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The DSM Sleep Disorders: One Episode to Make Sense Them All. · Pearls and Prep

0:00
Foreign.
0:05
Welcome
0:05
back
0:05
my
0:06
friends
0:06
to
0:06
another
0:06
episode
0:07
of
0:07
Pearls
0:08
and
0:08
Prep
0:08
npz.
0:09
Here
0:09
your
0:10
preceptor
0:10
in
0:11
your
0:11
pocket,
0:11
your
0:11
go
0:11
to
0:12
place
0:12
for
0:12
pearls
0:13
that
0:13
prep
0:13
you
0:14
to
0:14
practice.
0:15
My
0:15
friends,
0:16
we
0:16
are
0:16
going
0:16
to
0:16
talk
0:17
about
0:17
sleep
0:17
wake
0:18
disorders.
0:19
And
0:19
if
0:20
you
0:20
open
0:20
the
0:20
DSM
0:21
5TR,
0:22
you
0:22
may
0:23
be
0:23
very
0:23
intimidated
0:24
because
0:24
there's
0:24
10
0:25
different
0:25
categories
0:26
of
0:26
sleep
0:26
wake
0:27
disorders
0:28
and
0:28
between
0:28
all
0:29
of
0:29
them
0:29
you
0:29
might
0:29
get
0:29
really
0:30
confused
0:30
really
0:31
quickly.
0:31
And
0:32
when
0:32
you
0:32
see
0:32
patients
0:33
in
0:33
your
0:33
clinic,
0:34
it
0:34
might
0:34
get
0:34
real
0:35
very
0:35
fast
0:35
because
0:36
they're
0:36
going
0:36
to
0:36
use
0:36
terms
0:37
like
0:37
sleep
0:38
terrors
0:38
and
0:38
sleep
0:39
paralysis
0:39
and
0:41
they're
0:41
going
0:41
to
0:42
use
0:42
their
0:42
own
0:42
vernacular
0:43
to
0:43
describe
0:44
what
0:44
they're
0:44
going
0:44
through
0:45
and
0:46
add
0:46
a
0:46
layer
0:47
of
0:47
trauma
0:47
onto
0:47
that.
0:48
And
0:48
you're
0:48
not
0:48
going
0:48
to
0:48
understand
0:49
if
0:49
this
0:49
is
0:49
PTSD
0:50
or
0:51
this
0:51
is
0:51
a,
0:52
a
0:52
REM
0:53
style
0:54
sleep
0:54
disorder
0:55
or
0:55
a
0:55
non
0:56
REM
0:56
sleep
0:57
disorder.
0:57
It
0:57
gets
0:58
really
0:58
confusing
0:58
really
0:59
quickly.
0:59
Right.
1:00
Night
1:00
terrors
1:01
and
1:01
sleepwalking
1:02
and
1:03
confusion
1:05
and
1:06
just
1:06
a
1:06
loss
1:06
of
1:07
muscle
1:07
tone.
1:07
Like
1:07
what
1:08
is
1:08
all
1:08
this?
1:08
It
1:08
can
1:09
sound
1:09
almost
1:09
medical
1:10
and
1:10
we
1:10
can
1:11
feel
1:11
very
1:11
helpless
1:11
and
1:12
disoriented.
1:13
But
1:13
rest
1:13
assured,
1:14
we're
1:14
going
1:14
to
1:14
make
1:14
this
1:15
simple.
1:15
We're
1:15
going
1:16
to
1:16
talk
1:16
about
1:16
it
1:16
like
1:16
we
1:17
always
1:17
do,
1:17
just
1:17
a
1:18
nice
1:18
healthy
1:18
discussion,
1:19
not
1:19
a
1:20
lecture.
1:20
No
1:21
one's
1:21
going
1:21
to
1:21
get
1:21
quizzed,
1:22
nobody's
1:22
going
1:23
to
1:23
get
1:23
spanked.
1:24
This
1:24
is
1:24
just
1:25
a
1:25
normal
1:26
discussion.
1:27
And
1:27
by
1:27
the
1:28
end
1:28
of
1:28
this,
1:28
I
1:28
think
1:28
you're
1:28
going
1:29
to
1:29
have
1:29
a
1:29
good
1:29
mastery
1:30
when
1:30
it
1:30
comes
1:30
to
1:31
sleep
1:31
wake
1:31
disorders.
1:32
Okay?
1:33
So
1:34
it's
1:35
really
1:35
important
1:36
to
1:36
start
1:36
off
1:36
with
1:37
what
1:37
sleep
1:37
is
1:38
supposed
1:38
to
1:38
look
1:38
like.
1:39
Okay.
1:40
Normal
1:40
sleep
1:41
essentially
1:42
means
1:42
your
1:43
patient
1:43
is
1:43
going
1:43
to
1:44
bed
1:44
at
1:45
a
1:46
reasonably
1:46
predictable
1:47
time
1:48
and
1:48
getting
1:48
up
1:49
at
1:49
a
1:49
reasonably
1:49
predictable
1:50
time
1:51
the
1:51
next
1:51
day.
1:52
And
1:52
they're
1:52
generally
1:53
content
1:53
with
1:54
the
1:54
whole
1:54
process.
1:54
Right.
1:55
They
1:55
feel
1:55
generally
1:56
refreshed,
1:57
they're
1:57
not
1:57
waking
1:58
up
1:58
multiple
1:58
times
1:58
a
1:59
night.
1:59
They're
1:59
not
1:59
having
2:00
a
2:00
lot
2:00
of
2:00
time,
2:01
a
2:01
lot
2:01
of
2:02
a
2:02
hard
2:02
time
2:02
going
2:03
to
2:03
bed.
2:04
And
2:04
there's
2:04
not
2:04
a
2:05
lot
2:05
going
2:05
on
2:06
during
2:06
sleep.
2:07
They're
2:07
not
2:07
choking,
2:08
they're
2:08
not
2:08
gasping,
2:09
they're
2:09
not
2:10
fighting
2:11
their
2:11
spouse
2:12
to
2:12
death
2:13
as
2:13
they
2:14
sleep
2:14
next
2:14
to
2:14
them.
2:14
They're
2:15
not
2:15
kicking
2:15
their
2:15
dog,
2:16
they're
2:16
not
2:16
making
2:16
popcorn,
2:17
they're
2:17
not
2:17
having
2:17
sex
2:18
in
2:18
a
2:18
moving
2:19
vehicle.
2:19
Right.
2:20
It's
2:20
the
2:20
absence
2:21
of
2:21
theater
2:22
and
2:22
flair
2:23
and
2:23
drama
2:24
and
2:24
violence
2:25
and
2:26
it
2:26
otherwise
2:27
goes
2:27
off
2:27
without
2:27
a
2:28
hitch.
2:28
Are
2:28
there
2:29
days
2:29
the
2:29
patient
2:29
might
2:30
sleep
2:30
in?
2:30
Sure.
