Sleep Disorders in the DSM-5-TR | Symptoms and Diagnosis

Hey there everybody, and welcome to this presentation on sleep wake disorders in the DSM 5TR. I'm your host, Dr. Donnellice Snipes. In this presentation we'll explore the symptoms and prevalence of the major sleep wake disorders in the DSM 5 TR and identify risk factors and treatment targets that would be appropriate for behavioral health clinicians. Now, I don't know about you, but when I went through graduate school we didn't focus at all on the sleep wake disorders chapter. So going through it and learning all of the different disorders is often something that students have to do or counselors in training have to do on their own. Sleep wake disorders encompass 10 disorders or disorder groups that include insomnia, hypersomnolence, narcolepsy, breathing related sleep disorders, circadian rhythm, sleep wake disorders, non rapid eye movement, sleep arousal disorders, nightmare disorder, rapid eye movement, sleep behavior disorder, restless leg syndrome, and substance medication induced sleep disorder. We're not going to have time to go through all of those in today's hour long presentation, so we're going to hit the more common ones and obviously the biggies. What are we talking about in terms of prevalence? Is this something that you are going to encounter in practice? And the short answer is yes, regardless of what setting you're in? Yes. Four to 22% adults have symptoms that meet criteria for insomnia disorder. Wow, 22%. That's about, about one in five adults in the general population. When you look at people who have comorbid mental illness and you know, I don't like that term, but that's what the DSM uses. So people with anxiety, depression, PTSD, etc. That number rises to 40 or 50% or more who meet the criteria for insomnia disorder. That is a lot of people, and I've talked in other videos and we'll talk some today about the fact that sleep is when your body rests, repairs itself, resets itself for the next day and when sleep is impaired, it impacts everything. It impacts your circadian rhythms, it impacts your hormones, it impacts your neurotransmitters, it impacts inflammation, immunity, energy. The list goes, goes on. So sleep is super important and that's one of the things that we don't talk about a lot with our patients. Very often sleep is not something that comes up when we're talking about depression. Really looking at do they have a sleep disorder, do they have some sleep disruption? Even if their symptoms do not rise to the level of having a concurrent sleep disorder diagnosis, sleep disruption, inadequate, non restful sleep is going to be problematic and needs to be a focus of clinical attention. Hypersomnolence, this is the opposite of insomnia. This is sleeping too much. 5 to 33% of Americans experience hypersomnolence. Now we're going to talk about hypersomnolence in a little while, what the criteria are, because that is a pretty big why 5 to 33. A lot of it has to do with the criteria that are used in the individual studies to define hypersomnolence, circadian rhythm, sleep disorder. And I looked at multiple studies and they found that this impacts about 3% of Americans. That's three out of every hundred. In my clinical experience and in my personal experience, I find that to be very low. Now that's the research says 3%. So we're going to go with that. The DSM really doesn't talk about the prevalence. But why do I say 3% is low? Because there are more than 3% of the people in the United States that are on shift work. There are more than 3% of people in the United States that have difficulty syncing their endogenous circadian rhythms, their endogenous sleep cycles with what they need to be doing throughout the course of a 24 hour period. Not everybody is on a day shift. Some people are on night shift. And we're going to, again, we're going to talk about that more obstructive sleep apnea. This is another biggie. 15 to 30% of males let that sink in. So somewhere between 1 in 6 and 1 in 3 males struggle with obstructive sleep apnea. And 10 to 15%, about 1 in 10 or 1.5 in 10 females, have obstructive sleep apnea. Those are huge numbers. This is not out of a particular subset of the population. This is the general population, which means that, you know, right there we've got a just with obstructive sleep apnea, we have a significant portion of the American population that is at much higher risk for a variety of mental health, substance use and physical health disorders. Restless leg syndrome is also in this category. And 4 to 14% of people are qualify for a diagnosis of restless leg syndrome. Again, I find the span, 4 to 14% to be rather large. But just looking at the different research studies, it depends on the cohorts that you're looking at and the criteria that they really use to cut off what is subdromal and what meets clinical criteria. Sleep assessment considerations. Now, most of us, when we do our assessment, we have a section in there on sleep sleep. How well are you