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Pediatric Sleep Clinic

wpbedWe are the premier pediatric sleep disorders clinic in Central Florida and boasts the services of Central Florida’s only pediatric specialist with board certification in Pediatrics, Pediatric Pulmonology and Pediatric Sleep Medicine (by the American Board of Sleep Medicine and by the American Academy of Pediatrics). In addition, we have to providers who have received certification in behavioral sleep medicine from the American Board of Sleep Medicine. Kimberly Justice, PhD and MaryAlice Leinbach, DNP

Sleep Psychology Care Services

SLEEP PARASOMNIAS

Sleep parasomnias refer to disorders of arousal, partial arousal or sleep-wake transition.

Parasomnias are divided into 3 main classes.

Disorders of arousal (from NREM sleep)

  1. Confusional arousals
  2. Sleep terrors
  3. Sleepwalking

Parasomnias usually associated with REM sleep

  1. Nightmare disorder
  2. REM sleep behavior disorder
  3. Recurrent isolated sleep paralysis

Other parasomnias

  1. Sleep related dissociative disorders
  2. Sleep enuresis
  3. Sleep related groaning (Catathrenia)
  4. Exploding head syndrome
  5. Sleep related hallucinations
  6. Sleep related eating disorder
  7. Parasomnia, Unspecified
  8. Parasomnia due to drug or substance
  9. Parasomnia due to medical condition

The NREM parasomnias typically occur during slow wave sleep (stage 3) but can occur from stage 2 sleep and is due to an incomplete arousal from sleep. It is associated with apparent arousal, mental confusion, (Confusional arousals) to agitation, screaming and autonomic involvement, (Sleep terrors) to getting up and either walking around or performing tasks while still asleep (Sleep walking). They usually occur in the first half of the night but can occur later in the night. Usually occur no more than once a night but have been described in some cases to occur multiple times a night. In patients with teenage onset of sleepwalking, epilepsy and nocturnal seizures should be considered as differentials. The typical age for presentation of night terrors is 4-12 years of age, while confusional arousals present at an earlier age. Also, parasomnias appear to be familial. Most events last between 3-5 minutes and self terminate. Typical of any of the events is a lack of recollection on the part of the offending individual.

ICSD CLASSIFICATION FOR CONFUSIONAL AROUSALS:

  • Subject or observer noted recurrent mental confusion upon arousal or awakening in the subject
  • Spontaneous confusional episodes can be induced by forced arousal
  • An absence of fear, walking behavior or intense hallucinations with events
  • DPSG showing arousals from SWS
  • The symptoms are not associated with any other medical condition
  • The symptoms do not meet the diagnostic criteria for other sleep disorders

ICSD CLASSIFICATION FOR SLEEP TERRORS:

  • The patient has sudden episode of intense terror during sleep
  • The episodes usually occur in the first third of the night
  • Partial or total amnesia occurs for the events during the episodes
  • DPSG showing arousals from SWS. Also tachycardia
  • Other medical disorders are not the cause
  • Other sleep disorders are not the cause though they may also exist such as nightmares

Precipitating factors: Sleep disordered breathing, sleep apnea, allergic rhinitis, restless sleep and periodic limb movement in sleep.

Evaluation:

Complete history and physical examination. Usually does not require an overnight sleep study unless the cases are considered complicated. Videotaping may be helpful.

Management:

The key to treatment is accurate diagnosis. If events are rare and do not affect family dynamics treatment is not required. Reassurance is usually sufficient. Treatment should include avoidance of precipitating factors such as sleep deprivation and stress. Parents should be advised not to interfere with the event. Clear room of obstacles or safety hazards. If appropriate add additional locks to doors.

If the events have become disruptive and dangerous to the patient and family and no obvious precipitant is recognized then pharmacological management is an option.

Treatment:

First goal of management should be to get sufficient sleep as insufficient sleep can be a trigger for parasomnias.Address all precipitating factors as any triggers for arousal can predispose to parasomnia events.

