criteria & Bartlett for chronic Learning, or short-term LLC larity of its use, as well as individual factors. Alcohol can insomnia. haveNOT many FOR effects SALE on sleep, OR including DISTRIBUTION a reduced sleep NOT FOR SALE OR DISTRIBUTION latency, reduced wakefulness, and reduced rapid eye movement (REM) sleep and increased slow-wave sleep Isolated Symptoms and Normal Variants during the first third of the night. During the latter por- Individuals who routinely allot time in bed in excess © Jones & tionsBartlett of the Learning,night, alcohol LLC can increase the number of © Jonesof their & sleep Bartlett need and Learning, those who LLCroutinely obtain less NOT FOR SALEarousals OR and produceDISTRIBUTION sleep fragmentation. It can also NOTthan FOR 6 hours SALE of sleepOR perDISTRIBUTION night without daytime impair- increase the likelihood of nightmares because of a REM ments (short sleepers) fall into this category.

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Obstructive apneas © Jones &Insomnia Bartlett TreatmentLearning, Options LLC © Jonesapneas & and Bartlett hypopneas. Learning, LLC are respira- Insomnia can occur as a primary condition or second- NOTtory FOR events SALE classified OR DISTRIBUTIONby a complete cessation (defined NOT FOR SALE OR DISTRIBUTION as a decrease in amplitude of at least 90%) of airflow ary to another issue. When insomnia is the primary hypopnea condition, or the primary condition is unknown, the and continued respiratory effort. A is a respi- clinician must seek to resolve the insomnia indepen- ratory event characterized by a reduction in airflow by 30% to 90% in amplitude that is associated with a dently. Various therapeutic options are available to help oxygen desaturation patients treat their insomnia,© Jones including & Bartlett group therapyLearning,, LLC3% (a decrease© Jones in the & amount Bartlett of Learning, LLC light therapy sleep restriction self-control hemoglobin saturated by oxygen) or a brief (3 seconds , sleep hygiene,NOT FOR SALE OR, DISTRIBUTION NOT FOR SALEEEG arousal OR DISTRIBUTION techniques, and biofeedback. Group therapy is useful by or longer) shift in EEG frequency called an . allowing the patient to explore possible underlying psy- In adults, both apneic and hypopneic events must last chological causes for the insomnia and hear the causes at least 10 seconds in duration. Often these events are associated with body jerks, limb movements, of other people’s insomnias. Light therapy can help paradoxical breathing adjust© Jones the circadian & Bartlett rhythm and Learning, help the patient LLC initi- © Jones (chest & Bartlett and abdominal Learning, effort LLCasyn- ate NOTsleep at FOR the appropriate SALE OR time. DISTRIBUTION Biofeedback mecha- chrony), andNOT snoring. FOR SALE OR DISTRIBUTION nisms train the patient to control certain physiological Symptoms of OSA include snoring, gasping or chok- parameters such as muscle tension, skin temperature, ing during sleep, witnessed pauses in breathing by the and EEG recordings to gain control over their insomnia. bedpartner, restless sleep, sweating, waking with the These techniques have been shown to be effective in bed in disarray, and morning headaches. © Jones & patientsBartlett who Learning, are especially LLC tense or stressed. Self-control© JonesRisk & factors Bartlett for OSA Learning, include obesity, LLC advanced age, NOT FOR SALEtechniques OR are DISTRIBUTION more psychological in nature than bio- NOTbeing FOR male, SALE smoking, OR DISTRIBUTION and having a crowded upper feedback mechanisms, but the underlying purpose is airway. Crowding of the airway can result from vari- the same: to allow the patient to gain control over his ous factors, including enlarged tonsils, adenoids, or tongue; nasal obstruction; high arched (narrow) pal- or her ability to initiate and maintain sleep. These are micrognathia retrognathia helpful for patients who feel that their lives are out of ate; (having a small jaw) or control because of any© numberJones of & reasons. Bartlett Sleep Learning, restric- LLC(having a recessed jaw); craniofacial© Jones abnormalities; & Bartlett and Learning, LLC tion is another usefulNOT tool for FOR treating SALE chronic OR insomnia, DISTRIBUTION large neck size. An older maleNOT patient FOR who SALE is obese OR and DISTRIBUTION especially for older patients. This is particularly useful has a large neck is at particularly high risk for OSA. Diagnostic criteria for OSA call for an apnea–hypopnea for people who tend to stay in bed for longer and longer index (AHI) periods of time per night. Many people with chronic of at least a total of five apneas and insomnia may stay in bed for 10 hours per night but hypopneas per hour of sleep with complaints of day- © Jones & Bartlett Learning, LLC time sleepiness© Jones as well as& gasping,Bartlett choking, Learning, or snor- LLC only sleep 6 hours. For these patients, the clinician may respiratory disturbance index (RDI) decideNOT to treatFOR the SALE insomnia OR by DISTRIBUTION restricting the amount of ing or a NOT FOR SALE OR DISTRIBUTION of at time the patient is in bed per night. This is another case least 15 in the absence of these complaints. AHI is in which a sleep diary may be useful. calculated by dividing the total apneas and hypop- When insomnia develops as a result of another medi- neas by the total sleep time in hours. RDI is calculated by dividing the total apneas, hypopneas, and cal or psychological condition, treatment often focuses on respiratory effort–related arousals (RERAs) © Jones & theBartlett primary Learning,condition. For LLC example, a woman experienc-© Jones & Bartlett Learning, LLC by the total sleep time in hours. A RERA is an EEG arousal NOT FOR SALEing insomnia OR asDISTRIBUTION a result of painful arthritis will likely be NOT FOR SALE OR DISTRIBUTION able to sleep better if her pain is reduced by medications. that is associated with a marked decrease in airflow and continued or increasing respiratory effort. Upper-airway resistance syndrome is characterized by Sleep-Related Breathing Disorders frequent RERAs during sleep and results in symptoms Sleep-related breathing© Jones disorders & are Bartlett divided intoLearning, those LLCsimilar to those of OSA. © Jones & Bartlett Learning, LLC Figure 2-2 illustrates an obstructive apnea. The of central origin and NOTthose causedFOR SALEby an obstruction. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Central breathing disorders are characterized by a lack airflow is absent despite the persistence of respiratory of respiratory effort caused by either a central nervous effort. An airway obstruction exists when the chest and disorder or a cardiac dysfunction.3 Obstructive respira- abdomen expand and contract but no air flows through tory events are caused by partial or complete collapse of the nose or mouth. Figure 2-3 the© upper Jones airway. & Bartlett Learning, LLC © illustratesJones & a hypopnea,Bartlett alsoLearning, an obstruc- LLC NOT FOR SALE OR DISTRIBUTION tive respiratoryNOT event. FOR Like SALE obstructive OR DISTRIBUTION apneas, effort Obstructive Sleep Apnea, Adult persists; however, airflow is not completely absent but rather decreased. Obstructive sleep apnea (OSA) is one of the most com- Figure 2-4 shows an obstructive apnea. The respira- mon sleep disorders. Although both common and dan- tory effort decreases slightly but persists despite the © Jones & gerous,Bartlett it is Learning,relatively easily LLC diagnosed and treated. OSA© Jonescessation & Bartlett of airflow. Learning, At the end of LLC the event, the patient NOT FOR SALEis characterized OR DISTRIBUTION by the presence of repeated obstructiveNOT kicks FOR their SALE legs and OR has DISTRIBUTION an EEG arousal.

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Effort © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-2 An obstructive apnea.

©Hypopnea Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Airflow

FIGURE 2-3 A hypopnea. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

F3-M2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION F4-M1 C3-M2 C4-M1 O1-M2 © O2-M1Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC E1-M2 NOTE2-M2 FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chin EKG Snore Ptaf Thermistor © Jones & BartlettSum Learning, LLC © Jones & Bartlett Learning, LLC Thorax NOT FOR SALEAbdomen OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION L leg R leg SpO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURE 2-4 An obstructive apnea. At the end of the event, the patient jerks the right leg. Figure by Lisa M. Endee; producedNOT from a sleep FOR study provided SALE to Stony OR Brook UniversityDISTRIBUTION School of Health Technology and Management’s PolysomnographicNOT Technology FOR Program SALE by Dr. Kala OR Sury. DISTRIBUTION

The sample inFigure 2-5 shows another obstruc- OSA has been highly associated with cardiovascular tive© apnea Jones with & an Bartlett associated Learning, EEG arousal LLCand limb risk factors ©and Jones increased & Bartlettmortality. OSA-associatedLearning, LLC movements.NOT FOR SALE OR DISTRIBUTION intermittentNOT hypoxia FOR and SALE sleep fragmentation OR DISTRIBUTION result in The sample inFigure 2-6 shows an obstructive apnea sympathetic activation, oxidative stress, and systemic during REM sleep. Figure 2-7 also shows an obstructive inflammation; left untreated, they increase the risk of apnea. hypertension, coronary artery disease, atrial fibrillation, The epoch or designated time period inFigure 2-8 heart failure, and stroke.4 © Jones & showsBartlett a subtle Learning, hypopnea. LLC The decrease in airflow would© JonesOSA & has Bartlett also been Learning, linked to many LLC other serious NOT FOR SALEbe extremely OR DISTRIBUTIONdifficult to see using just a thermistor. NOThealth FOR consequences, SALE OR DISTRIBUTIONincluding insulin resistance

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© Jones & BartlettF3-M2 Learning, LLC © Jones & Bartlett Learning, LLC F4-M1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEC3-M2 OR DISTRIBUTION C4-M1 O1-M2 O2-M1 E1-M2 E2-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chin EKG NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore Ptaf Thermistor Sum ©Thorax Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Abdomen NOTL leg FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION R leg SpO2

FIGURE 2-5 Another obstructive apnea with an associated EEG arousal and limb movements. © Jones & FigureBartlett by Lisa M. Endee; Learning, produced from a sleepLLC study provided to Stony Brook University School© ofJones Health Technology & Bartlett and Management’s Learning, Polysomnographic Technology LLC Program by Dr. Kala Sury. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

F3-M2 F4-M1 C3-M2 C4-M1 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC O1-M2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION O2-M1 E1-M2 E2-M2 Chin EKG © SnoreJones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTPtaf FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thermistor Thorax Abdomen L leg R leg © Jones & BartlettSpO2 Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-6 An obstructive apnea during REM sleep. Figure by Lisa M. Endee; produced from a sleep study provided to Stony Brook University School of Health Technology and Management’s Polysomnographic Technology Program by Dr. Kala Sury.

and metabolic syndromes.© Jones Further, & Bartlettcontrol of manyLearning, LLCare also often associated with© snoring, Jones labored, & Bartlett or Learning, LLC comorbidities such asNOT hypertension, FOR SALE asthma, OR chronic DISTRIBUTION paradoxical breathing, as wellNOT as morning FOR SALE headaches, OR DISTRIBUTION obstructive pulmonary disease, and diabetes will be oxygen desaturation, and hypercapnia. The main dif- quite difficult if there is an underlying sleep disorder. ference between pediatric and adult OSA is in the Finally, there are various cognitive and psychoso- duration of the respiratory events. Although events in cial detriments associated with OSA. These include adults must be at least 10 seconds long, obstructive excessive© Jones daytime & Bartlett sleepiness Learning, (EDS), lack ofLLC motivation, apneic and© hypopneic Jones events& Bartlett in children Learning, are scored LLC memoryNOT loss,FOR lack SALE of concentration, OR DISTRIBUTION social withdrawal, using a two-breathNOT FOR duration SALE criteria. OR DISTRIBUTION depression, and increased risk of occupational errors, OSA has been shown to be more prevalent in accidents, and drowsy driving. infants and children who are obese, and those with Down syndrome or other craniofacial abnormalities. Obstructive Sleep Apnea, Pediatric © Jones & Bartlett Learning, LLC © JonesEven mild& Bartlett cases of pediatricLearning, OSA LLC can have lasting and Like OSA in adults, pediatric OSA is characterized severe effects. OSA in infants and children can impact NOT FOR SALEby obstructive OR DISTRIBUTION apneas and hypopneas. The events NOTboth FOR physical SALE and OR mental DISTRIBUTION growth, and it is believed to

