SLEEP–WAKE DISORDERS:

THE MAJOR DYSSOMNIAS

Clinical Presentation  DYSSOMNIAS
Research tells us that even minor sleep
deprivation over only 24 hours impedes our DYSSOMNIAS – Problems in the amount,
ability to think clearly. Lack of sleep also timing, or quality of sleep. DSM-5 identifies a
affects you physically. People who do not get number of different dyssomnias: Insomnia
enough sleep are more susceptible to illnesses Disorder, Hypersomnolence Disorders,
such as the common cold, perhaps because Narcolepsy, Breathing-Related Sleep
immune system functioning is reduced with the Disorders, and Circadian Rhythm Sleep
loss of even a few hours of sleep. Disorder.

Sleep problems may cause the difficulties  INSOMNIA DISORDER

people experience in everyday life or they may Insomnia is one of the most common sleep–
result from some disturbance common to a wake disorders. It is being awake all the time.
psychological disorder. One way to determine Insomnia to mean “not sleeping,” it actually
whether a person has a problem with sleep is applies to a number of complaints. People are
to observe his daytime sequelae, or behavior considered to have insomnia if they have
while awake. trouble falling asleep at night (difficulty
initiating sleep), if they wake up frequently or
Rapid Eye Movement (REM) sleep - region of too early and can’t go back to sleep (difficulty
the brain that is involved with our dream sleep. maintaining sleep), or even if they sleep a
This mutual neurobiological connection reasonable number of hours but are still not
suggests that anxiety and sleep may be rested the next day (nonrestorative sleep).
interrelated in important ways, although the
exact nature of the relationship is still Primary Insomnia - sleep problems were not
unknown. related to other medical or psychiatric
problems. Several psychological disorders
The two major categories of Sleep-wake are associated with insomnia. Total sleep time
Disorders are Dyssomnias and Parasomnias. often decreases with depression, substance
1. Dyssomnias use disorders, anxiety disorders, and
Dyssomnias involve difficulties in getting neurocognitive disorder due to Alzheimer’s
enough sleep, problems with sleeping disease.
when you want to, and complaints about
the quality of sleep, such as not feeling Alcohol is often used to initiate sleep. In small
refreshed even though you have slept the amounts, it helps make people drowsy, but it
whole night. also interrupts ongoing sleep.

2. Parasomnias Women report insomnia twice as often as

Parasomnias are characterized by men. Women more often report problems
abnormal behavioral or physiological initiating sleep, which may be related to
events that occur during sleep, such as hormonal differences or to differential reporting
nightmares and sleepwalking. of sleep problems, with women generally more
negatively affected by poor sleep than men
The clearest and most comprehensive picture
of your sleep habits can be determined only by Approximately one in five young children
a polysomnographic (PSG) evaluation. The experiences insomnia. Growing evidence
patient spends one or more nights sleeping in points to both biological and cultural
a sleep laboratory and being monitored on a explanations for poor sleep among
number of measures, including respiration and adolescents.
oxygen desaturation (a measure of airflow);
leg movements; brain wave activity, measured This higher rate in reports of sleeping
by an electroencephalogram; eye problems among older people makes sense
movements, measured by an when you remember that the number of hours
electrooculogram; muscle movements, we sleep decreases as we age.
measured by an electromyogram; and heart
activity, measured by an electrocardiogram. Insomnia accompanies many medical and
psychological disorders, including pain and
physical discomfort, physical inactivity during
the day, and respiratory problems.
 SLEEP–WAKE DISORDERS:
THE MAJOR DYSSOMNIAS
As a group, people with insomnia seem to
have higher body temperatures than good 1. Cataplexy occurs while the person is
sleepers, and their body temperatures seem to awake and can range from slight
vary less; this lack of fluctuation may interfere weakness in the facial muscles to
with sleep. complete physical collapse. Cataplexy
lasts from several seconds to several
Other sleep disorders, such as sleep apnea (a minutes; it is usually preceded by strong
disorder that involves obstructed nighttime emotion such as anger or happiness.
breathing) or periodic limb movement disorder Cataplexy appears to result from a sudden
(excessive jerky leg movements), can cause onset of REM sleep.
interrupted sleep and may seem similar to
insomnia. 2. Sleep paralysis, a brief period after
awakening when they can’t move or speak
Both biological and psychological factors that is often frightening to those who go
are present in most cases. In other words, through it.
personality characteristics, sleep difficulties,
and parental reaction interact in a reciprocal 3. Hypnagogic hallucinations, vivid and
manner to produce and maintain sleep often terrifying experiences that begin at
problems. the start of sleep and are said to be
unbelievably realistic because they include
Rebound Insomnia— where sleep problems not only visual aspects but also touch,
reappear, sometimes worse—may occur when hearing, and even the sensation of body
the medication is withdrawn. This rebound movement.
leads people to think they still have a sleep
problem, re-administer the medicine, and go Narcolepsy is relatively rare, occurring in
through the cycle repeatedly. 0.03% to 0.16% of the population, with the
numbers approximately equal among males
 HYPERSOMNOLENCE DISORDERS and females. Although some cases have been
Insomnia disorder involves not getting enough reported in young children, the problems
sleep (the prefix in means “lacking” or associated with narcolepsy usually are first
“without”), and hypersomnolence disorders seen during the teenage years. Excessive
involve sleeping too much (hyper means “in sleepiness usually occurs first, with cataplexy
great amount” or “abnormal excess”). Many appearing either at the same time or with a
people who sleep all night find themselves delay of up to 30 years.
falling asleep several times the next day.
Sleep paralysis and hypnagogic
People with hypersomnolence sleep through hallucinations may serve a role in explaining
the night and appear rested upon awakening a phenomenon—unidentified flying object
but still complain of being excessively tired (UFO) or alien abduction experiences. It
throughout the day. Another sleep problem occurs in a portion of people without
that can cause a similar excessive sleepiness narcolepsy, a phenomenon that may help
is a breathing-related sleep disorder called explain why not everyone with these
sleep apnea. People with this problem have “otherworldly” experiences has narcolepsy.
difficulty breathing at night. They often snore Sleep paralysis commonly co-occurs with
loudly, pause between breaths, and wake in anxiety disorders, in which case the condition
the morning with a dry mouth and headache. is termed isolated sleep paralysis.