Stress reduction and relaxation therapy, hypnosis. When significant psychopathology is identified then psychotherapy for the patient and possibly family should be considered

Medication:

Benzodiazepines are effective for controlling parasomnias but the effectiveness may decrease over time and the events may return once medications are stopped. Tricyclic antidepressants can also be used

Prognosis:

Most parasomnias will resolve without intervention but may take longer to clear up. Confusional arousals and night terrors tend to resolve though night terrors may occur even in adults. Sleep walking is more common in adults.

REM parasomnias occur in REM sleep and occur mostly in the second half of the night.

Nightmares:

These are REM related events and typically occur in the second half of the night. There is typically a recollection of the nightmare or scary event unlike sleep terrors. The age of onset of nightmares is typically around 3-6 years and can last into adulthood. Certain medications can induce an increase in nightmares as well as a condition in which there is REM rebound with very vivid dreams and nightmares when the medication is withdrawn. Most patients will awaken at termination of the nightmare and can typically remember the events in the morning and recollect the event and its content.

REM sleep behavioral disorder (RBD):

This is another manifestation of REM related parasomnias in which the patient acts out their dreams. In this condition, the patient appears not to have the typically protective atonia that is seen in REM sleep. This condition is commoner in older individuals and can be seen in patients with Parkinson’s disease. When seen in younger individuals it is associated with an increased likelihood that they will develop Parkinson’s disease in later life. In this condition, the patient may be a risk to themselves and others and it is not uncommon to see spouses injured by the actions of their bed partner.

Predisposing factors for parasomnias:

Genetic factors, insufficient sleep, stress, anxiety and affective disorders.

Evaluation:

Take a good history and physical examination. Obtain a good medication and drug use history. Does not typically require overnight sleep study although in cases of REM it may be helpful in clearly defining the condition. Videotaping of REM behavioral disorder events may also be helpful.

Treatment:

Safety is paramount especially in cases of RBD. Maintaining an uncluttered environment is helpful.

Psychotherapy may be necessary in some patients with nightmares

Review of drug management, and consideration of different drug options if such medications are inducing the nightmares.

Benzodiazepines can be used to ameliorate the nightmares. Tricyclic antidepressants and Selective serotonin reuptake inhibitors can also be used to reduce nightmares but withdrawal can result can result in REM rebound.

HYPERSOMNIAS

HYPERSOMNIAS OF CENTRAL ORIGIN

Not due to a circadian rhythm sleep disorder, sleep related breathing disorder, or other cause of disturbed nocturnal sleep

Hypersomnias of central origin are recognized within the international classification of sleep disorders and includes:

  • Narcolepsy with cataplexy
  • Narcolepsy without cataplexy
  • Narcolepsy due to medical condition
  • Narcolepsy, unspecified
  • Recurrent hypersomnia
  • Idiopathic hypersomnia with long sleep time
  • Idiopathic hypersomnia without long sleep time
  • Behaviorally induced insufficient sleep syndrome
  • Hypersomnia due to medical condition
  • Hypersomnia due to drug or substance
  • Hypersomnia not due to substance or known physiologic condition
  • Physiological hypersomnia (Unspecified)

Narcolepsy with/without cataplexy:

This is a medical condition associated with excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, cataplexy and poor night time sleep.

The incidence of narcolepsy is 0.2-1/1000 individuals. The first signs of narcolepsy (excessive daytime sleepiness) usually manifest in adolescence but are frequently unrecognized. Most patients are diagnosed as adults when cataplexy (sudden loss of voluntary muscle tone) occurs,

The classic tetrad of symptoms include

Excessive daytime sleepiness: Typically the patient complains of increased daytime sleepiness. In children this is typically ignored or considered secondary to poor sleep habits. This is usually the most debilitating of the features as the patient repeated naps or sleep phases during the day. In some cases the patient can have an automatic or semiautomatic behavior in which they appear to be continuing a task while in actual fact, they are asleep. The task usually does not get done appropriately.

Hypnagogic hallucinations: This is a condition in which the patient relates a history of having episodes wherein the patient goes to sleep, and promptly goes into a dream state, wakes up abruptly and has difficulty differentiating between wakefulness and dream events.

