A sleep disorder is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental, social and emotional functioning.

1. Sleep and Rest

2. Definition
• Rest: a condition in which body is in a
decrease state of activity with a feeling of
being refreshed.
• Sleep state of rest accompanied by altered
consciousness and relative inactivity.

3. Physiologic of sleep
• Two systems control sleep:
1. Reticular activating system (RAS).
2. Bulbar synchronizing region.

6. Physiologic of sleep
• Reticular activating system (RAS): at the core of
the brain stem between medulla oblongata and
midbrain and it important to maintain state of
consciousness.
• It is affected by many psychotropic drugs and
general anesthetics.

7. Physiologic of sleep
• It involved with the circadian rhythm &
damage can lead to permanent coma.
• It produce acetylcholine and catecholamine
neurotransmitters to maintain wakefulness.
• It brings relevant information to your
attention.

8. Physiologic of sleep
• Bulbar synchronizing region: which produce
chemicals such as GABA or serotonin to
promote sleep.
• Hypothalamus: control center for sleeping and
rest and walk.

9. Circadian rhythms
• It is complete a full cycle every 24 hours.
• Circa: approximately.
• Diem: day.
• Circadian: one day.

10. Circadian rhythms
A. Circadian synchronization: when an individual
sleep wake pattern follow the inner biologic clock.
• The hormones: melatonin and cortisol which
affect sleep circadian rhythm (awake and sleep).
• The regulating mechanism of sleep is the persons
biologic clock which is controlled by
hypothalamus.
• The rhythm doesn't present at birth and develop
over 2 years of life.

12. Circadian rhythms
B. DE- synchronization: when wake pattern are
frequently altered and the person attempt to
sleep during high activity rhythm or work when
the body is physiologically prepared to rest.

13. Stages of sleep
• Stage 1: non rapid eye movement (NREM).
• Stage 2: rapid eye movement (REM).
• The cycle for the two stages occur in 90-110
minutes cycle.
• During 8 hours sleep, the cycle of the two
stages repeats itself 5-6 times.

15. Non rapid eye movement (NREM)
• It consists of 4 stages:
• Stage I and II transition from wakefulness to
sleep and consume about 5% (stage I) and 45%
(stage II) of person sleep time (light sleep).
• The person can be aroused with relative ease.
• Stage III and IV represents 10-20% of total sleep:
deepest sleep states termed as delta sleep or
slow wave sleep, arouse threshold is greatest.
Occur in first one third to one half of the night.

16. Non rapid eye movement (NREM)
• Arousal during this stage (stage 3 or 4):
• (30-60 minutes) after sleep onset disoriented,
and disorganized thinking and problems may
result such as amnesia, enuresis, nightmare,
night terrors.
• Parasympathetic, nervous system dominates and
decrease in pulse, RR, BP, metabolic rate, tem.

17. REM
• More difficult to arouse person during this stage
than during NREM sleep and it lasts 15-40 min.
• It consumes about 20-25% of sleep time.
• Dreaming occur during this stage.
• PB, pulse, RR, metabolic rate and body tem
increase while skeletal muscles tone, deep
tendon reflex are depressed.
• High level of brain activity and physiological
activities.

18. REM
• Shortening of REM, result in depressive
disorders and nacrolepsy.

20. Sleep requirement and patterns
• Infant: 14-20 hours.
• Children: 10-14 hours.
• Adult: 7-9 hours.
• Elderly: vary (5-7 hours): need more longer
time to sleep than adult, wake early and
frequently during night.

21. Factors affecting sleep
• Developmental consideration.
• Psychological stress (illness and life events).
• Motivation.
• Culture (herbs instead of medication, privacy,
quite).
• Lifestyle and habit (shift work, watching TV,
outside activities).

22. Factors affecting sleep
• Physical activity and exercise: increase fatigue
especially 2 hours before sleep time, or
promote relaxation and sleep.
• Dietary habit: small protein and carbohydrate
snakes are effective, large amount of alcohol,
caffeine containing beverages, smoking (light
sleepers, easily aroused).
• Environmental factors: place of sleep, light,
quite and noisy environment.

23. Factors affecting sleep
• Illness: gastric secretion increased during REM
(e.g. peptic ulcer), pain associated with
coronary artery diseases and myocardial
artery diseases and myocardial infarction
(REM), liver failure (REM), encephalitis,
hypothyroidism (NREM).
• Medications: diuretic, barbiturate,
antidepressant, steroids, asthma medication.

24. Common sleep problems
• Primary sleep disorders: consist of:
• Dyssomnias (problem with initiating or
maintain sleep or excessive sleepiness).
• Parasomnias (particular physiologic or
behavioral reaction during sleep).

25. Primary sleep disorders:
Dyssomnias
• It consists of primary insomnia, primary
hypersomnia, narcolepsy.

26. Primary Insomnia

27. Primary Insomnia
• Difficulty to initiate or maintain sleep, or early
awakening from sleep far at least 1 month.
• It causes social and functional impairment.
• It does not occur during other mental disorders
(narcolepsy, depression, generalized anxiety).
• Not occur as a result of substance or drug use.