Genetic influences seem to be involved in a Research on Doberman pinschers and

portion of cases. Labrador retrievers, which also inherit this
disorder, suggests that narcolepsy is
 NARCOLEPSY associated with a cluster of genes on
Narcolepsy, a different form of the sleeping chromosome 6, and it may be an autosomal
problem. some people with narcolepsy recessive trait. It appears that there is a
experience cataplexy, a sudden loss of muscle significant loss of a certain type of nerve cell
tone. People with narcolepsy periodically (hypocretin neurons) in those with narcolepsy.
progress right to this dream-sleep stage
almost directly from the state of being awake.
Symptoms or characteristics of narcolepsy  BREATHING-RELATED SLEEP
includes cataplexy, sleep paralysis, and DISORDERS
hypnagogic hallucinations.
 SLEEP–WAKE DISORDERS:
THE MAJOR DYSSOMNIAS
Sleepiness during the day or disrupted sleep Mixed sleep apnea is a form of sleep apnea
at night has a physical origin—namely, that combines obstructive sleep apnea and
problems with breathing while asleep. In DSM- central sleep apnea.
5, these problems are diagnosed as
breathing-related sleep disorders. People  Sleep - related hypoventilation, is a
whose breathing is interrupted during their decrease in airflow without a complete
sleep often experience numerous brief pause in breathing. This tends to cause an
arousals throughout the night and do not feel increase in carbon dioxide (CO2) levels,
rested even after 8 or 9 hours asleep. because insufficient air is exchanged with
the environment.
For some, breathing is constricted a great deal
and may be labored (hypoventilation) or, in the  CIRCADIAN RHYTHM SLEEP
extreme, there may be short periods (10 to 30 DISORDER
seconds) when they stop breathing altogether, Circadian rhythm sleep disorder is
called sleep apnea. characterized by disturbed sleep (either
insomnia or excessive sleepiness during the
A bed partner usually notices loud snoring day) brought on by the brain’s inability to
(which is one sign of this problem), however, synchronize its sleep patterns with the current
or will have noticed frightening episodes of patterns of day and night. Rhythms don’t
interrupted breathing. Other signs that a exactly match our 24-hour day, they are called
person has breathing difficulties are heavy circadian (from circa meaning “about” and
sweating during the night, morning dian meaning “day”).
headaches, and episodes of falling asleep
during the day (sleep attacks) with no Our biological clock is in the suprachiasmatic
resulting feeling of being rested. nucleus in the hypothalamus. Connected to
the suprachiasmatic nucleus is a pathway that
There are three types of apnea: obstructive, comes from our eyes. The light we see in the
central, and mixed sleep apnea. morning and the decreasing light at night
signal the brain to reset the biological clock
1. Obstructive Sleep Apnea each day.
Obstructive sleep apnea hypopnea syndrome
occurs when airflow stops despite continued Types of circadian rhythm sleep disorders:
activity by the respiratory system. It is reported  JET LAG
snoring at night. Obesity is sometimes Caused by rapidly crossing multiple time
associated with this problem, as is increasing zones. People with jet lag usually report
age. use of MDMA (ecstasy) can lead to difficulty going to sleep at the proper time and
obstructive apnea hypopnea syndrome even in feeling fatigued during the day. Traveling more
young and otherwise healthy adults. It is most than two time zones westward usually affects
common in males and is thought to occur in people the most. Traveling eastward and/or
approximately 20% of the population. less than three time zones are usually
tolerated better. Research with mice suggests
2. Central Sleep Apnea that the effects of jet lag can be quite serious
The second type of apnea, central sleep — at least among older adults.
apnea, involves the complete cessation of
respiratory activity for brief periods and is often  SHIFT WORK
associated with certain central nervous system Type sleep problems are associated with work
disorders, such as cerebral vascular disease, schedules. Many people, such as hospital
head trauma, and degenerative disorders. employees, police, or emergency personnel,
Those with central sleep apnea wake up work at night or must work irregular hours; as
frequently during the night but they tend not to a result, they may have problems sleeping or
report excessive daytime sleepiness and often experience excessive sleepiness during
