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Ch apter
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6 : N o rm al Sl eep an d S l eep-Wake D i so r de de r s
reach pathological levels levels.. When sleep debt is added to sleep dis rption or a basic nerologic d!s"nction in sleep mechanisms# there is increasing risk that an individal $ill lapse ne%p ect edl! into slee p . Sleep onset in sch circmstances char acteristi acteristi call! occrs $ithot $arning. Sleepiness can be episodic and occr as irresistible sleep attacks# attacks# occr in the the morning as sleep drnk enne enne ss# or be chronic. &atige# tiredness# and sleepine epiness ss are terms that are sed b! most people s!non!mosl!' ho$ever# one can be tired bt not sleep!# sleep! bt not tired# or slee p! and tired. (n this section# the term sleepiness $ill re"er to dro$s iness# a propensit! to lapse lapse in into to sleep# an and d $h $hen en e%treme# an inabilit! to maintain $ake"lne ss. Sleepiness adversel! a""ects attention# concentration# mem or!# and higher-order cognitive processes. Serios reslts o" sleepiness inclde "ailre at school# loss o" emplo!ment# motor vehicle accidents# and indstrial disasters. )he transportation indstr!# inclding tr cking cking# railroad# marine # and aviation# is particlarl! particlar l! prone to sleep-related accidents. )here are man! sleep disorders associated $ith e%cessive da!time sleepine ss' ho$ever# sleep-di sleep-disordered sordered breathing breathing is b! "ar the most common d!ssomnia seen in sleep disorder centers. *rimar! h!persomnia is diagnosed diagnosed $hen no other case can be "ond "or e%cess e%cessiv ivee som somnol nolenc encee occrring "o "orr at least 1 mont month. h. Some persons are long sleepers $ho# as $ith short sleepers# sho$ a normal variation. )heir sleep# althogh long# is normal in architectre and ph!siolog!. ph!siolog!. Sleep e""icienc! e""icienc! and the sleep-$ake schedl schedlee are normal . )his patt pattern ern is $ith $ithot ot com plaints abot the +alit! o" sleep# da!time sleepiness# or di""icl " orma ormance. ties $i $ith th the a$a a$ake ke mo mood# od# motivation# and per " etime patter pattern# n# and it appears to have ,ong sleep ma! be a li" etime have a "amilial incidence. an! persons are variable sleepers and ma! beco me long sle epers at certain times in their lives es.. Some persons pers ons have sb ective complaints o" "eeling slee p! $ithot ob ective "indings. )he! do not have have a tendenc! to "all asleep more o"ten than is normal and do not have an! ob ective signs . Clinicians shold tr! to rle ot clear-ct cases o" e%ces sive somnolence.
)! pe o" /! /! pe r somnia pess o" 0leine- ,evin S!n d rome.
0leine-,evin s!ndrome is a relati relativel! vel! rare condition consisting o" recrrent periods o" prolonge d sleep "rom $hich patients ma! be arosed2 $ith intervening periods o" normal sleep and alert $aking. Dr ing th thee h!persomniac episodes# $ake"l periods are sall s all! ! ma marked rked b! $ithdra$al "r "rom om social con contac tacts ts and retrn to bed at the "irst opportni opport nit!. t!. 0leine-,evin s!ndrome s!ndr ome is the be st recogni3ed recrre recrrent nt h!persomnia thogh it is ncommon. (t predominantl! a""licts males in earl! adolescence' ho ho$e $eve ver# r# it can occr later in li"e and in "emales. With "e$ e%ceptions# the "irst attack occrs bet$een the ages o" 1 4 and 1 !ears. are instances o" onset in the "orth and "i"th decades o" li"e have been reported. (n its classi cla ssicc "o "orm rm## the recrrent epi episode sodess ar associated ed $i $ith th are e associat slee eep p periods2# e%tr e% trem emee slee sleepi piness ness 1 7-h 7-ho orr to -ho -hor r sl voracios eating# h!per h!perse%alit!# se%alit!# and disi disinhib nhibiti ition on e.g.# aggression2 agg ression2.. 8pisodes t!picall! last "or a "e$ da!s p to several $eeks and appear once to ten times per !ear. 9 mono s!mptomatic h!persomnolent "orm can occr. )he "r e+enc! e+enc! o" the hman lekoc!te antigen /,92 is increased in patients $ith this s!ndrome .
