Dr. M. Zain Yousuf
MBBS, MCPS (Resident)
SMO & In-charge In-patient Dept.
A. Q. Khan Institute
Nonorganic disorder of sleep-wake schedule
Sleep terrors [night terrors]
Diagnostic guidelines:1. The complaint is either of difficulty falling asleep or maintaining sleep, or of poor quality of sleep;
2. The sleep disturbance has occurred at least three times per week for at least 1 month;
3. There is preoccupation with the sleeplessness & excessive concern over its consequences at night & during the day;
4. The unsatisfactory quantity &/or quality of sleep either causes marked distress or interferes with ordinary activities in daily living.
Diagnostic guidelines:1. Excessive daytime sleepiness or sleep attacks, not accounted for by an inadequate amount of sleep, &/or prolonged transition to the fully aroused state upon awakening (sleep drunkenness);
2. Sleep disturbance occurring daily for more than 1 month or for recurrent periods of shorter duration, causing either marked distress or interference with ordinary activities in daily living;
3. Absence of auxiliary symptoms of narcolepsy (cataplexy, sleep paralysis, hypnagogic hallucinations) or of clinical evidence for sleep apnoea (nocturnal breath cessation, typical intermittent snorting sounds, etc.);
4. Absence of any neurological or medical condition of which daytime somnolence may be symptomatic.
Nonorganic Disorder of SleepWake Schedule
Diagnostic guidelines:1. The individual's sleep-wake pattern is out of synchrony with the sleep-wake schedule that is normal for a particular society & shared by most people in the same cultural environment;
2. Insomnia during the major sleep period & hypersomnia during the waking period are experienced nearly every day for at least 1 month or recurrently for shorter periods of time;
4. The unsatisfactory quantity, quality, & timing of sleep cause marked distress or interfere with ordinary activities in daily living.
Diagnostic guidelines:1. The predominant symptom is one or more episodes of rising from bed, usually during the first third of nocturnal sleep, & walking about; 2. During an episode, the individual has a blank, staring face, is relatively unresponsive to the efforts of others to influence the event or to communicate with him or her, & can be awakened only with considerable difficulty;
3. Upon awakening (either from an episode or the next morning), the individual has no recollection of the episode;
4. Within several minutes of awakening from the episode, there is no impairment of mental activity or behavior, although there may initially be a short period of some confusion & disorientation;
5. There is no evidence of an organic mental disorder such as dementia, or a physical disorder such as epilepsy.
Sleep Terrors [Night Terrors]
Diagnostic guidelines:1. The predominant symptom is that one or more episodes of awakening from sleep begin with a panicky scream, & are
characterized by intense anxiety, body motility, & autonomic hyperactivity, such as tachycardia, rapid breathing, dilated pupils, & sweating;
2. These repeated episodes typically last 1-10 minutes & usually occur during the first third of nocturnal sleep;
3. There is relative unresponsiveness to efforts of others to influence the sleep terror event & such efforts are almost invariably followed by at least several minutes of disorientation & perseverative movements;
4. Recall of the event, if any, is minimal (usually limited to one or two fragmentary mental images);
5. There is no evidence of a physical disorder, such as brain tumor or epilepsy.
Diagnostic guidelines:1. Awakening from nocturnal sleep or naps with detailed & vivid recall of intensely frightening dreams, usually involving threats to survival, security, or self-esteem; the awakening may occur at any time during the sleep period, but typically during the second half; 2. Upon awakening from the frightening dreams, the individual rapidly becomes oriented & alert;
3. The dream experience itself, & the resulting disturbance of sleep, cause marked distress to the individual.
Assessment & treatment of any physical condition.
Assessment & treatment of any other psychiatric condition.
Education about sleep (e.g. stages of sleep, changes in sleep patterns with age & the nature of the particular sleep problem).
4. Sleep hygiene:i. Control of environmental factors (e.g. light, noise, temperature). ii. Wind down timing.
iii. Avoidance of caffeine since early evening.
iv. Not smoking since 1 hour before bedtime.
v. Regular exercise (not late at night).
vi. A late tryptophan snack (e.g. warm milk)
vii. Avoiding naps during daytime.
viii. Learning to set aside a time during the day to reflect on problems & stresses.
5. Stimulus control:i.
Go to bed only when sleepy;
Avoid other activities while in bed;
If sleep does not occur, do not remain in bed for more than 10–20 mins, get up & go to another room (without turning on all the lights), returning to bed only when sleepy;
Establish a regular time to get up, with no more than 1 hour's variation (even at weekends & during holidays).
6. Medications – Stimulants, TCAs or SSRIs in case of hypersomnia or narcolepsy. Or melatonin in case of disturbed sleep-wake cycle.