Practice of Sleep Medicine: Sleep Disorders in Children and Adults

Contents
About the Authors
1: Physiological Basics of Healthy and  Disturbed Sleep
	1.1	 History of Sleep Medicine
	1.2	 Classification of Sleep Disorders
	1.3	 Phenomenology of Sleep
	1.4	 Physiological Alterations During Sleep
		1.4.1	 Cardiovascular System During Sleep
		1.4.2	 Thermoregulation
		1.4.3	 Hormone System and Sleep
	1.5	 Circadian Rhythm
	1.6	 Sleep Regulation
	1.7	 Functions of Sleep
	1.8	 Dreaming
		1.8.1	 Definitions
		1.8.2	 Dream Recall
		1.8.3	 General Characteristics of Dreams
		1.8.4	 Correlation Between Wakefulness and Dream
		1.8.5	 Function of Dreams
	1.9	 Questions
	Further Reading
2: Diagnostic Methods
	2.1	 History Taking
		2.1.1	 Sleep-Related Personal Anamnesis
		2.1.2	 Sleep-Related History Compiled by Third Parties
		2.1.3	 History Taking Regarding Sleepiness, Fatigue, and Daytime Performance
		2.1.4	 Further History Taking for Differential Diagnostic: Assessment of Possible Origins of Sleep Disorders
	2.2	 Laboratory Parameters for Sleep Disorders
	2.3	 Sleep Questionnaire
		2.3.1	 Insomnia Questionnaire
		2.3.2	 Questionnaires for the Assessment of Sleep-Related Breathing Disorders
		2.3.3	 Questionnaire Regarding Restless Legs Syndrome
	2.4	 Physical Examination
	2.5	 Actigraphy
	2.6	 Outpatient Step-by-Step Diagnostics for Sleep-Related Breathing Disorders and Polygraphy Systems
	2.7	 Polysomnography (PSG)
		2.7.1	 Standard Parameters of Polysomnography (PSG)
			2.7.1.1	 Measurement of Blood Pressure During Sleep
		2.7.2	 Parameters to Be Reported for Polysomnography (PSG)
			2.7.2.1	 Sleep Scoring Data
			2.7.2.2	 Phenomenology and Classification of Arousals
		2.7.3	 Polysomnography (PSG) in Patients with Insomnia
		2.7.4	 Polysomnography (PSG) in Patients with Periodic Limb Movements in Sleep and Patients with Restless Leg Syndrome
		2.7.5	 Polysomnography (PSG) in Cases of Bruxism
		2.7.6	 Polysomnography (PSG) in Cases of REM Behavior Disorders
		2.7.7	 Polysomnography (PSG) in Cases of Rhythmic Movement Disorders in Sleep
		2.7.8	 Polysomnography (PSG) in Cases of Sleep-Related Breathing Disorders
	2.8	 Examination of Sleepiness- and Fatigue-Related Daytime Impairments
		2.8.1	 Diagnostics of Daytime Sleepiness
			2.8.1.1	 Diagnostic Procedures of Central Nervous System Alertness
				Multiple Sleep Latency Test (MSLT)
				Maintenance of Wakefulness Test (MWT)
				Pupillographic Sleepiness Test
			2.8.1.2	 Diagnostic Procedures to Assess Vigilance
				Vigilance Test According to Quatember and Maly
				Sub-test of Vigilance of the Test Battery for Attentional Performance
			2.8.1.3	 Diagnostic Procedures to Assess Selective Attention
				Achievement Motivation Test Series, Version 3.00 of the Vienna Test System
				Go/NoGo of the Test Battery for Attentional Performance
			2.8.1.4	 Diagnostic Procedures to Assess Divided Attention
