PANCE Blueprint Psychiatry (6%)

Sleep-wake disorders (Pearls)

Sleep-wake disorders
Narcolepsy A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.
Insomnia disorder Difficulty initiating or maintaining sleep at least 3 times per week for 3 months
Hypersomnia Excessive nighttime or daytime sleep for > 1 month
Parasomnias Three parasomnias are important to know. You must know when and where they occur in the sleep cycle:

  • Non–Rapid Eye Movement (REM) Sleep Arousal Disorders: sleepwalking and sleep terrors
  • Nightmare disorder (REM sleep)
  • Restless leg syndrome
Narcolepsy
Patient will present as → a 19-year-old female complaining of an irresistible urge to sleep at sudden times throughout the day. This has disturbed her school functioning. She sometimes feels like she “is paralyzed” for several minutes when she wakes up. She “passed out” one day at school when she was startled by her boyfriend.

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
Patient will present as →  a 49-year-old female who reports feeling an uncomfortable deep crawling and aching sensation in her legs. The patient notes that she typically experiences this sensation at night when she gets into bed. Also associated is a strong urge to move her legs and she has to get up several times each night to relieve the feeling. She denies associated low back pain or recent blood donation. The neurologic and vascular examination is normal.

  • Non–Rapid Eye Movement Sleep Arousal Disorders (sleepwalking and sleep terrors)
  • Nightmare disorder
  • Restless leg syndrome
Schizophrenia spectrum and other psychotic disorders (Lecture) (Prev Lesson)
(Next Lesson) Narcolepsy
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