2:30
Are
2:31
there
2:31
days
2:31
that
2:31
the
2:31
patient
2:32
might
2:33
wake
2:33
up
2:34
not
2:34
exactly
2:35
satisfied
2:35
with
2:35
how
2:35
they
2:36
slept?
2:36
Sure.
2:37
But
2:38
they
2:38
don't
2:38
really
2:38
come
2:39
and
2:39
see
2:39
you
2:40
or
2:40
you
2:41
don't
2:41
really
2:41
diagnose
2:41
them
2:42
with
2:42
a
2:43
sleep
2:43
disorder.
2:44
Unless
2:44
it
2:45
is
2:45
a
2:46
consistent
2:46
problem
2:47
that
2:47
is
2:47
functionally
2:48
impairing
2:48
them
2:49
or
2:49
causing
2:49
them
2:50
severe
2:50
distress.
2:51
Right?
2:52
Where
2:53
it's
2:54
difficult
2:54
for
2:54
them
2:54
to
2:55
even
2:55
function
2:55
because
2:56
they
2:56
have
2:56
so
2:56
little
2:56
energy
2:57
the
2:57
next
2:57
day,
2:57
maybe
2:58
they're
2:58
irritable,
2:59
they
2:59
have
2:59
morning
2:59
headaches
3:00
because
3:01
of
3:01
their.
3:02
Their
3:02
OSA
3:03
or
3:03
their
3:03
obstructive
3:04
sleep
3:04
apnea
3:05
or
3:05
whatnot.
3:05
Right?
3:06
So
3:06
at
3:07
the
3:07
end
3:07
of
3:07
the
3:07
day,
3:07
this
3:08
has
3:08
to
3:08
be
3:08
impairing.
3:09
It
3:09
has
3:09
to
3:09
cause
3:09
significant
3:10
amount,
3:10
significant
3:11
amounts
3:11
of
3:11
distress.
3:12
And
3:12
it's
3:13
beyond
3:13
the
3:13
pale
3:13
of
3:14
just
3:14
Joe
3:14
and
3:14
Jane
3:15
regular.
3:16
I
3:16
didn't
3:17
sleep
3:17
as
3:17
well,
3:17
as
3:18
well
3:18
as
3:18
I
3:18
wanted
3:18
to
3:18
last
3:19
night.
3:19
This
3:19
is
3:20
beyond
3:20
the
3:20
pale,
3:21
okay?
3:22
And
3:22
so
3:22
that's
3:23
very
3:23
important
3:23
to
3:24
understand
3:24
is
3:24
to
3:24
just
3:25
compare
3:25
it
3:25
to
3:25
normal
3:26
sleep
3:26
first.
3:27
Okay?
3:28
And
3:28
normal
3:29
sleep
3:29
has
3:29
really
3:29
two
3:30
main
3:30
states,
3:30
the
3:31
non
3:31
REM
3:32
cycles
3:32
and
3:32
the
3:32
REM
3:33
cycles.
3:33
And
3:33
they
3:34
cycle
3:34
back
3:34
and
3:34
forth
3:35
about
3:35
every
3:35
90
3:36
minutes
3:37
for
3:37
about
3:37
four
3:37
to
3:37
six
3:38
cycles
3:38
per
3:38
night.
3:39
So
3:39
that's
3:39
really
3:39
important
3:40
to
3:40
remember
3:40
also.
3:41
And
3:41
the
3:41
vast
3:41
majority
3:42
of
3:42
your
3:42
sleep
3:42
is
3:43
going
3:43
to
3:43
be
3:43
in
3:43
non
3:44
rem.
3:44
That's
3:45
about
3:45
80%
3:45
of
3:46
the
3:46
night.
3:46
Okay?
3:47
And
3:47
we
3:47
won't
3:47
get
3:47
into
3:48
super
3:49
weed
3:49
territory
3:50
here,
3:51
but
3:51
there's
3:51
like
3:52
three
3:52
stages
3:53
of
3:53
the
3:53
non
3:53
rem.
3:54
There's
3:54
N1,
3:54
N2,
3:55
N3,
3:56
also
3:56
known
3:56
as
3:56
like
3:57
the
3:57
deep
3:57
sleep
3:57
or
3:57
the
3:57
slow
3:58
wave
3:58
sleep.
3:58
That's
3:59
the
3:59
most
3:59
restorative
4:00
stage
4:01
of
4:01
sleep.
4:01
We've
4:01
talked
4:02
about
4:02
that
4:02
in
4:02
previous
4:02
episodes,
4:03
how
4:03
it
4:03
really
4:04
helps
4:04
your
4:04
patients
4:05
kind
4:05
of
4:06
emotionally
4:06
and
4:06
cognitively
4:07
when
4:07
they
4:07
get
4:08
that
4:08
slow
4:08
wave
4:08
sleep.
4:09
We've
4:09
Talked
4:09
about
4:09
how
4:10
5ht2a
4:11
antagonism
4:12
can
4:13
often
4:13
improve
4:14
slow
4:14
wave
4:14
sleep.
4:15
And
4:15
that's
4:15
pretty
4:15
cool,
4:16
right?
4:16
So
4:17
I
4:17
encourage
4:17
you
4:17
to
4:17
look
4:17
at
4:18
those
4:18
episodes.
4:18
But
4:19
about
4:19
20
4:19
to
4:19
25%
4:20
of
4:20
the
4:20
night
4:21
is
4:21
happening
4:21
in
4:22
REM
4:22
sleep.
4:22
It's
4:23
the
4:23
dreaming
4:23
stage,
4:24
okay?
4:24
It's
4:24
when
4:25
your
4:25
brain
4:25
activity
4:26
looks
4:26
almost
4:26
like
4:27
you're
4:27
awake,
4:27
but
4:28
your
4:28
body
4:28
is
4:29
paralyzed,
4:30
okay?
4:30
So
4:30
your
4:31
dreams
4:31
are
4:31
not
4:31
acted
4:32
out.
4:32
Your
4:32
body's
4:32
paralyzed
4:33
during
4:33
REM
4:33
for
4:34
a
4:34
reason,
4:34
because
4:34
it
4:34
doesn't
4:35
want
4:35
you
4:35
to
4:35
actually
4:36
fight
4:36
that
4:36
bear.
4:37
It
4:37
wants
4:37
you
4:37
to
4:37
be
4:37
asleep
4:38
so
4:38
you
4:38
don't
4:38
start
4:39
swinging
4:39
and
4:39
hitting
4:40
your
4:40
spouse.
4:41
As
4:41
you
4:41
can
4:42
probably
4:42
predict,
4:43
REM
4:43
sleep
4:44
disorders
4:45
are
4:45
exactly
4:46
that.
4:46
Where
4:47
your
4:47
muscles
4:47
are
4:48
not
4:48
actually
4:48
paralyzed
4:49
and
4:49
you
4:49
are
4:49
swinging
4:50
and
4:51
fighting
4:51
the
4:51
dragon
4:52
in
4:52
real
4:52
time.
4:53
That
4:53
would
4:53
be
4:53
more
4:53
of
4:53
a
4:54
REM
4:54
sleep
4:54
disorder.