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F3-M2 © Jones & Bartlett Learning, LLC © Jones & BartlettF4-M1 Learning, LLC NOT FOR SALEC3-M2 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C4-M1 O1-M2 O2-M1 E1-M2 E2-M2 Chin © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ECG NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore L Leg R Leg Cannula © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Thermistor NOTThorax FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Abdomen SpO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC FIGURE 2-7 An obstructive apnea. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

F3-M2 F4-M1 C3-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C4-M1 O1-M2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION O2-M1 E1-M2 E2-M2 Chin © JonesEKG & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTSnore FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ptaf Thermistor Thorax Abdomen L leg © Jones & BartlettR leg Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALESpO2 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-8 A hypopnea followed by a subtle arousal and leg kick. Figure by Lisa M. Endee; produced from a sleep study provided to Stony Brook University School of Health Technology and Management’s Polysomnographic Technology Program by Dr. Kala Sury.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC be associated with suddenNOT FORinfant SALEdeath syndrome OR DISTRIBUTION, an opioid medications, as well asNOT in patients FOR using SALE OR DISTRIBUTION occurrence in which an infant dies during sleep seem- continuous positive airway pressure (CPAP) for the ingly without warning. Diagnostic criteria for pedi- first time or those with high CPAP pressures. atric OSA require an average of only one obstructive The normal drive to breathe is prompted by the apnea or hypopnea per hour of sleep. levels of carbon dioxide (CO2) in our bodies. Normal © Jones & Bartlett Learning, LLC CO2 levels ©range Jones from &35 Bartlettmm to 45 Learning,mm Hg. When LLC CentralNOT SleepFOR SALEApnea ORSyndromes DISTRIBUTION CO2 levels NOTare high FOR (hypercapnia SALE OR), feedback DISTRIBUTION loops Currently, there are eight different central sleep relay a message to the brain to prompt breathing, and apnea syndromes. Central sleep apnea (CSA) is CO2 levels are reduced at exhalation. Conversely, low hypocapnia characterized by cessation of airflow with a concur- CO2 levels ( ) decrease the drive to breathe. © Jones & rentBartlett cessation Learning, of respiratory LLC effort. Central apneas © JonesCSA is & thought Bartlett to result Learning, from an LLCunstable ventilatory control, especially during sleep–wake transitions, and NOT FOR SALEare often OR seen DISTRIBUTION in older patients, those with conges- NOT FOR SALE OR DISTRIBUTION tive heart failure, neurological conditions, or on low CO2 levels that are more likely to drop below the

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Central Sleep Apnea with Cheyne–Stokes © Jones &apnea Bartlett threshold. Learning, Patients LLC with resting partial pressure© Jones & Bartlett Learning, LLC carbon dioxide (PaCO ) levels less than 40 mm Hg are Breathing NOT FOR SALE OR DISTRIBUTION2 NOT FOR SALE OR DISTRIBUTION more likely to have CSA. Cheyne–Stokes breathing is characterized by a pat- Diagnostic features of CSA include an aver- tern of central apnea or hypopnea alternating with a age of at least five central apneas per hour during distinct waning and waxing breathing pattern. This sleep. Occasional central apneas are also common pattern is typically seen during nonrapid eye move- Figure 2-9 at sleep onset. © Jones illustrates & Bartlett a typical cenLearning,- LLCment (NREM) sleep and is corrected© Jones during & Bartlett REM. Learning, LLC tral apnea. The airflowNOT ceases FOR at SALEthe same OR time DISTRIBUTION as Most patients with Cheyne–StokesNOT FOR breathing SALE are OR DISTRIBUTION the respiratory effort and resumes as the breathing males over age 60. The diagnostic criteria for Cheyne– effort resumes. Stokes breathing is five or more central apneas or The sample epoch inFigure 2-10 shows a cen- hypopneas per hour of sleep, greater than 50% of the tral apnea. The airflow drops as a result of the lack total respiratory events being central in origin, and a of respiratory© Jones effort.& Bartlett When Learning,the patient attempts LLC to crescendo–decrescendo© Jones & pattern. Bartlett Learning, LLC breatheNOT at FOR the end SALE of the ORapnea, DISTRIBUTION he is able to do so NOT FOR SALE OR DISTRIBUTION without any difficulty because there is no obstruction Central Sleep Apnea Due to a Medical Disorder present. without Cheyne–Stokes Breathing Figure 2-11 The sample epoch in shows another Medical conditions such as degenerative brain stem © Jones & centralBartlett apnea, Learning, approximately LLC 15 seconds long. Notice in© Joneslesions & have Bartlett been known Learning, to cause centralLLC respiratory these samples that there is almost no oxygen desatura- NOT FOR SALE OR DISTRIBUTION NOTevents. FOR InSALE this case, OR the DISTRIBUTION central respiratory events occur tion, as is common in central events. as a secondary disorder. In this disorder, five or more Figure 2-12 is another example of a central apnea, central apneas or hypopneas per hour of sleep, greater this one during REM and lasting at least 20 seconds. than 50% of the total respiratory events being central in

Effort © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-9 A typical central apnea.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC F3-M2 NOT FOR SALEF4-M1 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C3-M2 C4-M1 O1-M2 O2-M1 E1-M2 E2-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chin NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ECG Snore L leg R leg ©Cannula Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Cessation of airflow ThermistorNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thorax Cessation of effort Abdomen SpO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FOR SALEFIGURE 2-10OR AnotherDISTRIBUTION central apnea. NOT FOR SALE OR DISTRIBUTION

9781284189490_CH02_Endee.indd 22 17/12/19 10:11 PM Sleep-Related Breathing Disorders 23

F3-M2 © Jones & BartlettF4-M1 Learning, LLC © Jones & Bartlett Learning, LLC C3-M2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALEC4-M1 OR DISTRIBUTION O1-M2 O2-M1 E1-M2 E2-M2 Chin © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

ECG NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore L Leg R Leg Cannula Thermistor© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thorax Abdomen SpO2

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Central apnea…cessation of airflow and respiratory effort NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-11 A 15-second-long central apnea.

F3-M2 F4-M1 C3-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C4-M1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION O1-M2 O2-M1 E1-M2 E2-M2 © JonesChin & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTECG FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore L Leg R Leg Cannula © Jones & BartlettThermistor Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEThorax OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Abdomen SpO2

© Jones & Bartlett Learning,Central LLC apnea…cessastion of airflow ©and Jones respiratory & effort Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-12 A central apnea during REM and lasting at least 20 seconds.

origin, and the absence of a crescendo–decrescendo pat- an altitude adjustment such as this is considered a nor- tern is diagnostic. mal response, and the condition tends to correct itself © Jones & Bartlett Learning, LLC when the subject© Jones returns & toBartlett lower altitudes. Learning, LLC CentralNOT Sleep FOR Apnea SALE Due OR to DISTRIBUTION High-Altitude Periodic NOT FOR SALE OR DISTRIBUTION Breathing Central Sleep Apnea Due to a Medication or Substance High-altitude periodic breathing disorder is characterized by central apneas and hypopneas occurring during Certain drugs, including methadone and hydrocodone, © Jones & aBartlett recent ascent Learning, to at least LLC4,000 meters (approximately © Joneshave been & Bartlett known to Learning, occasionally LLCcause central respi- NOT FOR SALE12,000 feet). OR TheDISTRIBUTION events occur at least five times per NOTratory FOR events. SALE In OR this DISTRIBUTIONcase, the disorder is secondary hour of sleep. The occurrence of central events during in nature.

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Primary Central Sleep Apnea 2 © Jones & Bartlett Learning, LLC © Jonesmass index& Bartlett (BMI) (measured Learning, by kg/mLLC) greater than 30, and the absence of a medical disorder or medi- NOT FOR SALEPrimary ORcentral DISTRIBUTION sleep apnea is idiopathic and cannot beNOT FOR SALE OR DISTRIBUTION explained by the use of a medication, substance, or the cation that may cause hypoventilation. Overnight presence of a medical illness. Diagnostic criteria include sleep testing on patients with OHS often reveals five or more central apneas or hypopneas per hour of worsening of hypoventilation during sleep, espe- sleep, greater than 50% of the total respiratory events cially during REM, and the presence of obstructive being central in origin,© Jonesand the absence & Bartlett of a crescendo– Learning, LLCsleep apnea. © Jones & Bartlett Learning, LLC decrescendo pattern.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Congenital Central Alveolar Hypoventilation Primary Central Sleep Apnea of Infancy Syndrome This life-threatening disorder occurs in infants Congenital central alveolar hypoventilation syndrome (CCHS) is a rare disorder characterized by the failure of auto- who© are at Jones least & 37 Bartlett weeks conceptional Learning, age, LLC and © Jones & Bartlett Learning, LLC is characterized by prolonged central apnea, last- matic central control of breathing attributed to a genetic ingNOT at least FOR 20 seconds SALE (or OR a periodic DISTRIBUTION breathing mutation inNOT the PHOX2B FOR SALE gene. Patients OR DISTRIBUTION with CCHS pattern at least 5% of the sleep time), desatura- experience sleep-related hypoventilation, hypercapnia, tion, and apnea or cyanosis noted by an observer. and oxygen desaturation. Hypoventilation may also be Primary central sleep apnea of infancy is usually present during wakefulness but is typically worse dur- © Jones & attributedBartlett toLearning, a developmental LLC issue or secondary to © Jonesing sleep. & Bartlett The condition Learning, usually firstLLC appears at birth but another medical condition. It is extremely dangerous may present later in life in some individuals. The disor- NOT FOR SALEfor newborns OR DISTRIBUTION and should be diagnosed and treated as NOTder FOR persists SALE for life OR and DISTRIBUTION often requires lifelong treatment quickly as possible. with ventilatory support.