				Test of Divided Attention of the Test Battery for Attentional Performance
				Vienna Determination Unit
			2.8.1.5	 Subjective Diagnostic Questionnaires for Assessment of Sleepiness-Related Impairments
				Stanford Sleepiness Scale (SSS)
				Epworth Sleepiness Scale (ESS)
	2.9	 Questions
	Further Reading
3: Insomnia
	3.1	 Classification of Insomnia Disorders
	3.2	 Chronic Insomnia Disorder
		3.2.1	 Definitions
			3.2.1.1	 Subtype of Psychophysiological Insomnia
			3.2.1.2	 Subtype of Paradoxical Insomnia
			3.2.1.3	 Subtype of Idiopathic Insomnia
			3.2.1.4	 Subtype of Insomnia Caused by a Mental Disorder
			3.2.1.5	 Subtype of Insomnia Resulting from Inadequate Sleep Hygiene
			3.2.1.6	 Subtype of Insomnia due to Psychiatric Disease, Medical Condition, or Drug and Substance Consumption
		3.2.2	 Etiology and Pathogenesis
			3.2.2.1	 Developmental Model of Chronic Insomnia
			3.2.2.2	 Risk Factors for the Development of Chronic Insomnia
		3.2.3	 Polysomnographic Findings
	3.3	 Short-Term Insomnia Disorder
	3.4	 Other Insomnia Disorders
	3.5	 Isolated Symptoms and Normal Variants
		3.5.1	 Excessive Time in Bed
		3.5.2	 Short Sleeper
	3.6	 Diagnostics of Insomnia
	3.7	 Therapy of Insomnia
		3.7.1	 Psychoeducation
			3.7.1.1	 Information About Sleep
			3.7.1.2	 Inadequate Behaviors Related to Insomnia
			3.7.1.3	 Good Sleep Hygiene
		3.7.2	 Cognitive-behavioral Therapy of Insomnia
			3.7.2.1	 Bedtime Rituals
			3.7.2.2	 Cognitive Techniques
				Cognitive Restructuring
				Rumination Chair
				Stopping Thoughts
			3.7.2.3	 Sleep Restriction
			3.7.2.4	 Stimulus Control
			3.7.2.5	 Group Therapy and Insomnia Workshops
		3.7.3	 Pharmacotherapy of Insomnia
			3.7.3.1	 Benzodiazepine Receptor Agonists (BZRAs)
			3.7.3.2	 Benzodiazepines (BZDs)
			3.7.3.3	 Treatment Strategies Regarding BZDs and BZRAs
				Standard Interval Therapy
				Controlled Interval Therapy
				Quota-Interval Therapy
				Low-Dose Long-Term Therapy
				Low-Dose Combination Therapy
			3.7.3.4	 Melatonin and Melatonin Receptor Agonists
			3.7.3.5	 Hypocretin/Orexin Antagonists
			3.7.3.6	 Second-line Hypnotics
				Antidepressants
				Neuroleptics
				Antihistamines
				Alcohol Derivatives
				Phytotherapeutics
	3.8	 Questions
	Further Reading
4: Sleep-Related Breathing Disorders
	4.1	 Breathing Disorders without Obstruction
		4.1.1	 Definitions
			4.1.1.1	 Central Sleep Apnea Syndromes
			4.1.1.2	 Sleep-Related Hypoventilation and Hypoxemia Syndrome
		4.1.2	 Etiology and Pathophysiology
			4.1.2.1	 Regulation of Breathing
			4.1.2.2	 Central Sleep Apnea Syndrome
			4.1.2.3	 Hypoventilation or Hypoxemia Syndromes
		4.1.3	 Epidemiology
		4.1.4	 Clinical Presentation
			4.1.4.1	 Central Sleep Apnea Syndromes
			4.1.4.2	 Hypoventilation or Hypoxemia Syndromes
	4.2	 Obstructive Sleep-Related Breathing Disorders
		4.2.1	 Definitions
		4.2.2	 Etiology and Pathophysiology