sleeping? What's it been like, you know, just general questions that we ask. But a lot of times we have not been taught why that's important. Or we do know the one fact that people who wake up in the middle of the night, especially if they've got depression, if they wake up in the middle of the night and have difficulty getting back to sleep, they often have more significant depressive symptoms and at our high, and are at a higher risk of suicidal ideation. But that grossly underestimates the number of people who are at risk of problems as a result of sleep disorders. So what are we looking at? Sleep latency? How long does it take a person to get to sleep? And this is just getting into that phase one sleep, it's not into a deep sleep. How long does it take? And for some people, they can lay down and drift off in a few minutes, and for others it's 30 minutes, 45 minutes. That's sleep latency. We also want to ask how long do you stay asleep before waking up? So when do you wake after sleep onset? How many times do you awaken each night and how much time are you actually asleep each night? They call that sleep efficiency. Some people may be in bed for nine hours, but they, it takes them 45 minutes to fall asleep. They stay asleep for two hours, they wake up, they're awake for an hour, they drift back to sleep. So a lot of the time they're spending in bed, they're awake. They're not very efficient in their, in their sleeping. All of these things are important because all of these things can contribute to sleep deprivation. We also need to recognize that human sleep varies across the lifespan. During childhood and early adolescence, people have large amounts of slow wave or deep sleep. Well, that makes sense. Childhood, early adolescence, the brain's still developing, the body's still developing. When the person's asleep, the body is doing a lot of hard work. Once our brain is fully developed, our body's fully developed, there's less going on behind the scenes than there was during that developmental period. Adults, once people get in to that place of being considered adults, 24, 25 and older adults show increased wakefulness and first stage sleep and decreased deep sleep. So again, we want to look at what's going on in the body, that the body may not need as much deep sleep. Age must be considered in the diagnosis of a sleep disorder. When you're looking at someone who is 75 versus someone who is 7, there are going to be differences in the amount that they sleep, how long it takes to get to Sleep, how long they stay asleep, etc. Sleep disorders are often accompanied by depression, anxiety, cognitive changes. When you sleep, one of the things that happens is your body removes a chemical called called adenosine from your brain and gets you ready for the next morning. If you don't have restful sleep, I.e. adenosine stays there and keeps you feeling groggy when you wake up in the morning, throughout the day, if you have a good night's sleep and you wake up and all that adenosine is cleared out throughout the day as you think, as you engage in cognitive processes, that adenosine builds up. The more adenosine there is in your brain, the sleepier you feel. They call it sleep pressure. And again, so if you go to sleep that night and you don't clear out the adenosine, you're still going to have sleep pressure in the morning. Cognitive changes can be confusion, difficulty making decisions, or even negativity and pessimism and irritability. We also see an increased risk for substance use and non substance use disorders like gambling disorder and Internet gaming disorder and other medical conditions, particularly cardiovascular related medical conditions. Sleep disorders may also represent early warning signs of an episode of mental illness, which provides us opportunities for early intervention to, to either stop that recurrence right in its tracks or to reduce the intensity of a full blown episode. This is true for substance use disorders, this is true for behavioral addictions as well as for mood disorders and potentially even schizophrenia and schizophrenia spectrum disorders. Sleep disorders may be accompanied by a variety of other impairments, including fatigue or in some people, an over aroused and wired sort of presentation, which is kind of counterintuitive. But sometimes people's HPA axis, their threat response system just goes into overdrive when they're tired and they become much more driven and focused and edgy if you will, they may have decreased energy. Well, if you're not sleeping well, if you're fatigued, you're probably going to have that decreased energy. Unless you're wired, of course. Mood disturbances. Think about when you personally are sleep deprived. And I encourage people, if you've had a baby or even a puppy in the house, and you know, babies, puppies, kittens that need to be bottle fed throughout the night, when you're not getting a solid seven to nine hours of sleep consistently for weeks on end, how does that impact your mood? And it's, I'm not