Sleep paralysis: In this condition, the patient has episodes in which they awake from sleep and are unable to move. The sensation typically only lasts a few seconds. Sleep paralysis is as a result of REM related atonia continuing into wakefulness, with an associated inability to move skeletal muscles

Cataplexy: This is a condition in which the patient has a sudden loss of muscle tone. It is typically associated with a strong emotional event (laughter, anger, happiness, extreme sadness). It may affect facial muscles and affect speech. There is no loss of consciousness.

A fifth manifestation is poor night time sleep: Patients with narcolepsy tend to report fragmented and poor night time sleep which runs counter to the fact that they have excessive daytime sleepiness

Several teenage patients with narcolepsy have mood disorders, mostly depression at the time of diagnosis. Occasionally patients are diagnosed following negative evaluations by cardiology and neurology for suspected seizures and near syncopal events.

Differential diagnosis:

  • Idiopathic hypersomnia
  • Depression
  • Bipolar disorder
  • Unexplained falls
  • Partial complex seizures
  • Near syncopal attacks

Associated psychopathology

  • The patient is more likely to have:
  • Poor or falling school grades (greater than50%)
  • Recurrent depression
  • Obsessive thoughts
  • Recurring suicidal thoughts
  • Reduced job performance, earnings, promotions.
  • Required psychotherapy

Diagnosis:

  • Cataplexy is diagnostic for narcolepsy in the presence of excessive daytime somnolence.
  • Multiple sleep latency test with 2 sleep onset REM episodes in a 4-5 nap series is also diagnostic.
  • HLA typing alone does not confirm diagnosis in the absence of either cataplexy or a multiple sleep latency test.
  • CSF hypocretin levels are helpful but not required for diagnosis.

Evaluation:

Patients require an evaluation by a sleep specialist and this should include a full history and physical examination, completion of a subjective sleepiness scale (Epworth sleepiness scale), maintenance of sleep logs, and performance of an overnight sleep study and a multiple sleep latency test.

Multiple sleep latency test:

  • A multiple sleep latency test is used for the diagnosis of narcolepsy and for differentiation from idiopathic hypersomnia.
  • The test is done following a diagnostic sleep polysomnogram and involves 4-5 naps 2 hours apart.
  • The patient is allowed 20 minutes to fall asleep and 15 minutes to sleep if sleep is achieved.

Parameters recorded include:

  • Time of lights out
  • Sleep latency
  • REM presence and latency

Results:

  • A sleep latency of less than 8 minutes is abnormal and less than 5 minutes is pathologic. Between 8-10 minutes requires a correlation with patient functioning. greater than 10 minutes is normal.
  • less than 2 sleep onset REM in 5 naps is normal.
  • 2 or more sleep onset REM diagnostic for narcolepsy

Maintenance of wakefulness test:

  • A maintenance of wakefulness test is used to assess the efficacy of treatment of excessive daytime somnolence.
  • The test involves 4-5 sessions 2 hours apart.
  • The patient is placed in a chair in a dark and quiet room for 40 minutes and asked to stay awake

Treatment:

  • Excessive daytime sleepiness: Behavioral and Medical management
  • Behavioral: Improved sleep hygiene, addition of a daytime nap, education of all parties involved with the patient including, parents, teachers, supervisors.

Medical:

  • Somnolytic agents: Modafinil (Provigil) 200-400mg/day, Armodafinil (Nuvigil) 150-250mg/day
  • Psychostimulants: Amphetmine-Dextroamphetamine salts (Adderall, Adderall XR) 5-50mg/day, Methylphenidate (Ritalin). 5-50mg/day
  • Cataplexy management:
  • Sodium Oxybate (Xyrem) 4.5-9gm/night
  • SSRI’s: Sertraline (Zoloft), Fluoxetine (Prozac) 10-80mg/day
  • SNRI’s: Venlafaxine (Effexor) 75-375mg/day
  • TCA’s: Clomipramine (Anafranil) 10-200mg/day, Protriptyline (Vivactil)

Idiopathic Hypersomnia with long sleep time:

Essential Features

  • Constant and severe sleepiness with prolonged naps
  • Unrefreshing naps of up to 3 or 4 hours
  • Prolonged major sleep episode (typically 12 to 14 hours)
  • Difficulty awakening from nap or in morning
  • Few or no nocturnal awakenings
  • Post – awakening confusion (sleep drunkenness) often reported

Associated Features:

  • Sleep drunkenness
  • Use special procedures to wake up
  • Symptoms of autonomic nervous system dysfunction
  • Headaches
  • Orthostatic hypotension with syncope
  • Peripheral vascular complaints (Raynaud’s type phenomena)
  • Unpredictable response to stimulants
  • Lack of drug efficacy, tolerance and side effects common
  • Timing of drug to relieve sleep drunkenness problematic

Demographics

  • Unknown
  • Ratio 1:10 (Narcolepsy)?

Predisposing and Precipitating Factors

  • Familial predisposition
  • No HLA association
  • Possible autosomal-dominant mode of inheritance
  • No consistent precipitating factors

Familial Patterns

  • Autosomal-dominant mode of inheritance suggest

Onset, Course and Complications

  • Onset usually before age 25
  • Stable in severity and long lasting
  • Few with spontaneous improvement
  • Social and professional complications

Pathology and Pathophysiology

  • Normal hypocretin-1 levels in CSF
  • Histamine transmission may be decreased

Polysomnography and Other Objective Findings

  • Normal sleep of prolonged duration
  • Increase in slow wave sleep may occur
  • MSLT 6.2 +0 less than 2 SOREMPs
  • Consider 24 – hour continuous PSG

Diagnostic Criteria

  • Complaint of EDS almost daily for at least 3 months
  • Prolonged nocturnal sleep (more than 10 hours) documented
  • Nocturnal PSG excluded other causes of EDS
  • PSG demonstrates short sleep latency and sleep period greater than 10 hours
  • If MSLT performed , mean latency less than 8 minutes, less than 2 SOREMPs
  • Hypersomnia not better explained by another condition

Differential Diagnosis

  • Idiopathic Hypersomnia without long sleep time
  • Sleep disordered breathing
  • Narcolepsy without cataplexy
  • Hypersomnia not due to substance or known physiological condition (personality or psychiatric condition)
  • Hypersomnia due to drug or substance
  • Hypersomnia due to medical condition
  • Posttraumatic hypersomnia
  • Chronic fatigue syndrome
  • Behaviorally induced insufficient sleep syndrome

Idiopathic hypersomnia without long sleep time

Essential Features

  • Constant and severe excessive daytime sleepiness
  • Unintended naps – non refreshing
  • Major sleep period normal or slightly prolonged (less than 10 hrs.)
  • Difficulty awakening from naps or in morning
  • Few or no nocturnal awakenings
  • Post- awakening confusion (sleep drunkenness)

Associated Features

  • Sleep drunkenness
  • Use special procedures to wake up
  • Symptoms of autonomic nervous system dysfunction
  • Headaches
  • Orthostatic hypotension with syncope
  • Peripheral vascular complaints (Raynaud’s –type phenomenon)
  • Unpredictable response to stimulants
  • Lack of drug efficacy, tolerance and side effects common

Demographics

  • Unknown

Predisposing and Precipitating Factors

  • Unknown

Familial Patterns

  • Autosomal-dominant mode of inheritance suggested

Onset, Course and Complications

  • Onset usually before age 5
  • Stable in severity and long lasting
  • Few with spontaneous improvement
  • Social and professional complications

Pathology and Pathophysiology

  • Unknown

Polysomography and other objective findings

  • Normal sleep or sleep of slightly prolonged duration (less than 10 hrs)
  • Nocturnal sleep must be more than 6 hours
  • NREM and REM are in normal proportion
  • MSLT 6.2 +0 less than 2 SOREMPs

Diagnostic Criteria

  • Complaint of EDS almost daily for at least 3 months
  • Normal nocturnal sleep (greater than 6 hours,but less than 10 hours) documented
  • Nocturnal PSG excluded other causes of EDS
  • PSG demonstrates a major sleep of normal duration
  • MSLT following PSG, mean latency less than 8 minutes, less than 2 SOREMPs
  • Hypersomnia not better explained by another condition