			4.2.2.1	 Anatomical Models
			4.2.2.2	 Functional Models
		4.2.3	 Epidemiology
		4.2.4	 Clinical Presentation
	4.3	 Snoring
		4.3.1	 Definitions
		4.3.2	 Etiology and Pathophysiology
		4.3.3	 Epidemiology
		4.3.4	 Clinical Presentation
	4.4	 Diagnostic Procedures
		4.4.1	 Examination Procedures and Sleep-Related Medical Diagnostics
			4.4.1.1	 Diagnostics in Cases of Central Sleep Apnea Syndromes
			4.4.1.2	 Diagnostics in Cases of Sleep-Related Hypoventilation or Hypoxemia Syndrome
			4.4.1.3	 Diagnostics in Cases of Obstructive Sleep Apnea
		4.4.2	 Differential Diagnoses
	4.5	 Therapeutic Principles
		4.5.1	 Therapeutic Principles in Cases of Snoring
		4.5.2	 Therapeutic Principles in Cases of Sleep Apnea
	4.6	 Ventilation Therapy
		4.6.1	 Different Types of Noninvasive Ventilation Therapy
			4.6.1.1	 Positive Pressure Ventilation in Cases of Spontaneously Breathing Patients
				CPAP
				APAP
				Bilevel-S
				C-Flex, EPR, SoftPAP, and A-Flex
			4.6.1.2	 Positive Pressure Ventilation in Cases of Disturbed Respiratory Drive
				Bilevel-T
				Bilevel-S/T
			4.6.1.3	 Positive Pressure Ventilation in Cases of Cheyne-Stokes Respiration
			4.6.1.4	 Practical Aspects
			4.6.1.5	 Accessories and Masks
			4.6.1.6	 Undesired Side Effects of Positive Pressure Ventilation
		4.6.2	 Ventilation Therapy in Cases of Central Sleep Apnea Syndromes
			4.6.2.1	 Primary Central Sleep Apnea and Central Sleep Apnea Due to a Medical Disorder
			4.6.2.2	 Cheyne-Stokes Respiration
		4.6.3	 Ventilation Therapy in Cases of Sleep-Related Hypoventilation and Hypoxemia
			4.6.3.1	 Sleep-Related Hypoventilation and Hypoxemia Syndromes that Are Not Caused by Bronchial Obstruction
			4.6.3.2	 Sleep-Related Hypoventilation and Hypoxemia Caused by Bronchial Obstruction
		4.6.4	 Ventilation Therapy in Cases of Obstructive Sleep Apnea
			4.6.4.1	 Indication
			4.6.4.2	 Practical Aspects
			4.6.4.3	 Therapeutic Effects
	4.7	 Therapeutic Alternatives
		4.7.1	 Conservative Procedures
			4.7.1.1	 Weight Loss
			4.7.1.2	 Behavioral Changes
			4.7.1.3	 Medication
			4.7.1.4	 Nocturnal Oxygen Therapy
		4.7.2	 Device-Based Procedures
			4.7.2.1	 Increase of Muscle Tone
			4.7.2.2	 Avoiding the Supine Position
			4.7.2.3	 Mandibular Advancement Devices
				Practical Aspects
				Patient Selection
				Acceptance and Side Effects
				Therapeutic Effects
	4.8	 Surgical Therapy
		4.8.1	 Indications and Contraindications
		4.8.2	 Selection of the Surgical Therapy
		4.8.3	 Surgery of the Nose
		4.8.4	 Surgery of the Soft Palate
			4.8.4.1	 Surgical Treatment of the Soft Palate in Cases of Snoring
				Radiofrequency Surgery
				Soft Palate Implants
			4.8.4.2	 Surgical Treatment of the Soft Palate in Obstructive Sleep Apnea
		4.8.5	 Surgery of the Retrolingual Space
		4.8.6	 Hypoglossal Nerve Stimulation
		4.8.7	 Maxillofacial Surgery
	4.9	 Questions
	Further Reading
5: Hypersomnia Disorders