28. Primary Insomnia
• Other information:
• Increase with age, women, stress.
• Begin in adulthood or middle age and rare in
childhood.
• Symptoms may stay for one year or less.
• Associated with anxiety.
• Specific treatment is usually not required.

29. Primary Hypersomnia

30. Primary Hypersomnia
• Excessive sleep for at least 1 month,
particularly during day (more than 8-12 hours)
e.g during lectures, driving, reading, watch TV,
it causes significant distress or impairment.
• It doesn't occur during other sleeping
disorders (narcolepsy, parasomnia) or
inadequate amount of sleep.
• Doesn’t occur during the course of other
mental disorders or substance abuse.

31. Primary Hypersomnia
• Other information:
• It doesn't occur sudden.
• Begins between age 15-30 years.
• More than 9 hours of sleep per 24 hours
periods suggest primary hypersomnia.
• M>F ,daytime nap is long (1 hour or more),
(coping mechanism to stress, no treatment is
necessary).

32. Primary Hypersomnia
• Fall sleep easily but have difficulty in
awakening in the morning and don’t feel
refresh after awakening.
• Interventions: caffeine drink and chocolate or
stimulant drugs (amphetamine).
• Chronic insomnia last 3-4 weeks or more.

33. Narcolepsy
• It is neurological disorder and characterized by
uncontrollable desire to sleep.
• Irresistible attacks of refreshing sleep that occur daily over
3 months and the presence of one or both of the following:
• Cataplexy (brief sudden bilateral loss of muscle tones
triggered by strong emotion such as laughter and stays for
seconds).
• Or/and recurrent intrusions of REM sleep into transition
between wakefulness and sleep as manifested by either
hallucination (hearing, visual, or sleep paralysis: unable to
move or speak when failing asleep or waking up and
terminate spontaneously or when someone touches the
person)at the beginning or the end of sleep episodes
• It is not due to substance abuse.

34. Narcolepsy
• Other information:
• Appear in adolescence and early adulthood.
• Last 10-20 minutes or one hour and dreams are
frequently reported.
• Respiratory and eye muscle aren't affected.
• Stay full conscious and alert and no confusion
before and after the episode.
• Cataplexy is triggered by strong emotional
stimulus (anger, laughter, surprise).

35. Narcolepsy
• They may isolate themselves or prevent
emotion to prevent this disorder.
• At the risk of accidental injury.
• Daytime sleep is the first symptom in addition
to sleep hallucination, and paralysis.

36. Common feature in narcolepsy
• M=F
• Cause: genetics (gene 6).
• Treatment:
• Generally no cure.
• Forced naps at regular time of the day.
• Central nervous system stimulant:
dextroamphetamine, ritalin, tricyclic antidepressant
(imipramine especially for cataplexy).
• Psych education (engage in activity while driving
such as music or munching on nuts, schedule naps.

37. Breathing related sleep disorder:
sleep apnea

38. Breathing related sleep disorder:
sleep apnea
• Repeated upper-airway obstruction during sleep.
• The absence of breathing between loud snoring
intervals and silence for 20-30 seconds or longer
(2min).
• O2 decreases, HR irregular, BP increase.
• Occur in middle aged men who are obese and short
thick neck, women and other ages, large neck size.
• Causes: obstruction of airways, large tonsils, adenoid
deviated nasal septum, thyroid enlargement and
allergic rhinitis, neurological problems.
• At risk of developing hypertension.

39. Sleep apnea
• Sign and symptoms: irritable during the day, fall
asleep during activity, lack of concentration,
involve in motor accident.
• Alcohol, tobacco and sleeping pills increase the
breathing disruption.
• treatment: surgery to remove soft tissues,
remove tonsils, avoid alcohol and sedation.

40. Parasomnia
• Abnormal behavior or physiological events occurring
in association with sleep stages or sleep wake
transition.
• It occurs in stage III and IV with poor recall.
• Involve activation of autonomic nervous system,
motor system, cognitive process during sleep.
• They present with complaints of unusual behavior
during sleep rather than complaints of insomnia or
excessive sleep.
• It includes: nightmare disorder, sleep terror disorder,
sleep walking disorder.

41. Nightmare disorder:
dream anxiety disorder
• Repeated occurrence of frightening dreams
that lead to awakenings from sleep.
• On waking from the frightening dream the
person rapidly becomes oriented and alert.
• Onset: 3-6 years and may persist for
adulthood, F>M causes severe stress.
• Dreams focus on physical danger and appear
during REM episodes (90-110 minutes) and
there is details recall of the dream.

42. Nightmare disorder:
dream anxiety disorder
• No specific treatment is usually required.
• Drugs: benzodiazepines and tricyclic drugs to
reduce REM.
• No harm to awaken the person during
nightmares.

43. Sleep terror disorder

44. Sleep terror disorder
• Diagnostic criteria:
A. recurrent episodes abrupt awakening from
sleep usually occurring during the first third of
the major sleep episode and beginning with a
panicky scream.
B. Intense fear and signs of autonomic arousal
such as tachycardia, rapid breathing, sweating.
C. Relative unresponsive to efforts of others to
comfort the person during the episode.