Differential Diagnosis

  • Idiopathic hypersomnia with long sleep time
  • Sleep disorder breathing
  • Narcolepsy without cataplexy
  • Hypersomnia not due to substance or known physiological conditions (personality or psychiatric conditions)
  • Hypersomnia due to drug or substance
  • Hypersomnia due to medical condition
  • Posttraumatic hypersomnia
  • Chronic fatigue syndrome
  • Behaviorally induced insufficient sleep syndrome

Full history and physical examination:

  • Also completion of sleep logs, and an Epworth sleepiness scale. Finally, an overnight sleep study and multiple sleep latency test to rule out cataplexy.

Treatment:

  • Use of Somnolytics; Modafinil (Provigil), Armodafinil (Nuvigil)
  • Use of psychostimulants; Methylphenidate (Ritalin), Amphetamine-Dextroamphetamine salts (Adderall)

Recurrent Hypersomnia

Essential Features

  • Recurrent episodes of hypersomnia
  • Last a few days to several weeks
  • Occur once to 10 times a year
  • Prodrome of fatigue or headache may precede episodes
  • Sleep may last 16 to 18 hrs. per day
  • Weight gain often occurs
  • Cognitive Abnormalities: feelings of unreality, confusion, hallucinations
  • Behavioral Abnormalities: binge eating, hypersexuality, irritability, aggressiveness
  • Episode Termination associated with amnesia, transient dysphoria or elation, insomnia
  • Sleep and general behavior must be normal between episodes

Associated Features

  • Occasional reddish face with severe perspiration
  • Social and occupational impairment during attacks

Demographics

  • Rare – ~ 200 cases reported
  • Male to female ratio 4:1

Predisposing Factors

  • Increase frequency of HLA DQB1* 02

Precipitating Factors

  • Flu-like or upper airway infection
  • Alcohol
  • Head trauma
  • Exposure to anesthesia

Familial Patterns

  • Rare

Onset, Course and Complications

  • Early adolescence age of onset
  • Recurrent episodes of severe sleepiness
  • Episodes last up to several weeks
  • Normal functioning between episodes
  • Duration, severity and frequency lessen over several years
  • Complications mainly social and occupational

Pathology and Pathophysiology

  • Inconsistent findings
  • lymphocytic infiltrations in the hypothalamus, amygdala and temporal grey matter (one case reported)
  • Symptoms may be of hypothalamic origin
  • In a few cases, moderately and transitory decreased CSF hypocretin-1 levels during episodes of hypersomnia

Diagnostic Criteria

  • Recurrent episodes of excessive sleepiness of 2 days to four weeks duration
  • Episodes recur at least once a year
  • Normal alertness, cognitive functioning,and behavior between attacks
  • Hypersomnia not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder

Clinical and Pathophysiologal subtypes

Kleine-Levin Syndrome:

This is a condition associated with excessive somnolence which may last for a few days to several weeks and can occur between one to ten times in a year. Individuals may sleep up to 16 hours a day and typically wake up just to void and eat. The patients tend to have neurocognitive manifestations such as hypersexuality, irritability and aggressiveness. Physical manifestations may include a reddish face with associated severe sweating.

Extremely rare disorder with male predominance, 4:1.

Flu like illnesses have been reported prior to the onset of the first episode in some cases.

Symptoms usually begin to occur in early adolescence and the median range for symptoms is 4 years in this self limiting condition. Differential diagnosis of waxing and waning sleepiness include, tumors in the 3rd ventricle, bipolar disorder, seasonal affective disorder and other disorders of excessive sleepiness including extrinsic disorders like sleep apnea, periodic limb movement in sleep and seizure disorders.