	5.1	 Narcolepsy
		5.1.1	 Definitions
		5.1.2	 Etiology and Pathophysiology
		5.1.3	 Epidemiology
		5.1.4	 Clinical Presentation
		5.1.5	 Diagnostic Procedures
		5.1.6	 Sleep Diagnostics
		5.1.7	 Differential Diagnostics
		5.1.8	 Therapy
			5.1.8.1	 Non-drug Therapy
			5.1.8.2	 Drug Therapy
			5.1.8.3	 Treatment of Comorbid Sleep Disorders
	5.2	 Idiopathic Hypersomnia
		5.2.1	 Definitions
		5.2.2	 Etiology and Pathophysiology
		5.2.3	 Epidemiology
		5.2.4	 Clinical Presentation
		5.2.5	 Diagnostics
		5.2.6	 Sleep Diagnostics
		5.2.7	 Differential Diagnostics
		5.2.8	 Therapy
	5.3	 Other Hypersomnias
		5.3.1	 Insufficient Sleep Syndrome
		5.3.2	 Recurrent Hypersomnias
	5.4	 Questions
	Further Reading
6: Circadian Rhythm Sleep–Wake Disorders
	6.1	 Basics and Diagnosis
	6.2	 Sleep–Wake Phase Disorders
		6.2.1	 Delayed Sleep–Wake Phase Disorder
		6.2.2	 Advanced Sleep–Wake Phase Disorder
	6.3	 Irregular Sleep–Wake Rhythm Disorder
	6.4	 Non-24-Hour Sleep–Wake Rhythm Disorder
	6.5	 Sleep Disorders in Cases of Jetlag or Shift Work
		6.5.1	 Sleep Disorder in Cases of Jetlag
		6.5.2	 Sleep Disorder in Cases of Shift Work
	6.6	 Circadian Sleep–Wake Disorders Not Otherwise Specified
	6.7	 Therapy
	6.8	 Questions
	Further Reading
7: Parasomnias
	7.1	 Pavor Nocturnus
		7.1.1	 Definitions
		7.1.2	 Etiology and Pathophysiology
		7.1.3	 Epidemiology
		7.1.4	 Clinical Presentation
		7.1.5	 Diagnostics
		7.1.6	 Sleep Diagnostics
		7.1.7	 Differential Diagnostics
		7.1.8	 Therapy
	7.2	 Sleepwalking
		7.2.1	 Definitions
		7.2.2	 Etiology and Pathophysiology
		7.2.3	 Epidemiology
		7.2.4	 Clinical Presentation
		7.2.5	 Diagnostics
		7.2.6	 Sleep Diagnostics
		7.2.7	 Differential Diagnostics
		7.2.8	 Therapy
	7.3	 Nightmares
		7.3.1	 Definitions
		7.3.2	 Etiology and Pathophysiology
		7.3.3	 Epidemiology
		7.3.4	 Clinical Presentation
		7.3.5	 Diagnostics
		7.3.6	 Sleep Diagnostics
		7.3.7	 Differential Diagnostics
		7.3.8	 Therapy
	7.4	 REM Sleep Behavior Disorder
		7.4.1	 Definitions
		7.4.2	 Etiology and Pathophysiology
		7.4.3	 Epidemiology
		7.4.4	 Clinical Presentation
		7.4.5	 Diagnostics
		7.4.6	 Sleep-Related Diagnostics
		7.4.7	 Differential Diagnostics
		7.4.8	 Therapy
	7.5	 Other Parasomnias
		7.5.1	 Sleep Drunkenness
		7.5.2	 Isolated Sleep Paralysis
		7.5.3	 Enuresis
		7.5.4	 Sleep-Related Eating Disorders
	7.6	 Questions
	Further Reading
8: Sleep-Related Movement Disorders
	8.1	 Restless Legs Syndrome
		8.1.1	 Definition
		8.1.2	 Etiology and Pathophysiology
		8.1.3	 Epidemiology
		8.1.4	 Clinical Presentation
		8.1.5	 Diagnostic Procedures
		8.1.6	 Sleep Diagnostics
		8.1.7	 Differential Diagnoses
		8.1.8	 Therapy
			8.1.8.1	 General Therapeutic Principles
			8.1.8.2	 l-DOPA
			8.1.8.3	 Dopamine Agonists
			8.1.8.4	 Opioids
			8.1.8.5	 Other Substances and Treatment Modalities of RLS
	8.2	 Periodic Leg Movement Disorders During Sleep
