eMedicine Specialties > Psychiatry > Psychosomatic

Sleep Disorders: Differential Diagnoses & Workup

Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Coauthor(s): Curley L Bonds II, MD, Adjunct Associate Professor and Chair, Department of Psychiatry and Human Behavior, Charles Drew University of Medicine and Science; Associate Clinical Professor, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles; Michael A Lucia, MD, FAASM, Owner/CEO, Pulmonary, Allergy and Sleep Medicine, Sierra Pulmonary and Sleep Consultants, LLC
Contributor Information and Disclosures

Updated: May 21, 2009

Differential Diagnoses

Alcoholism
Emphysema
Anxiety Disorders
Hyperthyroidism
Bipolar Affective Disorder
Hypoparathyroidism
Breathing-Related Sleep Disorder
Obstructive Sleep Apnea-Hypopnea Syndrome
Chronic Obstructive Pulmonary Disease
Opioid Abuse
Depression
Posttraumatic Stress Disorder

Other Problems to Be Considered

Stimulant abuse (eg, amphetamine abuse)

Workup

Laboratory Studies

Lab studies appropriate for those with sleep disorders include the following:

  • Hemoglobin and hematocrit
  • Arterial blood gases
  • Thyroid function tests
  • Drug and alcohol toxicology screening

Imaging Studies

Although no imaging studies are indicated directly for the workup of insomnia, underlying medical conditions require appropriate investigation using suitable studies.

Other Tests

  • Oximetry may be performed during sleep to examine blood oxygen levels for clinically important desaturations suggestive of sleep apnea or other sleep-disordered breathing.
  • A Beck Depression Index or similar clinical screening tool may be used to detect an underlying depressive illness as a contributing factor in insomnia.
  • An Epworth Sleepiness Score or other objective measure of daytime sleepiness may lead to clues of another underlying sleep disorder. For example, approximately 20% of patients with sleep apnea present with a history of nighttime insomnia; however, patients are excessively sleepy by day and have an abnormal score on the Epworth Sleepiness Scale.

Procedures

  • Subjective measures of sleep are obtained by means of a sleep journal.
    • A sleep journal kept for approximately 2 weeks may help determine the extent of the sleep disturbance.
    • Patients should record the total hours slept per night, frequency of nighttime awakenings, and level of restfulness provided after sleep.
    • Further objective history might be available if patients have a sleep partner who keeps a 2-week journal or provides history.
  • Objective measures of sleep may be obtained using EEG monitoring or polysomnography.
    • Monitored polysomnography is the criterion standard for evaluating measures of sleep. This study includes measures of multiple channels of electroencephalogram (EEG), electrooculogram (EOG), chin and leg electromyogram, nasal and oral airflow, oximetry, abdominal and chest movements, and ECG. Monitored polysomnography can help the physician discriminate between REM and NREM sleep, as well as causes of sleep arousal.
    • Polysomnogram may be useful in determining the etiology of the sleep disturbance.
    • These studies may be helpful in determining sleep and wakefulness in the intensive care unit or in the sleep laboratory.
    • Patients with chronic medical conditions, such as fibromyalgia or anxiety disorders, often have characteristic alpha brain-wave activity that intrudes into the deeper stages of sleep. This activity can readily be seen on the EEG during the polysomnogram (PSG).
    • Patients with insomnia often have some degree of sleep-state misperception, wherein they perceive and believe that they achieve significantly less sleep than they actually do. This can be documented by correlating the EEG findings from the PSG with patient subjective reports of sleep duration and onset.

More on Sleep Disorders

Overview: Sleep Disorders
Differential Diagnoses & Workup: Sleep Disorders
Treatment & Medication: Sleep Disorders
Follow-up: Sleep Disorders
References
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References

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Further Reading

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Keywords

sleep disorders, primary sleep disorders, disorders of initiating and maintaining sleep, DIMS, dyssomnias, insomnia, parasomnias, sleep-wake cycle disturbances, sleep apnea, obstructive sleep apnea, OSA, REM sleep, non-REM sleep, polysomnography, sleep maintenance, sleep onset, circadian rhythm, circadian cycle, nightmare, sleepwalk, sleepwalking, hypersomnia, narcolepsy, somnambulism

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Contributor Information and Disclosures

Author

Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Disclosure: Nothing to disclose.

Coauthor(s)

Curley L Bonds II, MD, Adjunct Associate Professor and Chair, Department of Psychiatry and Human Behavior, Charles Drew University of Medicine and Science; Associate Clinical Professor, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles
Curley L Bonds II, MD is a member of the following medical societies: American Medical Association and American Psychiatric Association
Disclosure: Nothing to disclose.

Michael A Lucia, MD, FAASM, Owner/CEO, Pulmonary, Allergy and Sleep Medicine, Sierra Pulmonary and Sleep Consultants, LLC
Michael A Lucia, MD, FAASM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Cardiovascular and Pulmonary Rehabilitation, and Nevada State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Denis F Darko, MD, Executive Director, Clinical Research and Development, Global Neuroscience, AstraZeneca
Denis F Darko, MD is a member of the following medical societies: American College of Physicians and American Psychiatric Association
Disclosure: AstraZeneca Salary Management position

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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