Primary Central Sleep Apnea of Prematurity Late-Onset Central Hypoventilation Central sleep apnea is© common Jones in& premature Bartlett infantsLearning, LLCwith Hypothalamic Dysfunction© Jones & Bartlett Learning, LLC and sometimes requiresNOT ventilator FOR SALE support. OR The DISTRIBUTION diag- Patients with late-onset centralNOT hypoventilation FOR SALE with OR DISTRIBUTION nostic criteria for primary central sleep apnea of pre- hypothalamic dysfunction are typically healthy until maturity includes being a conceptional age of less than approximately age two, when they develop severe 37 weeks and either recurrent central apneas of at least obesity and central hypoventilation. Diagnostic crite- 20 seconds in duration or periodic breathing for at least ria include the absence of symptoms during the first 5%© of Jonesthe duration & Bartlett of sleep study Learning, monitoring. LLC The con- few years of© life, Jones sleep-related & Bartlett hypoventilation, Learning, lack LLCof ditionNOT usually FOR improves SALE with OR maturation DISTRIBUTION of the ventila- PHOX2B geneNOT mutation, FOR SALEobesity, ORand eitherDISTRIBUTION endocrine tory control centers. dysfunction, neural tumor, or severe psychosocial disturbance. Patients with this disorder will often require Treatment-Emergent Central Sleep Apnea ventilatory support during sleep. Treatment-emergent central sleep apnea, often referred © Jones & toBartlett as complex Learning, sleep apnea LLC, is diagnosed after the © JonesIdiopathic & Bartlett Central AlveolarLearning, Hypoventilation LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION patient has been diagnosed with OSA and has had a Formerly called alveolar hypoventilation or central subsequent PAP titration. After resolution of obstruc- alveolar hypoventilation, idiopathic central tive events during the titration, central events emerge alveolar hypoventilation is defined in the ICSD-3 as and persist with at least five central events per hour of “the presence of alveolar ventilation resulting in sleep- sleep. These patients© are Jones often placed& Bartlett on bi-level Learning, PAP LLCrelated hypercapnia and hypoxemia© Jones in individuals & Bartlett with Learning, LLC therapy, sometimes with a backup rate to help resolve presumed normal mechanical properties of the lung NOT FOR SALE OR DISTRIBUTION 3 NOT FOR SALE OR DISTRIBUTION the central events. and respiratory pump.” Diagnostic criteria for this disorder include the presence of sleep-related hypoven- Sleep-Related Hypoventilation Disorders tilation that cannot be attributed to impairments in Sleep-related hypoventilation disorders have the com- respiration, obesity, medication use, or another medical disorder. The disorder usually presents in adolescence mon© featureJones of &abnormally Bartlett elevated Learning, arterial LLC PCO2 © Jones & Bartlett Learning, LLC (>45 mmHg),NOT FOR or SALEhypercapnia, OR DISTRIBUTIONduring sleep. and is graduallyNOT progressive. FOR SALE OR DISTRIBUTION

Obesity Hypoventilation Syndrome Sleep-Related Hypoventilation Due to a Medication or Substance Also referred to as hypercapnic sleep apnea, obesity hypoventilation syndrome (OHS) © Jones & Bartlett Learning, LLC is characterized by © JonesThis &disorder Bartlett is characterized Learning, by LLC hypoventilation hypoventilation during sleep in obese individuals. during sleep that can be attributed to a medica- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Diagnostic criteria for this disorder include a PaCO2 tion or other substance that is known to reduce greater than 45 mm Hg during wakefulness, a body ventilatory drive.

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Sleep-Related Hypoventilation Due to a Medical © Jones & Bartlett Learning, LLC © Jonesairway, & effectively Bartlett eliminatingLearning, apnea, LLC hypopnea, flow Disorder NOTlimitation, FOR SALE and snoring. OR DISTRIBUTION Alternative treatment options NOT FOR SALE OR DISTRIBUTION include dental appliances, positional therapy, and vari- This disorder is characterized by hypoventilation during ous surgical procedures. The effectiveness of many of sleep that can be attributed to an underlying medical these treatments varies greatly according to the severity disorder, including airway disease, muscular and neuro- and other characteristics of the patient. logical disorders, and disorders affecting the chest wall, In infants and children with large tonsils or adenoids, not including obesity.© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the most appropriate first-line OSA treatment would be NOT FOR SALE OR DISTRIBUTIONtonsillectomy adenoidectomyNOT FOR SALE OR DISTRIBUTION Sleep-related Hypoxemia Disorder a or . CPAP is occasionally prescribed but should be used with careful consider- This diagnosis is applied when significant oxygen desat- ation. Treatment of central apnea and hypoventilation uration during sleep is present to levels at or below 88% disorders includes using bi-level therapy and other in adults© Jones and at & or Bartlett below 90% Learning, in children. InLLC this disor- modes of ventilatory© Jones support. & Bartlett These therapiesLearning, will LLCbe der, the hypoxemia is not associated with hypoventila- discussed in more detail in subsequent chapters. tionNOT or primarily FOR SALE attributed OR to DISTRIBUTIONobstructive or central NOT FOR SALE OR DISTRIBUTION sleep apneic–hypopneic events. Often, primary lung disease is an underlying factor of this disorder. Central Disorders of Hypersomnolence Isolated Symptoms and Normal Variants © Jones & Bartlett Learning, LLC © JonesThe ICSD-3 & Bartlett refers toLearning, this group ofLLC sleep disorders NOT FOR SALEThis subcategory OR DISTRIBUTION includes sleep-related symptoms thatNOT as FOR those SALE in which OR “the DISTRIBUTION primary complaint is daytime may be benign in some patients but can be indicative of sleepiness not caused by disturbed nocturnal sleep or the presence of an underlying sleep disorder. Often the misaligned circadian rhythms.”3 Sleepiness can often be symptoms warrant further testing to rule out a primary classified by questionnaires such as the Epworth Sleepi- sleep disorder. ness Scale or the Stanford Sleepiness Scale or by tests © Jones & Bartlett Learning, LLCsuch as the multiple sleep latency© Jones test (MSLT) & Bartlett or the Learning, LLC Snoring NOT FOR SALE OR DISTRIBUTIONmaintenance of wakefulness NOTtest. FOR SALE OR DISTRIBUTION Snoring is an audible vibration of the upper airway during sleep. It is most often associated with inspiration Narcolepsy Type I but can occur during the expiration as well. Snoring is The termnarcolepsy is derived from the Greek words caused by turbulent airflow moving through the airway. narke, meaning numbness or stupor, and lepsis, meaning The© intensity Jones can& Bartlettvary from Learning,mild to loud and LLC can cause © Jones & Bartlett Learning, LLC attack. As the name suggests, narcolepsy is a disorder theNOT person FOR to wake SALE up or disruptOR DISTRIBUTION a bedpartner or others NOT FOR SALE OR DISTRIBUTION characterized by sleep attacks. Narcolepsy is primarily in adjacent rooms. Snoring often leads to dry mouth or caused by a physiological or pathological abnormal- irritated tissues in the throat. If snoring is not associ- ity. Although the severity and symptoms of narcolepsy ated with symptoms, it is referred to as primary snoring. may vary greatly between individuals, the disorder However, snoring is one of the most common symptoms includes a variety of symptoms, which may include EDS, © Jones & ofBartlett obstructive Learning, sleep apnea. LLC Therefore, the occurrence of© Jones & Bartlett Learning, LLC cataplexy, and other REM sleep phenomena such as daytime sleepiness, fatigue, insomnia, frequent arousals, NOT FOR SALE OR DISTRIBUTION NOTsleep FOR paralysis SALE and OR hypnagogic DISTRIBUTION hallucinations. These gasping, choking, or witnessed pauses in breathing or if four characteristics constitute the narcolepsy tetrad. the patient has been diagnosed with hypertension, cog- Few narcoleptic patients suffer from all of the listed nitive dysfunction, coronary artery disease, stroke, con- symptoms, but many suffer from more than one. Fre- gestive heart failure, atrial fibrillation, or type 2 diabetes quent and often irresistible napping is also a common warrants further evaluation© Jones through & Bartlett sleep testing. Learning, LLC © Jones & Bartlett Learning, LLC symptom of narcolepsy. Another common symptom of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Catathrenia narcolepsy seen in approximately 20% to 40% of narcoleptics is automatic behavior, which is characterized Sleep-related groaning catathrenia , or , consists of by the subconscious performance of activities. Often repeated groaning during exhalation, mainly in REM these activities appear to be performed deliberately. sleep. Typically the patient is not affected by this disor- © Jones & Bartlett Learning, LLC A common© example Jones of a&utomatic Bartlett behavior Learning, is speaking LLC der, but the bed partner’s sleep is often disrupted as a on a subject matter that is completely out of context for result.NOT This FOR disorder SALE is rare OR but DISTRIBUTION appears to be more com- the situation.NOT FOR SALE OR DISTRIBUTION mon in males than in females. Excessive daytime sleepiness is the most com- Sleep-Related Breathing Disorders mon symptom of narcolepsy. EDS can manifest itself Treatment Options in many ways, including difficulty concentrating, © Jones & Bartlett Learning, LLC © Jonesdifficulty & Bartlett remaining Learning, awake during LLCnormal waking hours, The most effective and common treatment option for decreased cognition, napping, hallucinations, memory NOT FOR SALEOSA is CPAPOR DISTRIBUTIONtherapy. This mode of treatment uses airNOT loss, FOR and SALE decreased OR performance DISTRIBUTION in work-related tasks. pressure to act as a split to maintain the patency of the Memory loss and difficulty concentrating as a result of

