sleep wake disorders for ncmhce study

Review of DSM5 Mental Disorders for NCMHCE Study

Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep

Disorders Circadian Rhythm Sleep-

Wake Disorders

Non-REM Sleep Arousal Disorders

Parasomnias Nightmare Disorder Restless Legs Syndrome Substance/Medication-

Induced Sleep Disorder

S1. Find Out Substance abuse Depression Medical conditions

Comorbidity Depressive disorders Anxiety disorders Autism ADHD OCD Adjustment disorder Dissociative disorders Feeding & Eating disorders Somatic Symptom disorders Neurocognitive disorders

Rule Out Depressive

disorders

S2. Assess & Refer IEvaluations Polysomnography

Expensive and to be avoided if possible

Sleep diaries Lab tests for neurotransmitter deficiencies, breathing

difficulties, etc.

S2. Assess & Refer IITests STQ Sleep Timing Questionnaire SII Sleep Impairment Index ISI Insomnia Severity Index PSQI Pittsburgh Sleep Quality

Index RBDSQ REM Sleep Behavior

Disorder Screening REM Sleep Behavior

Questionnaires – Hong-Kong GAD-7 PHQ-9

PROMIS Level 2 Sleep Disturbance Patient Reported Outcome Measurement Information System

Epworth Sleepiness Scale SCQ Sleep Disorders

Questionnaire SCI Sleep Condition

Indicator CSM Composite Scale of

Morningingness

S4. TreatmentTherapy CBT-Insomnia Relaxation Therapy Cognitive Thought Stopping Bright Light Therapy Neurostimulation

Medication Melatonin Amphetamines Antidepressants Monoamine Oxidase

Inhibitors (MOIs)

S1. Diagnosis I Difficulty initiating or

maintaining sleep, or poor quality sleep

At least 3 nights per week for at least 3 months, despite adequate opportunity for sleep

Not part of another Sleep Wake disorder

Not due to substance effects

Types1. Psychological Worries about insomnia

so they cannot sleep2. Sleep State Misperception Believes they sleep poorly

but sleep quality is good3. Hypnotic Dependent

Sleep Disorder Due to withdrawal of

sleeping pills

S1. Diagnosis IICo-occurring: Depression or other

mental disorder Chronic pain

Rule Outs: Breathing related disorders Circadian Rhythm Sleep

Disorder Periodic limb movement

disorder

S4. Treatments CBT EEG feedback Stimulus control Relaxation Therapy Psychoeducation Sleep-restriction Therapy Behavioral Therapy, such

as regulating the circadian clock

Lifestyle changes Reduced stress Exercise Restricted caffeineMedication Melatonin Brief use of hypnotics

Diagnosis I Recurrent episodes of

excessive daytime sleepiness or prolonged nighttime sleep

At least 3 times weekly Naps repeatedly

throughout the day, with no relief from symptoms

Common among adolescents and young adults

Often disoriented when

waking and may experience:

Anxiety

Increased irritation

Decreased energy

Restlessness

Slow thinking

Slow speech

Loss of appetite

Hallucinations

Memory difficulty

Diagnosis IICo-occurring: Other mental disorders, like depression Medical conditions like head injury, multiple sclerosis,

encephalitis, epilepsy, or obesity

S4. Treatments Medications Amphetamines Antidepressants Monoamine Oxidase Inhibitors (MOIs)

Diagnosis IRequires: Presence of

recurrent periods of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day

3x per week over the past 3 months

Also at least one of the following: Cataplexy

Brief episodes of sudden loss of muscle tone, usually with intense emotion like laughing or crying

Hypocretin neurotransmitter deficiency Recurrent intrusions of rapid eye

movement (REM) sleep into the transition between sleep and waking

With either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes

Diagnosis II Onset usually from childhood to

young adulthood, especially ages 5–25 and 30–35

Onset can be abrupt or progressive over years

Childhood onset most severe Early Symptoms:

Sleepiness

Vivid dreaming

Excessive movements during REM sleep

Co-occurring:Sleep apneaREM Sleep

Behavior Disorder

S2. Assess & Refer Lab tests

S4. TreatmentsMedications for sleepiness Central Nervous System

StimulantsMedications for sleepiness Tricyclic AntidepressantsMedication for both Sodium Oxybate

Lifestyle changes Reduced stress Exercise Restricted caffeine

Cataplexy: Brief episodes of sudden bilateral loss of muscle tone in neck, jaw, arms, legs, or whole body, resulting in head bobbing, jaw dropping, or complete falls, most often in association with intense emotion, like laughing

Apnea: No breathing airflow during sleep

Hypoapnea: Reduced airflow

S1. Diagnosis I

Nocturnal breathing

disturbances, pauses or

gasping/snorting for air

during the night

Often resulting in

daytime sleepiness

Patient unaware

Requires:

Repeated episodes, at least 5

per hour of sleep per night, of

upper airway obstruction

during sleep

Apneas (no airflow) or

hypopneas (restricted airflow)

S1. Diagnosis IICo-occurring: Rule Out:

Lung disease Neuromuscular disorder Skeletal malformation

S2. Assess & Refer Lab tests

S4. Treatments1. Physical devices Positive Airway Pressure mask over face Mouth device Higher upper body position2. Neurostimulation3. Surgery and weight loss

S5. Monitoring Progress Sleep diary

S6. Termination

S1. Diagnosis IAffects timing of sleep; unable to sleep and wake at the times required Requires:1. Pattern of sleep disruption mainly due

to an alteration of the circadian system

Or misalignment between the internal circadian rhythm and the sleep-wake schedule required