are not aware of having a serious breathing waking hours.
problem.
 DELAYED SLEEP
People who stay up late and sleep late where
sleep is delayed or there is a later than normal
bedtime.
3. Mixed Sleep Apnea
 ADVANCED SLEEP
 SLEEP–WAKE DISORDERS:
THE MAJOR DYSSOMNIAS
At the other extreme, people with an advanced sleep. People walk in their sleep, they are
sleep phase type of circadian rhythm disorder probably not acting out a dream. This
are “early to bed and early to rise.” Here, sleep parasomnia typically occurs during the first
is advanced or earlier than normal bedtime. few hours while a person is in the deep
stages of sleep. The DSM-5 criteria for
Finally, two other types, irregular sleep– sleepwalking require that the person leave
wake type (people who experience highly the bed, although less active episodes can
varied sleep cycles) and non-24-hour sleep– involve small motor behaviors, such as
wake type. sitting up in bed and picking at the blanket
or gesturing. Because sleepwalking occurs
Scientists believe the hormone melatonin during the deepest stages of sleep, waking
contributes to the setting of our biological someone during an episode is difficult; if
clocks that tell us when to sleep. This hormone the person is wakened, she typically will
is produced by the pineal gland in the center of not remember what has happened.
the brain. Melatonin has been nicknamed the Sleepwalking is primarily a problem during
“Dracula hormone” because its production is childhood, affecting more than 10% of
stimulated by darkness and ceases in daylight. school-aged children, but a small
When our eyes see that it is nighttime, this proportion of adults are affected.
information is passed on to the pineal gland,
which, in turn, begins producing melatonin. Occurs at least once during non-REM
sleep in 15% to 30% of children under age
15. Causes may include extreme fatigue,
 PARASOMNIAS sleep deprivation, sedative or hypnotic
drugs, and stress. Adult sleepwalking is
Parasomnias are not problems with sleep usually associated with other
itself but abnormal events that occur either psychological disorders. May have a
during sleep or during that twilight time genetic link.
between sleeping and waking. Some events
associated with parasomnia are not unusual if  NIGHTMARE DISORDER
they happen while you are awake (e.g., Frequently being awakened by extended
walking to the kitchen to look into the and extremely frightening dreams that
refrigerator) but can be distressing if they take cause significant distress and impaired
place while you are sleeping. functioning. It occur during REM or dream
sleep. To qualify as a nightmare disorder,
DSM-5 identifies a number of different according to DSM-5 criteria, these
parasomnias: experiences must be so distressful that
 DISORDER OF AROUSAL they impair a person’s ability to carry on
Motor movements and behaviors that normal activities (such as making a person
occur during NREM sleep including too anxious to try to sleep at night).
incomplete awakening (confusional Nightmares are defined as disturbing
arousals), sleep walking, or sleep terrors dreams that awaken the sleeper.
(abrupt awakening from sleep that begins Nightmares are thought to be influenced
with a panicky scream). by genetics, trauma, medication use, and
 Sleep terrors, which most commonly are associated with some psychological
afflict children, usually begin with a disorders.
piercing scream. The child is extremely
upset, often sweating, and frequently has  RAPID EYE MOVEMENT SLEEP
a rapid heartbeat. During sleep terrors, BEHAVIOR DISORDER
children cannot be easily awakened and Episodes of arousal during REM sleep that
comforted, as they can during a result in behaviors that can cause harm to
nightmare. As many as one third of 18- the individual or others.
month-old children may experience sleep
terrors, but this number drops to 13% by  RESTLESS LEGS SYNDROME
age 5 and just 5% by age 13. More Irresistible urges to move the legs as a
common in boys than girls, and possible result of unpleasant sensations
genetic link since they tend to run in (sometimes labeled “creeping,” “tugging,”
families. May subside with time. or “pulling” in the limbs) (otherwise
referred to as Willis-Ekbom disease).
 Sleep walking (also called
somnambulism) occurs during NREM
 SLEEP–WAKE DISORDERS:
THE MAJOR DYSSOMNIAS
 SUBSTANCE-INDUCED SLEEP
DISORDER
Severe sleep disturbance that is the result
of substance intoxication or withdrawal.