EU_Psychiatry_Mignot_Capasso_quark6.qxp 3/7/08 02:34 Page 48
Insomnia
antidepressants in SDB patients complaining of hypersomnolence who are therapy significantly improves subjective and objective measures of
misdiagnosed with depression). In contrast, a number of patients with daytime sleepiness in patients with OSA.
33,34
CPAP is safe, but often not
conversion disorder or depression can be misdiagnosed as having tolerated or used regularly, mainly due to a lack of care by providers, who
hypersomnia or narcolepsy, with negative consequences. Finally, as will be do not help the patients to tolerate and become accustomed to the
discussed later, it is not uncommon for patients with a hypersomnia
complaint to have a combination of problems that all contribute to the
symptoms they are experiencing (typically mood and anxiety disorder, mild
sleep apnoea, disturbed sleep at night and poor sleep hygiene).
Sleep apnoea is more frequent in males,
the obese or those with a small jaw, but
Sleep-related Breathing Disorders
The disorders of this subgroup are characterised by disordered breathing
should not be excluded in children or
during sleep (SDB). Chief among them is obstructive sleep apnoea (OSA),
even in an underweight female.
which causes fragmented sleep and sleepiness due to arousals secondary to
episodes of complete (apnoeas) or partial (hypopnoeas) upper airway
obstruction occurring during sleep with oxygen desaturations. Sleep apnoea
is more frequent in males, the obese or those with a small jaw, but should machine by finding the right pressure device, mask and accessories and
not be excluded in children or even in an underweight female. In addition coaching them during the first month of prescription. As a result,
to EDS, patients may complain of insomnia, fatigue and decreased energy although some patients find it effective immediately, many patients are
levels (symptoms that are mistakenly attributed to depression), and their discouraged and do not use the device for long enough to see benefits.
partners often report loud snoring or breathing interruptions.
30
The Alternatives to CPAP for the treatment of OSA include a variety of
estimated prevalence of SDB, defined as an apnoea–hypopnoea index (AHI) pharyngeal soft tissue and maxillary–mandibular surgical interventions.
(an index known to be associated with and to predict an increased risk of These procedures address the various points of obstruction in the upper
high blood pressure and various cardiovascular complications) of 5 or airway or any anatomical variants that predispose an individual to an
higher, is 9% for women and 24% for men.
31
SBD.
35,36
Mandibular advancing dental devices are a treatment option for
mild-to-moderate OSA in patients intolerant of CPAP who are not
A milder form of SDB, called upper airway resistance syndrome,
32
has candidates for surgery.
36
Surgical therapies for SDB, although liberating
also been described. In these cases, frank apnoea is not present, but when effective (no need for constant use of CPAP), should be carefully
the airway narrows during sleep, forcing the sleeper to increase considered, as many procedures are ineffective and painful. Similarly,
respiratory effort (fighting to breathe), leading to arousal and reducing nasal obstruction can ameliorate sleep apnoea by reducing airway
disturbing sleep without frank obstruction and oxygen desaturations. resistance and collapse, but is rarely curative. Finally, weight loss can be
These milder events, called respiratory-effort-related arousals (RERAs), effective in reducing SDB, although it is difficult to maintain. Any change
are best observed with the use of an oesophageal manometer during in body mass index (BMI) of more than 10% should prompt clinicians to
the polysomnogram. Problematically, there is only a weak correlation reconsider SDB severity.
between the presence of sleep apnoea and daytime symptoms such as
sleepiness. Consequently, some patients may have severe sleep apnoea, Narcolepsy
sleep fragmentation and desaturation with a higher risk of Narcolepsy is a serious sleep disorder characterised by excessive daytime
cardiovascular complications, but no memory of bad sleep or no sleepiness and abnormal REM sleep manifestations, including cataplexy
complaint of daytime sleepiness. (sudden loss of muscle tone triggered by strong emotions), sleep paralysis,
hypnagogic (at sleep onset) and hypnopompic (at wake-up time)
hallucinations and sleep-onset REM periods.
25
The main finding in these
patients is a decrease in hypocretin/orexin concentrations in the
Restless legs syndrome can be
cerebrospinal fluid (CSF)
37
and in the number of hypocretin neurons in
secondary to medical disorders, post mortem brain tissue.
38
EDS is usually the first symptom to appear, and
including iron deficiency,
is exacerbated when the patient is physically inactive. It is often irresistible,
despite the individual making desperate efforts to fight the urge to sleep,
neuropathies and renal disease.
and is frequently associated with dreaming.
39
Despite the EDS, narcoleptic
patients generally have disrupted nocturnal sleep, falling asleep as soon as
they get into bed but waking up several times during the night. Cataplexy
The gold standard diagnostic test is a polysomnogram performed in a is the best diagnostic marker of the disease. It is characterised by a sudden
sleep laboratory. The AHI is usually determined, as well as lowest and drop of muscle tone triggered by emotional factors, usually by positive
mean oxygen desaturations – two important severity factors. An AHI emotions such as laughing, or by anger, but almost never by stress, fear or
score of >30 and desaturation during sleep of below 80% is severe. physical effort. It is sometimes limited to facial muscles or to the arms
Continuous positive airway pressure (CPAP) is still considered to be first- or legs, with dysarthria, jaw tremor, head or jaw dropping, dropping of
line therapy for treatment of SDB. In CPAP, a nasal or nasal–oral mask is objects or unlocking of the knees.
39–41
provided and continuous positive pressure applied to the upper airway
during sleep. By stabilising the airway walls, CPAP alleviates the tendency Other symptoms of dissociated REM sleep in patients with narcolepsy
for the upper airway to collapse, ameliorating breathing disturbances and include sleep-related hallucinations and sleep paralysis (an inability to
allowing sleep with less interruption. Studies have shown that CPAP move the limbs or the head or to speak or breathe normally, either at
48 EUROPEAN PSYCHIATRIC REVIEW