		8.2.1	 Definition
		8.2.2	 Etiology and Pathophysiology
		8.2.3	 Epidemiology
		8.2.4	 Clinical Presentation
		8.2.5	 Examination Procedures
		8.2.6	 Sleep Diagnostics
		8.2.7	 Differential Diagnoses
		8.2.8	 Therapy
	8.3	 Sleep-Related Leg Cramps
		8.3.1	 Definition
		8.3.2	 Etiology
		8.3.3	 Epidemiology
		8.3.4	 Clinical Presentation
		8.3.5	 Diagnostics
		8.3.6	 Therapy
	8.4	 Bruxism
		8.4.1	 Definition
		8.4.2	 Etiology
		8.4.3	 Epidemiology
		8.4.4	 Clinical Presentation
		8.4.5	 Diagnostics
		8.4.6	 Therapy
	8.5	 Sleep-Related Rhythmic Movement Disorder
		8.5.1	 Definition
		8.5.2	 Epidemiology
		8.5.3	 Clinical Presentation
		8.5.4	 Diagnostics
		8.5.5	 Therapy
	8.6	 Questions
	Further Reading
9: Isolated Symptoms, Normal Variants, and Other Sleep Disorders
	9.1	 Isolated Symptoms, Normal Variants, and Unresolved Issues
		9.1.1	 Long and Short Sleepers
		9.1.2	 Sleep-Talking and Sleep-Related Groaning: (Somniloquy and Catathrenia)
		9.1.3	 Sleep-Related Movement Anomalies
	9.2	 Other Sleep Disorders
	Further Reading
10: Secondary Sleep Disorders
	10.1	 Sleep Disorders Caused by Organic Diseases
		10.1.1	 Insomnia as a Symptom of Organic Diseases
			10.1.1.1	 Endocrine Diseases
			10.1.1.2	 Chronic Pain
			10.1.1.3	 Neurological Diseases
			10.1.1.4	 Respiratory Diseases
		10.1.2	 Hypersomnia as a Symptom of Organic Diseases
			10.1.2.1	 Endocrine Diseases
			10.1.2.2	 Cardiovascular Diseases
			10.1.2.3	 Respiratory Diseases
			10.1.2.4	 Renal Dysfunction
	10.2	 Sleep Disorders and Mental Disorders
		10.2.1	 Insomnia Complaints as Symptom of Mental Disorders
			10.2.1.1	 Affective Disorders
			10.2.1.2	 Anxiety Disorders
			10.2.1.3	 Posttraumatic Stress Disorder
		10.2.2	 Hypersomnia Complaints as Symptom of Mental Disorders
			10.2.2.1	 Atypical or Seasonal Affective Disorder
			10.2.2.2	 Schizophrenia
	10.3	 Questions
11: Sleep Disorders in Children
	11.1	 Sleep Disorders in Children and Adolescents
		11.1.1	 Sleep and Sleep Development of Childhood and Adolescence
			11.1.1.1	 Development of Sleep
			11.1.1.2	 Sleep Duration
			11.1.1.3	 Parents’ Behavior and Impact of Children’s Sleep Disorders on Parents
		11.1.2	 Sleep Disorders of Childhood and Adolescence
			11.1.2.1	 Insomnia in Childhood and Adolescence
				Acute Insomnia/Short-Term Insomnia
				Chronic Insomnia
			11.1.2.2	 Sleep-Related Movement Disorders in Childhood
			11.1.2.3	 Sleep–Wake Rhythm Disorders
				Delayed Sleep Phase Syndrome
				Advanced Sleep Phase Syndrome
				Irregular Sleep–Wake Rhythm
			11.1.2.4	 Hypersomnia
			11.1.2.5	 Sleep Disorders and Psychological Disorders
				Anxiety Disorders and Sleep Problems
				Depression and Sleep Problems
				Posttraumatic Stress Disorders and Sleep Problems
				Attention-Deficit/Hyperactivity Disorder and Sleep Problems
				Emotion Regulation and Sleep
				Aggression and Sleep
				Autism and Sleep
