PANCE Blueprint Psychiatry (6%)

Sleep-wake disorders (Pearls)

DSM-5 Sleep-wake disorders

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.

Insomnia disor­der

Hypersomnolence disorder

Narcolepsy

Breathing-related sleep disorders

Circadian rhythm sleep-wake disorders

Parasomnias:

  • 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

PANCE/PANRE Sleep-wake disorders
Narcolepsy A sleep disorder characterized by uncontrollable sleep attacks. The sufferer may lapse directly into REM sleep, often at inopportune times.
Parasomnias Parasomnias are dissociated sleep states which are partial arousals during the transitions between wakefulness, NREM sleep, and REM sleep, and their combinations.

  • Non–Rapid Eye Movement (NREM) Sleep Arousal Disorders (sleepwalking and sleep terrors)
  • Rapid Eye Movement (REM) sleep behavior disorder (nightmare disorder)

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.

Parasomnias are dissociated sleep states which 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.
Restless leg syndrome

Patient will present as → 56-year-old female 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. Neurologic and vascular examination is normal.

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 Difficulty initiating or maintaining sleep at least 3 times per week for 3 months
Hypersomnolence disorder Excessive nighttime or daytime sleep for > 1 month

References: Merck Manual

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