blaming the child, I'm not saying anything negative about that. I'm just saying this is how our body works. And we start to see People have more anxiety, irritability, depression, getting overwhelmed easier when they are tired. When we are tired, our HPA axis, our threat response system, actually goes into overdrive. That's kind of interesting. Now, not everybody is gonna go from being tired to wired, but it is important to remember that sleep, sleep deprivation represents a stress on the body. The HPA axis, your threat response system, the hypothalamic, pituitary, adrenal axis, whatever you want to call, is activated during periods where there is a stress, physical or emotional. So that HPA axis gets activated and says, hey, let me help you out, let me give you a little bit of energy. I'll dump some cortisol, some adrenaline, you know, some thyroxin, thyroid hormones to try to give you energy, some blood glucose to try to give you energy. And as a result of that HPA axis being activated or primed, the person may be more reactive to stress. There's also an increased incidence of stress related somatic or bodily symptoms, including tension, headaches, muscle tension or pain, or gastrointestinal symptoms. Well, if the stress response system, HPA axis is activated and pushing out those stress hormones, it's gonna make sense that you're gonna have some of those symptoms that you have when you're in that fight or flight mode. Maybe not to the same degree, but when you're in that fight or flight mode. And as I mentioned, there's also a significantly increased risk of cardiovascular diseases, including hypertension, stroke and heart attack. Remember, in the DSM 5TR, they did add a section on suicidality, suicidal ideation, and it's noted in the diagnostic criteria, or not the diagnostic criteria, but in the write up that insomnia may increase the risk for suicidal thoughts, behavior and death, even after adjustment for depression, which means even after they take out people who are clinically depressed, people with insomnia are at a much higher risk for suicidal behavior. We need to be aware of this. So if they present in your office as a behavioral health person or a case manager with insomnia, regardless of their mood presentation, we need to take it seriously because they are at higher risk. People with insomnia and nightmares are an increased increased risk for suicidal thoughts and behavior. That's kind of intensifying the risk. According to the DSM 5TR, they didn't cite the study, but 31.3% of college students with sleep problems had suicidal thoughts and 82.7% of those students with suicidal thoughts had sleep problems. So think about your Venn diagram. If you have college students with sleep problems and college students with suicidal thoughts. Those with suicidal thoughts. Most of the people with suicidal thoughts had sleep problems and a portion of the people with sleep problems had suicidal thoughts. So the takeaway for us is if somebody presents with sleep problems, they definitely need to be assessed for suicidal thoughts. And if they are presenting with suicidal thoughts, they definitely, definitely underscore, bold and italicized and need to be assessed for sleep problems. Now, some sleep problems they may not know about. It may not be insomnia or hypersomnolence. It may be something like obstructive sleep apnea that they don't even realize they have. A consensus statement of the American Academy of Sleep Medicine concluded that in adolescence, less than eight hours of sleep is associated with increased risk of self harm, suicidal thoughts and suicidal behavior. Let that sink in for a minute. Think about the middle schoolers and high schoolers that, you know, think about how many of them actually get eight or more hours of sleep every night. My experience, knowing my, you know, with my children's friends who were in public school and private school, etc. Is that's the minority. The majority of adolescents do not, with regularity, get eight or more hours of sleep. And that is a huge problem. That is a huge problem for cognitive development, for physical development, as well as putting them at risk for mood and substance disorders. As we talk about these sleep disorders, we're going to be talking some about the sleep stages. Most of us are familiar with REM sleep. That's when most of the dreaming occurs. And if you go to the Sleep foundation website, they've got a lot of great articles about sleep that are written for the average person. So it's really a good resource for patients. But REM sleep accounts for 20 to 25% of our total sleep and lasts in episodes of 10 to 60 minutes. If you have a fitness tracker, it may track your sleep and theoretically it will identify when you're in REM sleep and deep sleep and throughout the night. However, those are not super accurate. So don't get too hung up on the feedback from the, from the fitness tracker. It's really better to get a professional assessed sleep study done if you feel like you've got sleep