Mr. Potato Head

This case illustrates diagnostic challenges in patients with epilepsy and suspected sleep disorders. Specifically, the symptomatic generalized epilepsy Lennox-Gastaut syndrome is an age-related epileptic encephalopathy characterized by developmental delay; multiple seizure types, including tonic seizures in drowsiness and sleep; and generalized slow spike-wave complexes on electroencephalography (EEG). Tonic seizures in sleep can be unrecognized or can be confused with sleep disorders such as sleep apnea. The case demonstrates how to identify generalized epileptic abnormalities and seizures on the limited EEG montage used in routine polysomnography and expanded EEG using the 10-20 system of electrode placement.

Rewriting One Patient’s Story of Disrupted Sleep

This chapter covers treatment options for individuals with chronic insomnia disorder. We describe the effectiveness of cognitive behavioral therapy for insomnia (CBT-i) and various modalities of delivery of the treatment. CBT-i is an alternative treatment for insomnia that has been demonstrated to be as successful as pharmacological therapies in the short term, and more effective in the long term. CBT-i comprises sleep restriction, stimulus control, relaxation training, sleep hygiene, and cognitive restructuring. The authors examine group CBT-i as a way to increase social support and enhance treatment adherence. Computerized CBT-i is a newer option to provide increased access to this treatment.

But I Need Marijuana to Function as a Mother!

Polysomnography and multiple sleep latency testing (MSLT), along with detailed history and sleep logs and actigraphy, are essential for the diagnosis of narcolepsy with cataplexy (narcolepsy type 1). Interpreting polysomnography and MSLT data is challenging in patients with substance abuse. This chapter presents the case of a young woman with a history of substance abuse and confounding MSLT results due to covert use of recreational drugs. Recreational drugs affect sleep architecture, and the results of urine drug screening become a critical part of diagnostic evaluation in patients with substance abuse. Patients undergoing MSLT to characterize and confirm central hypersomnia need proper preparation to reduce false-positive, false-negative, and confounding results. Unexpected positive urine toxicology results are common in adolescents and adults undergoing MSLT and maintenance of wakefulness testing.

The Chicken and/or the Egg?

This chapter covers the bidirectional relationship between depression and insomnia. Patients with insomnia are more likely to develop depression; the prevalence of depression in people with comorbid insomnia is almost 10 times greater than in those without insomnia. Conversely, depression itself has sleep disturbance as a symptom 80% of the time. Treatment of comorbid insomnia and depression should aim at treating both conditions. While cognitive-behavioral therapy for insomnia (CBT-i) should always be considered in the treatment of chronic insomnia, instances may arise when medications are required. Sedative–hypnotics derive from a wide variety of classes of medications and may need to be used in conjunction with antidepressants in the depressed insomniac.

Dying to Fall Asleep

Fatal familial insomnia (FFI) is a rare autosomal dominant genetic disease characterized by progressive insomnia, autonomic hyperactivity, memory deficits, hallucinations, and myoclonus. Unlike its name, insomnia is not the most common initial presentation in patients with FFI. More common features like autonomic hyperactivity (hypertension and tachycardia) are often missed, delaying the diagnosis of FFI. Genetic analysis of FFI shows a D178N-129M mutation that results in generation of insoluble proteins (prion proteins) that aggregate to form amyloid plaques, leading to deterioration of the central nervous system, particularly in the hypothalamus. This case illustrates the difficulty in determining a definitive diagnosis in patients with FFI. Unfortunately, no treatment or cure is available for FFI. The disease is fatal in all the patients.

More Sleep Is a Slam Dunk

Sleep loss may impair athletic performance. Sleep extension may improve performance in sleep-deprived athletes. In elite sports, where the slightest edge can make a difference in individual and team success, ways to improve performance are of great interest to athletes and teams. In the presented case, a male basketball player sought to improve his free throw shooting accuracy. With a disciplined approach to sleeping longer periods of time each night over a 12-week period, there was a substantial improvement in free throw percentage, sleepiness, and self-reported confidence in making free throws. This result is consistent with an extensive literature showing that improving sleep can improve athletic performance.

Introduction to Pediatric Sleep Clinic and Sleep Testing

This chapter covers the diagnostic evaluation of children and adolescents referred to sleep centers. Diagnosis of sleep disorders in children begins with a structured history. Pediatric sleep questionnaires can be useful. Polysomnography can be frightening for children, and child-friendly polysomnography techniques are discussed. The authors outline how sleep studies are scored in children. The use of actigraphy, nocturnal home oximetry, and multiple sleep latency testing is reviewed. Smartphone apps for monitoring sleep/wake are summarized. The authors believe that more evidence of the validity of smartphone apps is needed before we accept data from them and integrate this information into decision making and the electronic medical records.

Unwanted Overtures by Night, Remorse by Day

Sexual behavior in sleep has only recently been recognized as a variant of non–rapid-eye-movement (NREM) arousal parasomnias. This chapter discusses a case of sexsomnia precipitated by obstructive sleep apnea, the ensuing impact on the subject and his bed partner, and evaluation and management strategies. Sexsomnia is suspected to be highly underreported and carries significant physical, psychosocial, and forensic ramifications. Polysomnography with expanded electroencephalography can help identify concurrent sleep disorders and exclude other etiologies such as epilepsy. Treatment of comorbid sleep disorders such as obstructive sleep apnea and sleep deprivation is highly effective in controlling the abnormal sexual behavior. There is a pressing need for research and expansion of current understanding to develop a standardized approach to evaluation and management of sexsomnia.

Introduction to Sleep Testing

This chapter provides an overview of sleep testing performed inside or outside the sleep laboratory. The chapter reviews the classification of sleep studies and methodology of in-lab polysomnography and home sleep apnea testing. Specifically, the indications for and relative contraindications and limitations of both procedures are discussed. Positive airway pressure (PAP) titration procedures are reviewed and the PAP-NAP, an abbreviated daytime study for patients with sleep apnea and PAP intolerance or hesitancy, is described. The authors also discuss the methodology of, indications for, and interpretation of the multiple sleep latency test and the maintenance of wakefulness test, which are daytime studies performed to evaluate excessive daytime sleepiness. Finally, the role of actigraphy in the evaluation of sleep disorders is discussed.

Stimulation Ultimately Prevails

This chapter discusses the role of neuromodulation in the treatment of obstructive sleep apnea (OSA). Various forms of hypoglossal nerve stimulation (HNS) have been researched, and one commercially available form of stimulation was approved for treatment of moderate to severe OSA by the U.S. Food and Drug Administration in 2014. Because of the novelty of this treatment and subgroup responsiveness, inclusion and exclusion criteria have been developed. The treatment is reserved for select patients who have been deemed to fail or are intolerant of positive airway pressure therapy. The nature of the therapy requires multidisciplinary care from both otolaryngology and sleep medicine specialists. Of the available outcome data, the therapy is effective at not only reducing the severity of OSA but also improving patient-reported outcomes of daytime sleepiness and quality of life.