2. The sleep disruption leads to excessive sleepiness or insomnia, or both

Specify:Episodic: Lasts 1 to 3 monthsPersistent: Lasts 3 months or moreRecurrent: Two or more episodes occur within 1 year

S2. Assess & Refer Polysomnography

S4. Treatments Light therapy Dark therapy Melatonin supplements Sleep Deprivation Phase Advance


S6. Termination

Diagnosis I

Episodes of incomplete awakenings during sleep

1. Sleep walking

2. Sleep terrors

Diagnosis IllCo-occurring in children Restless Leg Syndrome Sleep Breathing Disorder Bed-wetting (Enuresis)

Co-occurring in adults: Delirium Seizure disorder Drug toxicity Schizophrenia Anxiety disorders Migraine headaches Tourette Syndrome

Diagnosis Il Most common among children and adolescentsRequires:1. Rising from bed during sleep and walking about Usually during the first third of sleep period2. While sleepwalking, they have a blank, staring face, are

relatively unresponsive to communicate efforts, and can be awakened only with great difficulty

3. No memory of the episode upon awakening4. Shortly after awakening, there is no impairment of mental

activity or behavior May be an initial short period of disorientation

S1. Find Out S2. Assess & Refer Polysomnography

S2. Assessments to Rule Out Options Polysomnography

S4. Treatments Avoidance of

neuroleptics or hypnotics Avoidance of alcohol

Medications Tricyclic

Antidepressants Benzodiazepine


6. Recommendations after Termination

Diagnosis IIMore likely in young peopleRequires:1. Recurrent periods where the individual

abruptly wakes from sleeping with a scream

2. Experience of intense fear and symptoms of autonomic arousal, like rapid heart rate, heavy breathing and sweating

3. Cannot be soothed during the episode 4. Unable to remember details of the

dream or episode

Co-occurring Neurological

disease Hypoglycemia Poor nutrition

S1. Find Out S2. Assess & Refer Polysomnography

S4. Treatments Psychotherapy Scheduled Awakenings

Therapy very effective Increasing quality of sleep

Medications, in extreme cases Tricyclic

Antidepressants Benzodiazepine

Diagnosis I

Requires:

Repeated awakenings with recollection of terrifying dreams,

usually involving threats to survival, or safety

During REM sleep, after 90 minutes

Awakes alert and able to recall the dream well

May be anxious and unable to fall back asleep

Onset from childhood to adolescence, improvement with age

Diagnosis IIRule out: Sleep Terrors: Cannot recall dream Side effect of illicit drugs, like cocaine

and amphetamines Side effect of prescribed drugs, for

blood pressure, depression, Parkinson’s

PTSD

Co-occurring:Dissociative

disordersBorderline

Personality disorder

S4. TreatmentsTherapy Dealing with frightening dream themes Relaxation Therapy Hypnosis Stress reductionMedications Prazosin, used in PTSD


6. Termination

Diagnosis I

Desire to move the

legs or arms, usually

associated with

sensations described

as creeping,

crawling, tingling,

burning or itching

Worse when at rest

Requires:

1. An urge to move the legs, related to uncomfortable sensations in the legs, characterized by all of the following:

Begins or worsens during periods of rest or inactivity

Partially or totally relieved by movement

Worse in the evening or occurs only in the evening

2. Occurs at least 3 times/week, for at least 3 months

Diagnosis IICo-occurring:Periodic Limb Movement Disorder, where limbs jerk

during sleepNeurologic conditions like Parkinsons diseaseRenal disease

S4. Treatments Stretching, walking

(temporary) Iron supplements

Medications Benzodiazepines Anticonvulsants for pain Non-dopaminergic

Gabapentin or Pregabalin Dopamine Agonists,

cautiously


S6. Termination

Diagnosis IRequires:

Repeatedly

waking up

after REM

sleep

Movements

related to

dreams

Requires:1. Repeated episodes of arousal during sleep,

associated with vocalization and/or complex motor behaviors

2. During rapid eye movement (REM) sleep, usually 90 minutes after sleep onset and more frequent later in sleep period

3. Awakening alert and not disoriented4. Either of the following: Polysomnographic confirmation of REM sleep

without normal muscle paralysis History suggestive of this disorder and

diagnosis of Parkinson’s or related diseases

Diagnosis II Onset usually from childhood to

young adulthood, especially at ages 15–25 years and ages 30–35 years

Onset can be abrupt or progressive over years

Childhood onset most severe Early Symptoms: Sleepiness, vivid

dreaming, and excessive movements during REM sleep

Co-occurring:Other sleep

disordersParkinson’s

diseaseMultiple System

Atrophy andLewy Body

Dementia

S1. Find Out S2. Assess& ReferLab tests RBDSQ Rapid Eye

Movement (REM) Sleep Behavior Disorder Screening Questionnaire

REM Sleep BehaviourQuestionnaires – Hong-Kong

S4. Treatments Medications Clonazepam and

melatonin most effective

Avoid sleep deprivation, alcohol, and certain medications

Make bedroom safe

Cataplexy: Brief episodes of sudden bilateral loss of muscle tone in neck, jaw, arms, legs, or whole body, resulting in head bobbing, jaw dropping, or complete falls, most often in association with intense emotion, like laughing

Apnea: No breathing airflow during sleepHypoapnea: Reduced airflowAkathisia: Movement disorder characterized by a feeling of restlessness and a compelling need to be in constant motionAtonia: Muscle paralysis, as in normal sleep

sleep wake disorders for ncmhce study

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