problems. But anyway, REM sleep when dreams occur, 20 to 25% of our sleep non REM sleep, stage one. This is dozing. So this is when you lay down and you start to kind of doze off. Maybe you're not even laying down, you're trying to stay awake until it's a reasonable hour to go to sleep and you Just start dozing off or in class, that is non REM stage one sleep. This should only account for about 5% of total sleep. You don't sleep stay in this stage for very long, but it's that sort of twilight area. Non REM Sleep Stage 2, this lasts 10 to 60 minutes and increases in length throughout the night. It accounts for about 50% of your sleep. Non REM sleep stage 3 is also known as your slow wave or your deep sleep. It accounts for about 20% of your sleep, but it tends to reduce throughout the night. So during the beginning of the night, your deep sleep, those periods where you're really out are longer because the cleaning crew comes in and they have a bunch of garbage to get out. They have a bunch of stuff to do after the activities of the day. And then you end that sleep cycle and you go into the next one. They come back around and double check their work or whatever they're doing, and there's less to do. So you don't need to stay in deep sleep for quite as long. There's a whole lot of stuff to do at the beginning of the night, not as much toward the end. As deep sleep decreases, sleep stage two increases. And this is kind of where they balance each other out. Now, obviously non REM stage two is 50% of your sleep and deep sleep is only 20%. So you're not doing minute for minute. But what we're looking for is to see that expected pattern of stage two increasing and stage three decreasing as the night goes on. Stage three sleep, or deep sleep is critical to restorative sleep, allowing for body recovery, growth immunity enhancement and memory consolidation, among other things. When people don't get that deep sleep, think about if you were studying before final exams and you didn't get good deep sleep, then you may not have solidified a lot of the things that you actually learned. One of the things that I talk about in the video on reprogramming your subconscious is using guided imagery or meditations kind of right before bed. Because then you fall off to sleep and you get into that first stage of deep sleep. And it is right there on the top of the pile for your brain to assimilate and do something with. So let's talk about some of these disorders. Insomnia. And all of these disorders have to occur at least three nights per week for at least three months. So the three and three rule for your sleep disorders. At least three nights per week for at least three months. Despite adequate opportunity for sleep. The person complains of dissatisfaction with sleep quantity or quality and has one or more of the following symptoms. They have difficulty getting to sleep, so their sleep latency is all screwed up. They define this as taking more than 20 to 30 minutes to get to sleep. Now, if people fall asleep too quickly, less than eight minutes, it's usually an indication that they're sleep deprived. But when we're talking about insomnia, we're looking at a sleep latency of greater than 20 to 30 minutes. In children, this could be difficulty getting to sleep in less than 20 to 30 minutes without caregiver intervention. It's really important to think about the age of the child as well and what's going on. What happens with an infant. You know, infants need a lot more caregiver intervention than say a seven year old. Difficulty maintaining sleep, characterized by frequent awakenings after more than 20 to 30 minutes. So they fall asleep, they get through that stage one, they get into stage two, the stage two non REM, then they wake up or problems returning to sleep after awakenings. Sometimes people will wake up, they'll go through a full sleep cycle and they'll wake up after that first cycle of deep sleep, and then they have difficulty getting back to sleep. They have a good sleep latency the first time of the night. But then after that first sleep cycle, they wake up and they just lay in bed and toss and turn, stare at the clock and whatever. Again with children, children have difficulty getting back to sleep in less than 20 to 30 minutes without caregiver intervention. And the third criteria, remember that you just have to meet one or more early morning awakening, which is characterized as waking one hour before your scheduled time and before total sleep time reaches six and a half hours with the inability to return to sleep. Why is that important? Well, if you wake up one hour before your scheduled time, maybe you're supposed to be up at 5 and you wake up at 3. You may be like, Ah, I'm awake at 3. If you went to bed at 11 and woke up at 3, that's what we're talking about with insomnia. If you were really tired the night before and you fell asleep at six o' clock and you woke up at three, that's way more than six and a half hours. So that's not really qualifying as early morning