Sleep disorders

1.1 Introduction to sleep disorders

Sleep disorder or somnipathy is characterised by the disturbance of an individuals normal
sleep pattern which may have negative impact upon physical, mental or emotional
functioning. However, subclinical sleep disturbances are common and may affect everyone at
some point of their life. Sleep disorders affect all ages and is often a symptom of psychiatric
disorder. Thus, a poor understanding of sleep disorders predispose a physician to misdiagnose
a patient as primary psychiatric disorders (depressive, bipolar or anxiety disorders). Besides,
some medications and physical disorders are known to cause sleep disorders.
Sleep offers the beneficial effect to human such as
a)
b)
c)
d)
e)

Recovery of physical and psychological strength

Energy conservation
Memory consolidation
Discharge of emotions
Restoration (immune system, wound healing, correction of metabolic disturbance)

The degree of sleep can be detected by using electroencephalography (EG) that record the
brains net electrical activity. Two distinct sleep states have been identified according to the
patter of ECG, namely non-rapid eye movement (NREM) and rapid eye movement (REM)
sleep. NREM is further divided into four stages while the REM sleep typically precedes
them.
1.2 NREM, REM sleep and circadian sleep-wake rhythms
NREM is divided into four stages. Stage 1 account for 4-16% of total overnight sleep and the
EEG reading shows a waves at 4-7Hz. It occurs at the onset of sleep or when aroused from
another stage of sleep where sudden twitches or hypnagogic jerks may develop during the
sleep onset and there is a gradual loss of some muscle tone and consciousness. Stage 2
contribute to 45-55% of overnight sleep and high-frequency bursts (sleep spindles) is shown
on the EEG. There is a complete loss of muscle tone and awareness to the surrounding.
The combination of stage 3 and stage 4 is called delta sleep or slow-wave. Stage 3 occupied
4-6% of total sleep while stage 4 comprised of 12-15% of sleep. Stage 4 has the slowest
activity on the EEG (0.5-4Hz) and is the deepest stage of sleep. Parasomnias such as night
terrors, bed wetting and sleep walking occurred at this stage.
In contrast, REM sleep confer to a quarter of normal sleep time in healthy adults. Although
the EEG pattern of REM sleep is similar to the awake state, there is a complete loss of muscle
tone except for spontaneous movements of the extraocular and middle ear muscles. Besides,
heart rate, blood pressure, respiratory rate and temperature homeostasis have all become
irregular. People who are awoken from REM sleep complaint that they are dreaming but the
content of dream is quickly forgotten.
Generally, the sleep cycles of a typical night begins with the NREM sleep for 80 minutes,
subsequently followed by REM sleep for a future 10 minutes. As the night progresses, NREM
sleep tends to shorten while REM stage begin to lengthen. The total sleep time is different
among individuals, however, it is between 5 to 9 hours. Suprachiasmatic nucleus (SCN) in
the anterior hypothalamus is responsible for the timing of sleep, affected by the light,

exercise, work schedules and social interactions. It also controls the temperature and the
release of growth hormone and cortisol which is links into the sleep-wake cycle. In addition,
pineal gland secretes melatonin into the blood during darkness. Melatonin crosses the bloodbrain barrier to act upon the SCN, thereby linking the light-dark and sleep-wake cycles.

1.3 Consequences of sleep disturbance

Short-term consequences
Fatigue (mental, emotional, physical)
Irritability or depression
Poor concentration and attention
Impaired judgement
Increased reaction time, inaccuracy

Long-term consequences
Decreased cognitive function
Memory loss
Reduced immune system function
Growth suppression
Increased risk of type 2 diabetes, heart
disease and obesity

Yawning, aches, tremors, shivers

Hallucinations, disorientation, persecutory
ideas
1.4 Classification of sleep disorder
A simple way to classify sleep disorder may fall into the four basic categories:
a)
b)
c)
d)

Not enough sleep (insomnia)

sleeping too much (hypersomnia)
disturbed episodes during or related to sleep (parasomnias)
inappropriate sleep timing / sleep-wake cycle loses synchrony with the rest of society
(circadian rhythm disorders.

A more complex classification system may refer to the DSM-IV and ICD-10. Owing to the
confusing terminology between these two systems, the international classification of sleep
disorder (ICSD-2) had been developed as the third classification system. All these system are
summarised in figure 1. Recently, DSM-V has come out with the latest classification of sleepwake disorders, where it comprises of 10 disorders.
Insomnia disorder
Hypersomnolence disorder
Narcolepsy
Breathing-related sleep disorders
Circadian rhythm sleep-wake disorders

Non-rapid eye movement (NREM) sleep

arousal disorders
Rapid eye movement (REM) sleep
behaviour disorder
Nightmare disorder
Restless legs syndrome
Substance/ medication-induced sleep

Figure 1: Classification of sleep disorder according to three main systems.

2.1 Hypersomnolence disorder
2.1.1 Introduction
Hypersomnolence is a self-reported excessive sleepiness despite a main sleep period lasting
at least 7 hours, with one of the following symptoms:
a) recurrent periods of sleep/ lapses into sleep within the same day
b) a prolonged main sleep episode of more than 9 hours per day that is non-restorative
c) difficulty being fully awake after abrupt awakening
Hypersomnolence occurs at least 3 times per week for at least 3 month, accompanied with
significant distress or impairment in cognitive, social, occupational or other important areas
of functioning. It is not attributed to the physiological effect of a substance, such as drug
abuse or medication. The severity of hypersomnolence can be classified into
a) mild: difficulty maintaining daytime alertness 1-2days/week
b) moderate: difficulty maintaining daytime alertness 3-4 days/week
c) severe: difficulty maintaining daytime alertness 5-7 days/week

The diagnostic symptoms of hypersomnolence are non-restorative sleep, automatic

behaviour, difficulties awakening in the morning and sleep inertia (period of impaired
performance and reduced vigilance following awakening from the regular sleep episode or
from a nap. Physiological stress and the use of alcohol can increased the hypersomnolence
attacks. Other risk factors may include viral infection genetic predisposition.