Features:

  • Recurrent episodes of hypersomnia clearly associated with behavioral abnormalities
  • Binge eating
  • Hypersexuality
  • Irritability, aggression and odd behavior
  • Cognitive abnormalities (feelings of unreality, confusion, and hallucinations)

Common Symptoms

  • Hypersomnia 100%
  • Cognitive changes 96%
  • Eating disorders 80%
  • Hypersexuality 43%
  • Compulsions 29%
  • Depressed mood 48%

Precipitating Factors

  • Infection 38%
  • Head Trauma 9%
  • Alcohol Consumption 5.4%
  • Somnolence ↓ with stimulants in 40% of cases
  • Neuroleptics and antidepressants poor benefit
  • Lithium, not carbamazepine or other antidepressants, stopped relapses 41%
  • Lasted longer in women
  • Secondary cases (stroke, hematoma, MS, developmental disease, encephalitis) had more frequent and longer episodes

Menstrual Related Hypersomnia:

  • Recurrent episodes of hypersomnia in association with menstrual cycle
  • Occurs within 1st months after menarche
  • Last generally 1 week with rapid resolution at menses.
  • Oral contraceptives usually lead to prolong remission

Differential Diagnosis

  • Tumors within 3rd ventricle
  • Psychiatric disorders
  • OSAS
  • Narcolepsy
  • Idiopathic hypersomnia
  • PLMD
  • Insufficient sleep
  • Environmental sleep disorder

INSOMNIA

Insomnia: 307.42

The term insomnia is loosely used to refer to all complaints of inability to initiate or maintain sleep. Although this loose definition is close to true, there are several disorders that may be misdiagnosed as insomnia if a complete understanding of sleep medicine is not present but most importantly if a complete sleep history is not elicited.

 INSOMNIA (Classification from: The International classification of sleep disorders, 2nd Edition)

ADJUSTMENT INSOMNIA  (ADJUSTMENT  SLEEP DISORDER):

This is typically seen in patients that develop insomnia following a significant event such as a death, divorce or major upheaval that disrupts their lives. There is usually a clear complaint of the symptom developing after the precipitating event.

Evaluation: Strong history taking is required. Identification of the precipitating event, and a review of sleep patterns required

Treatment: This involves a recognition of the precipitating event and making efforts to address it. That may include the use of psychotherapy or counseling in cases of grief or other major upheavals.

In cases of adjustment insomnia, it is considered more appropriate to use sedatives and hypnotics to help with sleep and to prevent long term or chronic insomnia.

PSYCHOPHYSIOLOGIC INSOMNIA 

This is a condition in which an individual is unable to initiate sleep easily. In this condition the patient dwells on things and issues that prevent the patient from being able to go to sleep. The patient develops bad routines and habits that are not supportive of sleep. Example is focusing on the next days work etc. it is also referred to as learned insomnia.

Not common between 6-12 years of age. Occurs in adolescence

The patient develops significant frustration around the sleep process and sleep may be perceived as an impossible task. In a situation in which the patient is very tired, the patient may go to bed and begin to perform sleep inappropriate functions as well as having an increased alertness. The sleep latency is prolonged, and the sleep may be fragmented with prolonged wake after sleep onset intervals.

Evaluation: History and physical examination sleep logs, actigraphy.

Treatment:

Education and reassurance:

Improved sleep hygiene (Not sufficient as a standalone measure), cognitive-behavioral therapy, sedative/hypnotics in difficult cases.

Improved sleep hygiene: General guidelines about health and sleep practices including, diet, exercise, substance use and abuse, also environmental factors including, light, noise and temperature and any other factors that may disturb sleep.

Also general information about normal sleep

Cognitive –behavioral treatment:

Relaxation training (Validated): This involves the use of clinical procedures aimed at reducing somatic tension

  • Progressive muscle relaxation
  • Biofeedback
  • Diaphragmatic breathing
  • Autogenic training. Also to reduce intrusive thoughts at bedtime
  • Imagery training, thought stopping
  • Meditation

 Stimulus control (Validated)

This is considered the first line and most validated behavioral therapy for chronic insomnia. Designed to decondition presleep arousal and reassociate the bed/bedroom environment with rapid well consolidated sleep

Typical instructions include:

  • Maintain fixed wake time 7 days a week
  • Avoid any behavior in bed/bedroom outside of sleep and sexual activity
  • Sleep only in bedroom
  • Leave the bedroom when awake for approximately 15-20 minutes
  • Return only when sleepy.

