PANCE Blueprint Psychiatry (7%)

Sleep-wake disorders encompass 10 disorders or disorder groups. Items in bold are covered as part of the NCCPA PANCE/PANRE Psychiatry Blueprint and include narcolepsy and the parasomnias. The two important categories of parasomnias include the NREM sleep arousal disorders (of which I have included sleepwalking and sleep terrors) and the REM sleep behavior disorders, of which I have included nightmare disorder. Sleep-wake disorders are NOT covered as part of the PAEA EOR™ Psychiatry Topic List.

Included are brief descriptions of insomnia disorder and hypersomnolence disorder, as well as restless legs syndrome, because they are important to know, but they are not included as part of the PANCE/PANRE Psychiatry Blueprint.

Hypersomnolence disorder

Narcolepsy

Breathing-related sleep disorders

Circadian rhythm sleep-wake disorders

• Non-rapid eye movement (NREM) sleep arousal disorders
  • Sleepwalking
  • Sleep terrors
  • Sleep-related eating disorder
• Rapid eye movement (REM) sleep behavior disorder
  • Nightmare disorder

Restless legs syn­drome

Substance/medication-induced sleep disorder

Narcolepsy presents with a classic tetrad:

1. Excessive daytime sleepiness: naps can be refreshing
2. Hallucination: 
   1. Hypnagogic: just before sleep
   2. Hypnopompic: just before waking
3. Cataplexy: loss of muscle tone following strong emotional stimulus
4. Sleep paralysis: short paralysis with awakening.

Caused by: Hypocretin deficiency in lateral hypothalamus (per DSM-V)

• Strong genetic component, typical onset in young adulthood

Diagnosed with polysomnography 

Treatment: modafinil (Provigil), methylphenidate (Ritalin), or amphetamines

• Planned naps during the day may prevent sleep attacks

Parasomnias are dissociated sleep states that are partial arousals during the transitions between wakefulness, NREM sleep, and REM sleep, and their combinations.

NREM sleep arousal disorder:

Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:

• • Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively un­ responsive to the efforts of others to communicate with him or her, and can be awakened only with great difficulty.
    • Sleep-related eating disorder: Sleep-related eating disorder (SRED) (sleep eating) is a variant of sleepwalking characterized by recurrent episodes of involuntary eating associated with diminished levels of consciousness during an arousal from sleep and not linked to daytime eating disturbances such as bulimia nervosa, binge eating disorder, or anorexia nervosa.
  • Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually be­ ginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

REM sleep behavior disorder:

Repeated episodes of arousal during sleep associated with vocalization and/or com­plex motor behaviors that arise during REM sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later por­tions of the sleep period, and uncommonly occur during daytime naps.

• Nightmare disorder (occurs during REM sleep): Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical in­tegrity and that generally occur during the second half of the major sleep episode. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

RLS is a condition in which patients are unable to lie still and report experiencing unpleasant, creeping, crawling, or tingling sensations in the legs. Must occur at least 3 x per week x 3 months. 

1. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
   • The urge to move the legs begins or worsens during periods of rest or inactivity.
   • The urge to move the legs is partially or totally relieved by movement.
   • The urge to move the legs is worse in the evening or at night than during the day or occurs only in the evening or at night.
2. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months.
3. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
4. The symptoms in Criterion A are not attributable to another mental disorder or medical condition (e.g., arthritis, leg edema, peripheral ischemia, leg cramps) and are not better explained by a behavioral condition (e.g., positional discomfort, habitual foot tapping).
5. The symptoms are not attributable to the physiological effects of a drug of abuse or medication (e.g., akathisia).

Diagnosis:

• Polysomnography
• Iron status: serum ferritin, total iron-binding capacity, percent saturation
• CBC for anemia in case of iron deficiency
• Metabolic panel: blood urea nitrogen and serum creatinine for renal insufficiency

Treatments

• Gabapentin, Dopamine Agonists (Pramipexole (Mirapex), Ropinirole, Rotigotine), Levodopa, Benzodiazepines

Insomnia Disorder is characterized by persistent difficulty with sleep initiation, maintenance, or early morning awakening, resulting in daytime impairment

• Diagnostic criteria require symptoms at least 3 nights per week for ≥3 months, causing distress or impairment in social, occupational, or other important areas of functioning
• Symptoms include difficulty falling asleep, frequent nighttime awakenings, early waking, and non-restorative sleep, often leading to fatigue, poor concentration, irritability, and mood disturbances
• Risk factors include stress, anxiety, depression, chronic pain, medical conditions, and use of stimulants or certain medications

DX: Diagnosis is clinical, based on history and sleep diary; polysomnography is not routinely needed but may be used to exclude other sleep disorders

TX: Management starts with cognitive behavioral therapy for insomnia (CBT-I), the first-line treatment, focusing on sleep hygiene, stimulus control, and relaxation techniques

• Pharmacologic therapy may include short-term use of hypnotics (e.g., zolpidem) or sedating antidepressants (e.g., doxepin) when CBT-I alone is insufficient, but medications should be used cautiously due to risk of dependence and side effects
• Lifestyle modifications include maintaining a regular sleep schedule, avoiding caffeine or electronics before bedtime, and creating a comfortable sleep environment

Hypersomnolence Disorder is characterized by excessive daytime sleepiness despite adequate or prolonged nighttime sleep, causing significant impairment in daily functioning

• Symptoms include recurrent episodes of excessive sleepiness, difficulty waking up, prolonged non-refreshing naps, and cognitive impairment (e.g., poor concentration, memory problems) during wakefulness
• Episodes of sleep inertia (prolonged grogginess after awakening) are common

DX: Diagnosis is clinical, supported by polysomnography and multiple sleep latency testing (MSLT) showing short sleep latency and prolonged sleep episodes

• Symptoms must occur at least three times per week for at least three months to meet diagnostic criteria
• Differential diagnosis includes narcolepsy, obstructive sleep apnea, major depressive disorder, and effects of substance use or medications

TX: Behavioral modifications (regular sleep schedule, avoiding alcohol and sedatives) and stimulant medications (e.g., modafinil, methylphenidate) to promote wakefulness

• Complications include occupational or academic impairment, increased risk of accidents, and negative effects on social relationships
• Patient education should emphasize sleep hygiene and the importance of avoiding activities like driving when excessively sleepy