4:55
Okay?
4:55
This
4:56
is
4:56
a
4:56
rapid
4:56
eye
4:57
movement
4:57
time
4:57
of
4:58
sleep.
4:58
Okay.
4:59
But
4:59
that's
4:59
basically
5:00
the
5:00
point,
5:00
right?
5:01
Again,
5:01
you
5:01
have
5:02
two
5:02
main
5:02
states,
5:02
non
5:03
REM
5:03
and
5:03
REM.
5:04
Okay?
5:05
They
5:05
cycle
5:05
back
5:06
every
5:06
90
5:06
minutes.
5:07
Most
5:07
of
5:07
your
5:08
time
5:08
is
5:08
in
5:08
non
5:08
REM.
5:10
A
5:10
quarter
5:10
of
5:10
your
5:10
time
5:11
is
5:11
in
5:11
REM.
5:11
And
5:12
it's
5:12
worth
5:12
noting
5:12
too
5:13
that
5:13
most
5:13
of
5:13
the
5:14
REM
5:14
sleep
5:15
is
5:15
happening
5:15
towards
5:15
the
5:16
end
5:16
of
5:16
the
5:16
night.
5:16
And
5:17
that's
5:17
very
5:17
important
5:17
for
5:18
you
5:18
to
5:19
understand
5:19
because
5:20
when
5:20
you
5:20
ask
5:21
your
5:21
patient
5:21
what's
5:21
going
5:22
on
5:22
with
5:22
their
5:22
sleep,
5:23
if
5:23
they
5:23
are
5:24
experiencing
5:25
sleep
5:26
disordered
5:27
behavior
5:27
towards
5:27
the
5:28
end
5:28
of
5:28
the
5:28
night,
5:28
it's
5:28
a
5:29
soft
5:29
clue
5:29
that
5:30
they
5:30
might
5:30
be
5:30
talking
5:30
about
5:31
a
5:31
REM
5:31
problem,
5:32
not
5:33
a
5:33
non
5:34
REM
5:34
problem,
5:34
which
5:35
would
5:35
be
5:35
more
5:35
at
5:35
the
5:35
beginning
5:36
of
5:36
the
5:36
night.
5:36
And
5:36
that
5:36
has
5:37
diagnostic
5:37
implications.
5:38
Okay?
5:39
Now
5:39
the
5:40
five
5:40
patterns
5:41
that
5:41
can
5:41
help
5:42
you
5:42
group
5:42
all
5:42
of
5:43
these
5:43
ten
5:44
separate
5:45
conditions
5:45
in
5:45
the
5:45
DSM
5:47
are
5:48
really
5:49
boil
5:49
down
5:49
to
5:49
what
5:50
the
5:50
patient
5:50
says
5:50
to
5:51
you
5:51
in
5:51
session.
5:52
And
5:52
that's
5:52
what
5:52
we're
5:52
going
5:52
to
5:52
talk
5:53
about,
5:53
right?
5:55
The
5:55
five
5:55
patterns
5:56
are,
5:56
number
5:57
one,
5:57
the
5:57
patient
5:58
will
5:58
say,
5:58
I
5:58
can't
5:58
fall
5:58
asleep.
5:59
Right?
5:59
These
5:59
would
5:59
be
6:00
your
6:00
insomnia
6:00
disorders,
6:01
your
6:01
circadian
6:02
rhythm
6:02
disorders,
6:03
your
6:03
restless
6:03
leg
6:04
syndrome.
6:04
They
6:04
just
6:04
can't
6:04
sleep.
6:05
Something
6:05
is
6:05
preventing
6:06
them
6:06
from
6:06
falling
6:07
asleep.
6:07
An
6:07
insomnia
6:08
disorder.
6:09
It's
6:09
not
6:09
my
6:09
favorite
6:10
diagnosis
6:10
of
6:10
the
6:10
dsm.
6:11
I
6:11
find
6:11
that
6:11
it's
6:12
kind
6:12
of
6:12
a,
6:12
just
6:13
a
6:13
placeholder
6:13
as
6:14
kind
6:14
of
6:14
the
6:14
DSM's
6:15
way
6:15
of
6:15
saying,
6:15
here's
6:16
insomnia.
6:16
We
6:17
don't
6:17
know
6:17
why
6:17
it's
6:17
there,
6:17
but
6:18
it's
6:18
insomnia.
6:19
That's
6:20
another
6:20
episode,
6:20
another
6:21
conversation.
6:22
But,
6:22
but
6:22
it's
6:23
just
6:23
folks
6:23
who
6:23
can't
6:24
fall
6:24
asleep,
6:24
right?
6:25
There's
6:25
no
6:25
exact
6:26
reason
6:26
we
6:26
can
6:27
pinpoint
6:27
as
6:28
to
6:28
why
6:28
they
6:28
can't
6:28
fall
6:28
asleep.
6:29
Maybe
6:30
we've
6:30
even
6:30
ruled
6:30
out
6:31
other
6:31
reasons
6:31
they
6:32
can't
6:32
fall
6:32
asleep.
6:32
Like,
6:33
we
6:33
know
6:33
it's
6:33
not
6:34
obstructive
6:34
sleep
6:35
apnea.
6:35
We
6:36
know
6:36
it's
6:36
not
6:36
central
6:36
sleep
6:37
apnea.
6:37
We
6:37
know
6:37
it's
6:37
not
6:37
any
6:38
of
6:38
those
6:38
other
6:38
things.
6:38
They're
6:39
not
6:39
talking
6:39
about
6:39
nightmares.
6:40
They
6:40
just
6:40
can't
6:40
fall
6:41
asleep.
6:41
Same
6:41
with
6:42
circadian
6:42
rhythm
6:42
and
6:43
restless
6:43
legs.
6:43
They
6:43
have
6:44
restless
6:44
legs.
6:44
They
6:45
can't
6:45
fall
6:45
asleep.
6:45
So
6:45
that
6:45
would
6:46
be
6:46
the
6:46
first
6:46
pattern,
6:47
Is
6:47
the
6:47
first
6:48
pattern
6:48
or
6:49
way
6:49
that
6:49
you
6:50
can
6:50
categorize
6:50
these
6:51
10
6:51
different
6:52
sleeping
6:52
conditions
6:52
is
6:53
category
6:53
one,
6:54
the
6:54
folks
6:54
who
6:54
just
6:55
can't
6:55
fall
6:55
asleep.
6:56
Now,
6:56
category
6:57
two
6:57
would
6:57
be
6:57
people
6:57
who
6:57
tell
6:58
you,
6:58
tell
6:58
you
6:58
they're
6:58
always
6:59
tired
6:59
and
6:59
they
7:00
sleep
7:00
too
7:00
much.
7:01
Okay.
7:02
Kind
7:02
of
7:02
like
7:02
koala
7:03
bears
7:03
or
7:03
sloths.
7:04
They're
7:04
sleeping
7:04
all
7:04
the
7:05
time.
7:05
Hyper
7:06
somnolence
7:07
disorder.