Sleep restriction (Validated)

Restrictions limit a patient’s time in bed to average total sleep time. Improves sleep quality by improving sleep efficiency.

Instructions:

  • Establish a fixed wake time
  • Limit subjects total time in bed to an amount that averages total sleep time
  • Increase sleep time by 15 minutes if sleep efficiency is greater than 90% and sleep latency is less than 15 minutes.

Cognitive therapy (Validated)

Psychologic methods aimed at challenging and changing misconceptions about sleep and faulty beliefs about insomnia and its perceived daytime consequences.

  • Cognitive therapy
  • Paradoxical intention

PARADOXICAL INTENTION (VALIDATED):

Medical management of insomnia and Non pharmacologic/natural/herbal aids

  • Valerian
  • Kava-kava
  • L-Tryptophan
  • Melatonin

Pharmacologic and OTC aids

  • Antihistamines: Either alone or with analgesics. (Benadryl)
  • Melatonin

Pharmacologic aids (FDA approved >16 yrs)

  • Benzodiazepine hypnotics
  • Non-benzodiazepine hypnotics
  • Selective melatonin receptor agonist

 Pharmacologic off Label sleep aids

  • Trazodone: Sedating antidepressant
  • Other antidepressants: Amitriptyline, doxepin and mirtazapine
  • Sedating antipsychotics: Quetiapine

Paradoxical insomnia

This is a condition in which a patient relates a history of insufficient sleep that is incompatible with the patient. Also this is a condition where the perceived sleep time is less than the true sleep time in the patient.

Idiopathic insomnia

This condition is also now as chronic insomnia of childhood and the symptoms typically start in childhood. The patient has a history of persistent difficulty with sleep initiation which has been present from childhood. is a condition in which a patient relates a history of insufficient sleep that is incompatible with the patient. Also this is a condition where the perceived sleep time is less than the true sleep time in the patient.

Insomnia due to mental disorder

Inadequate sleep hygiene

This results from behaviors or practices that have a negative effect on sleep by reducing total sleep to a period less than that required by the patient for optimal sleep time.

Treatment:

Improved sleep hygiene: General guidelines about health and sleep practices including, diet, exercise, substance use and abuse, also environmental factors including, light, noise and temperature and any other factors that may disturb sleep.

Also general information about normal sleep

Behavioral insomnia of childhood

Behavioral insomnia of childhood; Limit setting type:

ICSD CLASSIFICATION CRITERIA

  • The patient has difficulty in initiating sleep
  • The patient stalls or refuses to go to bed at an appropriate time
  • Once sleep period is initiated, sleep is of normal quality quantity and duration
  • Sleep study demonstrates normal timing, quality and duration of the sleep period
  • No significant underling mental or medical disorder to account for complaint
  • Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep

In this condition the patient typically a child resists going to bed. The child is typically put to bed and continuously finds reasons to leave the sleep environment in order to stay awake. There is also a strong component of lack of firm disciplinary controls on the part of the parents. Typically the parents do not enforce sleep time and when attempted the child will attempt to engage parents a variety of ways including making requests for things, tantrums, complaining of fears. Parents give in to child and habit becomes formed over time.

Evaluation: Strong history taking

Treatment: First educating the caregivers on the problem and their role in perpetuating it. Setting firm limits for activities that the child can engage in at or after bedtime. The use of bedtime pass cards. Reward and removal strategies for reinforcement of good sleep patterns.

