B Y:

A R U S H I R AV E E N B A J A J

M . S C C L I N I C A L P S Y C H O L O G Y

M A N I PA L U I N V E R S I T Y

F51:

Nonorganic Sleep Disorders

What is sleep?

A natural periodic state of rest for the body and mind , in

which:

1. The eyes usually close and consciousness is completely

partially lost,

2. There is decreased body movement and

3. Reduced responsiveness to external stimuli.

During sleep, the brains of humans and mammals undergo

a characteristic cycle of brain wave activity that includes

intervals of dreaming.

Types of non organic sleep disorders:

Dyssomnias:

Primarily psychogenic conditions in which the

predominant disturbance is in the amount,

quality, or timing of sleep due to emotional causes,

i.e.

• Insomnia,

• Hypersomnia,

• Disorder of sleep - wake schedule.

Parasomnias:

• Abnormal episodic events occurring during sleep;

• In childhood these are related mainly to the child's

development, while in adulthood they are predominantly

psychogenic,

i.e. sleepwalking,

sleep terrors,

nightmares.

Excludes: sleep disorders (organic) (G47.-)

F51.0 - Nonorganic Insomnia

What is insomnia?

Insomnia is a condition of unsatisfactory quantity and/or quality of sleep, which persists for a considerable period of time.

The actual degree of deviation from what is generally considered as a normal amount of sleep should not be the primary consideration in the diagnosis of insomnia, since it is subjective and open to interpretation.

Among insomniacs, difficulty falling asleep is the most prevalent complaint, followed by difficulty staying asleep and early final wakening, or a combination of both.

Clinical Features:

Typically, insomnia develops at a time of increased life-

stress.

Insomnia tends to be more prevalent among women,

older individuals and psychologically disturbed and

socioeconomically disadvantaged people.

Other risk factors include high levels of stress, change in

routine, sedentary lifestyle.

When insomnia is repeatedly experienced, it can lead to

an increased fear of sleeplessness and a preoccupation

with its consequences. This is cyclic in nature.

In the morning, they frequently report feeling physically

and mentally tired; during the day, they

characteristically feel depressed, worried, tense,

irritable, and preoccupied with themselves.

The presence of other psychiatric symptoms such as depression,

anxiety or obsessions does not invalidate the diagnosis of

insomnia, provided that insomnia is the primary complaint or the

chronicity and severity of insomnia cause the patient to perceive

it as the primary disorder.

Most chronic insomniacs are usually preoccupied with their sleep

disturbance and deny the existence of any emotional problems.

The present code does not apply to so-called "transient insomnia".

Transient disturbances of sleep are a normal part of everyday life

Diagnostic Guidelines:

a. The complaint is either of difficulty falling asleep or

maintaining sleep, or of poor quality of sleep;

b. The sleep disturbance has occurred at least three times per

week for at least 1month;

c. There is preoccupation with the sleeplessness and excessive

concern over its consequences at night and during the day;

d. The unsatisfactory quantity and/or quality of sleep either

causes marked distress or interferes with ordinary activities

in daily living.

Differential Diagnosis:

1) Insomnia is a common symptom of other mental disorders, such

as affective, neurotic, organic, and eating disorders, substance

use, and schizophrenia, and of other sleep disorders such as

nightmares.

2) It is associated with physical disorders in which there is pain

and discomfort or with taking certain medications.

3) If insomnia occurs only as one of the multiple symptoms of a

mental disorder or a physical condition, the diagnosis should be

limited to that of the underlying mental or physical disorder.

Moreover, the diagnosis of another sleep disorder, such as

nightmares, should be made only when these disorders lead to a

reduction in the quantity or quality of sleep.

However, in all of the above instances, if insomnia is one of the

major complaints and is perceived as a condition in itself, the

present code should be added after that of the principal diagnosis.

Comorbidity:

An estimated 40% of individuals with insomnia have a comorbid psychiatric condition. It was found

that insomnia predicted depression, anxiety, substance abuse or dependence, and suicide. In fact, the correlation between insomnia and later development of depression within 1–3 years is

particularly strong.

In a community sample of adolescents that in 69% of cases, insomnia preceded comorbid depression, while an anxiety disorder preceded insomnia 73%

of the time.

. In a large group of subjects aged 15 to 100 years, insomnia either appeared before (>40%) or at the same time (>22%) as

mood disorders. This study also found that insomnia appeared at the same time (>38%) of the time or after (34%) as anxiety

disorders (Individuals with insomnia complaints in the last year but without any previous psychiatric history were shown to have an increased risk of first onset major depression, panic disorder, and alcohol abuse the following year when compared to controls.

Furthermore, adolescents who completed suicide were found to have higher rates of insomnia in the week preceding death than

community control adolescents.

Ms. W. was a 41-year-old, divorced, white female who presented with a 2 ½ year complaint of sleeplessness. She had some difficulty falling asleep (30- to 45-minute sleep-onset latency) and awakened every hour or two after sleep onset. These awakenings might last 15 minutes to several hours, and she estimated having approximately 4.5 hours of sleep on an average night. She rarely takes daytime naps notwithstanding feeling tired and edgy. The patient described her sleep problem with the following words. “It seems like I never get into a deep sleep.”Sometimes I have a hard time getting my mind to shut down.” She viewed the bedroom as an unpleasant place of sleeplessness.