9781284189490_CH02_Endee.indd 25 17/12/19 10:11 PM 26 CHAPTER 2 Sleep Disorders

muscles that occurs on awakening or at sleep onset. When © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLChypnagogic NOToccurring FOR SALE at sleep OR onset, DISTRIBUTION this is called ; when NOT FOR SALE OR DISTRIBUTION it occurs on awakening, it is referred to as hypnopompic. The average REM latency for a normal, healthy adult sleeper is 90–120 minutes; in contrast, narcoleptics with sleep paralysis may enter REM sleep immediately © Jones & Bartlett Learning, LLCor almost immediately after sleep© Jones onset. Sleep & Bartlett paralysis Learning, LLC NOT FOR SALE OR DISTRIBUTIONoccurs in approximately 25% ofNOT narcoleptic FOR patientsSALE andOR DISTRIBUTION is also often associated with hypnagogic or hypnopompic hallucinations, which are seen in approximately 30% of narcoleptic sufferers. Hallucinations experienced by narcoleptic patients are characterized by vivid, dreamlike © Jones & Bartlett Learning, LLC experiences ©occurring Jones at & sleep Bartlett onset or Learning, on awakening. LLC NOT FOR SALE OR DISTRIBUTION They are oftenNOT accompanied FOR SALE by intense OR feelingsDISTRIBUTION of fear. FIGURE 2-13 Individuals with narcolepsy often experience severe Sleep paralysis and hypnagogic and hypnopompic halluci- Excessive Daytime Sleepiness, which can lead to poor performances nations may also be seen in patients other than narcolep- in school or at work. tics who are severely sleep deprived. © Cristi Lucaci/Shutterstock. Typical onset for narcolepsy is during the late teen © Jones & Bartlett Learning, LLC © Jonesyears or& earlyBartlett twenties. Learning, It is now established LLC that narco- NOT FOR SALEEDS often OR lead DISTRIBUTION to poor performance in school or work NOTlepsy FOR type SALE I is caused OR byDISTRIBUTION a deficiency in hypocretin sig- (see Figure 2-13). Excessive daytime sleepiness can also naling in the hypothalamus. In some cases, severe head negatively affect one’s personal relationships. Individu- injuries and brain tumors have been known to cause als experiencing profound EDS are also at an increased narcolepsy. risk for automobile accidents and work-related acci- Narcoleptic patients often suffer from depression, dents. Nearly half of narcoleptics have reported falling possibly as a result of the inability to carry out certain 5© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC asleep at the wheel. NOTNarcoleptic FOR patients SALE are OR often DISTRIBUTION normal activities, and they areNOT often FOR underachievers. SALE OR DISTRIBUTION able to detect an oncoming sleep attack in time to fight This can also lead to low self-esteem. it off. Narcoleptics, however, are known to fall asleep Because of the large number of sleep disorders with unintentionally and at inappropriate times, such as in resulting symptoms similar to those of narcolepsy, diag- the middle of a conversation, while laughing, or during nosing the disorder may be difficult. Physicians suspect- sexual© Jones activity. &Even Bartlett those who Learning, fight off sleep LLC attacks ing narcolepsy© Jones may have & the Bartlett patient complete Learning, certain LLC microsleep mayNOT experience FOR periodsSALE of OR DISTRIBUTION. Microsleep is sleepiness scalesNOT or FOR a sleep SALE diary. MostOR DISTRIBUTIONimportantly, the a brief lack of consciousness or awareness. Often, the physician should order an MSLT preceded by an over- microsleep period is so brief the individual may not be night diagnostic sleep study. The overnight diagnostic aware that it occurred. Scheduled nap periods may help sleep study is to rule out the presence of other sleep narcoleptic patients momentarily with feelings of EDS disorders such as OSA or periodic limb movement dis- © Jones & andBartlett the occurrence Learning, of periods LLC of microsleep. © Jonesorder, &which Bartlett are often Learning, the underlying LLC causes of certain One of the most well-known and disruptive symp- narcoleptic symptoms. The MSLT is performed the NOT FOR SALEtoms of ORnarcolepsy DISTRIBUTION is cataplexy. Cataplexy comes from NOTfollowing FOR SALE day and OR consists DISTRIBUTION of a series of five short nap the Greek words kata, meaning down, and plexis, opportunities. The patient is given 20 minutes to fall meaning stroke or seizure. Cataplexy is sometimes asleep. If the patient does not sleep, the nap opportu- mistaken for seizure activity and is characterized by a nity is ended and the patient is moved out of the bed. bilateral loss of muscle© tone,Jones usually & Bartlett provoked Learning,by strong LLCIf the patient falls asleep, he or© sheJones is monitored & Bartlett for the Learning, LLC emotion. It manifests itself as muscle weakness that can next 15 minutes. Whereas the average sleep latency range from a mild feelingNOT of FOR weakness SALE to complete OR DISTRIBUTION limb for normal sleepers usually rangesNOT from FOR 5 minutes SALE toOR DISTRIBUTION atonia with a resulting fall. Patients suffering from cata- 20 minutes and REM latency falls between 60 minutes plexy may drop items they are holding, which can cause and 120 minutes, more than 80% of narcoleptic patients embarrassment or be hazardous. Periods of cataplexy have an average sleep latency of less than 5 minutes and usually© Jones last only & a Bartlett few seconds, Learning, but if prolonged LLC they experience ©significantly Jones & reduced Bartlett REM Learning, latencies. Dur-LLC mayNOT lead toFOR a period SALE of REM OR sleep. DISTRIBUTION Cataplexy is seen in ing the MSLT,NOT the FOR15-minute SALE sleep OR period DISTRIBUTION is evaluated approximately 70% of narcoleptics, but often these indi- for two main outcomes: sleep latency and the presence viduals are able to control the symptoms by controlling of a sleep-onset REM period (SOREMP). The diagnostic emotional stimuli. Narcolepsy type I includes the diag- criteria for narcolepsy include the irresistible need to nosis of narcolepsy with the complaint of cataplexy. This sleep or daytime lapses into sleep for at least 3 months © Jones & typeBartlett was formerly Learning, called narcolepsyLLC with cataplexy. © Jonesand either & Bartlett (1) a mean Learning, sleep latency LLC of 8 minutes or NOT FOR SALESleep OR paralysis, DISTRIBUTION another symptom of narcolepsy, is NOTless FOR during SALE an MSLT OR andDISTRIBUTION at least two sleep-onset REM characterized by a partial or total paralysis of skeletal periods during the five MSLT naps and previous night’s

9781284189490_CH02_Endee.indd 26 17/12/19 10:11 PM Central Disorders of Hypersomnolence 27

© Jones &diagnostic Bartlett study Learning, or (2) hypocretin-1 LLC concentrations © JonesIdiopathic & Bartlett Hypersomnia Learning, LLC <110pg/mL. Narcolepsy type I patients report cataplexy NOT FOR SALE OR DISTRIBUTION NOTIdiopathic FOR SALE hypersomnia OR DISTRIBUTION is characterized by daily but narcolepsy type II patient do not. Ultimately, the periods of the irrepressible need to sleep for at least final diagnosis must consider medical history, physi- 3 months, nonrefreshing naps, decreased sleep cal examination, patient questionnaires, and sleep latency (mean sleep latency less than or equal to study results. 8 minutes on an MSLT), an absence of cataplexy, and Narcolepsy currently© Jones has no known& Bartlett cure, but Learning, certain LLCa 24-hour sleep period of at ©least Jones 11 hours. & Bartlett Although Learning, LLC behavioral and medicalNOT treatments FOR SALE have been OR shown DISTRIBUTION many of these symptoms mayNOT be common FOR SALE symptoms OR DISTRIBUTION to be effective in treating its symptoms. A behavioral of other sleep disorders, the diagnostic criteria for this treatment that has been shown to be highly effective in disorder require that other relevant sleep disorders be narcoleptics is taking short, regularly scheduled naps ruled out. during the daytime. Narcoleptics also may find it helpful to discuss© Jones their & disorder Bartlett and Learning,its associated LLCsymptoms Kleine-Levin© JonesSyndrome & Bartlett Learning, LLC withNOT friends, FOR family SALE members, OR DISTRIBUTIONand coworkers. Doing so NOT FOR SALE OR DISTRIBUTION can help relieve some of the embarrassment and stress Also referred to as recurrent hypersomnia or that may occur with EDS and some of the other symp- periodic hypersomnolence, Kleine-Levin syndrome is toms of narcolepsy. a rare disorder that occurs when a patient experiences Perhaps the most significant behavioral treatment repeating episodes of hypersomnia (excessive sleep- © Jones & forBartlett narcoleptics Learning, is to practice LLC proper sleep hygiene. © Jonesing). Episodes & Bartlett can range Learning, from 2 days LLC to 5 weeks, with NOT FOR SALESleep hygiene OR DISTRIBUTION techniques include practices that are NOTan FOR average SALE episode OR lasting DISTRIBUTION approximately 10 days and beneficial to the quality of one’s sleep, and they have recurring at least once a year. During the episodes, been shown to be effective in improving a patient’s abil- patients may sleep 16–18 hours a day and have associ- ity to initiate and maintain sleep and remain awake and ated symptoms, including hallucinations, confusion, alert during the daytime. Examples of sleep hygiene excessive eating, and disinhibited behaviors. Between practices include retiring© Jones and awakening & Bartlett at consistent Learning, LLCepisodes the patients exhibit© normal Jones levels & Bartlettof alertness, Learning, LLC times from day to day;NOT avoiding FOR caffeine, SALE alcohol,OR DISTRIBUTION and mood, behavior, and cognitiveNOT function. FOR Kleine-Levin SALE OR DISTRIBUTION sedatives; getting regular exercise but avoiding heavy syndrome typically occurs first during adolescence exercise within 4 hours of retiring; avoiding reading or and lasts 14 years on average. Males are twice as likely watching television while in bed; and avoiding greasy to be affected. The underlying cause is not fully under- or fatty foods and snacks. Consistently practicing stood, but several risk factors have been identified, proper© Jones sleep hygiene & Bartlett techniques Learning, can greatly LLC improve including birth© Jones and developmental & Bartlett issues Learning, and having LLC theNOT quality FOR of sleep SALE and the OR quality DISTRIBUTION of life for both nar- a Jewish heritage.NOT FORTreatment SALE of this OR disorder DISTRIBUTION is mainly coleptics and normal sleepers. supportive. In addition to behavioral modifications, narcoleptics may use certain medications to treat the disorder and Hypersomnia Due to a Medical Disorder its symptoms. The most common medications used This disorder exists when a primary medical condition to treat narcolepsy are central nervous system (CNS) © Jones & Bartlett Learning, LLC © Jonesis the underlying& Bartlett cause Learning, for hypersomnia. LLC Various medi- stimulants such as Provigil, Ritalin, and dexedrine. cal conditions can cause excessive sleepiness include NOT FOR SALEAmphetamine-like OR DISTRIBUTION stimulants such as methylphenidateNOT FOR SALE OR DISTRIBUTION neurologic, endocrine, and metabolic disorders. and methamphetamine are also commonly used to treat narcolepsy. CNS stimulants are the most commonly prescribed drugs for treating narcoleptics with Hypersomnia Due to a Medication or Substance excessive daytime sleepiness;© Jones REM & Bartlettsuppressants Learning, and LLC © Jones & Bartlett Learning, LLC antidepressants are often used to treat narcoleptics NOT FOR SALE OR DISTRIBUTIONThis disorder is present whenNOT the useFOR or abuse SALE of a ORdrug DISTRIBUTION with cataplexy, hypnagogic hallucinations, and sleep or medication is responsible for extended periods of paralysis. In recent years, fluoxetine and monoamine sleepiness or excessive sleep. This can occur as a result oxidase inhibitors have also been shown to be useful in of drug abuse or prescribed use of certain medications. treating cataplexy. © Jones & Bartlett Learning, LLC Hypersomnia© Jones Associated & Bartlett with Learning, LLC NarcolepsyNOT FOR Type SALE II OR DISTRIBUTION a PsychiatricNOT Disorder FOR SALE OR DISTRIBUTION Narcolepsy type II is characterized by a diagnosis of Patients with this disorder meet the diagnostic crite- narcolepsy as defined in the ICSD-3 but without the ria for hypersomnolence, but the daytime sleepiness presence of cataplexy. An additional diagnostic criterion is associated with an underlying psychiatric disorder. © Jones & forBartlett narcolepsy Learning, type II requires LLC that either cerebrospinal© JonesThis is& mostBartlett common Learning, among those LLC with mood disor- NOT FOR SALEfluid hypocretin-1 OR DISTRIBUTION concentration was not measured or NOTders FOR such SALE as depression, OR DISTRIBUTION bipolar disorder, and seasonal that it is measured at >110 pg/mL. affective disorder.