Medication: Should not be considered in this condition

Behavioral insomnia of childhood; Sleep onset type:

ICSD CLASSIFICATION:

  • The patient has a complaint of insomnia
  • Complaint is temporally associated with the absence of certain conditions
  • The disorder is present for at least 3 weeks
  • With the particular association present, sleep is normal in onset, duration and quality
  • Sleep study demonstrates normal timing, duration and quality of sleep when association is present and prolonged sleep latency and frequency or duration of awakenings when association is absent
  • No significant underling mental or medical disorder to account for complaint
  • Symptoms do not meet criteria for any other sleep disorder causing difficulty initiating sleep

 In this condition, the subject is unable to sleep or resists going to sleep unless a specific set of conditions are present at bed/sleep time. That condition may be a parent lying down beside the child till the child has fallen asleep. If the condition is not available at bedtime or when the patient wakes up, then the patient has extreme difficulty returning to sleep and typically stays awake. Behavior is usually set between 6 months and 3 years. Usually occurs at greater than 3 months as the patient enters a developmental stage characterized by greater attachment to parents, fear of strangers and realization of threatening circumstances.

Evaluation: Strong history taking

Treatment: Good sleep hygiene, breaking any bedtime patterns that you do not want to have to reenact after the patient has initiated sleep. Behavioral modification techniques including extinction (Graduated or total), scheduled awakenings, appropriate non pharmacologic sleep/relaxation aids

If these techniques are used, there is an expectation that crying spells may persist for 2-3 hours and place significant burden on parents resulting in shorter sleep duration and poor quality sleep in the child. With most patients the period of severe protestation is about a week with a significant decrease in protestation thereafter provided the routine has remained firm. Usually there may be a rebound in about 2 weeks. If parent stays firm this usually lasts 2-3 days.

Unmodified/total extinction: This involves parents putting the child to bed at a designated bedtime and then ignoring the child till morning. Parents may continue to monitor for issues related to safety and illness. Objective is to reduce undesired behaviors by eliminating parental attention as a reinforcer.

Graduated extinction: This involves parents ignoring bedtime crying and tantrums for pre-determined periods before briefly checking on the child. A progressive or fixed schedule is used to check on the child. Like unmodified extinction, the goal is for the child to develop self soothing techniques and be able to fall asleep independent of undesired sleep associations

Positive routines: With positive routines a set of enjoyable and quiet routines are established leading up to bedtime

Faded bedtime with response costs: With faded bedtime, the bedtime is temporarily delayed to more naturally coincide with the child’s natural sleep onset time and is then fading it earlier as the child begins to fall asleep rapidly. Response cost involves taking the child out of the bed for prescribed brief periods if sleep is not achieved

Scheduled awakenings: This involves parents preemptively awakening their child prior to typical spontaneous awakening, and then providing the usual response (feeding, rocking, soothing) as though the child had awakened spontaneously.

Parental education: Involves parent education to prevent the occurrence of the development of sleep problems. Behavioral interventions are incorporated into these parent education programs

Medication: Not typically required or recommended, though may be considered in cases when the parents/caregivers are going to use it as part of an active behavioral process.

Insomnia due to drug or substance:

Several of the medications that are used today have the ability to cause insomnia because of their stimulant natures. In these cases, medication management in terms of timing of use of medication or altering the dose or type of medicine used may be necessary

Evaluation: History and physical examination. Review medication history

Treatment: Improve sleep hygiene, Adjust dose and timing of medication, Change medication. Start sedative hypnotics if necessary

Insomnia due to medical condition

Insomnia not due to substance or known physiologic condition, Unspecified (Nonorganic insomnia NOS)

Physiological(Organic) Insomnia, Unspecified

  • Other disorders that may mimic insomnia include circadian rhythm disorders such as delayed sleep phase syndrome, Non 24 hour sleep wake syndrome and irregular sleep-wake pattern.
  • In general, a good history will help to differentiate the etiology of the complaint of insomnia and the correct definition of this diagnosis will allow for the implementation of an effective treatment plan.
  • Every treatment plan should include:
  1. Reinforcement of sleep hygiene
  2. Maintenance of sleep logs
  3. Behavioral modification and the addition if necessary, of modalities such as stimulus control, sleep
  4. restriction, relaxation techniques, biofeedback
  5. Close follow up
  6. When necessary pharmacologic aids

If there is any question regarding the diagnosis and management of these conditions then refer the patient to a sleep disorders specialist for further evaluation and management.

** Pharmacologic management without emphasis on behavioral modification should be discouraged strongly**

Close follow up is important!!!