-e ns tral - elated
/! pe per r s om n ia.
(n somee som $omen# recrrent episodes o" h!persomnia are related to the the menstral intermitte rmittent nt episodes o" marked h!persom c!cle# e%periencing inte ore# the onset o" their menses. )he s!mp nia at# or shortl! be " ore# toms t!picall! last "or 1 $eek and resolve $ith menstration. Nonspeci"ic electroencephalogram 88:2 abnormalities similar to those associated $ith 0leine-,evin s!ndrome have been doc mented in several instances. 8ndocrine "actors are probabl probabl! ! involved# bt no speci"ic abnormalities in laborator! endocrine measres have been reported. )reatment $ith oral contracep tives is e"" ective# ective # and there"ore the disorder is believed to be secondar! to a hormone imbalance.
( d i op ath ic /!persomnia. (diopathic h!persomnia 1(/2 presents in several "orms . (t ma! be associated $ith ver! long sleep periods# a"ter $hich the individal remains sleep!. (/ can also occr $ithot long sleep periods. (/ is a disorder o" e%cessive sleepiness in $hich patients do not have the ancil s!## lar! s!mptoms associated $ith narcoleps!. ;nlike narc olep s! remain sleep is sal sall! l! $ell preserved# and sleep e""icienc! s high even in "orms associated $ith ver! e%tended sleep sched les 1 hors or more2 . &rthermore# the patient readil! "al "alls ls asleep i" given an opportnit! to nap the "ollo$ing da!. )here is o"ten o"ten elevated slo$ $ave $ave sleep sleep'' ho$ ho$eve ever# r# the 88: sleep pat individa dals tern is essentiall! the same as that "ond in normal indivi $ho are sleep deprived. ;nlike a sleep-deprived individal# the pattern ern contines in this pro"ile even a"ter several nights sleep patt o" e%tended slee p . 9s the name indic indicates# ates# the etiolog! etiolog! o" idio pathic h!persomnia is not kno$n ' ho$ ho$eve ever# r# a central nervos s!stem case is presmed. )hree general categories have been developed. Sbgrop 1 incldes individals $ho are /,9-C$5 posi tive # have atonomic nervos s!stem d!s" nct ions# and have other a""ected "amil! members. Sbgrop incldes sta ts postviral in" ection ection patients e.g.# :illain-
# mononcleosis# and at!pical viral pnemonia2 pnemon ia2 . Sbgrop ? idiopathic h!persomnia patients are non" amilial milial and are not postviral 1i.e.# trl! idiopathic2. 9ge o" onset is characteristicall! bet$een 1 5 and ? !ears# and an d the h!persomnia becomes a li" elong (n e long problem. addi tion to the prolonge prolonged# d# ndistrbed# and nre"reshing noctrnal sleep# (/ is associated $ith long nonre"reshing naps# di""ic di" "iclt lt! ! a$akening# slee sleep p drnk enne enne ss# an and atomatic behaviors $it $ith h amne nesi sia. a. @ther s!mptoms sggesting atonomic nervos s!s tem d!s"nction are t!pical# inclding migraine-like headaches# "ainting spells# s!ncope# orthostatic a!nad t!pe phenomena $i h!potens !potension# ion# and a!nad $ith th cold han hands ds "eet. and "e et. Some patients $ith (/ sleep less than 1 4 hors per night# have re shed di""iclt! di"" iclt! a$akening# a$ak a$akee nre" re shed and even con"sed# and ma! take ni ninte ntentional# ntional# nre"res nre"reshing hing da!tim da!time e naps provoked pr ovoked b! the heir ir da!time somn somnolence. olence. @nset is t!picall! be " ore ore 5 !ears !ears o" age# and the corse o" the disorder disorder is persistent and nremitting.
accontant nt complained o" e%cessive sleepiness 9 64 -!ear-old acconta and reported th that at he had to ta take ke ab abot ot "i "ive ve hal"-hor naps throgh ot the da!. /e a$akened "eeling re"reshed bt nless he na pped he cold cold not "nction at $ork . /e did not not ab abse se and an d histo hi stor! r! sbstances narcoleps! $a $ass rled rled o ot' t' bt on he that at bo both th hi hiss "ather and paternal grand"ather had the report rep orted ed th same sleep pattern. /e $as