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© Jones &Insufficient Bartlett Learning, Sleep Syndrome LLC © JonesAdvanced & Bartlett Sleep–Wake Learning, Phase LLC Disorder NOT FOR SALEAn extremely OR DISTRIBUTIONcommon sleep disorder in today’s busy NOTAdvanced FOR SALE sleep–wake OR DISTRIBUTION phase disorder is characterized world, insufficient sleep syndrome is characterized by not by a significant advance in the primary sleep period sleeping long enough to satisfy physical and psychologi- compared to what is expected or desired. A patient cal needs. Common alternate terms include chronic sleep with this disorder has difficulty staying awake until the deprivation and sleep restriction. Diagnostic criteria for normal or expected bedtime, often falling asleep by 7 in insufficient sleep syndrome© Jones include & Bartlett daytime lapses Learning, into LLCthe evening. As a result, the patient© Jones awakens & Bartlett extremely Learning, LLC sleep, a total sleep timeNOT less thanFOR expected SALE for OR the DISTRIBUTIONpatient’s early in the morning. This is NOTcommon FOR in olderSALE adults OR DISTRIBUTION age for a period of at least 3 months, and an absence of who develop the lifestyle of eating and sleeping at ear- another sleep disorder, medication, or mental or physical lier times than they did at younger ages. disorder that may cause the symptoms. Sleep patterns, durations, and times are often recorded in a sleep log or Irregular Sleep–Wake Rhythm Disorder with© actigraphy. Jones & Although Bartlett insufficient Learning, sleep LLC syndrome © Jones & Bartlett Learning, LLC Irregular sleep–wake rhythm disorder is character- has many possible causes, it is common during the teen- NOT FOR SALE OR DISTRIBUTION ized by an abnormalNOT FOR and undefinedSALE OR circadian DISTRIBUTION rhythm age years when the need for sleep is high but the subject’s of sleep and wake times. Although the total sleep time lifestyle is not conducive to adequate sleep periods. during the 24-hour cycle is comparable with normal sleepers, the sleep periods come in the form of variable © Jones & CircadianBartlett Learning, Rhythm LLC Sleep–Wake © Jonessleep episodes& Bartlett rather Learning, than one primary LLC sleep period. Disorders Patients with irregular sleep–wake rhythm disorder NOT FOR SALE OR DISTRIBUTION NOToften FOR experience SALE OR periods DISTRIBUTION of insomnia and EDS rel- circadian rhythm The is an internal biological sleep– evant to the sleep–wake pattern they are experiencing. wake clock that all living organisms possess. In Although considered rare, irregular sleep–wake rhythm humans, this cycle is slightly longer than 24 hours disorder is experienced most commonly in patients with but is entrained (maintained on a 24 hour cycle) neurological or developmental disorders. daily by exposure to ©sunlight. Jones When & Bartlett an individual’s Learning, LLC © Jones & Bartlett Learning, LLC sleep period matchesNOT his or FOR her underlying SALE OR circadian DISTRIBUTION Non–24-Hour Sleep–WakeNOT Rhythm FOR SALE OR DISTRIBUTION rhythm, optimal sleep is most likely to be achieved. A Sleep Disorder circadian rhythm sleep–wake disorder (CRSWD) is characterized by a disturbance or disruption to the normal Formerly called free-running disorder, non–24-hour sleep–wake rhythm, either because of internal altera- sleep–wake rhythm sleep disorder is characterized tion© or Jones misalignment & Bartlett with what Learning, is required LLC by the indi- by a sleep–wake© Jones cycle that& Bartlett is not entrained Learning, to the LLC vidual’sNOT environment. FOR SALE A CRSWD OR DISTRIBUTION can cause the patient 24-hour light–darkNOT FOR cycle. SALE The patient’s OR DISTRIBUTION circadian to experience excessive daytime sleepiness, insomnia, or rhythm is often longer than 24 hours and marked by both, and its impact can extend to other adverse health a delay in the main sleep episodes each night. Over consequences, including detriments to physical, social, time, this creates a pattern that seems to “free run” emotional, or educational well-being. The complaints across the 24-hour period. Symptoms of non–24-hour © Jones & ofBartlett CRSWDs Learning, must be reported LLC for a period of at least © Jonessleep–wake & Bartlett rhythm Learning, sleep disorder LLC can vary over NOT FOR SALE3 months, OR and DISTRIBUTION the sleep disturbance cannot be attrib- NOTtime. FOR When SALE the ORsleep–wake DISTRIBUTION cycle is misaligned with uted to another sleep or medical disorder. Diagnoses of the external environment, symptoms of insomnia CRSWDs are often aided by the use of sleep diaries or and EDS can be severe. Conversely, when the cycle actigraphy monitoring. Actigraphy monitoring has the eventually aligns to external cues, the patient will be ability to track trends in the sleep–wake cycle over time, free from symptoms. Many patients with this disorder usually 7 days to 3 weeks,© Jones through & theBartlett use of a Learning,wearable LLCare blind. © Jones & Bartlett Learning, LLC sensor that tracks motion.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Shift Work Disorder Delayed Sleep–Wake Phase Disorder Patients with shift work disorder have work schedules Delayed sleep–wake phase disorder is characterized that overlap with the normal sleep period. Shift work- by ©a significant Jones & delayBartlett in the Learning,primary sleep LLCperiod com- ers often work© Jones during the & lateBartlett night, overnight,Learning, or LLC paredNOT to whatFOR is SALEexpected OR or desired. DISTRIBUTION A patient with this extremely earlyNOT morning FOR SALEhours. As OR a result DISTRIBUTION of the distur- disorder is unable to fall asleep at the desired time or bance of the underlying circadian rhythm, patients typi- at a time that is considered normal but is successful at cally experience EDS during their shifts and insomnia a later time in the night. As a result, the patient often during the daytime hours when they attempt to sleep. sleeps until late in the morning in an effort to achieve Many shift workers experience a variety of other detri- © Jones & theBartlett required Learning, sleep time. Delayed LLC sleep–wake phase dis-© Jonesments, & including Bartlett poor Learning, work performance, LLC impaired NOT FOR SALEorder is ORcommon DISTRIBUTION in adolescents or young adults who NOTjudgment, FOR SALE and episodes OR DISTRIBUTION of drowsy driving, as well as develop habits of staying up late at night. other health consequences.

9781284189490_CH02_Endee.indd 28 17/12/19 10:11 PM Parasomnias 29

Sleepwalking © Jones &Jet Bartlett Lag Disorder Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEJet lag disorder OR DISTRIBUTION occurs when an individual experiences NOTSleepwalking FOR SALE, also OR called DISTRIBUTION somnambulism (somna, asso- reduced sleep time and symptoms of EDS or insomnia ciated with sleep, and ambulate, to move) is a disorder as a result of travel across two or more time zones. This characterized by sitting up in bed, walking, or jump- disorder is also associated with impairments in daytime ing up and running from the bed. Sleepwalking can function, fatigue, and gastrointestinal disturbances. range from common behaviors such as walking calmly Duration and severity© of Jones symptoms & Bartlettdepends on Learning, the LLCthrough the bedroom or house© toJones other complex& Bartlett behav- Learning, LLC direction of travel, numberNOT FORof time SALE zones crossed, OR DISTRIBUTION and iors occurring out of the bed.NOT FOR SALE OR DISTRIBUTION individual tolerance. Sleep Terrors Circadian Rhythm Sleep Disorder Sleep terrors, also known as night terrors, are charac- Not Otherwise Specified © Jones & Bartlett Learning, LLC terized by awakenings© Jones from & Bartlett slow-wave Learning, sleep with feel- LLC ings of intense fear that often begin with a loud scream ThisNOT disorder FOR is SALEcharacterized OR DISTRIBUTIONby a disturbance to the NOT FOR SALE OR DISTRIBUTION normal circadian rhythm that does not meet the criteria or cry. Other signs consistent with fear will be evident for other disorders in this class of sleep disorders. Most such as sweating and increased heart and respiratory of these are secondary to medical conditions or medica- rates. During a sleep terror episode, individuals will tion or substance use. Examples of medical conditions often have their eyes open but are not responsive to © Jones & associatedBartlett withLearning, this condition LLC include disturbances © Jonesthe environment. & Bartlett When Learning, returning LLC to sleep after a sleep NOT FOR SALEfrom dementia, OR DISTRIBUTION Alzheimer’s disease, and movement NOTterror, FOR the SALE patient OR will DISTRIBUTION usually return directly to slow- disorders such as Parkinson’s disease. wave sleep and have no recollection of the event in the morning. Parasomnias Sleep-Related Eating Disorder A parasomnia is an unwanted physical movement © Jones & Bartlett Learning, LLCSleep-related eating disorder© is Jonescharacterized & Bartlett by Learning, LLC or action during sleep.NOT Commonly FOR SALE occurring OR para DISTRIBUTION- NOT FOR SALE OR DISTRIBUTION somnias include walking and talking in sleep. This repeated episodes of eating or drinking during arousals group of sleep disorders is subdivided into disorders from sleep. In most individuals affected, this disorder of arousal from NREM sleep, those associated with occurs on a nightly basis. Often the patient chooses junk REM sleep, and other parasomnias. Parasomnias foods that are not typically eaten during the day. Most can affect the patient or bedpartner and often result patients with this disorder are exceptionally difficult to © Jones & Bartlett Learning, LLC awaken during© Jones these episodes & Bartlett and have Learning, no recollection LLC in injuries,NOT FOR disruption SALE in OR sleep, DISTRIBUTION and other health NOT FOR SALE OR DISTRIBUTION consequences. of the episode in the morning. Patients with this disorder will often gain weight as a result of the high volume Disorders of Arousal from NREM Sleep of junk foods eaten during the night. They may also injure themselves while cooking during sleep or by eat- Disorders of arousal from NREM sleep are charac- ing strange combinations of foods or toxic substances. © Jones & terizedBartlett by incompleteLearning, awakenings LLC from sleep that © Jones & Bartlett Learning, LLC NOT FOR SALEare associated OR DISTRIBUTION with limited or absent responsiveness NOTREM-Related FOR SALE ParasomniasOR DISTRIBUTION to the environment, dream imagery, or recollec- REM-related tion of the event. Most episodes occur during stage Unlike NREM-related parasomnias, parasomnias N3 sleep and in the first third of the sleep period. occur during episodes of stage R. Because In general, disorders of arousal from NREM sleep episodes of REM sleep tend to be shorter in the begin- are common in children© Jones but tend & toBartlett decrease Learning, in LLCning of the sleep period and progressively© Jones & lengthen Bartlett Learning, LLC prevalence with age.NOT FOR SALE OR DISTRIBUTIONthroughout the course of the NOTnight, REM-relatedFOR SALE OR DISTRIBUTION parasomnias are often reported to occur in the early Confusional Arousals morning hours. confusional arousal A occurs when a person awakens REM Sleep Behavior Disorder (RBD) from© sleepJones in a & confused Bartlett state. Learning, On awakening, LLC individu- © Jones & Bartlett Learning, LLC REM sleep behavior disorder (RBD) consists of physical alsNOT exhibit FOR confusion SALE about OR who DISTRIBUTION they are, where they NOT FOR SALE OR DISTRIBUTION are, and what is happening around them. During the events or activities occurring during REM sleep. In nor- event, speech and cognition may be delayed, slurred, mal sleepers, muscle atonia occurs during REM. How- or slow. Confusional arousals are not associated with ever, in patients with RBD, muscle tone is maintained fear or movement to leave the bed. Other sleep disor- during REM sleep. As a result, isomorphism often occurs, © Jones & dersBartlett such as Learning, insomnia or hypersomniaLLC can increase the© Joneswhere &the Bartlett muscles move Learning, in response LLC to the patient’s dream content. On awakening, the patient is likely to NOT FOR SALEprevalence OR of DISTRIBUTION confusional arousals, as can shift work orNOT FOR SALE OR DISTRIBUTION sleep deprivation. remember the dream he or she acted out. Occasionally,

