Sleep is regulated by two processes: a homeostatic sleep drive that builds with time awake (adenosine accumulation) and a circadian rhythm set by the suprachiasmatic nucleus and entrained by light, which controls melatonin release. Normal sleep cycles about every 90 minutes through non-REM stages N1–N3 (N3 = deep, restorative slow-wave sleep) and REM sleep (dreaming, muscle atonia, memory consolidation). Wakefulness is supported by orexin (hypocretin), histamine, and other arousal systems.

Poor sleep worsens depression, anxiety, psychosis, mania, pain, and substance use, and insomnia is a risk factor for suicide. Sleep disturbance is often an early sign of relapse in mood and psychotic disorders.

Major DSM-5-TR sleep-wake disorders

Periodic limb movement disorder (classified in sleep medicine rather than DSM-5-TR) involves repetitive, stereotyped limb movements during sleep, usually unnoticed by the person but disturbing sleep.

• Sleep history: bedtime, time to fall asleep, awakenings, wake time, naps, total sleep time, work schedule
• Sleep diary for 1–2 weeks
• Daytime effects: sleepiness, fatigue, concentration, mood, drowsy driving
• Snoring, witnessed apneas, morning headache, nocturia, hypertension, obesity, large neck circumference
• Caffeine, alcohol, nicotine, screen use, exercise timing
• Medications that disturb sleep: stimulants, SSRIs, bupropion, corticosteroids, beta blockers, decongestants, diuretics at night
• Co-occurring depression, anxiety, mania (decreased need for sleep), PTSD (nightmares), pain
• Bed partner report: leg kicking, dream enactment, sleepwalking

Insomnia

• Cognitive behavioral therapy for insomnia (CBT-I) is first-line for chronic insomnia, before medication. Components:
  • Stimulus control: use the bed only for sleep and sex; go to bed only when sleepy; get up if unable to sleep in about 20 minutes; fixed wake time
  • Sleep restriction: limit time in bed to actual sleep time, then extend gradually
  • Cognitive therapy for worry about sleep; relaxation training; sleep hygiene
• Hypnotics are for short-term or selected use:

Obstructive sleep apnea

• Continuous positive airway pressure (CPAP) is first-line
• Weight loss; tirzepatide was approved by the FDA in 2024 for moderate to severe OSA in adults with obesity
• Oral appliances, positional therapy, hypoglossal nerve stimulation, or surgery for selected clients
• Avoid alcohol and sedatives, which worsen airway collapse

Narcolepsy

• Wake-promoting agents: modafinil/armodafinil (headache, insomnia, serious rash; reduces hormonal contraceptive effectiveness); solriamfetol (raises blood pressure and heart rate — control hypertension first); pitolisant (QT prolongation; reduces hormonal contraceptive effect — use a non-hormonal method)
• Stimulants (methylphenidate, amphetamines) — cardiovascular effects, misuse potential
• Oxybates (sodium oxybate) for cataplexy and sleepiness — boxed warning for CNS and respiratory depression; never with alcohol or sedatives; restricted distribution program
• Scheduled short naps; regular sleep schedule

Restless legs syndrome (AASM 2024 update)

• Iron replacement when iron stores are low (oral or IV)
• Gabapentinoids (gabapentin enacarbil, gabapentin, pregabalin) are preferred first-line drugs — dizziness, sedation, dose adjust in kidney impairment; respiratory depression when combined with opioids or other CNS depressants or in lung disease; misuse potential
• Dopamine agonists (pramipexole, ropinirole) are no longer recommended for routine use because of augmentation (symptoms worsen and start earlier over time)
• Avoid aggravating drugs: sedating antihistamines, most antidepressants, dopamine-blocking antipsychotics

Other

• RBD: make the bedroom safe; melatonin or clonazepam (clonazepam: caution in older adults because of falls and confusion, and in untreated OSA)
• Circadian disorders: timed light exposure and timed low-dose melatonin; consistent schedules

Listed in priority order.

1. Airway and breathing — observe for apneas and oxygen desaturation during sleep; ensure CPAP is used in hospital, including after surgery; avoid sedatives in suspected OSA
2. Safety
   • After hypnotics: bed low, call light, assist to bathroom — high fall risk, especially in older adults
   • RBD and sleepwalking: remove sharp objects, pad the floor, lock windows and doors, consider separate beds
   • Narcolepsy: avoid driving and hazardous work until controlled
3. Assess sleep pattern, diary, and contributing factors; monitor for relapse signs in mood and psychotic disorders
4. Promote sleep in hospital — cluster care, reduce night noise and light, daytime activity and light exposure, pain control, limit caffeine after midday
5. Support CBT-I — reinforce stimulus control and fixed wake times; discourage long daytime naps
6. CPAP adherence — mask fit, humidification, desensitization practice; explain that early discomfort is common and improves with regular use

Sleep hygiene

• Keep a regular wake-up time every day, including weekends
• Limit caffeine for at least 6 hours before bedtime; avoid nicotine and alcohol near bedtime (alcohol fragments sleep)
• Exercise regularly, but not close to bedtime
• Keep the bedroom dark, quiet, and cool; avoid screens for about an hour before bed
• If unable to sleep after about 20 minutes, get up and do something quiet until sleepy
• Avoid long daytime naps; a short nap under 30 minutes early in the afternoon is acceptable

Medications

• Hypnotics may cause daytime drowsiness; do not drive or operate machinery until you know the effect
• Never combine sleep medicines with alcohol, opioids, or other sedatives
• Report sleepwalking, sleep eating, or sleep driving immediately
• Do not stop long-term benzodiazepines suddenly — withdrawal seizures can occur; taper with the prescriber

CPAP — use every night and for naps; clean the mask and tubing regularly; bring the device to the hospital

Shift workers

• After a night shift, sleep in a dark, quiet room (blackout curtains, earplugs), and protect a consistent main sleep block
• A short nap (about 20–30 minutes) before or during a night shift improves alertness
• Wear dark glasses on the commute home; limit caffeine late in the shift; plan for safe driving

• Insomnia disorder: 3 nights a week for 3 months with daytime impairment
• CBT-I first-line; stimulus control = bed only for sleep and sex
• Fixed wake time is the core of sleep hygiene; limit caffeine 6 hours before bed
• OSA → CPAP first-line; screen with STOP-BANG; AHI 15 or more = moderate
• Narcolepsy tetrad: sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations; treat with modafinil
• RBD = acting out dreams in REM; secure the environment
• RLS = urge to move legs at rest in the evening; check ferritin; gabapentinoids preferred over dopamine agonists
• Periodic limb movements = repetitive limb movements during sleep
• Delayed sleep phase = falls asleep and wakes much later than socially required
• Z-drugs → complex sleep behaviors; hypnotics → daytime drowsiness, falls
• Never stop benzodiazepines abruptly