awakening. That's just, you know, disrupted circadian rhythm for that night. So we do want to recognize that the time spent in bed is important. The time that the person went to sleep is important in relation to when they woke up. With insomnia, the sleep disturbance causes clinically significant distress or impairment in one or more areas of functioning and is not better explained and does not occur exclusively during the course of another sleep, wake disorder or attributable to the physiological effects of a substance or medical condition. That is the boilerplate that goes at the end of just about everything in the dsm. So we do want to recognize that if the insomnia is not causing somebody clinically significant distress or impairment, they may not be bothered by it, but if it's impairing their ability to function safely, then that's a problem. Coexisting mental disorders and medical conditions cannot adequately explain the insomnia. However, a diagnosis of insomnia can be given if the comorbid with another condition, even if that condition, like depression, has sleep disturbance as a symptom if they meet all of the criteria for insomnia and it's prominent symptom. The diagnosis of insomnia, unlike some other disorders in this category, is based on the individual's or caretaker's subjective perception of sleep, not necessarily on polysomnography. If the person complains of if the person's complaints of non restorative sleep occur without difficulty initiating or maintaining sleep, diagnosis of other specified sleep wake disorder is made. The person has to have difficulty in either initiating or maintaining sleep to get the diagnosis of insomnia. Hypersomnolence again 3 times a week for at least 3 months self reported excessive sleepiness despite a main sleep period lasting at least seven hours with at least one of the following symptoms. Now you can For a lot of our clients, the condition that it has to last they have to have a main sleep period lasting at least seven hours is going to negate this diagnosis anyway. But for people, especially people with major depressive disorder or underlying physical issues like chronic fatigue syndrome or fibromyalgia, they may have a schedule arranged where they are sleeping more than seven hours a night. However, the person is still excessively sleepy even though they've slept at least seven hours and at least one of the following symptoms Recurrent periods of sleep or lapses into sleep within the same day. So they get that sleep but then at a meeting they're just like dozing off. A prolonged main sleep episode of more than 9 hours per day that is non restorative or unrefreshing. Difficulty being fully awake after abrupt awakening. A lot of people with hypersomnolence, when they wake up, they're super groggy and have difficulty getting reoriented and they have a hard time. It's called sleep Drunkenness sometimes, but that is a key feature of hypersomnolence. Like insomnia, it causes clinically significant distress or impairment in one or more areas of functioning and is not better explained by another sleep disorder or attributable to the physiological effects of a substance. Additionally, coexisting mental and medical disorders do not adequately explain the hypersomnolence. If somebody has chronic fatigue syndrome, then they're probably not going to get a diagnosis of hypersomnolence. People with hypersomnolence generally fall asleep quickly and have good sleep efficiency. So they're out and they sleep right through. They are not going to be waking up and awake for long periods of time during the night. They also feel sleepiness developing over a period of time rather than experiencing a sudden sleep attack, which is more characteristic of narcolepsy. Unintentional sleep episodes typically occur in sedentary situations, but can happen in high attention situations such as at work or while driving. So most of the time, if a person's active, they're doing something, they are not going to get super sleepy and start dozing off. But there are occasions, more severe cases where somebody may start dozing off even while they're in the midst of doing something very active, such as cooking or driving or something. The persistent need for sleep can lead to automatic behavior like driving being carried out with little or no recall. In Florida there's this long stretch of highway we call Alligator Alley. But it's a long stretch of highway that is just flat and there's not a whole lot of anything but swamp. And some people develop what they call highway hypnosis while they're driving and they just kind of zone out. This not exactly what we're talking about with hypersomnolence. But if anybody's experienced that, then that's sort of what we're talking to, talking about when you're driving, maybe driving to work and you just don't even remember driving there. 