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  • Cited by 10
  • Edited by Michael J. Thorpy, Sleep-Wake Disorders Center, Montefiore Medical Center, Bronx, NY, USA, Michel Billiard, Guide Chauliac Hospital, Montpellier, France
Cambridge University Press
Online publication date:
February 2011
Print publication year:
Online ISBN:

Book description

Written and edited by leading clinicians and researchers in sleep medicine, this is the first book to focus on the causes, consequences and treatment of disorders of excessive sleepiness. Extensive coverage is provided for all known causes of sleepiness, including sleep deprivation, obstructive sleep apnea syndrome, narcolepsy and other hypersomnias of central origin, shift work, and medical and psychiatric disorders. Since many causes of sleepiness are difficult to differentiate from each other, and treatment modalities can vary greatly from one disorder to another, this book helps the clinician to formulate a differential diagnosis that will ultimately lead to the correct diagnosis. Epidemiology, evaluation of the sleepy patient, diagnostic investigations including neuroimaging, subjective and objective testing, cognitive effects of sleepiness, motor vehicle driving issues, medico-legal aspects of sleepiness, and therapy are also discussed in detail. This is an essential resource for neurologists, psychiatrists and sleep specialists.


'… an excellent reference for sleep clinicians and sleep researchers, providing an extensive review of the causes, consequences, and treatment of excessive sleepiness.'

Source: Doody's Notes

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Page 1 of 2

  • Chapter 9 - Medico-legal consequences of excessive sleepiness
    pp 92-98
  • View abstract


    This chapter presents a summary of excessive sleepiness definitions used in epidemiological studies. Studying prevalence, incidence and risk factors for excessive daytime sleepiness bears little impact on the development of new treatments for this symptom. Three sleep disorders are characterized by excessive sleepiness and are divided into 12 diagnoses: hypersomnia, behaviorally induced insufficient sleep syndrome, and narcolepsy. Hypersomnia and behaviorally induced insufficient sleep syndrome are virtually undocumented in the general population. Excessive sleepiness can be caused by various factors such as poor sleep hygiene, work conditions, and psychotropic medication use. Excessive sleepiness has been found to be associated also with sleep-disordered breathing, psychiatric disorders, especially depression, and physical illnesses. Excessive sleep quantity is an associated symptom in depressive disorders in the DSM-IV classification. Several clinical studies have also pointed out the high occurrence of subjective excessive sleepiness in association with mental disorders, organic disorders, or both.
  • Chapter 10 - Sleep deprivation: biomarkers for identifying and predicting individual differences in response to sleep loss
    pp 101-110
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    This chapter discusses the neurochemistry of excessive daytime sleepiness (EDS) with various etiologies. It presents a brief discussion of basic sleep physiology and narcolepsy symptoms to explain the specific neurochemistry of hypersomnia. The significant roles hypocretin deficiency and postnatal cell death of hypocretin neurons as the major pathophysiological process underlying narcolepsy with cataplexy emerged from a decade of investigation, employing both animal and human models. The chapter talks about idiopathic hypersomnia and hypocretin non-deficient primary hypersomnia. It explains how hypocretin ligand deficiency may cause narcolepsy phenotype. Narcolepsy symptoms can also occur during the course of other neurological conditions, and discovery of hypocretin ligand deficiency in idiopathic narcolepsy has led to new insights into the pathophysiology of symptomatic narcolepsy and EDS. The metabolic data may support the hypothesis of a primary deficient arousal system in patients with idiopathic hypersomnia.
  • Chapter 11 - Narcolepsy
    pp 111-125
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    Functional neuroimaging studies support a role for sleep in restoration/rejuvenation/growth in broad thalamocortical neural networks that play important roles in waking executive function, attention, concentration, working memory, and emotion regulation. This chapter reviews the use of neuroimaging studies that relate to the brain mechanisms of sleepiness. Narcolepsy is a sleep disorder characterized by recurrent daytime sleep attacks and often cataplexy, sleep onset paralysis and hypnagogic hallucinations. The role of functional neuroimaging studies in human narcoleptic patients further clarifies the mechanisms of the extrahypothalamic manifestations of the illness, such as cataplexy, sleep attacks, and hypnogogic hallucinations. Neuroimaging studies related to pharmacotherapy of narcolepsy may reveal insights into the neurobiology of sleepiness. Pharmaceutical agents that produce alertness have been shown to increase activity in arousal networks that maintain generalized thalamocortical activity, reversing sleepiness associated with pathological conditions. Sleepiness therefore appears intimately related to a loss of function in diffuse thalamocortical networks.
  • Chapter 12 - Idiopathic hypersomnia
    pp 126-135
  • View abstract