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© Jones &the Bartlett patient mayLearning, act out violently, LLC performing such acts as© Jonesthe patient & Bartlett may believe Learning, that he or sheLLC sees a flash of flailing arms, hitting, kicking, yelling, and so on. For thisNOT bright FOR light. SALE The ORepisodes DISTRIBUTION are not associated with com- NOT FOR SALEreason, sleep-relatedOR DISTRIBUTION injuries to both individuals and bed plaints of pain, usually last a few seconds, and can vary in partners are common with this disorder. Periodic limb frequency from many in one night to infrequent events. movements also frequently occur during REM in patients The disorder is more commonly reported in women, with with RBD. Polysomnograms with corresponding video an age of onset averaging 58 years. Most patients report are important to diagnose© Jones RBD by & documenting Bartlett Learning, the lack LLCthat symptoms resolve spontaneously© Jones over & several Bartlett years. Learning, LLC of muscle atonia and NOTassociated FOR movements. SALE OR Typically, DISTRIBUTION NOT FOR SALE OR DISTRIBUTION additional arm and EEG leads are used to detect move- Sleep-Related Hallucinations ments and rule out seizure activity. RBD is most com- Like sleep paralysis, sleep-related hallucinations are mon in men 50 and older. Recent research has come to common features of narcolepsy. Hypnagogic and hyp- identify the association of RBD with various neurological nopompic hallucinations often occur in patients with disorders such as Parkinson’s disease. © Jones & Bartlett Learning, LLC narcolepsy; ©the Jones patient experiences& Bartlett a visualLearning, hallucina- LLC NOT FOR SALE OR DISTRIBUTION tion either justNOT before FOR sleep SALE onset ORor at DISTRIBUTIONawakening. Recurrent Isolated Sleep Paralysis These hallucinations are often related to sleep-onset Sleep paralysis, a symptom sometimes associated with REM periods and may be frightening and vivid enough narcolepsy, refers to the inability to move at sleep onset to cause patients to jump out of bed and occasionally (hypnagogic) or on awakening (hypnopompic). The injure themselves. Diagnostic criteria for sleep-related © Jones & experienceBartlett isLearning, quite frightening, LLC and thus sleep paralysis © Joneshallucinations & Bartlett require Learning, the absence LLC of other sleep disor- NOT FOR SALEis often associatedOR DISTRIBUTION with anxiety and stress surrounding NOTders FOR such SALE as narcolepsy OR DISTRIBUTION that could be the primary cause. the bedtime period. Episodes of sleep paralysis may last These episodes occur more frequently in adolescents a few seconds to several minutes. Because sleep paralysis and young adults, with frequency decreasing with age. is a common symptom of narcolepsy, diagnostic criteria for recurrent isolated sleep paralysis requires that nar- Sleep Enuresis colepsy be ruled out.© Sleep Jones paralysis & Bartlett occurring Learning,outside LLC © Jones & Bartlett Learning, LLC Also called nocturnal enuresis or bedwetting, sleep the diagnosis of narcolepsyNOT FORis often SALE caused byOR periods DISTRIBUTION of NOT FOR SALE OR DISTRIBUTION enuresis is characterized by repeated episodes of invol- sleep deprivation or shifting sleep times or habits. untary urination during sleep. Because bladder control Nightmare Disorder is a normal developmental milestone, this diagnosis is reserved for patients 5 years of age and older. Diag- A nightmare© Jones is &a common Bartlett occurrence Learning, in which LLC a nostic criteria© Jonesfor sleep &enuresis Bartlett require Learning, that the events LLC personNOT has FOR an in tense,SALE frightening OR DISTRIBUTION dream that causes occur at leastNOT twice FOR a week SALE for at leastOR 3DISTRIBUTION months. In an awakening. Often on awakening, the person is still primary sleep enuresis, patients have never demon- frightened because of the intensity of the nightmare. strated the ability to stay dry during sleep, while in the Nightmares are common in children and are considered secondary disorder patients have demonstrated at least normal for this age group. As a person grows into ado- a 6-month period where they have stayed dry over the © Jones & lescence,Bartlett nightmares Learning, typically LLC reduce in frequency and © Jonescourse & of Bartlett the night. SecondaryLearning, sleep LLC enuresis can occur intensity. Nightmare disorder is diagnostic when the in patients with PTSD, those who are victims of abuse, NOT FOR SALEdreams orOR sleep DISTRIBUTION disturbance causes significant distress NOTor FOR those SALE who are OR experiencing DISTRIBUTION the enuresis as a result of to emotional, social, physical, or occupational well- a medical condition such as diabetes. Secondary enure- being. Nightmare disorder is common in patients with sis has been highly correlated to sleep apnea relevant posttraumatic stress disorder (PTSD). A patient with to the respiratory disturbance index. For this reason, PTSD is likely to experience© Jones nightmares & Bartlett that relive Learning, or LLCsleep-related breathing disorders© Jones should be& consideredBartlett Learning, LLC cause the patient to reexperience whatever event led as underlying in a patient 5 or older who exhibits bed- to PTSD. NightmaresNOT occur FOR during SALE REM sleep, OR whichDISTRIBUTION wetting but who was previouslyNOT dry. FOR SALE OR DISTRIBUTION is when most dreaming occurs, and often cause the person to delay falling back to sleep. Parasomnias Due to a Medical Disorder Other Parasomnias These disorders are diagnosed when a medical condition © Jones & Bartlett Learning, LLC can be identified© Jones as the &cause Bartlett of a parasomnia. Learning, For exam LLC- ThisNOT subcategory FOR SALE includes OR those DISTRIBUTION parasomnias that are not ple, certain NOTneurological FOR disorders SALE suchOR asDISTRIBUTION Parkinson’s dis- reported as being associated with specific sleep stages. ease or dementia can lead to sleep-related parasomnias.

Exploding Head Syndrome Parasomnias Due to a Medication or Substance Exploding head syndrome © Jones & Bartlett Learning, LLC is a sleep disorder character- © JonesThese & disorders Bartlett are Learning,diagnosed when LLC a parasomnia ized by an imagined loud noise or sense of explosion in can be attributed to a drug, medication use, or abuse. NOT FOR SALEthe head OR while DISTRIBUTION falling asleep or awakening. Occasionally,NOT Various FOR SALEmedications OR haveDISTRIBUTION the potential to prompt

9781284189490_CH02_Endee.indd 30 17/12/19 10:11 PM Sleep-Related Movement Disorders 31

© Jones ¶somnias. Bartlett Learning, For example, LLC some tricyclic antidepres- © Joneswith RLS & Bartlett is iron deficiency. Learning, Obstructive LLC sleep apnea, sants and treatments for Alzheimer’s disease can cause NOTParkinson’s FOR SALE disease, OR diabetes, DISTRIBUTION renal failure, and rheuma- NOT FOR SALERBD. Sedative OR DISTRIBUTION hypnotics and beta adrenergic medica- toid arthritis are other conditions associated with RLS. tions have also been associated with various NREM Certain medications such as antihistamines, antidepres- parasomnias. sants, and antipsychotics can worsen the symptoms of RLS. Medications used to treat RLS often include dopa- Isolated Symptoms© Jones and Normal & Bartlett Variants Learning, LLCmine agonists, opioids, benzodiazepines,© Jones & and Bartlett anticon- Learning, LLC vulsants. Massage and musculoskeletal manipulations Talking during sleepNOT can occur FOR at anySALE age, duringOR DISTRIBUTION any NOT FOR SALE OR DISTRIBUTION have also been found to be helpful in some cases. stage of sleep, and in people who are otherwise normal Sleep technicians should watch their patients care- and healthy. Sleep talking, also called somniloquy, is fully for signs of RLS and make note of them for the often considered benign unless it disturbs the sleep of physician. Because patients are often not aware of this the talker or the bed partner or is associated with other disorder, the technician should ask the patient appro- behaviors© Jones in sleep. & Bartlett Many people Learning, talk in their LLC sleep with- © Jones & Bartlett Learning, LLC priate questions to help the physician determine if RLS outNOT knowing FOR it until SALE they ORbegin DISTRIBUTION to share their room with NOT FOR SALE OR DISTRIBUTION is present. Many patients with RLS also have periodic someone else. limb movement disorder. Sleep-Related Movement Disorders Periodic Limb Movement Disorder (PLMD) Sleep-related movement disorders © Jones & Bartlett Learning, LLC are a class of sleep © JonesPeriodic & limbBartlett movement Learning, disorder LLC(PLMD) disorders characterized by simple, often repetitive move- , also called NOT FOR SALE OR DISTRIBUTION NOTperiodic FOR SALE limb movements OR DISTRIBUTION in sleep, and formerly known ments during sleep or the onset to sleep. These move- as nocturnal myoclonus, is a common sleep disorder ments disrupt the sleep of the patient, the bed partner, or affecting approximately one-third of adults 60 and older. both. As a result, patients with sleep-related movement This disorder occurs when the patient involuntarily disorders report disturbed nocturnal sleep and excessive moves the limbs (usually the legs) during sleep. The sleepiness during the© day. Jones Diagnosis & Bartlettof these disorders Learning, LLC © Jones & Bartlett Learning, LLC movements are repetitive, occur in periodic episodes, often necessitates overnightNOT FOR sleep testing SALE with OR video. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and are seen mostly in stage N2. Periodic leg move- Restless Legs Syndrome (RLS) ments are not usually seen during REM sleep because of the muscle atonia that occurs during REM. Restless legs syndrome (RLS) is a disorder character- The most common PLMD symptoms include fre- ized© by Jones the irresistible & Bartlett urge to Learning, move the body LLC while at quent EEG ©arousals, Jones fragmented & Bartlett sleep Learning, architecture, LLC day- rest.NOT Most FOR patients SALE report OR having DISTRIBUTION uncomfortable sensa- time sleepiness,NOT and FOR other SALE psychosocial OR DISTRIBUTION or occupational tions in their legs in the evening or at night, although impairments. The symptoms of PLMD tend to increase between 21% and 57% of patients report arm sensations with stress and certain medications such as tricyclic as well. The unusual feelings are described as creeping, antidepressants. A periodic limb movement disorder crawling, itchy, burning, or tingling and tend to increase not only affects the sleep of the individual suffering © Jones & duringBartlett periods Learning, of relaxation, LLC such as while watching © Jonesfrom the& Bartlettdisorder but Learning, also can affect LLC the sleep of the television, reading, or attempting to fall asleep. Individ- bed partner who is being kicked during the night. As a NOT FOR SALEuals suffering OR DISTRIBUTION from RLS often find themselves rubbing NOTresult, FOR PLMD SALE patients OR DISTRIBUTION are often referred to a physician or slapping their legs, twitching their muscles, bounc- by the spouse or bed partner. ing their feet, jerking their legs, and getting up to walk Diagnosis of PLMD requires the use of overnight around the room to alleviate feelings of restlessness. sleep testing. To be scored, limb movements must last The amount of time ©required Jones to &alleviate Bartlett the symptomsLearning, LLCbetween 0.5 and 5 seconds and© haveJones an amplitude & Bartlett of Learning, LLC of RLS can vary and often causes a delay in sleep onset. least 8 μV higher than the resting electromyogram As a result, RLS is oftenNOT associated FOR SALE with complaints OR DISTRIBUTION of (EMG) amplitude. Periodic limbNOT movements FOR SALE occur OR DISTRIBUTION insomnia at night, excessive sleepiness during the day, within 5–90 seconds of each other, and at least four and other psychosocial or occupational impairments. of these movements must occur to create a series. A The onset of RLS can occur at any age. RLS in chil- PLM index is calculated by dividing the total number dren© isJones often misdiagnosed & Bartlett as Learning, hyperactivity LLC or growing of periodic ©limb Jones movements & Bartlett by the total Learning, sleep time LLC in pains. Most RLS sufferers begin experiencing symptoms hours, giving an average number of periodic limb move- by NOTyoung FORadulthood SALE and continueOR DISTRIBUTION to experience these ments per hourNOT of FORsleep time.SALE PLMD OR is DISTRIBUTION diagnosed if the symptoms throughout their lives. RLS affects more than patient has a PLM index greater than 15 per hour in 5% of the total population in the United States. The adults or greater than 5 per hour in children. severity and frequency of RLS symptoms tend to vary The sample shown inFigure 2-14 shows a series of © Jones & withBartlett stress, Learning,pain, illness, orLLC other factors. Symptoms can© Jonessix periodic & Bartlett limb movements Learning, on a LLC 300-second epoch. appear during pregnancy and disappear immediately They are not associated with respiratory events, and NOT FOR SALEafter. The OR most DISTRIBUTION common medical condition associated NOTthey FOR occur SALE during OR NREM DISTRIBUTION sleep.