45. Sleep terror disorder
D. No detailed dream is recalled and there is
amnesia for the episode.
E. The episode cause clinically significant distress
or impairment in social, occupational, or other
important areas of functioning.
F. The disturbance is not due to physiological
effects of a substance or medical condition.

46. Sleep terror disorder
• Other information:
• Difficult to awaken or to recall the episode the
next morning.
• Last 1-10 minutes and occurs during stage III
and IV (NREM) and may develop into sleep
walking.
• Begin in children between 4-12 years old and
resolve spontaneously during adolescence.

47. Sleep terror disorder
• In adult, begins ages 20-30 years and follows
chronic course.
• Causes: genetics, minor neurological
abnormalities in temporal lope.
• Treatment: specific treatment is not required,
investigate family situations.
• Medication: diazepam (valium) may cure it.

48. Sleep walking disorder
(somnambulism)

49. Sleep walking disorder
(somnambulism)
• Diagnostic criteria:
A. Repeated episode of rising from bed during
sleep and walking about usually occurring
during the first third of major sleep episode.
B. While sleep walking the person has blank staring
face, is relatively unresponsive to the effort of
others to communicate with him or her.
C. On walking the person has amnesia for the
episode.

50. Sleep walking disorder
(somnambulism)
D. Within several minutes after awakening from
the sleepwalking episode, there is no
impairment of mental activity or behavior.
E. The sleep walking causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
F. The disturbance is not due to physiological
effects of a substance or medical condition.

51. Sleep walking disorder
(somnambulism)
• Sleep walking occurs during the first third of the
night, unresponsive to communication or effort to
awake and cannot recall in morning (can eat, talk,
use bathroom, go around home or drive car during
the episode for several min to 30 min).
• First time: common in children, ages 4-8 years, peak:
age 12 years and childhood episodes disappear early
adolescence (M>F).
• Interventions: remove hazards from bedroom, lock
windows, locate bedroom in first floor and
medication (benzodiazepine) in difficult cases.

52. Sleep walking disorder
(somnambulism)
• Causes: genetics, internal stimuli (distend
bladder) or external stimuli (noises),
psychological stressors, alcohol, sedative use.
• Some may eat during the episode and don’t
remember it morning or injure themselves.
• It occurs in first hours, stage (3-4) of sleep.
• F>M.
• It disappears spontaneously by age 15 years.
• In adult: it is a chronic course.
• May occur with sleep terror disorder.

53. Assessment
• Description: how the patient describe the problem:
• Stability: does it happen every night.
• Intensity: how bad is the problem.
• Duration: when did the problem begin? Transient
(from one to several nights) short term (<1 month)
or chronic (<1 month).
• Sleep history: problem, cause, sign&symptoms,
when it begins and how often occurs.
• How it affects every day living, severity of the
problem, coping.

54. Assessment
• Sleep diary: kept for 24 days to provide more
specific data on sleep pattern page.
• Physical assessment: energy level (fatigue,
lethargy) facial characteristics (narrowing or
glazing of eyes) behavioral characteristics (yawing,
rubbing eyes, slow speech) physical data (obesity,
enlarge neck, deviated nasal septum).

55. Assessment
• Snoring: obstruction to airway through the
nose and mouth and it may accompanied
apnea.

56. Interventions
• Preparing a restful environment.
• Comfortable bed: linen.
• Good body alignment to decrease muscles
strain.
• Quite and dark room with privacy.
• Temp (thermal blanket, cotton sheets, leg
warmer, long underwear).

57. Interventions
• Promoting bedtime rituals: reading, music,
listening to radio, TV, praying, talking to family,
personal hygiene, taking snacks.
• Offering appropriate bed time snacks:
carbohydrate snacks, avoid alcoholic, spicy
food, avoid caffeine for at least 4-5 hours
before sleep, or fluid.
• Promoting relaxation: stress and anxiety
interfere with sleep so use backrub, warm
bath, washing face.

58. Interventions
• Promoting comfort: one of the greatest
deterrents to rest and sleep is pain. Measures:
back message, extra blanket, analgesic.
• Using medication to produce sleep: sedative
hypnotic induce sleep which loos its effects
after 1-2 weeks.
• Sleep medications offer prn.
• Teaching about rest and sleep.

59. Sleep hygiene
• Sleep restriction: spend less time in bed to provide more
opportunity to sleep.
• Use bed only for sleep.
• Only go to bed when sleepy.
• Get up if awake after 10 minutes.
• Encourage activities such as reading, eating or watching TV
outside of bedroom.
• Avoid caffeine product, nicotine, alcohol.
• Hot bath (20 minutes).
• Relaxation techniques.
• Avoid large meals before sleep.
• Avoid daytime naps.

60. Cognitive behavioral therapy
• Cognitive behavioral therapy (CBT): is a form
of therapy that emphasizes observing and
changing negative thoughts about sleep such
as, “I will never fall asleep”. It uses actions
intended to change behavior.

61. Light therapy
• The circadian rhythm is more a function of
darkness and light rather than actual time of
day. Bright light can discourage drowsiness,
and darkness can cause sleepiness, day or
night.