At times, Ms. W. was unsure whether she was asleep or awake. She had a history of clock watching (to time her wakefulness. Reportedly the insomnia is unrelated to seasonal changes, menstrual cycle, or time-zone translocation. Her basic sleep hygiene was good. Appetite and libido were unchanged. She denied mood disturbance, except for being quite frustrated and concerned about sleeplessness and its effect on her work. Her work involved sitting at a microscope 6 hours of a 9-hour working day and meticulously documenting her findings. Her final output hadn't suffered, but she had to “double check” for accuracy.

F51.1 - Nonorganic hypersomnia

What is Hypersomnia?

Hypersomnia is defined as a condition of either excessive

daytime sleepiness and sleep attacks (not accounted for by

an inadequate amount of sleep) or prolonged transition to

the fully aroused state upon awakening.

Nonorganic hypersomnia can be primary or associated with a

number of psychiatric disorders such as :

o reaction to severe stress

o adjustment disorders,

o affective disorders,

o other functional disorders,

o tolerance to or withdrawal of CNS-stimulating substances

o chronic use of CNS-sedating substances.

Diagnostic Guidelines:

a) Excessive daytime sleepiness or sleep attacks, not accounted for by

an inadequate amount of sleep, and/or prolonged transition to the

fully aroused state upon awakening (sleep drunkenness);

b) Sleep disturbance occurring daily for more than 1 month or for

recurrent periods of shorter duration, causing either marked

distress or interference with ordinary activities in daily living;

c) Absence of auxiliary symptoms of narcolepsy (cataplexy, sleep

paralysis, hypnogogic hallucinations) or of clinical evidence for sleep

apnea (nocturnal breath cessation, typical intermittent snorting

sounds, etc.);

d) Absence of any neurological or medical condition of which daytime

somnolence may be symptomatic.

Narcolepsy (G47.1) : Hypersomnia F(51.1) :

1. One or more auxiliary

symptoms such as cataplexy,

sleep paralysis, and

hypnogogic hallucinations are

usually present;

2. The sleep attacks are

irresistible and more

refreshing

3. And nocturnal sleep is

fragmented and curtailed.

1. Daytime sleep attacks in hypersomnia are usually fewer per day.

2. Each of longer duration; the patient is often able to prevent their occurrence.

3. Nocturnal sleep is usually prolonged, and there is a marked difficulty in achieving the fully aroused state upon awakening (sleep drunkenness)

Differential Diagnosis:

Hypersomnia and sleep apnea:

In addition to the symptom of excessive daytime sleepiness,

most patients with sleep apnea have a history of nocturnal

cessation of breathing, typical intermittent snorting sounds,

obesity, hypertension, impotence, cognitive impairment,

nocturnal hypermotility and sweating, morning headaches and

in coordination.

Hypersomnia due to an unidentified organic cause can be

differentiated from non organic hypersomnia by proof of the

presence of the organic disorder.

Mr. J. was a 28-year-old, single, African-American male with an approximately 10-year history of fatigue and sleepiness in the daytime. He began to recognize the daytime sleepiness as a problem in his freshman year of college, when he would fall asleep in class or in the dormitory. He admitted that his sleep-wake schedule was disrupted during college due to taking long naps and then having to stay up until 1:00 or 2:00 AM to complete his studies. His grades and social life suffered and he described himself as depressed, isolated, and hopeless. As a child, Mr. J. said he slept “normally”.

Mr. J.'s excessive sleepiness continued, notwithstanding some improved sleep hygiene, like more-consistent bedtime, trying not to nap, and a month-long trial without caffeine. He remained dysphoric and discouraged about his future, blaming his chronic sleepiness as the continuing impediment to his life plans. “I'm just tired of being tired,” he said.

When last seen his bedtime was between 10:00 and 10:30 PM; his wake-up alarm was set for 6:30 AM. He oversleeps at least once a week on work days and sleeps from 10:30 PM until 10:00 AM on weekends in an attempt to “catch up.” He has difficulty awakening and feels unrefreshed or mildly refreshed. He drinks 6-8 cups of coffee in the morning. After lunch he falls asleep at the computer while working. He sleeps for 20 to 60 minutes. He then drinks another two cups of coffee and continues with his work. he has “nodded off” while driving. He sleeps alone; He does not awaken gasping or choking. He denied hypnagogichallucinations and sleep paralysis but thought he might feel weak after the rare occasions when he participated in a heated argument.

F51.2: Nonorganic disorder of the sleep-wake

schedule

What are disorders of the sleep wake schedule?

A disorder of the sleep-wake schedule is defined as a lack

of synchrony between the individual's sleep-wake

schedule and the desired sleep-wake schedule for the

environment, resulting in a complaint of either insomnia

or hypersomnia

This disorder may be either psychogenic or of presumed organic

origin, depending on the relative contribution of psychological or

organic factors.

Individuals with disorganized and variable sleeping and waking

times most often present with significant psychological

disturbance, usually in association with various psychiatric

conditions such as personality disorders and affective disorders

Diagnostic Guidelines:

a) The individual's sleep-wake pattern is out of synchrony with

the sleep-wake schedule that is normal for a particular

society and shared by most people in the same cultural

environment;

b) Insomnia during the major sleep period and hypersomnia

during the waking period are experienced nearly every day

for at least 1 month or recurrently for shorter periods of

time;

c) The unsatisfactory quantity, quality, and timing of sleep

cause marked distress or interfere with ordinary activities in

daily living.