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Sleep disorders
In chronic insomnia the first treatment is CBT-I, not a sleeping pill; daytime sleepiness calls for a search for sleep apnoea or narcolepsy; and in night-time movements one separates restless legs, REM sleep behaviour disorder and sleepwalking.
Why it matters in the exam
Exam questions present a person who does not sleep, a person who falls asleep by day, or a person who "does things" at night. In chronic insomnia (at least 3 nights a week, for at least 3 months) the proven treatment is cognitive behavioural therapy for insomnia (CBT-I) — limiting time in bed, linking the bed to sleep only and dealing with thoughts; drugs only short term, and in older people benzodiazepines and anticholinergic drugs are avoided. Obstructive sleep apnoea: snoring, breathing pauses seen by others, sleepiness and hypertension; the diagnosis is by sleep study, and treatment is CPAP and weight loss.
Narcolepsy: severe sleepiness with cataplexy (sudden loss of muscle tone with strong emotion), hallucinations on falling asleep and sleep paralysis; type 1 is linked to hypocretin (orexin) deficiency. Diagnosis is by sleep study and the MSLT, and treatment is modafinil, pitolisant or sodium oxybate. Restless legs: an urge to move the legs in the evening and at rest, relieved by movement; ferritin is checked and iron given when it is low, and the preferred drugs today are pregabalin or gabapentin, because dopamine agonists cause worsening over time. REM sleep behaviour disorder: an older person who "acts out dreams" — sometimes an early sign of Parkinson disease or dementia with Lewy bodies. Sleepwalking and night terrors: children, in the first third of the night, with no memory; reassurance and safety.
Key points
- Chronic insomnia: CBT-I first; drugs short term.
- Sleep apnoea: snoring and sleepiness → sleep study → CPAP.
- Narcolepsy: cataplexy, MSLT, low hypocretin.
- Restless legs: ferritin and iron; pregabalin or gabapentin.
- REM sleep behaviour disorder: an early sign of synucleinopathy.
Summary table
| Disorder | Feature | Diagnosis | Treatment |
|---|---|---|---|
| Chronic insomnia | Difficulty falling or staying asleep, 3 nights a week, 3 months | History and sleep diary | CBT-I; short-term drug; avoid benzodiazepines in older people |
| Obstructive sleep apnoea | Snoring, breathing pauses, sleepiness, hypertension | Sleep study (laboratory or home) | CPAP, weight loss |
| Narcolepsy | Sleepiness, cataplexy, hallucinations on falling asleep, sleep paralysis | Sleep study and MSLT; low hypocretin in type 1 | Modafinil, pitolisant, sodium oxybate |
| Restless legs | Urge to move the legs in the evening, relief with movement | Clinical; ferritin | Iron when ferritin is low; pregabalin or gabapentin |
| REM sleep behaviour disorder | Older person acting out dreams, injuries at night | Sleep study with EMG | Safety, melatonin; follow for Parkinson and Lewy body disease |
| Sleepwalking, night terrors | Children, first third of the night, no memory | Clinical | Reassurance and safety |
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Sources
- American Academy of Sleep Medicine Clinical Practice Guideline, 2017 — Pharmacologic treatment of chronic insomnia in adults
- American Academy of Sleep Medicine Clinical Practice Guideline, 2024 — Treatment of restless legs syndrome and periodic limb movement disorder
- International Classification of Sleep Disorders (ICSD-3-TR), 2023 — Hypersomnolence; parasomnias
- Kaplan and Sadock's Synopsis of Psychiatry, 12th edition (2021) — Sleep-Wake Disorders
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.