Sleep–Wake Disorders

Abstract

Insomnia and poor sleep are among the most common reasons patients consult their primary care physician. However, the diagnosis of insomnia is nonspecific and is easily confused with parasomnias and hypersomnias. Thus, the clinician must fully assess the sleep problem and rule out a primary or underlying condition before treating sleeplessness symptomatically with sedative hypnotics (medication to induce sleep). The three cases in this chapter illustrate insomnia as well as less common sleep disorders.

“But I, being poor, have only my dreams; I have spread my dreams under your feet; Tread softly because you tread on my dreams.”William Butler Yeats—He Wishes for the Cloths of Heaven

Appendices

Appendix A—Possible Answers to Clinical Vignettes

Table 26.1.1: Maria Thompson

Facts	Hypotheses	Information needed	Learning issues
36-year-old woman, married, mother of two preteens	She is overwhelmed with perceived family obligations, and stress leads to abnormalities in cortisol regulation/PHA feedback?	What does overwhelmed mean?	What are the different types and causes of insomnia?
Trouble falling asleep (2 h)	Trouble falling asleep and awakenings with concerns about problems and adequacy could point toward a mood or anxiety disorder?	Were there any periods when she did NOT have sleep problems?	What is the epidemiology of insomnia?
Trouble staying asleep	Use of substances to cope with stress having negative effects on sleep?	Assessment of sleep hygiene?	What should be considered as differential diagnoses?
Cannot go back to sleep once awakened	Medical etiology?	Are there any other signs and symptoms of a mood disorder?	What would a sleep study tell us about her sleep patterns?
Worried about household problems		Any PMH suggestive of endocrine abnormalities, manic or hypomanic episodes, substance abuse?
		Lab: Thyroid panel

Table 26.1.2

Facts	Hypotheses	Information needed	Learning issues
Intervention of adjusting sleep time has failed	Symptoms suggestive of a major depressive episode as a cause for sleep impairment	Are there any recent stressors?	What are the symptoms of a major depressive episode?
Early morning awakenings feeling exhausted and worn out	Excessive caffeine or other substance use in response to stress as an etiology for sleep dysfunction	History and family history of psychiatric illness?	What are the interventions for impaired sleep that do not require medications?
Difficulty getting motivated for her day		Evaluation for other symptoms of depression?	What are the components of proper sleep hygiene?
Daytime sleepiness		Other substance use history?	How do sleep medications exert their effects?
Caffeine use
Perceived laziness
Lack of sexual desire/intimacy
Normal TSH
Failed trials of zolpidem, trazodone, hydroxyzine

Table 26.2.1: Vickie Sippets

Facts	Hypotheses	Information needed	Learning issues
17-year-old female sleepwalking beginning 6 weeks ago	Experiencing sleep arousal disorder due to multiple possible factors including recent stress	Psychiatric history and family history	What are the different stages of sleep?
Not responsive during episodes	Substance use contributing to disruption in sleep	Substance abuse history	In what stages of sleep would somnambulism or sleepwalking occur?
No recollection of events	Psychiatric etiology for sleep disturbances including major depression, anxiety, PTSD	Recent life stressors or changes	What are parasomnias? What are the differential diagnoses for parasomnias?
		History of sleep disturbances as a child	What are the sleep architecture changes associated with psychiatric illness and substance use?

1. PTSD posttraumatic stress disorder

Table 26.2.2

Facts	Hypotheses	Information needed	Learning issues
No past psychiatric history	Non-REM sleep arousal disorder secondary to recent emotional stress of breakup with boyfriend	Polysomnographic data assessing movement and sleep abnormalities in a controlled setting	What is a sleep study, and how can it help diagnose a sleep disorder?
Normal intellectual functioning	Anxiety or depressive symptoms not addressed during clinical interview contributing to sleep loss	More extensive psychiatric interviewing regarding depressive and anxiety symptoms	What are the primary causes of non-REM sleep arousal disorders?
Recent stress of breakup with boyfriend			What patient population does somnambulism primarily affect?
Denies any drug use or alcohol			What are the treatments for somnambulism?
No current sexual activity
Normal mental status examination

Table 26.3.1: Randolph Jegniff

Facts	Hypotheses	Information needed	Learning issues
30-year-old obese male	Fatigue from recent honeymoon with expected increase in sleep drive	Full sleep history including hygiene and quality	What is the normal physiologic response to sleep deprivation?
Frequent little naps	Psychiatric illness causing impaired sleep	Substance use history	Which stage of sleep is associated with muscle paralysis?
Looking funny and collapsing asleep, slumping down	Abnormal intrusion of sleep in form of narcolepsy or other hypersomnia	Psychiatric history and family history	What is the most common chief complaint of patients diagnosed with narcolepsy?
Short period of somnolence followed by abrupt return of consciousness and muscle tone	Substance use or intoxication altering level of consciousness	Recent history of activities while on honeymoon	What is the association between narcolepsy and insomnia?
	Sleep apnea causing decreased quality of sleep	History of gasping, snoring, and other descriptors for sleep apnea	What are the types of sleep apnea?

Table 26.3.2

Facts	Hypotheses	Information needed	Learning issues
Postdoctoral student	Frequent naps and intrusion of sleep into daytime due to hypersomnia with cataplexy	Polysomnogram study and multiple sleep latency test to evaluate for apnea and decreased REM latency	How is narcolepsy diagnosed?
No medical problems	Central sleep apnea or obstructive sleep apnea contributing to poor quality of sleep		Which neck circumference increases risk for apnea?
Occasional glass of wine			What are relieving and exacerbating factors for narcolepsy and what are treatments options? What are the treatments for sleep apnea?
Frequent naps
Falling asleep while teaching classes
No snoring, catching his breath
15 in. neck with clear oropharynx

Appendix B—Answers to Self-assessment Questions

• 1. D—Primary insomnia

• 2. A—Psychological evaluation

• 3. C—Sleep hygiene

• 4. E—Socioeconomic class

• 5. D—Chronic obstructive pulmonary disease

• 6. C—Sleep disturbances

• 7. Proper sleep hygiene includes going to bed and rising at the same time each day, avoiding caffeine, alcohol, television (or other blue light), and exercise in the evening, and sleeping in the same quiet, dark environment that is used only for sleeping.