7:07
Right.
7:07
They
7:07
have
7:07
this
7:08
huge
7:08
opportunity
7:08
to
7:09
sleep
7:09
and
7:10
they're
7:11
sleeping
7:11
a
7:11
lot,
7:11
but
7:12
they're
7:12
not
7:12
waking
7:12
up
7:13
rested.
7:13
That's
7:14
a
7:14
problem,
7:14
right?
7:14
That
7:15
sucks.
7:15
If
7:15
you
7:15
have
7:15
all
7:16
that
7:16
time
7:16
and
7:16
you're
7:16
just
7:16
not
7:17
Waking
7:17
up
7:17
or
7:18
you're
7:18
not
7:18
waking
7:18
up
7:19
feeling
7:19
like
7:19
you're
7:19
full
7:19
of
7:20
vigor
7:20
and
7:20
activity
7:21
and
7:21
you're
7:22
not
7:22
feeling
7:22
refreshed.
7:23
That's
7:23
a
7:23
big
7:23
problem.
7:23
So
7:24
category
7:24
two,
7:25
they're
7:25
always
7:25
tired.
7:25
That
7:25
would
7:26
be
7:26
hypersomnolis
7:27
disorder,
7:27
narcolepsy,
7:28
where
7:28
they're
7:29
literally
7:29
napping
7:29
throughout
7:30
the
7:30
day.
7:31
And
7:31
then
7:32
I
7:32
would
7:32
also
7:33
say
7:34
this
7:34
would
7:34
be
7:36
a
7:37
pretty
7:37
good
7:37
cat.
7:38
We'll
7:38
talk
7:38
about
7:38
narcolepsy
7:39
1
7:39
and
7:40
type
7:40
1
7:40
and
7:40
type
7:40
2.
7:41
We
7:41
won't
7:41
get
7:41
too
7:41
far
7:41
in
7:42
the
7:42
weeds
7:42
with
7:42
that.
7:42
But
7:43
now
7:43
category
7:44
three
7:44
would
7:44
be
7:44
weird
7:45
stuff
7:45
happens
7:45
when
7:45
I
7:46
sleep.
7:47
This
7:47
is
7:47
the
7:47
stuff
7:47
you're
7:47
gonna
7:48
hear
7:48
a
7:48
lot
7:48
about
7:48
in
7:48
clinic.
7:49
Non
7:50
REM
7:50
arousal
7:51
disorders.
7:51
People
7:52
who
7:52
sleepwalk,
7:52
they
7:52
have
7:53
sleep
7:53
terrors,
7:54
okay?
7:54
They
7:54
have
7:55
nightmares.
7:56
Then
7:56
there's
7:57
REM
7:57
sleep
7:58
behavior
7:58
disorder.
7:58
So
7:59
this
7:59
is
7:59
the
7:59
weird
7:59
stuff
8:00
we're
8:00
talking
8:00
about,
8:00
right?
8:01
It's
8:01
not
8:01
the
8:01
I
8:01
can't
8:02
fall
8:02
asleep
8:02
category
8:03
one
8:03
insomnia,
8:04
or
8:04
like
8:04
your
8:04
circadian
8:05
rhythm
8:05
is
8:05
off
8:05
or
8:06
you
8:06
have
8:06
restless
8:06
legs.
8:07
It's
8:07
not
8:07
the
8:08
I'm
8:08
always
8:08
tired.
8:09
Like
8:09
maybe
8:09
there's
8:09
narcolepsy
8:10
going
8:10
on
8:11
or
8:11
I
8:11
have
8:11
hypersomnolence.
8:13
This
8:13
is
8:14
weird
8:14
stuff.
8:15
Sleepwalking,
8:16
sleep
8:16
terrors,
8:16
nightmares.
8:17
REM
8:18
sleep
8:18
behavior
8:18
disorder.
8:19
We'll
8:19
get
8:19
into
8:19
that
8:19
in
8:20
a
8:20
moment.
8:20
But
8:21
weird
8:21
stuff,
8:21
right?
8:22
This
8:22
is
8:22
a
8:22
whole
8:22
different
8:22
category.
8:23
And
8:23
when
8:23
you
8:24
hear
8:24
the
8:24
weird
8:24
stuff,
8:24
you've
8:25
got
8:25
to
8:25
get
8:25
granular
8:26
and
8:26
figure
8:26
out
8:26
like,
8:27
okay,
8:27
what.
8:28
What
8:29
weird
8:29
disorder
8:29
is
8:30
this
8:30
exactly?
8:30
And
8:31
it's
8:31
really
8:31
not
8:31
that
8:31
complicated.
8:32
We'll
8:32
go
8:32
over
8:32
that
8:32
in
8:33
a
8:33
little
8:33
bit.
8:33
Okay?
8:34
Category
8:34
four
8:35
is
8:35
are
8:35
the
8:35
folks
8:35
who
8:36
have
8:36
trouble
8:36
breathing,
8:36
right?
8:37
Obstructive
8:38
sleep
8:38
apnea,
8:39
or
8:39
there's
8:39
an
8:39
airway
8:40
obstruction,
8:41
sleep
8:42
central
8:42
sleep
8:43
apnea,
8:43
where
8:43
your
8:43
brain
8:43
is
8:44
just
8:44
not
8:44
delivering
8:44
the
8:45
message
8:45
to
8:45
fall
8:45
asleep.
8:46
And
8:46
then
8:46
there's
8:47
sleep
8:47
related
8:47
hypoventilation,
8:49
which
8:49
we'll
8:49
get
8:49
into
8:49
in
8:50
a
8:50
little
8:50
bit.
8:50
But
8:50
just
8:51
suffice
8:51
it
8:51
to
8:51
say,
8:51
these
8:52
are
8:52
breathing
8:52
problems,
8:53
right?
8:53
You
8:53
notice
8:53
how
8:53
they're
8:53
all
8:54
different.
8:54
Then
8:55
I
8:55
can't
8:55
fall
8:55
asleep.
8:56
I'm
8:57
too
8:57
tired.
8:57
Weird
8:58
stuff
8:58
is
8:58
happening.
8:59
And
9:00
then
9:00
there's
9:00
breathing,
9:01
right?
9:01
So
9:01
this
9:01
is
9:01
a
9:01
diverse
9:02
group
9:02
of
9:02
sleep
9:03
disorders.
9:03
They're
9:03
all
9:03
very
9:04
different
9:05
in
9:06
how
9:06
they
9:06
come
9:07
about.
9:07
And
9:07
then
9:07
the
9:08
fifth
9:08
pattern
9:08
and
9:09
final
9:09
pattern
9:09
you
9:09
have
9:10
to
9:10
remember,
9:10
which
9:10
is
9:10
pretty
9:11
easy.
9:11
One
9:11
actually
9:12
is
9:13
my
9:13
sleep
9:13
problem
9:14
started
9:14
when
9:14
I
9:14
began
9:15
taking
9:15
something,
9:15
usually
9:16
a
9:16
substance,
9:17
medication
9:17
induced
9:18
sleep
9:18
disorder,
9:18
okay?