9781284189490_CH02_Endee.indd 31 17/12/19 10:11 PM 32 CHAPTER 2 Sleep Disorders

© Jones & BartlettF3-M2 Learning, LLC © Jones & Bartlett Learning, LLC F4-M1 NOT FOR SALEC3-M2 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C4-M1 O1-M2 O2-M1 E1-M2 E2-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Chin NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ECG Snore L Leg R Leg ©Cannula Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ThermistorNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thorax Abdomen SpO2

FIGURE 2-14 A series of six periodic limb movements on a 300-second epoch.

F3-M2 F4-M1 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC C3-M2 C4-M1 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION O1-M2 O2-M1 E1-M2 E2-M2 © JonesChin & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTECG FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore L Leg R Leg Cannula © Jones & BartlettThermistor Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEThorax OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Abdomen SpO2

© Jones & BartlettPeriodic Learning, limb movements LLC in both legs © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-15 Another 300-second epoch, this one showing four periodic limb movements.

The sample inFigure 2-15 shows another 300-second below). Because the respiratory events appear to be the epoch© Jones in which & four Bartlett periodic Learning, limb movements LLC occur. In primary cause© Jones of the limb & Bartlettmovements, Learning, PLMD would LLC thisNOT example, FOR both SALE legs are OR showing DISTRIBUTION movement. not be initiallyNOT diagnosed. FOR SALE If periodic OR limb DISTRIBUTION movements Other sleep disorders that could cause the limb persist after the sleep-disordered breathing is corrected, movements (for example, sleep-related breathing dis- then the patient would likely be diagnosed with PLMD. orders) should be ruled out or treated before making a The most common treatments for PLMD include diagnosis of PLMD. Figure 2-16 shows limb movements the use of certain medications. Benzodiazepines, which © Jones & (outlinedBartlett with Learning, dark circles) LLC in a 300-second epoch. In © Jonessuppress & Bartlettthe muscle Learning, contractions, LLC are perhaps the NOT FOR SALEthis case, OR the DISTRIBUTIONlimb movements are preceded by respi- NOTmost FOR commonly SALE ORprescribed DISTRIBUTION medications for PLMD. ratory events (outlined with lighter circles on the line Dopaminergic agents have been shown to regulate

9781284189490_CH02_Endee.indd 32 17/12/19 10:11 PM Sleep-Related Movement Disorders 33

© Jones & BartlettF3-M2 Learning, LLC © Jones & Bartlett Learning, LLC F4-M1 NOT FOR SALEC3-M2 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION C4-M1 O1-M2 O2-M1 E1-M2 E2-M2 Chin © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ECG NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Snore L Leg R Leg Cannula © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ThermistorNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thorax

Abdomen SpO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEFIGURE OR2-16 LimbDISTRIBUTION movements in a 300-second epoch preceded byNOT respiratory FOR events. SALE OR DISTRIBUTION

muscle movements during sleep. Anticonvulsant agents For many, a dental appliance such as a mouth guard is have also been effective in inhibiting the muscle con- appropriate and can be effective in preventing further tractions, and GABA© agonists Jones also & Bartletthelp relax muscleLearning, LLCdamage to the teeth. © Jones & Bartlett Learning, LLC contractions. NOT FOR SALE OR DISTRIBUTIONThe sample epoch inFigure NOT 2-17 FORshows aSALE patient ORwith DISTRIBUTION sleep-related bruxism. The events directly under the Sleep-Related Leg Cramps arrows show disruptions in the EEGs, electrooculograms, This disorder is characterized by intense and sudden chin EMG, and snore channel. When a patient clenches muscle cramps in the legs during sleep. These muscle his or her jaw or grinds teeth, many muscles in the face, cramps© Jones can last & up Bartlett to several minutes,Learning, are often LLC painful, head, jaw, and© neckJones will &tighten, Bartlett causing Learning, disruption inLLC andNOT result FORin the patientSALE waking OR DISTRIBUTION up from sleep, thereby several channels,NOT as FOR shown SALE in the figure. OR DISTRIBUTION Heavy snoring disturbing the sleep period. Sleep-related leg cramps can cause the same effect, so it is important that the tech- are common in the elderly and have been reported less nician make note of snores. In this case, the technician frequently in children and adolescents. This disorder has saw these events and noted that no snoring was present. Figure 2-18 been associated with numerous underlying conditions, The arrows in the sample shown in point to episodes of bruxism or grinding of the teeth or © Jones & includingBartlett diabetes, Learning, peripheral LLC vascular disease, neuro- © Jones & Bartlett Learning, LLC clenching of the jaw. NOT FOR SALEmuscular OR disorders, DISTRIBUTION and dehydration, as well as medica-NOT FOR SALE OR DISTRIBUTION The sample epoch inFigure 2-19 shows another tions including oral contraceptives, diuretics, and statins. example of sleep-related bruxism. The episodes of jaw Sleep-Related Bruxism clenching or teeth grinding are shown underneath the arrows. Again, the muscle activity is shown throughout Bruxism is grinding the© Jonesteeth or clenching& Bartlett the jaw.Learning, LLCall the leads on the head. © Jones & Bartlett Learning, LLC Sleep-related bruxism occurs when the sleeping patient rhythmic masticatoryNOT muscle FOR activitySALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION has or repeated Sleep-Related Rhythmic Movement Disorder or sustained jaw muscle contractions. The unusual and grating sound can cause the patient to awaken or dis- Sleep-related rhythmic movement disorder is charac- rupt the bed partner. The symptoms of sleep-related terized by repetitive and rhythmic body movements bruxism© Jones include & muscleBartlett soreness Learning, in the face, LLC locking of during drowsiness© Jones or sleep, & Bartlett and it often Learning, includes LLC body rocking head banging theNOT jaw, and FOR morning SALE headaches. OR DISTRIBUTION Over time, bruxism NOT or FOR SALE. As OR the namesDISTRIBUTION suggest, can wear away tooth enamel, predisposing the patient body rocking refers to the entire body moving back to cavities and tooth sensitivity. Bruxism is most com- and forth, whereas head banging refers to movements monly seen among children and adolescents, who typi- of the head. The movements usually begin near sleep cally grow out of the disorder; however, some people onset and typically persist for as long as 15 minutes. It is © Jones & experienceBartlett bruxismLearning, their LLCentire lives. The disorder is © Jonescommon & Bartlettfor infants Learning,and young children LLC to have sleep- NOT FOR SALEusually discoveredOR DISTRIBUTION or initially suspected by the patient’sNOT related FOR rhythmicSALE OR movements. DISTRIBUTION However, by age five, the dentist, who may see evidence of the teeth grinding. prevalence declines significantly. At any age, diagnostic

9781284189490_CH02_Endee.indd 33 17/12/19 10:11 PM 34 CHAPTER 2 Sleep Disorders

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION F3-M2 F4-M1 C3-M2 C4-M1 O1-M2 O2-M1 E1-M2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC E2-M2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chin ECG Snore L Leg © JonesR Leg & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTCannula FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Thermistor Thorax Abdomen © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC SpO2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-17 Sleep-related bruxism.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION F3-M2 F4-M1 C3-M2 C4-M1 O1-M2 O2-M1 © E1-M2Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTE2-M2 FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chin ECG Snore L Leg © Jones & BartlettR Leg Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALECannula OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Thermistor Thorax Abdomen SpO2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 2-18 Another episode of bruxism.

criteria for this disorder require that the behavior The condition is often confused with seizure activity and causes© Jones disturbance & Bartlett to sleep, impairedLearning, daytime LLC function, may prompt© further Jones investigation. & Bartlett However, Learning, it does LLCnot or NOThas caused FOR harm SALE to the OR individual. DISTRIBUTION appear to poseNOT any FOR serious SALE threat toOR the DISTRIBUTION infant’s sleep or health other than occasional arousals from sleep. Benign Sleep Myoclonus of Infancy Propriospinal Myoclonus at Sleep Onset Myoclonus describes limb jerks or movements. Benign © Jones & sleepBartlett myoclonus Learning, of infancy LLC is a rare disorder that occurs© JonesPropriospinal & Bartlett myoclonus Learning, at sleep LLConset is an event sim- NOT FOR SALEwhen repetitive OR DISTRIBUTION leg jerks or movements in sleep occur NOTilar FOR to a SALEsleep start OR but DISTRIBUTION mainly involves body movements during infancy, typically from birth to 6 months of age. in the abdominal, trunk, and neck areas. They typically

9781284189490_CH02_Endee.indd 34 17/12/19 10:11 PM Other Sleep Disorders 35

Thermistor Thorax Abdomen © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC SpO2 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

FIGURE 2-19 A third example of sleep-related bruxism.

occur at sleep onset ©or duringJones brief & Bartlettarousals from Learning, sleep LLCHypnagogic Foot Tremor and© Jones Alternating & Bartlett Learning, LLC and result in sleep-onsetNOT insomnia. FOR SALE OR DISTRIBUTIONLeg Muscle Activation NOT FOR SALE OR DISTRIBUTION Hypnagogic foot tremor Sleep-Related Movement Disorder Due to a is characterized by rhythmic leg or foot movements at sleep onset. Medical Disorder Alternating leg muscle activation is similar but presents This disorder is classified as movement disorders itself as a movement by one leg followed by a movement that disturb© Jones sleep & Bartlett and caused Learning, by an underlying LLC in the other© leg. Jones These &events Bartlett can cause Learning, brief arousals LLC or medicalNOT condition. FOR SALE Various OR neurological DISTRIBUTION conditions, awakeningsNOT from sleepFOR but SALE are typically OR DISTRIBUTION benign in most such as Parkinson’s disease, can cause involuntary patients who have no complaint of the movements or muscle movements during sleep and disrupt the associated daytime impairments. sleep period. Sleep Starts (Hypnic Jerks) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Sleep-Related Movement Disorder Due to a A sleep start, also called a hypnic jerk, is a sudden mus- NOT FOR SALEMedication OR DISTRIBUTIONor Substance NOTcle FOR jerk orSALE movement OR DISTRIBUTIONat sleep onset often accompanied This category is reserved for movement disorders by feelings of surprise, fear, or falling. Sleep starts are in sleep that are caused by drug use, abuse, or common and affect individuals of all ages but are typi- withdrawal. cally benign. They may disturb the sleep of the bed part- © Jones & Bartlett Learning, LLCner and sometimes cause difficulty© Jones returning & Bartlett to sleep. Learning, LLC Isolated SymptomsNOT and FOR Normal SALE Variants OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Excessive Fragmentary Myoclonus Other Sleep Disorders Excessive fragmentary myoclonus (EFM) is charac- These disorders are not classified in other categories terized by frequent small twitches of fingers, toes, or because either they overlap categories or are rela- muscles© Jones of the &mouth Bartlett during Learning, wake or sleep. LLC On a poly- tively new or© proposedJones &disorders Bartlett with Learning, limited data. LLC Although the ICSD-3 does not specifically list any somnogram,NOT FOR the SALEmovements OR appear DISTRIBUTION as isolated brief NOT FOR SALE OR DISTRIBUTION increases in EMG, which usually ranges from 50 to sleep disorders in this category, the ICSD-2 listed more than 100 microvolts. They are typically insignifi- environmental sleep disorder here. Environmental sleep cant and benign in nature. They occur during NREM disorder can consist of many different factors, includ- sleep and may persist from 10 minutes to several hours. ing a disorder held by the bed partner that is causing a © Jones & EFMBartlett has been Learning, associated LLCwith various sleep disorders. © Jonesdisruption. & Bartlett For example, Learning, if a person LLC has PLMD, the bed partner is likely to experience sleep disruptions, caus- NOT FOR SALEincluding OR sleep-related DISTRIBUTION breathing disorders, narcolepsy,NOT FOR SALE OR DISTRIBUTION and PLMD. ing EDS, fatigue, or insomnia. This would be considered