    The evaluation of a patient with excessive sleepiness requires that a detailed sleep history is taken with medical, psychiatric, and psychosocial factors considered, and a differential diagnosis developed. This chapter deals with the important elements in the clinical evaluation of patients with excessive sleepiness. The social history should be elicited, particularly relationships with other family members, and including determination of any financial, personal or social stresses that may contribute to sleep disturbance. Some sleep disorders including sleep apnea syndrome, narcolepsy, recurrent hypersomnia as well as restless legs syndrome, have a familial tendency. The physical examination ideally should be comprehensive and focus on respiratory, cardiovascular, gastrointestinal, endocrine and neurological evaluation. The patient who is sleepy may be asked to complete various tests of performance, such as a psychomotor vigilance test (PVT), or other tests of cognitive ability.
  • Chapter 13 - Kleine–Levin syndrome
    pp 136-146
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    This chapter presents the methodology, normative data, results from clinical populations and problems associated with the objective measures of sleepiness. The multiple sleep latency test (MSLT) is used in the diagnosis of narcolepsy and the hypersomnias. The maintenance of wakefulness test (MWT) has been used by the FAA and state departments of transportation as a means of screening pilots and commercial drivers for ability to maintain alertness in sedentary work settings. Less research supports the Oxford Sleepiness Resistance (OSLER) and pupillography tests, but the OSLER, which attempts to measure sleep onset without traditional measurement of either performance or EEG, holds promise as a simpler but still time-consuming measure. The tests measure more than a single sleep system and almost certainly reflect the summation of numerous sources of state and trait arousal in addition to the effects of circadian time, prior wakefulness and numerous underlying sleep and arousal pathologies.
  • Chapter 14 - Menstrual-related hypersomnia
    pp 147-153
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    This chapter reviews the psychometric properties, validation, and strengths and weaknesses of the most common measurement tools used for the subjective evaluation of sleepiness. Subjective measures of sleepiness described in the chapter include visual analogue scales (VAS), Stanford sleepiness scale (SSS), Karolinska sleepiness scale (KSS), Epworth sleepiness scale (ESS) pediatric sleep questionnaire, sleepiness subscale (PSQ-SS) and pediatric daytime sleepiness scale (PDSS). Children present with a variety of sleep disorders associated with excessive sleepiness. Subjective sleepiness is critical as it is often the initial symptom of underlying sleep pathology, and a major presenting complaint that clinicians must understand and address. More work is needed on potential cultural and racial differences in subjective sleepiness and in relation to specific types of measurement. It has been shown that subjective sleepiness is accompanied by EEG changes including selective slowing of specific frequency bands.
  • Chapter 15 - Sleepiness due to sleep-related breathing disorders
    pp 154-167
  • View abstract


