sleep disorders

Question 1

normal sleep-wake cycle

Answer 1

• NREM/REM alternate every 90 min
• NREM: transition from waking state to deep sleep
• progression through NREM: slower brain wave patterns, higher arousal thresholds

Question 2

dyssomnia

Answer 2

insufficient, excessive, or altered timing of sleep

Question 3

parasomnia

Answer 3

unusual sleep-related behavior

Question 4

primary insomnia: dx

Answer 4

• difficulty initiating or maintaining sleep (or nonrestorative sleep) for 1+ MONTH
• clinically signif distress or impairment
• not exclusively in course of other sleep do
• not exclusively in course of other psych do
• not due to substance or GMC

Question 5

acute insomnia

Answer 5

• b/w 1-4 weeks in duration
• usually assoc with stress or changes in sleep schedule
• usually resolves spontaneously

Question 6

primary insomnia: epidem and etiology

Answer 6

• prev 5-10%
• subclinical mood/anxiety do
• preoccupation with perceived inability to sleep
• poor sleep hygiene
• idiopathic

Question 7

primary insomnia: tx

Answer 7

• sleep hygiene
• CBT (first line!)
• BZOs (short term efficacy only)
• zolpidem, eszopiclone, zaleplon (short term efficacy) - zolpidem causes increased risk of falls and cog impairment in elderly
• TRAZODONE, amitriptyline, doxepin (SEs: sedation, dizziness, psychomotor impairment)

Question 8

OSA: features

Answer 8

• excessive daytime sleepiness
• apneic episodes
• sleep fragmentation
• loud stertor
• frequent awakenings from gasping/choking
• nonrefreshing sleep
• morning headaches

Question 9

narcolepsy: features

Answer 9

• irresistible attacks of REFRESHING sleep
• occur DAILY for AT LEAST 3 MONTHS
• cataplex
• hallucinations and/or sleep paralysis at beginning/end of sleep episodes (hypnagogic - at beginning, hypnopompic - at end)

Question 10

narcolepsy: pathophys

Answer 10

• loss of hypothalamic neurons that contain hypocretin

- may have autoimmune component

Question 11

narcolepsy: tx

Answer 11

• sleep hygiene
• scheduled daytime naps
• avoidance of shift work
• daytime sleepiness: ampehtamines, methylphenidate, modafinil, sodium oxybate
• cataplexy: SODIUM OXYBATE (1st line), TCAs, SSRI/SNRI

Question 12

idiopathic hypersomnia

Answer 12

• excessive daytime sleepiness
• prolonged nocturnal sleep episodes
• frequent irresistible urges to nap

Question 13

Kleine-Levin syndrome

Answer 13

• recurrent hypersomnia with episodes of daytime sleepiness
• hyperphagia
• hypersexuality
• aggression

Question 14

delayed sleep phase do

Answer 14

• chronic/recurrent delay in sleep onset and awakening times; preserved quality and duration of sleep
• risk factors: puberty, caffeine/nicotine use, irregular sleep schedules
• tx: morning phototherapy, evening melatonin, chronotherapy

Question 15

advanced sleep phase disorder

Answer 15

• normal duration and quality of sleep with ONSET and AWAKENING times earlier than desired
• risk factors: older age
• tx: phototherapy, NO MORNING MELATONIN

Question 16

shit work disorder

Answer 16

• sleep deprivation and misalignment of the circadian rhythm 2/2 nontrad work hours
• risk factors: night shift, rotating shift, shifts >16h, being a medical/psych resident
• tx: avoid risk factors, phototherapy, modafinil if severe

Question 17

jet lag disorder

Answer 17

• sleep disturbances assoc with travel across multiple time zones
• risks: recent sleep dep
• tx: self-limiting, usually resolve after 2-3 days of travel

Question 18

sleepwalking: features

Answer 18

• simple to complex behaviors initiated during short wave sleep
• sitting up in bed, eating, going outdoors
• eyes are usually open, “glassy”
• difficulty arousing sleepwalker during episode
• confusion on awakening, amnesia for episode
• rare: violent behavior, esp with forced awakening

Question 19

sleepwalking: epidem

Answer 19

• 1-4% of adults
• 10-20% of children/adol
• more often in children with OSA

Question 20

sleepwalking: risk factors

Answer 20

• sleep dep
• irreg sleep sched
• stress
• hyperthyroidism
• OSA
• sz
• migraines
• sedatives/hypnotics, lithium, anitcholinergics
• Mg deficiency

Question 21

sleepwalking: tx

Answer 21

• address precipitating factors

- refractory cases: clonazepam, other BZOs, TCAs

Question 22

sleep terrors: features

Answer 22

• episodes of sudden arousal with screaming from slow-wave sleep
• sympathetic hyperactivation
• afterward, return to sleep without awakening
• usually amnesic about episode
• confused and disoriented upon forced awakening
• rare: awakening elicits aggressive behavior

Question 23

sleep terrors: epidem

Answer 23

• 1-6% of children, 1-2% of adults
• prev higher in 1st degree relatives
• high comorbidity with sleepwalking

Question 24

sleep terrors: risk factors

Answer 24

• fever
• nocturnal asthma
• GERD
• sleep dep
• CNS-stimulating mx
• other sleep disorder

Question 25

sleep terrors: tx

Answer 25

• reassurance (benign, self-limited)
• low-dose short-acting BZOs if refractory?
• sleep hygience, psychotherapy

Question 26

nightmare do: features

Answer 26

• recurrent frightening dreams that terminate in awakening with vivid recall
• no confusion or disorientation upon awakening
• can cause signif distress, anxiety

Question 27

nightmare do: epidem

Answer 27

• 5% of adults, women > men

- at least 50% of PTSD

Question 28

nightmare do: tx

Answer 28

• imagery rehearsal therapy

- severe: antidepressants?

Question 29

REM sleep behavior do: features

Answer 29

• muscle atonia during REM sleep and complex motor activity with dream mentation
• dream-enacting behaviors
• presenting complaint: violent behaviors during sleep –> injury to patient or bed partner

Question 30

REM sleep behavior do: epidem

Answer 30

• 0.5% prev

- men > women

Question 31

REM sleep behavior do: risk factors

Answer 31

• older age
• psych mx (TCAs, SSRIs, MAOIs)
• narcolepsy
• brain stem lesions
• dementias

Question 32

REM sleep behavior do: Tx

Answer 32

• clonazepam: works in 90%
• imipramine, carbamazepine, pramipexole, levodopa
• environmental safety