2.1.2 Narcolepsy and cataplexy

According to ICSD-2, narcolepsy is classified under hypersomnolence. It is characterized by
excessive daytime sleepiness, extreme fatigue and irresistible episodes of sleep. The sleep
attacks typically occur 2 to 6 times a day and last for 10 to 20 minutes. There are three
subtypes of narcolepsy.
a) Narcolepsy with cataplexy (The irresistible sleep episodes with sudden bilateral loss of
skeletal muscle tone)
b) Narcolepsy without cataplexy
c) Narcolepsy secondary to a medical condition (medical or psychiatric disorder)
It is a condition caused by irregular secretion of brain neurotransmitter hypocretin (orexin)
which regulates sleep, resulted in low CSF levels of these neurotransmitter. Most cases of
narcolepsy is related to autoimmune damage of hypothalamic cells and is strongly related to
HLA-DR2 and HLA-DQBI*0602 antigens. This chronic disorder affect males and females
equally with a prevalence of 0.4 per 1000.

2.1.3 Clinical presentation / Sign and symptoms of narcolepsy

The classical tetrad features of narcolepsy are:
a) Excessive daytime sleepiness (EDS)
EDS is the main cause of disability and most frequent presenting feature. It tends to
worsen gradually until there is an irresistible and refreshing short episode of sleep. This
uncontrollable feature is varied in the frequency of naps. Patient will suffer from frequent
irresistible sleep attacks during daytime, occasionally in inappropriate situation, such as
during conversation, driving, talking, during sex or having meals. Night time sleep may
be disrupted and paradoxically insomnia may occur. However, EDS is quantifiable by
using Epworth Sleepiness Scale.
b) Cataplexy
It is characterised by sudden loss of muscle tone, causing the head droop or even falling
with intact awareness. Attacks are often triggered by specific emotional, stressful or
surprising stimuli in the environment. All voluntary muscles are involved except the
respiratory and extraocular musculature. The patient may fall to the ground or merely
become suddenly very weak. Consciousness is preserved during the attack and there is
rapid recovery.
c) Hypnagogic/ hypnopompic hallucinations
This is a frightening condition where dream-like hallucinations happened while falling
asleep (hypnagogic) or upon waking from sleep. (hypnopompic)
d) Sleeps paralysis

A brief paralysis or inability to move on waking or while falling asleep due to intrusion of
REM atonia into wakefulness. This occasionally occurs in people without narcolepsy.
Other sign and symptoms are
e)
f)
g)
h)
i)

Sleep talking
Frequent awakenings whilst asleep
Nightmare (often violent and terrifying), night terrors, and sleep walking
There is an association with obesity
Secondary depression, anxiety and underachievement at school or work

2.1.4 Diagnosis of narcolepsy

Narcolepsy has no specific diagnostic test and totally depend on a clinical diagnosis by
specialist to confirm a suspected case. However, there are some diagnostic testing to facilitate
the diagnosis of narcolepsy, including
a) Polysomnography/ Multiple Sleep Latency Testing
It shows a distinctive pattern of a short sleep latency (time to get to sleep), short
periods of REM sleep, increased stage 1 NREM sleep and frequent awakening.
b) Human leucocyte antigen (HLA) typing
c) Reduced Hypocretin-1 concentration in CSF
2.1.5 Treatment of narcolepsy
There is no cure for narcolepsy, but symptom management is possible. Although drug therapy
is the mainstay of treatment, the overall therapeutic approach should consider general
measures as well.
a) General measure
Treat the underlying cause of the problem (medical or psychiatric)
Practical support (Psychoeducation, support at school or work, participation in
support groups for narcolepsy) especially if cataplexy limits activities that can be
undertaken (e.g. driving)
Ensure good sleep hygiene / scheduled maps (short 20min naps reduce the
likelihood of irresistible sleeps.
Advise on safety or protective measure (e.g. for sleepwalking)
Lifestyle adjustment (Relaxation therapy, yoga, mindfulness training)
b) Pharmacology treatment
Stimulants (methylphenidate, methamphetamine and modafinil dexamfetamine)
are most commonly used to treat hypersomnolence associated with some sleep
disorders such as intrinsic dyssomnias (eg., narcolepsy, idiopathic hypersomnia
and recurrent hypersomnia) and dyssomnias associated with sleep related medical
condition (e.g., sleep-related asthma). However, they should not be used to treat
sleepiness associated with other intrinsic dyssomnias (e.g., obstructive sleep
apnea) or most of the extrinsic dyssomnias. Taking stimulants to overcome
daytime sleepiness caused by inadequate sleep hygiene or hypnotic-dependent
sleep disorder constitutes drug abuse. Generally, they are safe and effective, but
may cause restlessness, irritability and GI upset. Drug-free holidays should be

applied to reduce tolerance or loss of drug efficacy. Besides, scheduled naps may
be used as stimulant dose replacements.
REM sleep-suppressing drugs such as tricyclic antidepressants (clomipramine,
imipramine,protriptyline) or SSRI (venlafaxine, fluoxetine) are used to improve
cataplexy condition because cataplexy is presumably an intrusion of REM sleep
phenomena into the awake state.
Sodium oxybate is also used to improve cataplexy
Careful monitoring of drug refills, general health and cardiac status.