9:19
You
9:19
can
9:19
see
9:19
this
9:19
with
9:20
disordered
9:21
sleep.
9:21
All
9:22
of
9:22
a
9:22
sudden,
9:22
if
9:22
you
9:22
start
9:22
an
9:23
SSRI
9:24
or
9:24
the
9:24
patient's
9:24
drinking
9:25
a
9:25
lot,
9:25
or
9:25
they're
9:25
withdrawing
9:26
off
9:26
a
9:26
substance,
9:27
and
9:27
then
9:27
there's
9:28
there's
9:28
a
9:28
home
9:28
for
9:29
them
9:29
in
9:30
this
9:30
sleep
9:30
disorder.
9:31
And
9:31
I
9:31
won't
9:31
go
9:31
into
9:31
that
9:32
too
9:32
much
9:32
today
9:32
in
9:33
our
9:33
discussion.
9:33
I
9:34
don't
9:34
want
9:34
to
9:34
say
9:34
it's
9:34
obvious
9:35
when
9:35
it's
9:35
happening,
9:36
but
9:36
usually
9:36
you
9:37
do
9:37
have
9:37
a
9:37
clue.
9:38
When
9:38
there
9:38
has
9:38
been
9:39
a
9:39
big
9:39
medication
9:39
change
9:40
or
9:40
the
9:41
patient
9:41
just
9:41
suddenly
9:42
stopped
9:42
utilizing
9:43
a
9:43
specific
9:43
substance,
9:44
then
9:45
their
9:45
sleep
9:46
could
9:46
get
9:46
disordered.
9:47
And
9:47
it's
9:47
worth
9:48
pinpointing
9:49
the
9:49
temporal
9:50
association
9:51
between
9:51
that
9:52
versus
9:52
this
9:52
long
9:53
standing
9:53
sleep
9:53
issue
9:54
that
9:54
you
9:54
probably
9:54
would
9:54
have
9:55
known
9:55
about
9:55
if
9:55
you
9:55
had
9:56
assessed
9:56
it
9:57
prior
9:57
to
9:57
that.
9:57
Right?
9:58
So
9:58
in
9:58
other
9:58
words,
9:59
you'll
9:59
probably
9:59
have
10:00
a
10:00
sense
10:00
that
10:00
there's
10:01
a
10:01
substance,
10:02
medication
10:02
induced
10:03
sleep
10:03
disorder,
10:03
hopefully,
10:04
if
10:04
you've
10:05
been
10:05
tracking
10:05
their
10:05
substance
10:06
use
10:06
and
10:07
you
10:07
also
10:07
have
10:08
been
10:08
tracking
10:08
any
10:08
chronic
10:09
sleep
10:09
issues
10:10
before
10:10
that.
10:11
Okay,
10:12
so
10:12
let's
10:12
get
10:12
into
10:13
this
10:13
and
10:13
let's
10:13
just
10:14
make
10:14
this
10:14
simple,
10:15
right?
10:15
We
10:15
already
10:15
kind
10:15
of
10:16
categorized
10:16
these
10:17
disorders
10:19
into
10:19
five
10:19
different
10:20
ways.
10:20
That
10:21
helps
10:21
separate
10:22
it
10:22
at
10:22
least.
10:22
So
10:22
it's
10:22
not
10:23
one
10:23
big
10:23
blur
10:23
anymore,
10:24
right?
10:24
It's
10:25
not
10:25
one
10:25
big
10:25
blur
10:26
of
10:26
like
10:26
sleep
10:27
disorders
10:27
that
10:27
confuse
10:28
us.
10:28
Okay,
10:30
but
10:30
let's
10:31
talk
10:31
about
10:31
this
10:31
a
10:31
little
10:31
bit.
10:32
So
10:32
insomnia
10:33
disorder,
10:34
very
10:34
simple,
10:35
right?
10:36
You
10:36
can't
10:37
fall
10:37
asleep,
10:37
you
10:37
can't
10:38
stay
10:38
asleep,
10:38
or
10:39
you
10:39
wake
10:39
up
10:39
too
10:40
early.
10:40
Okay?
10:41
It's
10:41
greater
10:41
than
10:42
or
10:42
equal
10:42
to
10:42
three
10:42
nights
10:43
a
10:43
week
10:43
for
10:44
greater
10:44
than
10:44
or
10:44
equal
10:45
to
10:46
over
10:46
three
10:47
months.
10:47
Okay.
10:48
And
10:49
you
10:50
have
10:50
an
10:50
adequate
10:50
opportunity
10:51
to
10:51
sleep.
10:52
Right?
10:53
But
10:54
again,
10:54
it's
10:54
just
10:54
very
10:55
debilitating
10:55
because
10:56
these
10:56
folks
10:57
are
10:57
just
10:57
always
10:57
tired.
10:58
They
10:58
have
10:58
bags
10:59
under
10:59
their
10:59
eyes.
10:59
It's
11:00
the
11:00
most
11:00
common
11:00
sleep
11:01
disorder.
11:02
Okay.
11:03
And
11:04
they
11:04
have
11:04
a
11:04
normal
11:05
sleep
11:05
architecture.
11:06
But
11:06
the
11:06
problem
11:07
is
11:08
getting
11:09
to
11:09
sleep
11:09
or
11:09
staying
11:10
asleep.
11:10
Usually
11:11
it
11:11
takes
11:11
more
11:11
than
11:11
30
11:12
minutes
11:12
to
11:12
get
11:12
asleep.
11:13
Or
11:13
when
11:13
they
11:14
wake
11:14
up
11:14
in
11:14
the
11:14
middle
11:14
of
11:15
the
11:15
night,
11:15
it
11:15
takes
11:15
over
11:15
30
11:16
minutes
11:16
to
11:16
go
11:16
back
11:16
to
11:17
bed.
11:17
Sometimes
11:17
it
11:17
takes
11:18
them
11:18
hours,
11:18
sometimes
11:18
they
11:19
don't
11:19
even
11:19
go
11:19
back
11:20
to
11:20
bed
11:20
at
11:20
all.
11:21
Okay.
11:21
The
11:22
key
11:22
here
11:22
is
11:22
that
11:23
there's
11:23
no
11:23
abnormal
11:24
breathing
11:24
issues
11:24
in
11:25
insomnia
11:25
disorder,
11:26
right?
11:27
There's
11:27
no
11:27
abnormal
11:28
dreams.
11:28
Nobody's
11:29
fighting
11:29
in
11:29
their
11:29
dreams.
11:30
This
11:30
is
11:30
strictly
11:31
I
11:31
can't
11:31
fall
11:31
asleep,
11:32
I
11:32
don't
11:32
know
11:32
why,
11:33
I
11:33
can't
11:33
stay
11:33
asleep,
11:34
I
11:34
don't
11:34
know
11:34
why.
11:35
And
11:35
I
11:35
would
11:36
argue
11:36
not
11:36
to
11:37
state
11:37
the
11:37
obvious,
11:37
but
11:38
it
11:38
is
11:38
very
11:38
important.