9781284189490_CH02_Endee.indd 35 17/12/19 10:11 PM 36 CHAPTER 2 Sleep Disorders

© Jones &an Bartlett environmental Learning, sleep disorder. LLC Other factors in the © Jonescorrected. & Bartlett Proper sleep Learning, hygiene refers LLC to practices such environment can cause these disruptions, such as poor NOTas FOR maintaining SALE a ORcomfortable DISTRIBUTION bedroom temperature, NOT FOR SALEroom temperature OR DISTRIBUTION or lighting, music, or leaving the not consuming caffeine shortly before bedtime, and not television on. watching television in bed. Sleep-related breathing disorders are pervasive Chapter Summary and occur most frequently in overweight and obese © Jones & Bartlett Learning, LLCindividuals. Obstructive sleep© apneaJones occurs & Bartlett when an Learning, LLC Seven main classes ofNOT sleep FOR disorders SALE have ORbeen DISTRIBUTIONiden- individual is unable to maintainNOT an FORopen airwaySALE during OR DISTRIBUTION tified by the American Academy of Sleep Medicine the night and suffers periods of no breathing. Chronic and are outlined and detailed in the ICSD-3. The main sleep apnea can lead to excessive daytime sleepiness, classes of sleep disorders are (1) insomnia, (2) sleep- morning headaches, frequent awakenings during the related breathing disorders, (3) central disorders of night, hypertension, memory loss, and other symp- hypersomnolence,© Jones & Bartlett (4) circadian Learning, rhythm sleep–wake LLC toms. Central© Jonessleep apnea & Bartlettdiffers from Learning, OSA in that LLC disorders,NOT FOR(5) parasomnias, SALE OR (6) DISTRIBUTION sleep-related movement the patient NOTis not attemptingFOR SALE to breathe OR DISTRIBUTION during the disorders, and (7) other sleep disorders. events. Rather than an obstruction in the upper airway Insomnia is the inability to initiate or maintain sleep causing the apnea, the central nervous system is the or restful, restorative sleep. Insomnia can be caused by underlying cause. a wide variety of factors ranging from stress and anxiety Central disorders of hypersomnolence cause exces- © Jones & toBartlett poor sleep Learning, hygiene. The LLC complaint of the inability to© Jonessive daytime & Bartlett sleepiness Learning, and include LLC disorders such as NOT FOR SALEfall asleep OR is aDISTRIBUTION symptom and does not always preclude NOTnarcolepsy FOR SALE that canOR be DISTRIBUTION debilitating and disruptive to the diagnosis of insomnia. For example, some patients normal daytime functions. Narcolepsy is characterized experience sleep state misperception and believe that by periods of REM at times when REM should not pres- they do not sleep or sleep little, when in actuality they ent itself, including during wakefulness. Symptoms of are sleeping. Frequently, after evaluating these patients narcolepsy can include excessive daytime sleepiness, further, it is discovered© Jonesthey have & other Bartlett underlying Learning, LLChypnagogic hallucinations, sleep© Jones paralysis, & and Bartlett cataplexy. Learning, LLC sleep disorders that reduceNOT FORthe quality SALE of sleep. OR InDISTRIBUTION these Circadian rhythm sleep–wakeNOT disorders FOR SALE are char OR- DISTRIBUTION cases, the underlying sleep disorder is diagnosed, not acterized by disruptions to the normal 24-hour sleep– the symptom of insomnia. Poor sleep hygiene can be wake cycle. These disruptions may be self-induced, a common contributor to insomnia, but it is easily externally induced, or caused by medical conditions

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC CaseNOT FOR Study SALE Example OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A 21-year-old women reports to the sleep disorders features are highly suggestive of narcolepsy. Alterna- center complaining of severe excessive daytime sleep- tively, hypersomnia is also possible. The patient’s history iness that has progressively gotten worse over the does not indicate a high risk for sleep-related breathing © Jones & Bartlettlast 5 years. Learning, She reports LLC difficulty staying awake in ©her Jonesdisorder, & butBartlett it cannot Learning, be ruled out atLLC this time. NOT FOR SALEcollege OR classes DISTRIBUTION and episodes of “sleep attacks” daily.NOT FOR SALE OR DISTRIBUTION Think about what other questions or information What type of testing is indicated? you would like to collect from this patient to narrow To confirm a diagnosis of narcolepsy, an overnight down which sleep disorders are relevant. sleep study followed by a multiple sleep latency test Physical exam reveals© Jones a patient & withBartlett a BMI ofLearning, 21 and LLCis indicated. In this case, testing© Jonesrevealed &an Bartlettovernight Learning, LLC sleep study within normal limits with the exception a neck size and oralNOT anatomy FOR within SALE normal OR limits. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION No nasal congestion or deviation is observable. The of short sleep onset and REM latencies. There were patient’s sleep diary demonstrates a regular and suf- no abnormal respiratory events observed. The MSLT ficient nighttime sleep routine, and a subjective sleep revealed three SOREMPs and a mean sleep latency of assessment reveals moderate daytime sleepiness. On 5 minutes. further© Jones questioning, & Bartlett the patient Learning, describes LLC vivid lifelike © Jones & Bartlett Learning, LLC dreamsNOT FORat sleep SALE onset andOR times DISTRIBUTION when she wakes up What Is theNOT Most FOR Likely SALE Final Diagnosis? OR DISTRIBUTION but feels like she cannot move. The overnight testing ruled out the presence of sleep-related breathing disorders. The presence of These features are consistent with which sleep SOREMPs on the MSLT also rules out hypersomnia. disorder or disorders? Instead, the MSLT findings support the diagnosis of © Jones & BartlettThis patient Learning, reports chronic LLC EDS, episodes of sleep pa- © Jonesnarcolepsy & Bartlett type II because Learning, the patient LLC does not report NOT FOR SALEralysis, OR and DISTRIBUTIONhypnogogic hallucinations. These clinical NOTcatapl FORectic SALE episodes. OR DISTRIBUTION

9781284189490_CH02_Endee.indd 36 17/12/19 10:11 PM Footnotes 37

© Jones &or Bartlett drugs. One of Learning, the most LLC common circadian rhythm © JonesChapter & Bartlett 2 Questions Learning, LLC sleep disorders is jet lag disorder. This occurs when NOTPlease FOR consider SALE theOR following DISTRIBUTION questions as they relate to NOT FOR SALEa person OR experiences DISTRIBUTION insomnia or excessive daytime the material in this chapter. sleepiness as a result of traveling across two or more time zones. Shift work is another common cause of 1. What are the classes of sleep disorders? Why are circadian rhythm disorder. Individuals who work shifts they grouped the way they are? 2. that overlap into their© normalJones sleep & Bartlett schedule Learning,are more LLC What are some important© Jones features & of Bartlett sleep Learning, LLC hygiene? Why are these important practices for likely to experience NOTfatigue, FOR EDS, SALEinsomnia, OR and DISTRIBUTION lack of NOT FOR SALE OR DISTRIBUTION concentration. everyone to follow? 3. Parasomnias are sleep disorders in which an indi- Why is OSA important to diagnose and treat vidual performs some sort of undesirable or unwanted quickly and effectively? 4. action during sleep. These can cause disturbances to What is narcolepsy? What social impacts might the© individual’s Jones &sleep Bartlett and can Learning, put the patient LLC and those narcolepsy© Jones have &on Bartlett an individual? Learning, LLC 5. How do delayed sleep–wake phase disorder and nearbyNOT in FORphysical SALE danger. OR Sleepwalking DISTRIBUTION is a parasom- NOT FOR SALE OR DISTRIBUTION nia in which the individual will arise from bed during advanced sleep–wake phase disorder differ from NREM sleep to walk, run, or perform other normal each other? 6. activities. In some cases, the individual may jump out of What is a night terror? In what ways can a night terror be dangerous? a high window or assault the bed partner. Sleep enuresis 7. © Jones & isBartlett a parasomnia Learning, in which theLLC individual has limited or © Jones &How Bartlett does R LSLearning, differ from LLC PLMD? In what ways are they similar? NOT FOR SALEno bladder OR control DISTRIBUTION during sleep. NOT FOR8. SALE OR DISTRIBUTION Sleep-related movement disorders are a class of What are hypnic jerks, and how can they affect a sleep disorders that cause smaller, less significant, and person’s sleep? often rhythmic or repetitive movements during sleep. Perhaps the most common of these is periodic limb Footnotes © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC movement disorder. Patients with PLMD exhibit fre- 1. Dickens, C. (1873). The posthumous papers of the Pickwick Club. quent, repetitive movementsNOT FOR of the SALE limbs during OR DISTRIBUTION sleep. New York: Harper & Brothers.NOT FOR SALE OR DISTRIBUTION These movements can disturb the sleep of the patient or 2. Rechtschaffen, A., & Kales, A. (1968). A manual of standardized the bed partner. Sleep-related bruxism is another com- technology techniques and scoring systems for sleep stages of human mon movement disorder in which the individual grits or subprojects. Los Angeles: UCLA Brain Information Service. 3. American Academy of Sleep Medicine. (2014). The international grinds his or her teeth or clenches the jaw during sleep. classification of sleep disorders (3rd ed.). Darien, IL: American This© Jonescan disrupt & theBartlett sleep period Learning, and can LLCdamage the Academy© of JonesSleep Medicine. & Bartlett Learning, LLC individual’sNOT FOR teeth. SALE OR DISTRIBUTION 4. Maeder, M.NOT T., Schoch, FOR O. D., SALE & Rickli, ORH. (2016). DISTRIBUTION A clinical approach The final class of sleep disorders is called other sleep to obstructive sleep apnea as a risk factor for cardiovascular disease. Vascular Health and Risk Management, 12, 85. disorders and is reserved for disorders that may over- 5. Pizza, F., Jaussent, I., Lopez, R., Pesenti, C., Plazzi, G., Drouot, X., . . . & lap other classes or that need to be researched further Dauvilliers, Y. (2015). Car crashes and central disorders of hypersom- before being properly classified. nolence: A French study. PLoS One, 10(6), e0129386. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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