40% of individuals with hypersomnolence disorder may have sleep inertia or sleep drunkenness, that difficulty actually getting oriented after you wake up. For some individuals with hypersomnolence disorder, the major sleep episode may last between nine hours up to 20 hours. Wow. Especially since they've got good sleep efficiency. If some, that means they're going to bed and they're sleeping straight through for 20 hours. This isn't after a, you know, three day party weekend or something. This is with regularity. They go to sleep and they can sleep solidly. However, sleep is non restorative and followed by Difficulty awakening. Most people with hypersomnolence disorder take daytime naps nearly every day, regardless of the nocturnal sleep duration. Many people with hypersomnolence can reduce their sleep time during work days, but weekend and holiday sleep is greatly increased, sometimes by up to three hours. And that's important to remember because we may see people who have who sleep seven, remember, go back here. The sleep only has to be seven hours. So during the week they may only sleep seven, seven, seven and a half hours. But then during the weekend they may bump it up significantly to try to catch up on the sleep that's lost because they are so fatigued. People with hypersomnolence disorder may have a family history of hypersomnolence or symptoms of autonomic nervous system dysfunction, including pots, recurrent headaches, reactivity of the peripheral vascular system and fainting. It's important to recognize that there are a lot of things that can trigger sleep disruption. And anytime somebody presents with a sleep disorder, it's helpful, especially if you think it's over and above what you would expect for, for example with major depressive disorder to have a medical evaluation done because there very well may be endocrine, neurological or other underlying conditions. In about 10% of cases of hypersomnolence, the hypersomnolence began after a viral infection. Interesting little note in terms of circadian rhythm disorders. This represents a persistent or recurrent pattern of sleep disruption caused by an alteration or misalignment of endogenous or your internal circadian rhythms and the sleep wake schedule required by the individual. Now that's kind of interesting because we have our natural circadian rhythms are set in part by light levels and light levels are set in part by, you know, the sky. Therefore, if somebody's working night shift or something and they are not keeping the same sleep schedule, then the external environment may need to be modified. But they can qualify for circadian rhythm disorder if they are having difficulty sleeping, when they need to be asleep as opposed to when their body wants to sleep. Sleep disruption leads to excessive sleepiness or insomnia or both and causes clinically significant distress. Now, there are three basic types of irregular sleep wake, where the person just sleeps, falls asleep at various times. There's no set pattern when they're going to fall asleep, when they're going to wake up. Non 24 hour sleep wake type. Our circadian rhythms are not really set on 24 hours, but that's generally the standard that we use in our current society. And if somebody is their circadian rhythms, they're not falling asleep about the same time each day, not waking up about the same time, then that might fall under non 24 hour sleep wake disorder. It's important to recognize, for example, that people who are blind may not receive the light input that is responsible in part for circadian rhythm regulation. And there are medications that are out there to help them. And then shift work type circadian rhythm disorders. And this is what I was talking about earlier. The people who are on midnight shift who have difficulty falling asleep at 8am and sleeping until 2 or 3 in the afternoon in order to accommodate their work schedule. Restless leg syndrome three times per week for at least three months. An urge to move the legs usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs. Characterized by all of the an urge to move the legs that begins or worsens during periods of rest or inactivity. It's partially or totally relieved by movement and is worse in the evening or at night than during the day. What's important to differentiate here? There is that nervous leg movement that people do when they're agitated or if they have difficulty sitting still, if they're fidgety. That's not what we're talking about. What we're talking about here is that uncomfortable and unpleasant sensation when the legs are still. It's important that it's worse in the evening or at night than during the day. Restless leg syndrome has been associated with low levels of dopamine. As dopamine levels fall throughout the day, then the restless leg syndromes or restless leg symptoms can start to become worse. Causes significant distress or impairment not attributable to another mental disorder. Yada yada. Interestingly enough, we do need to note antipsychotics are a common cause of restless leg syndrome. Why is that? Because antipsychotics and atypical antipsychotics reduce dopamine. And restless leg syndrome is caused by low