11:39
This
11:39
is
11:39
not
11:40
the
11:40
same
11:40
thing
11:40
as
11:41
I'm
11:41
so
11:42
anxious,
11:42
I'm
11:42
thinking
11:42
about
11:43
what
11:44
I
11:44
have
11:44
to
11:44
do
11:44
tomorrow.
11:45
I'm
11:45
thinking
11:45
of
11:45
things
11:46
that
11:46
could
11:46
go
11:46
wrong
11:46
tomorrow
11:47
that
11:47
would
11:47
be
11:47
more
11:47
of
11:47
an
11:47
anxiety
11:48
disorder.
11:49
And
11:49
there
11:49
is
11:49
a
11:49
diagnostic
11:51
feature
11:51
of
11:52
generalized
11:52
anxiety
11:52
disorder
11:53
that
11:53
would
11:54
be
11:54
more
11:54
appropriate
11:54
in
11:55
this
11:55
case.
11:55
You
11:55
wouldn't
11:56
call
11:56
it
11:56
an
11:57
insomnia
11:57
disorder
11:58
if
11:58
the
11:58
root
11:59
cause
11:59
of
11:59
why
11:59
they
12:00
can't
12:00
sleep
12:00
is
12:01
anxiety.
12:02
So
12:02
this
12:03
is
12:03
why
12:03
I
12:03
don't
12:03
really
12:04
love
12:04
this
12:04
diagnosis,
12:05
because
12:05
I
12:05
feel
12:05
it's
12:05
exceedingly
12:06
rare.
12:06
I
12:06
have
12:07
seen
12:07
it
12:07
before.
12:07
I'm
12:07
not
12:08
saying
12:08
it
12:08
doesn't
12:08
exist.
12:08
I'm
12:09
not
12:09
saying
12:09
it's
12:09
Bigfoot,
12:10
but
12:11
I
12:11
find
12:11
that
12:11
almost
12:12
always
12:12
there
12:12
is
12:13
a
12:13
reason
12:13
your
12:14
patient
12:14
can't
12:14
fall
12:15
asleep.
12:15
And
12:15
it's
12:15
not
12:16
as
12:16
simple
12:16
as,
12:17
as
12:17
insomnia
12:18
disorder.
12:18
Again,
12:19
I
12:19
almost
12:19
feel
12:19
like
12:20
that
12:20
was
12:20
the
12:21
DSM's
12:22
way
12:22
of
12:23
saying,
12:24
hey,
12:24
I
12:24
don't
12:25
really
12:25
know
12:25
what's
12:26
causing
12:26
this,
12:26
so
12:26
we're
12:26
just
12:26
going
12:27
to
12:27
call
12:27
it
12:27
insomnia
12:28
disorder.
12:29
There's
12:30
probably
12:30
more
12:30
to
12:30
it
12:30
than
12:30
that.
12:31
That's
12:31
my
12:31
own
12:31
personal
12:31
opinion.
12:32
Don't
12:32
take
12:32
that
12:33
to
12:33
the
12:33
bank.
12:33
But
12:34
it's
12:34
a
12:34
frustrating
12:34
diagnosis
12:35
for
12:35
me
12:35
because
12:36
it
12:36
doesn't
12:36
really
12:36
tell
12:37
us
12:37
exactly
12:38
why
12:38
the
12:39
patient
12:39
can't
12:39
fall
12:40
asleep
12:40
or
12:40
stay
12:40
asleep.
12:41
Of
12:41
course,
12:41
gold
12:42
standard
12:42
treatment
12:42
for
12:42
this
12:43
would
12:43
be
12:43
cbt,
12:43
I,
12:44
not
12:44
medications.
12:45
Um,
12:46
but
12:46
that's
12:47
another
12:47
rabbit
12:47
hole.
12:48
That's
12:48
another
12:48
conversation.
12:49
Now,
12:50
in
12:50
hypersomnolence
12:51
disorder,
12:51
we're,
12:52
we're
12:52
so
12:52
sleepy,
12:53
despite
12:54
seven
12:54
or
12:54
more
12:54
hours
12:55
of
12:55
sleep.
12:57
And
12:58
that's
12:58
a
12:59
real
12:59
problem,
12:59
right?
12:59
These
13:00
people
13:00
are
13:00
just
13:00
tired
13:01
despite
13:02
having
13:02
ample
13:03
opportunity
13:04
to
13:04
fall
13:04
asleep.
13:04
They'll
13:05
nap
13:05
during
13:05
the
13:05
day,
13:06
but
13:06
even
13:06
those
13:06
naps
13:07
are
13:07
not
13:07
refreshing
13:08
at
13:09
all,
13:09
okay?
13:10
And
13:11
they're
13:11
just
13:11
kind
13:11
of
13:11
sleep
13:12
drunk
13:12
all
13:12
the
13:12
time,
13:13
okay.
13:14
It's
13:15
very
13:15
hard
13:15
for
13:15
them
13:16
to
13:16
just
13:16
like,
13:17
get
13:17
up
13:17
and
13:17
not
13:18
be
13:18
extremely
13:18
sleepy.
13:19
Now
13:19
this
13:20
is
13:20
different
13:20
though,
13:21
than,
13:21
than
13:22
narcolepsy,
13:22
which
13:23
we're
13:23
gonna
13:23
get
13:23
into
13:23
shortly
13:24
because
13:25
they
13:25
don't
13:25
have
13:26
a
13:26
loss
13:26
of
13:26
muscle
13:27
tone,
13:27
okay?
13:28
They're
13:28
not
13:28
entering
13:29
their
13:29
REM
13:30
cycle
13:30
early.
13:31
That's
13:31
what
13:31
happens
13:31
in
13:32
narcolepsy.
13:33
Okay?
13:34
That's
13:34
what
13:34
happens
13:35
in
13:35
narcolepsy.
13:35
Narcolepsy,
13:36
you
13:36
have
13:36
these
13:36
sleep
13:37
onset
13:37
REM
13:38
periods,
13:39
okay?
13:40
Normally
13:40
it
13:41
takes
13:41
you
13:42
and
13:42
me
13:42
about
13:42
90
13:43
minutes
13:43
to
13:43
enter
13:43
a
13:44
REM
13:44
cycle.
13:44
In,
13:45
in
13:45
narcolepsy,
13:46
it
13:46
takes
13:47
them
13:47
15
13:47
minutes
13:48
or
13:48
less.
13:48
That's
13:48
called
13:49
a
13:49
sleep
13:49
onset
13:50
REM
13:50
period
13:51
or
13:51
a
13:51
SO
13:51
REM.
13:52
Okay?
13:53
And
13:53
so
13:53
when
13:54
in
13:54
hypersomnolence
13:55
disorder,
13:55
they're,
13:55
they
13:56
have
13:56
all
13:56
this
13:56
opportunity
13:57
to
13:57
sleep
13:57
and
13:57
they're
13:57
just
13:58
not
13:58
feeling
13:59
refreshed
13:59
when
13:59
they
14:00
wake
14:00
up.