			11.1.2.6	 Sleep Disorders and Other Comorbid Disorders
				Epilepsy and Sleep
				Headaches and Sleep
				Atopic Dermatitis and Sleep
				Functional Abdominal Pain and Sleep
				Chronic Inflammatory Bowel Disease and Sleep
		11.1.3	 Etiology and Pathophysiology
		11.1.4	 Epidemiology
			11.1.4.1	 Chronification
		11.1.5	 Clinical Presentation
		11.1.6	 Examination Procedures
			11.1.6.1	 History Taking
			11.1.6.2	 Sleep Protocol
			11.1.6.3	 Questionnaires on Parents’ Information
				Children’s Sleep Habits Questionnaire (CSHQ)
				Sleep Disturbance Scale for Children (SDSC)
			11.1.6.4	 Questionnaires for Self-Reporting
				Children’s Sleep Comic (CSC)
				Sleep Self-Report (SSR)
				Screening of Pediatric Sleep Disorders (PSS-J)
				Epworth Sleepiness Scale for Children (ESS-C)
				Nightmares Effects Questionnaire (NEQ)
			11.1.6.5	 Interviews
				Diagnostic Interview of Pediatric Sleep Disorders (DIKS)
				Sleep Inventory for Children and Adolescents (SI-KJ)
				Diagnostic Interview of Adolescent Sleep Disorders (DIAS)
			11.1.6.6	 Test Psychological Examinations
			11.1.6.7	 Physical Examination
		11.1.7	 Sleep Medical Diagnostics
			11.1.7.1	 Actigraphy
			11.1.7.2	 Polysomnography
		11.1.8	 Differential Diagnostics
		11.1.9	 Insomnia Therapy in Childhood
			11.1.9.1	 Sleep Education and Sleep Hygiene
			11.1.9.2	 Stimulus Control and Structured Bed Routine
			11.1.9.3	 Extinction
			11.1.9.4	 Positive Reinforcement
			11.1.9.5	 Relaxation Techniques
			11.1.9.6	 Cognitive Restructuring
			11.1.9.7	 Imaginative Techniques/Modern Hypnotherapy
			11.1.9.8	 Bedtime Restriction
			11.1.9.9	 Age-Oriented Interventions
			11.1.9.10 Treatment of Infants and Children of Preschool Age
				Mini-KiSS Training: Treating Early Childhood Sleep Disorders
			11.1.9.11 Treatment of Schoolchildren
				KiSS Training: Treating Sleep Disorders in Schoolchildren
			11.1.9.12 Treatment of Adolescents
				JuSt Training: Sleep Training of Adolescents
		11.1.10 Therapy of Other Pediatric Sleep Disorders
			11.1.10.1 Treatment of Delayed Sleep Phase Syndrome
			11.1.10.2 Treatment of the Advanced Sleep Phase Syndrome
		11.1.11 Drug Therapy
		11.1.12 Rehabilitation Measures
	11.2	 Sleep-Related Breathing Disorders in Children
		11.2.1	 Nonobstructive Sleep-Related Breathing Disorders
			11.2.1.1	 Congenital Central Alveolar Hypoventilation Syndrome
			11.2.1.2	 Primary Sleep Apnea of Infancy
			11.2.1.3	 Sleep-Related Hypoventilation Syndrome
		11.2.2	 Obstructive Sleep-Related Breathing Disorders
			11.2.2.1	 Definitions
			11.2.2.2	 Etiology and Pathophysiology
			11.2.2.3	 Epidemiology
			11.2.2.4	 Clinical Presentation
			11.2.2.5	 Examination Procedures
			11.2.2.6	 Sleep-Related Medical Diagnostics
			11.2.2.7	 Differential Diagnoses
			11.2.2.8	 Treatment
				Conservative Treatment
				Device-Related Therapy
				Surgical Therapy
	11.3	 Questions
	References
Index