levels of dopamine, which can be problematic. Sometimes people will be prescribed atypical antipsychotics off label for sleep and that can lead to the development of restless leg syndrome symptoms. So it is important to examine or talk with the person about what has changed. Additionally, it's not just dopamine. They found that low iron is also associated with restless leg syndrome. Now you can ingest toxic levels of iron. It is not recommended that you unless you're a medical professional or a registered dietitian. You know, you're not going to prescribe or advise people to take iron. You know, it's something that they should have tested by their doctor. And if their Iron levels are low. Their doctor will advise them accordingly. Obstructive sleep apnea. Remember, this is like up to 30% of men is evidenced by polysomnography of at least five OSAs or hypopneas, which is when the person stops breathing per hour of sleep and either of the following sleep symptoms. Nocturnal breathing disturbances such as snoring, snorting, gasping or breathing pauses. Daytime sleepiness, fatigue or unrefreshing sleep despite sufficient opportunities to spend sleep that's not better explained by another mental disorder, including a sleep disorder or medical condition. Think about people, you know that sleep and, and you know, my husband will gasp in his sleep sometimes he will have breathing pauses and I'm laying there, I'm counting, I'm like, come on, start breathing. And if he doesn't, I kick him. But. And then he starts breathing again. But it's important to recognize that that is a problem. And it is. It does set people up, puts them at much higher risk for a lot of conditions. Or even if the person doesn't have this snoring, snorting, gasping or daytime sleepiness and fatigue. If they go undergo a sleep study and they show 15 or more obstructive sleep apneas or hypopneas per hour of sleep, then it doesn't matter what their other symptoms are, they are going to meet the criteria for obstructive sleep apnea. So with osa, there has to be a sleep study in order to get the diagnosis. We don't do the sleep studies, but if somebody reports that unrefreshing sleep. We want to inquire about snoring. We want to inquire if they've had a sleep study. In terms of development and course of sleep disorders, the onset of insomnia symptoms can occur at any time during life, but the first episode is more common in young adulthood. In women, the incidence of first episode of insomnia increases with childbirth or menopause and may persist even after other symptoms of menopause like hot flashes have resolved. Therefore, they think there is some relation between hormonal levels and insomnia. Hypersomnolence disorder usually begins in late adolescence or early adulthood with a mean age at onset of 17 to 24 years. The DSM5TR does note that it is extremely rare for hypersomnolence to appear in children. What can we as behavioral health professionals do? We need to look at some of the risk factors for sleep disorders and as well as treatment targets. Anxiety can cause sleep disorders. Anxiety can result after significant periods of inadequate quality sleep. We want to obviously refer for a sleep study. Make sure that people are getting adequate sleep, but then provide cognitive behavioral tools to address their anxiety to help them down regulate. There's also a variety of tools that can be used to trigger the relaxation response or stimulate the vagus nerve to trigger the relaxation response, which can be helpful for anxiety. Negative cognitive styles are risk factors for sleep disturbances because they often lead to rumination, anxiety, worry, you know, that mind racing at night. But people can also start to become very frustrated and pessimistic and negative about sleep itself if they have a hard time sleeping or if they wake up and they just don't feel rested. I looked at a couple of studies that indicated that fitness trackers and things that purport to measure your sleep may actually increase sleep problems. Because people get so hung up on trying to get their sleep phases to look right that they actually increase their stress about their sleep and worsen their sleep. People with higher stress reactivity or emotional dysregulation are at greater risk for sleep problems and this also can develop with sleep problems. We want to help people develop distress tolerance skills and coping skills, cognitive processing, acceptance and commitment therapy. All of these can be really helpful for the stress reactivity. Ptsd. PTSD can contribute to sleep problems, but they found, for example, people with PTSD have a 70% greater risk of developing obstructive sleep apnea irrespective of their weight. A lot of people think that obstructive sleep apnea is related to being overweight and it's not necessarily so. It is important to recognize that PTSD is a huge risk factor for OSA or obstructive sleep apnea. If you've got a client with ptsd, it's advisable to encourage them to undertake a sleep study. Noise, light