1. Mind – Body Implications
Major Sleep Disorders
Mind – Body Implications
Charles Atwood, MD, FCCP
VA Pittsburgh Healthcare System
UPMC Sleep Medicine Center
Pittsburgh Mind–Body Center
Core D:
“the sleep core”

2. Major Sleep Disorders

3. Objectives Review major disorders of sleep
Provide clinical context for MBC investigators who think about sleep as a mediator of MB processes and interactions
Attempt to put the major disorders into the MBC framework

4. Health Relationships
Sleep
HEALTH
Exercise
Nutrition

5. Lifespan/Development

6. Attitudes Toward Sleep
Sleep ranks among the 3 most important considerations in maintaining good health
62% of US population experiences sleep problems
80% of US adults have NEVER discussed sleep problems with their physician
Societal bias equates sleepiness with laziness
Adequate nutrition, stress management, and sleep are the 3 most important considerations in the maintenance of good health. An estimated 62% of the US population experiences sleep problems, yet approximately 80% of US adults have never discussed sleep or sleep problems with their physicians. This may largely be due to the stigma that sleepiness equates with laziness.
Adapted from National Sleep Foundation omnibus sleep in America poll.
National Sleep Foundation omnibus sleep in America poll. Available at: Accessed October 12, 2002.

7. “All I want is a good night’s sleep…”
Sleep in America Poll, 2005
N = 1506

8. Top 10 Diagnoses by Internists
Percentage of visits
Source: IM news, 6/1/05

9. How sleep problems relate to the top 10 diagnoses
Sleepiness, fatigue
OSA, fatigue
Insomnia, poor quality sleep
OSA
OSA
OSA
Percentage of visits
Source: IM news, 6/1/05

10. Classification of Sleep Disorders
Disorders of Excessive Sleepiness (DOES)
Disorders of Initiating and Maintaining Sleep (DIMS)
Parasomnias
Miscellaneous disorders

11. Other Classifications
Classified by primary site of affliction
Neurological
Breathing disorders
Psychiatric
Insomnia
Parasomnia
Cardiovascular
Others

12. International Classification of Sleep Disorders Version 2 (ICSD-2)
Insomnias
Sleep-Related Breathing Disorders
Hypersomnias Not Due to a Sleep-Related Breathing Disorder
Circadian Rhythm Sleep Disorders
Parasomnias
Sleep-Related Movement Disorders
Isolated Symptoms, Apparently Normal Variants and Unresolved Issues
Other Sleep Disorders
AASM, Chicago

13. Major Sleep Disorders Insufficient sleep Insomnia Sleep Apnea
Shift Work Sleep Disorder
Restless Legs Syndrome
Narcolepsy

14. We Get Too Little Sleep 8 hrs recommended = adequate sleep
National Sleep Foundation (NSF): “Sleep in America” Poll
(N = 1,010 adults)

15. Change in average amount of sleep per night over the past century
1910 = 9.0 hrs/night
1975 = 7.5 hrs/night
Today = 6.9 hrs/night
Bull Psychon Soc
1975 6:47-48
Neurophysiol Clin
:30-39

16. ICSD-2: Insomnias Adjustment sleep disorders (acute insomnia)
Psychophysiological Insomnia
Paradoxical Insomnia (formerly Sleep State Misperception)
Idiopathic Insomnia
Insomnia due to mental disorder
Behavioral Insomnia of Childhood
Insomnia due to a medical condition
Insomnia due to a a drug or substance
Insomnia not due to a substance or known psychological condition (Nonorganic Insomnia, NOS)
Physiological (organic) insomnia, unspecified, unspecified; (Organic Insomnia, NOS)
AASM, Chicago

17. Insomnia in the Population
Insomnia symptoms -Overall prevalence 30-48% -Often or always: 16-21% -Moderate to extreme: 10-28%
Insomnia symptoms + daytime consequences 9-15%
Insomnia diagnosis 6%
Why DX only 6%?
Direct ecomonic costs of insomnia alone in the US are estikmated at close to $14 billion.”
Direct economic costs
of insomnia in the US
are estimated ~ $14 billion
Ohayon, Sleep Med Rev, 2002

18. Insomnia vs. Insufficient Sleep
Cannot initiate or maintain sleep
“Can’t sleep”
May be transient
May persist
High likelihood of medical/psych sequelae
Insufficient sleep
Self-limits sleep
“chooses not to sleep”
Transient
Lower likelihood of sequalae

19. Insomnia: Effects on Health
Poor concentration
Decreased QOL
Contributes to depression and anxiety, other illness
Decrements in work quality
Increased healthcare utilization
PERSONAL
SOCIETAL