14:00
And
14:01
it's
14:01
a
14:02
very
14:03
difficult
14:03
problem.
14:04
Um,
14:06
it's
14:06
very
14:06
difficult
14:07
for
14:07
them
14:07
to
14:08
be
14:08
fully
14:08
awake
14:08
after
14:09
you
14:09
abruptly
14:10
wake
14:10
them.
14:11
And
14:11
their
14:11
naps
14:12
are
14:12
not
14:12
refreshing,
14:12
but
14:13
they're
14:13
not
14:13
losing
14:13
muscle
14:14
tone
14:14
and
14:14
they're
14:14
not
14:14
entering
14:15
rem.
14:16
Too
14:16
soon.
14:17
Okay.
14:17
That's
14:17
exactly
14:18
what
14:18
separates
14:18
it
14:19
from
14:19
narcolepsy.
14:20
And
14:20
you
14:21
can
14:21
diagnose
14:21
this
14:21
with
14:22
a
14:22
polysonography.
14:23
Okay.
14:24
And
14:24
you
14:24
probably
14:24
want
14:25
an
14:25
MSLT
14:26
test,
14:27
that's
14:27
a
14:27
multiple
14:28
sleep
14:28
latency
14:29
test
14:29
to
14:29
rule
14:30
out
14:30
narcolepsy.
14:30
We've
14:31
talked
14:31
all
14:31
about
14:31
that
14:31
in
14:31
previous
14:32
episodes.
14:33
Right.
14:33
And
14:33
that's
14:34
basically
14:34
a
14:34
fancy
14:34
way
14:35
MSLT
14:35
tests
14:36
want
14:36
to
14:36
really
14:37
see
14:37
if
14:37
you're
14:37
falling
14:37
asleep
14:38
in
14:38
under
14:38
eight
14:39
minutes.
14:39
Okay.
14:40
Most
14:40
people
14:40
don't
14:40
fall
14:41
asleep
14:41
in
14:41
under
14:41
eight
14:42
minutes.
14:42
That's
14:42
very
14:43
quickly.
14:43
They're
14:43
suspicious
14:44
of
14:44
narcolepsy.
14:45
If
14:45
you're
14:45
falling
14:45
asleep
14:46
within
14:46
eight
14:47
minutes,
14:47
they're
14:48
suspicious
14:48
of
14:49
narcolepsy.
14:49
They're
14:50
also
14:50
suspicious
14:50
of
14:51
narcolepsy
14:52
if
14:52
they
14:52
see
14:53
that
14:53
you're
14:53
entering
14:54
a
14:54
REM
14:54
cycle
14:55
in
14:55
under
14:55
15
14:55
minutes.
14:56
Because,
14:56
again,
14:57
you
14:57
and
14:57
me
14:57
normally
14:58
take
14:58
90
14:58
minutes
14:59
to
14:59
enter
14:59
REM.
14:59
15.
15:00
Folks
15:00
with
15:00
narcolepsy
15:01
have
15:02
that
15:02
same
15:02
thing.
15:03
They're.
15:03
They're
15:03
tired
15:04
throughout
15:04
the
15:04
day,
15:05
just
15:05
like
15:05
hypersomnolence
15:06
disorder,
15:06
but
15:07
they
15:07
have
15:08
that
15:08
loss
15:08
of
15:08
muscle
15:08
tone,
15:09
potentially.
15:09
They're
15:10
entering
15:10
REM
15:11
way
15:11
too
15:12
soon
15:12
in
15:12
under
15:12
15
15:12
minutes,
15:13
and
15:13
they're
15:13
falling
15:14
asleep
15:14
in
15:14
under
15:15
eight
15:15
minutes.
15:15
Right.
15:16
And
15:16
the
15:16
way
15:16
to
15:16
check
15:17
that
15:17
is,
15:17
of
15:17
course,
15:18
polysonography.
15:19
You
15:19
can
15:19
see
15:19
how
15:20
quickly
15:20
they
15:20
can
15:20
fall
15:20
asleep.
15:21
And
15:21
then
15:21
the
15:22
mslt,
15:22
as
15:22
well
15:23
as
15:23
how
15:23
quickly
15:23
they
15:24
can
15:24
fall
15:24
asleep,
15:25
you
15:25
can
15:25
also
15:25
see
15:26
if
15:26
they're
15:26
entering
15:27
REM
15:27
sooner.
15:27
And
15:28
that's
15:28
how
15:28
you
15:28
diagnose.
15:29
The
15:29
narcolepsy
15:30
would
15:30
be
15:30
polysonography.
15:32
Okay.
15:33
So
15:33
you
15:33
can
15:33
kind
15:33
of
15:33
see
15:34
the,
15:34
the,
15:35
the
15:35
subtle
15:36
difference
15:36
here.
15:36
Right?
15:37
Narcolepsy.
15:37
Just
15:38
think
15:38
about
15:38
it
15:38
being
15:38
a
15:38
little
15:39
more
15:39
complicated.
15:39
Right?
15:40
You
15:40
have
15:40
that
15:40
loss
15:41
of
15:41
muscle
15:42
tone.
15:42
You
15:42
have
15:43
the
15:43
REM
15:43
stuff
15:44
where
15:44
you're
15:44
getting
15:44
into
15:45
REM
15:45
too
15:45
quickly.
15:46
That
15:46
is
15:46
not
15:46
a
15:46
feature
15:46
of
15:47
hypersomnolence
15:47
disorder.
15:48
Hypersomnolence
15:49
is
15:49
just
15:50
what
15:50
it
15:50
says
15:50
it
15:51
is.
15:51
It's.
15:52
You're
15:52
just.
15:52
You're
15:53
too
15:53
tired.
15:53
Hypersomnolence,
15:55
too
15:55
sleepy.
15:56
Okay.
15:56
Despite
15:57
having
15:57
all
15:58
the
15:58
opportunities
15:58
to
15:59
sleep.
15:59
Notice
16:00
how
16:00
that's
16:00
different
16:00
than
16:00
insomnia,
16:02
where
16:03
insomnia,
16:03
you
16:04
can't
16:04
fall
16:04
asleep.
16:05
Like,
16:05
it's
16:05
a
16:05
deficiency
16:06
of
16:06
sleep.
16:07
Okay?
16:07
Hypersomnolence,
16:08
you
16:09
have
16:09
all
16:09
the
16:09
opportunities
16:10
to
16:10
sleep,
16:11
so
16:11
you
16:11
can't
16:11
diagnose
16:12
hypersomnolence
16:13
disorder
16:13
if
16:13
your
16:14
patient
16:14
is
16:14
telling
16:14
you
16:15
they
16:15
can't
16:15
fall
16:15
asleep.
16:16
That's
16:16
the
16:16
key
16:16
there.
16:16
That's
16:17
the
16:17
key
16:17
diagnostic
16:18
difference.