or uncomfortably high or low temperatures can impact people's sleep. That just goes with sleep hygiene. And we need to educate people about the impact of their environment on their sleep and help them devise strategies to create the most conducive sleep environment possible. A lot of times they haven't thought about it and it's one of those things that they're not real motivated to look at without being helped to see how much of an impact poor sleep is having on their presenting symptoms and quality of life. Interestingly, high altitude may predispose people to insomnia and periodic breathing difficulties during during sleep Heritability may be highest for insomnia disorder in terms of ptsd. I'm sorry, obstructive sleep apnea, obesity and Being male are your two risk factors? Now, we can't address the genetics of being male, but we can help people develop an awareness of how their body composition may be impacting their sleep. This is another thing that is helpful to do in a multidisciplinary team because we are not in a position to tell somebody if they are overweight, over, you know, obese, whatever that is something between them and their doctor and whether that obesity is actually problem for their sleep. Not everybody who is overweight has obstructive sleep apnea. Poor sleep hygiene practices like excessive caffeine use or irregular sleep schedules are also risk factors that we can help people become aware of. When my husband was on midnight shift, in his best efforts to be with the family, he, he would work midnight shift two days and then he'd come home after the second day and instead of going to sleep and getting up and being up all night long like he would if he were working, he would stay up and then go to sleep with the family. So he would have two days of night shift and then two days of day shift and then three days of night shift and his body never knew whether it was coming or going. It is important to help people recognize, especially shift workers recognize the difference between quality and quantity, time with their family, and try to figure out something that, that works. Now, you're not always going to be able to keep that schedule, but typically I found that shift workers I've worked with have ultimately preferred a couple of good, high quality, energetic hours as opposed to, you know, an entire day where they're just living on caffeine and in a, in a jet laggy haze all day long. People asleep issues are also at much greater risk for alcohol and other substance use issues, sometimes to deal with their mood disturbances, but a lot of times they start misusing substances to try to help them get to sleep or stay asleep. Additionally, people with sleep problems often pay excessive attention to their efforts to sleep and they can get really obsessive about it, especially when they do this in the environment in which the individual has frequently spent sleepless nights, it can compound the issue. So that bedroom, that bed, that time of day start to become associated with distress. So when they walk into that room, when the clock hits that time of day, their HPA axis actually activates and says, okay, here we go again. This is going to be a bugger and a half. We do need to address those issues and help the person decondition those stimuli so they can approach their sleep environment and have the sleep environment be one that promotes relaxation and rest. Individuals with persistent sleep disruption may also acquire maladaptive sleep habits, such as spending excessive time in bed, following erratic sleep schedules or napping, and cognitions like fear of sleeplessness. They just dread going to bed because they know they're not going to be able to sleep through the night. Apprehensions about daytime impairment they just are frequently frustrated and worried that they're going to make a mistake at work or do something wrong because they're overtired. Clock watching and I think we've all done clock watching at one time or another. Sleep disorders impact millions of Americans and increase the risk of a variety of health and mental health issues. Sleep disorders can have both physical like viral, nutritional, medication induced and neurological causes, as well as behavioral causes like poor sleep habits. People presenting with sleep disorder should be referred to a medical doctor for an assessment, even if what you're what they're presenting for has sleep disruption as a symptom. If their sleep disruption seems to be a prominent symptom, it's definitely helpful to to have them get a medical evaluation to assist them in improving their sleep and rule out any underlying physiological causes like hyper or hypothyroid or something else that would require medical intervention. Behavioral health clinicians can assist with addressing sleep hygiene such as lifestyle factors, emotional regulation, negative cognitive styles, and negative cognitions as they relate to being able to sleep and assisting with deconditioning negatively conditioned stimuli.