    This chapter discusses the three domains of cognition for which the effects of sleepiness are reasonably well understood: attention and vigilance, executive functioning, and learning and memory. It investigates the effects of sleepiness on distinct cognitive processes involved in the performance of cognitive tasks. Sleepiness due to sleep loss or circadian misalignment causes an increase of average reaction times in vigilance and reaction time tasks. Sleepiness has the potential to alter emotional states and bias the interpretation of the emotional context of a situation, and may thereby influence decision-making. Memory encoding, or the conversion of sensory input into a neural representation, appears to be adversely affected by lack of prior sleep. Sleepiness may affect these cognitive processes differentially, so that the effects of sleepiness depend on the ensemble of cognitive processes required to perform the task at hand.
  • Chapter 16 - Daytime sleepiness in insomnia patients
    pp 168-175
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    This chapter focuses on traffic fatalities and injuries as a public health problem and driver sleepiness involvement in crashes. It explains how physiology and behavior change during sleepy driving and what is the precipitating cause of the impaired behavior involved in a crash. Considering the central role of sleepiness in crash causation, knowledge of the use of countermeasures is an important issue. Apart from driver-initiated countermeasures one may also consider various types of information to the driver about fatigue risks in driving. In order to reduce driver sleepiness, a holistic approach may be a promising strategy that takes technological, organizational and individual factors into account. Evidence-based fatigue management programs are a key factor in this approach and should reassure that professional drivers have the rosters, tools and knowledge to maintain high alertness and safe driving.
  • Chapter 17 - Sleepiness in advanced and delayed sleep phase disorders
    pp 176-185
  • View abstract


    The legal consequences of excessive sleepiness may impact patients, their physicians, and the public at large. Individuals with daytime sleepiness and/or known or suspected sleep disorders need to take precautions at work or when driving to ensure that they do not pose a risk to themselves or others. Physicians should inquire about excessive sleepiness or other symptoms of sleep apnea in any patient who drives, but especially in patients who are commercial vehicle drivers. Physicians and healthcare workers need to be aware of the accident risks associated with sleep disorders and the legal implications around this in their particular jurisdiction. The development of new guidelines and medical standards in the transportation industry will eventually have an impact on physicians, employers and drivers alike. Legislators must continue to work with practitioners and scientists to balance adequate protection of the public interest with individual rights.
  • Chapter 19 - Sleepiness in healthcare workers
    pp 204-214
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    This chapter summarizes trait-like (phenotypic) individual differences in neurobehavioral vulnerability to sleep deprivation, and current promising efforts to identify objective and biological markers of such differences. Sleep loss has increasingly become a major public health concern as population studies worldwide have found reduced sleep duration associated with increased risks of obesity, morbidity, and mortality. Available data suggest that common genetic variations (polymorphisms) involved in sleep-wake, circadian, and cognitive regulation may underlie symptomatic aspects of these large interindividual differences in neurobehavioral vulnerability to sleep deprivation in healthy adults. The impairing effects of sleep loss on neurobehavioral functions are the most well-established and conspicuous consequences of sleep deprivation. They include fatigue and sleepiness and unstable wakefulness; deficits in attention, working memory and executive functions; reduced mood-affect regulation; and increased accidents and injuries. Identifying who is likely to suffer neurobehavioral impairments would improve prevention of sleep deprivation and mitigation of its behavioral morbidity.
  • Chapter 20 - Sleepiness in the military: operational implications and research imperatives
    pp 215-224
  • View abstract


    Narcolepsy is best characterized as a disorder of the regulation of sleep and wakefulness, resulting in a variety of symptoms such as excessive daytime sleepiness (EDS), cataplexy, hypnagogic hallucinations (HH), sleep paralysis, and disturbed nocturnal sleep. This chapter focuses on narcolepsy with cataplexy and narcolepsy without cataplexy. Cataplexy is characterized by a sudden bilateral loss of muscle tone, with preserved consciousness, elicited by emotions. Narcolepsy with cataplexy is diagnosed according to the criteria of the International Classification of Sleep Disorders (ICSD-2). The chapter summarizes the differential diagnoses of EDS and cataplexy. Cataplexy and sleep paralysis are both regarded as expressions of the atonia that physiologically occurs during REM sleep, occurring during wakefulness. Two treatment modalities have proven to be effective: behavioral modification and pharmacological therapy. Pharmacological treatment is supplementary to behavioral advice and should be tailored individually.

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