General Approach to the Patient with a Sleep Disorder

General Approach to the Patient with a Sleep Disorder

Disorders of sleep and wakefulness are common. Insomnia com-plaints are reported by about one-third of adult Americans during a 1-year period; clinically significant obstructive sleep apnea may be seen in as many as 10% of working, middle-aged men; and sleepiness is an underrecognized cause of dysphoria, automobile accidents and mismanagement of patients by sleep-deprived physicians. Nearly all physicians will hear complaints of sleep problems. Psychiatrists may be even more likely than other medical specialists to receive these complaints. Of particular importance for mental disorders, prospec-tive epidemiological studies suggest that persistent complaints of either insomnia or hypersomnia are risk factors for the later onset of depression, anxiety disorders and substance abuse.

This attempts to provide a framework for psychia-trists and other mental health specialists to use in understand-ing the multiple causes of the sleep disorders, their diagnostic evaluation and their treatment. To assist the patient with a sleepcomplaint, the psychiatrist needs to have a diagnostic frame-work with which to obtain the information needed about both the patient as a person and his or her disorder. Two issues are particularly important: 1) How long has the patient had the sleep complaint? Transient insomnia and short-term insomnia, for example, usually occur in persons undergoing acute stress or other disruptions, such as admission to a hospital, jet lag, be-reavement, or change in medications. Chronic sleep disorders, on the other hand, are often multidetermined and multifaceted: 2) Does the patient suffer from any preexisting or comorbid disorders? Does another condition cause the sleep complaint, modify a sleep complaint, or affect possible treatments? In gen-eral, because common sleep disorders are frequently secondary to underlying causes, treatment should be directed at underlying medical, psychiatric, pharmacological, psychosocial, or other disorders.

A detailed history of the complaint and attendant symp-toms must be obtained (Tables 59.3 and 59.4). Special atten-tion should be given to the timing of sleep and wakefulness; qualitative and quantitative subjective measures of sleep and wakefulness; abnormal sleep-related behaviors; respiratory difficulties; medications or other substances affecting sleep, wakefulness, or arousal; expectations, concerns, attitudes about sleep, and efforts used by the patient to control symp

toms; and the sleep–wake environment. The psychiatrist must be alert to the possibility that sleep complaints are somatic symptoms, which reflect individual ways of experiencing, expressing and coping with psychosocial distress, stress, or psychiatric disorders

Sleep disorders vary with age and gender and, possibly, with culture and social class. As mentioned previously, the circa-dian timing of rest–activity, sleep duration at night, and daytime napping and sleepiness vary with age and gender. In addition, parasomnias are most common in boys, Kleine–Levin syndrome in adolescent boys, delayed sleep phase syndrome in adolescents and young adults, insomnia in middle-aged and elderly women, REM sleep behavior disorder and sleep-related breathing disor-ders in middle-aged men, and advanced sleep phase syndrome in the elderly. Sleep–wake patterns are also influenced by cultural or geographical factors, such as the siesta and late bedtime com-monly associated with tropical climates, or the winter hypersom-nia and summer hyposomnia said to occur near the Arctic circle. Insomnia is more common in lower than in middle and upper socioeconomic classes, perhaps reflecting the stress of poverty, crowding and lack of privacy, poor medical care, drugs and alco-hol, lack of physical security and so forth.

One approach to the differential diagnosis of persistent sleep disorders is suggested in the algorithm in Figure 59.1. First, determine whether the sleep complaint is due to another medical, psychiatric, or substance abuse disorder. Secondly, consider the role of circadian rhythm disturbances and sleep disorders associ-ated with abnormal events predominantly during sleep. Finally, evaluate in greater detail complaints of insomnia (difficulty initi-ating or maintaining sleep) and excessive sleepiness.