Breathing related sleep disorder, Circadian rhythm sleep-wake Disorder


Breathing related sleep disorder.

Breathing related sleep disorder is a primary sleep disorder marked by excessive sleepiness or insomnia arising from sleep disruption due to breathing difficulties during sleep, for example, sleep apnea. In DSM5, the classification refers to three specific disorders: obstructive sleep apnea hypopnea (characterized by episodes of absent or reduced breathing during sleep and by daytime sleepiness); central sleep apnea (repeated episodes of absent or reduced breathing caused by variability in respiratory control during sleep); and sleep-related hypoventilation (decreased respiration during sleep).

Sleepiness during the day or disrupted sleep at night has a physical origin-namely, problems with breathing while asleep. In DSM-5, these problems are diagnosed as breathing-related sleep disorders. People whose breathing is interrupted during their sleep often experience numerous brief arousals throughout the night and do not feel rested even after 8 or 9 hours asleep.

For all of us, the muscles in the upper airway relax during sleep, constricting the passageway somewhat and making breathing a little more difficult. For some, unfortunately, breathing is constricted a great deal and may be labored (hypoventilation) or, in the extreme, there may be short periods (10 to 30 seconds) when they stop breathing altogether, called sleep apnea. Often the affected person is only minimally aware of breathing difficulties and doesn’t attribute the sleep problems to the breathing.

Three types of apnea: Breathing related sleep disorder.

Each with different causes, daytime complaints, and treatment: obstructive, central, and mixed sleep apnea.

1. Obstructive sleep apnea hypopnea syndrome

It occurs when airflow stops despite continued activity by the respiratory system. In some people, the airway is too narrow; in others, some abnormality or damage interferes with the ongoing effort to breathe. Everyone in a group of people with obstructive sleep apnea hypopnea syndrome reported snoring at night. Obesity is sometimes associated with this problem, as is increasing age.

Diagnostic Criteria for Obstructive Sleep Apnea Hypopnea.

A. Either (1) or (2):

1. Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:

  • (a) Nocturnal breathing disturbances: snoring, snorting/gasping or breathing pauses during sleep.
  • (b) Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.

2. Evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms.

Specify current severity:
Mild: Apnea hypopnea index is less than 15
Moderate: Apnea hypopnea index is 15-30
Severe: Apnea hypopnea index is greater than 30

2. Central Sleep Apnea.

It involves the complete cessation of respiratory activity for brief periods and is often associated with certain central nervous system disorders, such as cerebral vascular disease, head trauma, and degenerative disorders. Unlike people with obstructive sleep apnea hypopnea syndrome, those with central sleep apnea wake up frequently during the night but they tend not to report excessive daytime sleepiness and often are not aware of having a serious breathing problem.

Diagnostic Criteria for Central Sleep Apnea.

A. Evidence by polysomnography of five or more central apneas per hour of sleep.

B. The disorder is not better explained by another current sleep disorder.

Specify current severity:
Severity of central sleep apnea is graded according to the frequency of the breathing disturbances as well as the extent of associated oxygen desaturation and sleep fragmentation that occur as a consequence of repetitive respiratory disturbances.

3. Sleep-Related Hypoventilation.

It is a decrease in airflow without a complete pause in breathing. This tends to cause an increase in carbon dioxide (CO2) levels, because insufficient air is exchanged with the environment. All these breathing difficulties interrupt sleep and result in symptoms similar to those of insomnia.

Diagnostic Criteria for Sleep-Related Hypoventilation.

A. Polysomnography demonstrates episodes of decreased respiration associated with elevated CO2 levels.

(Note: In the absence of objective measurement of CO2, persistent low levels of hemoglobin oxygen saturation unassociated with apneic/ hypopneic events may indicate hypoventilation.)

B. The disorder is not better explained by another current sleep disorder.

Specify current severity:
Severity is graded according to the degree of hypoxemia and hypercarbia present during sleep and evidence of end organ impairment due to these abnormalities (e.g., right-sided heart failure). The presence of blood gas abnormalities during wakefulness is an indicator of greater severity.

Circadian rhythm sleep-wake Disorder.

It is a sleep disorder that is due to a mismatch between the sleep–wake schedule required by a person’s environment or occupational circumstances (e.g., shift work) and his or her circadian sleep–wake pattern, resulting in excessive sleepiness or insomnia. This disorder was formerly called sleep–wake schedule disorder.

This disorder is characterized by disturbed sleep (either insomnia or excessive sleepiness during the day) brought on by the brain’s inability to synchronize its sleep patterns with the current patterns of day and night. In the 1960s, German and French scientists identified several bodily rhythms that seem to persist without cues from the environment, rhythms that are self-regulated. Because these rhythms don’t exactly match our 24-hour day, they are called circadian (from circa meaning “about” and dian meaning “day”).

Diagnostic Criteria for Circadian Rhythm Sleep–Wake Disorder.

A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep–wake schedule required by an individual’s physical environment or social or professional schedule.

B. The sleep disruption leads to excessive sleepiness or insomnia, or both.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.

Specify if:
Episodic: Symptoms last at least 1 month but less than 3 months
Persistent: Symptoms last 3 months or longer
Recurrent: Two or more episodes occur within the space of 1 year.

Also read about Hyper-somnolence disorder, Narcolepsy


David H. Barlow, V. Mark Durand. Abnormal Psychology, An Integrative Approach. (7th ed).

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