20. ICSD-2: Sleep-Related Breathing Disorders
Central Sleep Apnea Syndromes
Primary Central Sleep Apnea
Other Central Sleep Apnea due to a medical condition
Central Sleep Apnea due to a drug or substance
Other Sleep-Related Breathing Disorder due to a drug or substance
Obstructive Sleep Apnea Syndromes
Obstructive Sleep Apnea, Adult
Obstructive Sleep Apnea, Pediatric
Sleep-Related Hypoventilation / Hypoxemic Syndromes
Sleep-Related Non-Obstructive Alveolar Hypoventilation, Idiopathic
Congenital Central Alveolar Hypoventilation Syndrome
Sleep-Related Hypoventilation / Hypoxemia due to a medical condition
Other Sleep-Related Breathing Disorder
Sleep Apnea / Sleep Related Breathing Disorder, unspecified
AASM, Chicago

21. Sleep Apnea is Common Children (age 2 - 8) Middle aged adults
Older adults ( > 65)
2 – 3%
5 -7%
>15%
AJRCCM 2002
165:

22. QUIZ
Which upper airway segments or sites are important in OSA pathophysiology?
Nasopharynx
Velopharynx (tongue base, soft palate)
Hypopharynx (lower pharynx)

23. ANSWER
ALL of THEM!!!

24. Upper Airway Sites Contributing to OSA

25. Sleep-Sensitive Neuromodulators
Phasic Respiratory Input
Superior
Laryngeal
Nerve
White, PATS, 2005

26. Major Variables Contributing to Airway Patency / Collapse
Promotion of Airway Collapse
Promotion of Airway Patency
Negative pressure on inspiration
Pharyngeal dilator
muscle contraction
(genioglossus)
Extralumenal positive pressure
Fat deposition
Small mandible
Lung volume
(longitudinal traction)
White, PATS, 2005

27. Prevalence of Sleep Apnea
0.3
0.3
0.25
0.25
0.2
0.2
OSA Prevalence
0.15
0.15
0.1
0.1
Plateau
0.05
0.05 35 45 55 65 75 85
Age in years
AJRCCM 2002
165:1217–1239

28. Sleep Apnea is Associated with Significant Co-morbidities
Cardiovascular
Complications
Metabolic
Complications
Neuro-cognitive
Complications

29. Sleep Disordered Breathing and Cardiovascular Disease
Odds
Ratio
AJRCCM 2001
163:19-25
AHI (Quartiles)

30. Incident Hypertension within 4 years according to Apnea-Hypopnea Index
Adj OR
> 15 hr
A/H Index
Adjusted for baseline hypertension, age, sex, BMI, waist and neck
circumference, alcohol and cigarette use.
NEJM :

31. Sleep Apnea & Sleepiness
Apnea / Hypopnea Index
AJRCCM 1999
159:

33. Automobile Accident Rates in OSA Patients*
Number per Year
n = 581
n = 229
n = 107
n = 246
Sleep 1999
22:790-95

34. ICSD-2: Hypersomnias not due to a breathing disorder
Narcolepsy
Narcolepsy with Cataplexy
Narcolepsy without Cataplexy
Narcolepsy due to a medical condition
Narcolepsy, unspecified
Other Hypersomnias
Recurrent Hypersomnia
Idiopathic Hypersomnia with long sleep time
Idiopathic Hypersomnia without long sleep time
Behaviorally Induced Insufficient Sleep Syndrome
Hypersomnia due to a medical condition
Hypersomnia due to a drug or substance
Hypersomnia not due to a substance or known physiologic condition
Physiological (Organic) Hypersomnia, unspecified (Organic Hypersomnia, NOS)
AASM, Chicago

35. Narcolepsy: Epidemiology
Prevalence ~1 in 2000 (US)
~150,000+ patients in US
Men and women affected equally
Age at onset
Can present at any age
Majority years of age
6% prior to 10 years of age
Narcolepsy affects approximately 1 in 2000 people in the United States, a prevalence that is greater than that of cystic fibrosis but comparable to that of multiple sclerosis.
The prevalence of narcolepsy in men and women is comparable. Although it may occur at any age, narcolepsy usually first appears in patients between 15 to 30 years of age; only 6% of patients under the age of 10 are affected, and the condition is usually present in patients before the age of 55.
J Clin Neurophysiol
2001;18:78.
Overeem S, Mignot E, van Dijk JG, Lammers GJ. Narcolepsy: clinical features, new pathophysiologic insights, and future perspectives. J Clin Neurophysiol. 2001;18:

36. Prevalence of Narcolepsy/Cataplexy (USA)
260
162
Prevalence per 100,000
113 40
Narcolepsy is not a rare disorder. The prevalence of narcolepsy in the United States is only slightly less than that of other well-known and economically significant diseases such as multiple sclerosis, Parkinson's disease, and insulin-dependent diabetes mellitus (IDDM, type 1).1-7
4-6
ALS = amyotrophic lateral sclerosis.
National Sleep Foundation. Mittler. An Introduction to Narcolepsy. National Sleep Foundation Slide Kit.
1. Hubin C, Partinen M, Kaprio J, Koskenvuo M, Guilleminault C. Epidemiology of narcolepsy. Sleep. 1994;17:S7-S12.
2. Young T, Palta M, Dempsey J. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:
3. Kurtzke JF. The current neurologic burden of illness and injury in the U.S. Neurology. 1982;32:
4. Kondo K. Epidemiology of motor neuron disease. In: Leigh PN, Swash M, eds. Motor Neuron Disease: Biology and Management. London, UK: Springer-Verlag; 1995:19-33.
5. Merniti-Ippolito F, Spila-Alegiani S, Vanacore N, et al. Estimate of parkinsonism prevalence through drug prescription histories in the province of Rome. Acta Neurologica Scandinavica. 1995;92:49.
6. LaPorte RE, Fishbein HA, Drash AL. The Pittsburgh Insulin-dependent Diabetes Mellitus (IDDM) Registry. Diabetes. 1981;30:
7. Mittler MM. An Introduction to Narcolepsy. National Sleep Foundation Slide Kit.

37. …from a narcolepsy patient I saw last year…

38. Narcolepsy Fundamentally a sleep disorder
Drop out of hypocretin neurons in hypothalamic nuclei
Results in “loss of boundaries between sleep and wakefulness”
“Can’t stay awake during the day; can’t stay asleep during the night”

39. Narcolepsy Symptoms Sleepiness with more or less discrete attacks
Cataplexy (lacking in ~40%)
Hypnogogic hallucinations
Sleep paralysis
Disrupted nocturnal sleep

40. How often daytime sleepiness was reported to interfere with daily activities?
NSF: “Sleep in America” Poll of adults

41. ICSD-2: Circadian Rhythm Sleep Disorders
Primary Circadian Rhythm Sleep Disorders
Circadian Rhythm Sleep Disorder, Delayed Phase type
Circadian Rhythm Sleep Disorder, Advanced Phase type
Circadian Rhythm Sleep Disorder, Irregular sleep-wake type
Circadian Rhythm Sleep Disorder, Free running type
Circadian Rhythm Sleep Disorders due to a medical condition
Primary (Organic) Circadian Rhythm Sleep Disorder
Behaviorally Induced Circadian Rhythm Sleep Disorders
Jet lag type
Shift work type
Delayed phase type
Unspecified
Other not due to a substance or known physiologic condition
Other due to a drug or substance
AASM, Chicago

42. ICSD-2: Parasomnias Disorder of Arousal (From Non-REM Sleep)
Confusional arousals
Sleepwalking
Sleep terrors
Parasomnias Usually Associated with REM Sleep
REM Sleep Behavior Disorder
Recurrent Isolated Sleep Paralysis
Nightmare Disorder
Other Parasomnias
Sleep-Related Dissociative Disorder
Sleep-Related Enuresis
Sleep-Related Groaning
Exploding Head Syndrome
Sleep-Related Hallucinations
Sleep-Related Eating Disorder
Parasomnia, unspecified
Parasomnia due to drug or substance
Parasomnia due to a medical condition
AASM, Chicago

43. ICSD-2: Sleep-related Movement Disorders
Restless Legs Syndrome (included Sleep-Related Growing Pains)
Periodic Limb Movement Sleep Disorder
Sleep-Related Leg Cramps
Sleep-Related Bruxism
Sleep-Related Rhythmic Movement Disorder
Sleep-Related Movement Disorder, unspecified
Sleep-Related Movement Disorder due to a drug or substance
Sleep-Related Movement Disorder due to a medical condition
AASM, Chicago

45. What is RLS? Common yet frequently undiagnosed
Sensorimotor disorder of extremities
Common yet frequently undiagnosed
Irresistible urge to move legs
Relieved by movement of legs
Circadian predilection
Earley CJ. New Engl J Med. 2003;348:

46. Primary RLS Genetic predisposition
Tends to be earlier onset and more severe than secondary causes
Natural history poorly understood
Long delays in seeking attention
Few longitudinal studies
Allen RP, et al. Sleep Med. 2002;3:S3-S7;
Garcia-Borreguero D, et al. Neurology. 2003;61(Suppl 3):S49-55;
Desautels A, et al. Am J Hum Genet. 2001;69: ;
Allen RP, et al. Sleep Med. 2003;4:

47. Secondary RLS Associated with:
Iron deficiency
End-stage renal disease
Pregnancy
Secondary RLS may remit upon resolution of the causative condition (eg, after pregnancy)
Akyol A, et al. Clin Neurol Neurosurg. 2003;106:23-27; O’Keeffe ST, et al. Age Ageing. 1994;23: ; Winkelman JW, et al. Am J Kidney Dis. 1996;28: ; Berger K, et al. Arch Intern Med. 2004;164: ;
Lee KA, et al. J Womens Health Gend Based Med. 2001;10:

48. RLS: Essential Diagnostic Criteria
U An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs
R The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity, such as lying or sitting
G The urge to move or unpleasant sensations are partially or totally relieved by movement, such as walking or getting up, at least as long as the activity continues
E The urge to move or unpleasant sensations are worse in the evening or night than during the day or only occur in the evening or night
Allen RP, et al. Sleep Med. 2003;4:

49. ISCD-2: Isolated symptoms, apparently normal variants and unresolved issues
Long Sleeper
Short Sleeper
Snoring
Sleeptalking
Sleep Starts, Hypnic Jerks
Benign Sleep Myoclonus of Infancy
Hypnagogic Foot Tremor and Alternating Leg Muscle Activation during Sleep
Propriospinal Myoclonus at Sleep Onset
Excessive Fragmentary Myoclonus
AASM, Chicago

50. ISCD-2:Other Sleep Disorders
Other Physiologic (Organic) Sleep Disorder
Physiological (Organic) Sleep Disorder, unspecified
Other sleep Disorder not due to a substance or physiological condition
Environmental Sleep Disorder
Sleep Disorder not due to a substance or physiologic condition, unspecified
Appendix A: Sleep Disorders Associated with conditions Classifiable Elsewhere
Appendix B: Other Psychiatric / Behavioral Disorders Frequently Encountered in
the Differential Diagnosis of Sleep Disorders
AASM, Chicago

51. Sleep Disorders are...
Common
Serious
Treatable
Under-diagnosed
Costly

52. Sleep Disorders are common
An estimated 70 million adult Americans have clinically significant sleep problems
Insomnia affects about one-third of the adult population at some point and 9 to 10% suffer from chronic insomnia
OSA affects 4% of men, 2% of women
Over 25% of patients with essential hypertension have OSA

53. Sleep Disorders are serious
Chronic insomniacs
impaired daytime functioning, decreased work productivity, quality of life, & physical health
Insomnia is a risk factor for depression
Sleep disordered breathing (SDB) patients,
adults and adolescents with insufficient sleep have an increased incidence of motor vehicle crashes
Insufficient sleep and use of sleeping pills may be associated with increased falls, injuries, $$$

54. Sleep Disorders are treatable
Successful treatment modalities exist:
pharmacotherapy,
behavioral therapy,
continuous positive airway pressure (CPAP), dental appliances
surgical therapy

55. Sleep Disorders are under-diagnosed
As many as 95% of people with a sleep problem remain unidentified and undiagnosed
Few health care providers question patients about sleep
Little content in medical schools
Essentially everything learned about sleep is in post-graduate courses (a booming academic business)

56. Sleep Disorders are Costly
Possibly 100,000 motor vehicle accidents annually are sleep-related.
The annual direct cost estimate of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs:
Accidents
Litigation
Property destruction
Hospitalization
Death

57. 3 Mile Island Exxon Valdez Oil Spill Challenger Explosion
Exxon Valdez – 1989 – cleanup effort was $2billion
Challenger – 1986 – declared absence of data on o-ring function at low temperatures and the decision to launch was an error – human factors subcommittee attributed the error to sleep deprivation on behalf of NASA managers
Challenger Explosion

58. Lifespan/Development

59. How do sleep disorders interact with this model?
Increased chronic burdens of disease
Primary sleep disorders
Secondary effects
Decreased coping mechanisms
Excess sleepiness
Biological pathway interuption
Modulator of inflammation?

60. Sleep disorders medicine and mind-body interactions
Sleep medicine is in its adolescence as a field
Understanding mind-body interactions with respect to sleep is in its infancy
Fundamental processes relating sleep as a mediator of M-B processes is very much needed