16:19
Because
16:19
in
16:20
insomnia,
16:20
of
16:20
course,
16:21
they're
16:21
going
16:21
to
16:21
be
16:21
tired
16:21
all
16:21
day
16:22
because
16:22
they're
16:22
not
16:22
able
16:23
to
16:23
even
16:23
fall
16:23
asleep.
16:24
And
16:24
they
16:24
wake
16:24
up
16:24
in
16:24
the
16:24
middle
16:25
of
16:25
the
16:25
Night.
16:25
But
16:25
hypersomnolence
16:26
is
16:27
weird
16:27
and
16:27
different
16:28
because
16:28
they
16:28
have
16:28
every
16:29
opportunity
16:29
and
16:30
they
16:30
just
16:31
still
16:31
are
16:31
sleepy
16:32
throughout
16:32
the
16:32
day.
16:32
Their
16:33
sleep
16:33
is
16:33
non
16:33
restorative.
16:34
Their
16:34
naps
16:35
are
16:35
non
16:35
restorative.
16:36
Narcolepsy
16:38
type
16:38
1
16:38
is
16:39
the
16:39
muscle
16:39
tone.
16:39
That's
16:40
the
16:40
key
16:40
of
16:41
what
16:41
makes
16:41
it
16:41
not
16:41
type
16:42
2.
16:42
Type
16:42
1
16:42
means
16:43
the
16:43
loss
16:43
of
16:43
muscle
16:43
tone,
16:44
but
16:45
they
16:45
are
16:45
also
16:46
tired,
16:47
sleepy
16:47
throughout
16:47
the
16:48
day.
16:48
They
16:48
will
16:48
often
16:48
fall
16:49
asleep
16:49
like
16:49
we
16:49
just
16:50
talked
16:50
about,
16:50
right?
16:51
In
16:51
under
16:51
eight
16:51
minutes.
16:52
They
16:52
enter
16:52
REM
16:52
in
16:53
under
16:53
15
16:53
minutes.
16:54
And
16:55
the
16:56
cataplexy,
16:57
or
16:57
the
16:57
loss
16:57
of
16:57
muscle
16:58
tone
16:58
is
16:58
the
16:58
giveaway.
16:59
There's
16:59
no
16:59
other
16:59
sleep
17:00
disorder
17:00
that
17:00
has
17:00
that.
17:00
If
17:01
they're
17:01
losing
17:01
muscle
17:01
tone
17:02
suddenly,
17:03
bam.
17:05
That
17:05
is
17:05
a
17:05
big
17:06
red
17:06
flag
17:07
that
17:07
you
17:07
are
17:07
entering
17:08
narcolepsy
17:09
territory.
17:10
Okay?
17:11
Classic
17:11
narcolepsy.
17:12
That's
17:12
type
17:13
one,
17:13
okay?
17:14
And
17:14
again,
17:14
you
17:14
do
17:14
need
17:14
polysonography.
17:15
You
17:15
need
17:16
that
17:16
MSLT
17:17
to.
17:18
To
17:18
detect
17:19
that.
17:20
And,
17:20
you
17:21
know,
17:21
you
17:21
may
17:21
want
17:21
to
17:21
look
17:21
at
17:22
modafinil
17:22
to
17:23
keep
17:23
them
17:23
awake.
17:24
Kind
17:24
of
17:24
a
17:24
different
17:25
episode.
17:25
We
17:25
have
17:25
talked
17:26
about
17:26
that
17:26
in
17:26
previous
17:26
episodes,
17:27
so
17:27
definitely
17:27
look
17:27
at.
17:28
Look
17:28
that
17:28
up.
17:28
Type
17:29
2
17:29
of
17:29
narcolepsy.
17:30
Don't
17:30
overthink
17:30
it,
17:30
my
17:30
friends.
17:31
It
17:31
just
17:31
doesn't
17:31
have
17:31
the
17:32
loss
17:32
of
17:32
muscle
17:32
tone,
17:33
okay?
17:34
It's
17:34
still.
17:35
The
17:35
patient
17:35
is
17:35
still
17:35
sleeping,
17:37
sleepy,
17:37
excessively
17:38
sleepy
17:38
throughout
17:39
the
17:39
day.
17:39
Okay?
17:40
They
17:40
still
17:41
enter
17:42
REM
17:42
too
17:43
quickly.
17:43
You
17:44
and
17:44
I
17:44
take
17:44
90
17:44
minutes.
17:45
They
17:45
take
17:46
less
17:46
than
17:46
15.
17:47
They're
17:47
also
17:47
sleeping
17:48
a
17:48
lot
17:48
faster
17:48
than
17:49
the
17:49
average
17:49
person.
17:49
Within
17:50
eight
17:50
minutes
17:50
or
17:50
less,
17:51
they're
17:51
falling
17:51
asleep,
17:52
but
17:52
they
17:52
don't
17:52
have
17:52
a
17:53
loss
17:53
of
17:53
muscle
17:53
tone.
17:53
That
17:54
would
17:54
be
17:54
the
17:54
difference
17:54
between
17:55
one
17:55
and
17:55
two.
17:55
One
17:56
is
17:56
the
17:56
big
17:56
dog,
17:57
the
17:57
main
17:57
squeeze.
17:58
The
17:58
gold
17:59
medal
17:59
goes
17:59
to
18:00
the
18:00
guy
18:00
who
18:00
loses
18:01
muscle
18:02
tone.
18:03
And
18:03
type
18:04
two
18:04
is
18:04
the
18:05
baby.
18:05
Still
18:06
very
18:06
distressing
18:07
and
18:07
disturbing
18:08
and
18:08
awful.
18:09
But
18:10
no
18:10
loss
18:10
of
18:10
muscle
18:11
tone.
18:11
Okay?
18:11
Obstructive
18:12
sleep
18:12
apnea.
18:12
Making
18:13
that
18:13
simple.
18:13
You
18:13
all
18:13
know
18:14
this
18:14
probably
18:14
already.
18:14
It
18:15
shows
18:15
up
18:15
in
18:15
clinic
18:16
all
18:16
the
18:16
time.
18:16
We've
18:17
talked
18:17
about
18:17
this
18:17
before,
18:18
how
18:19
OSA
18:19
is
18:20
doubles
18:21
the
18:21
risk
18:21
of
18:21
depression
18:22
if
18:22
it's
18:22
untreated.
18:23
There
18:24
is
18:24
a
18:24
byproduct
18:25
of
18:25
this.
18:26
Hypoxic
18:26
events
18:27
that
18:27
actually
18:27
destroy
18:28
neurotransmitters,
18:29
which
18:29
I
18:29
didn't
18:29
realize,
18:29
which
18:30
is
18:30
a
18:30
big
18:30
deal.
18:31
So
18:31
definitely
18:32
ask
18:32
about
18:32
OSA
18:33
in
18:33
every
18:34
single
18:35
session.
18:36
You
18:36
know,
18:36
new
18:36
eval.
18:37
You
18:37
don't
18:37
want
18:37
to
18:37
ignore
18:38
this.
18:38
It's
18:38
huge.
18:39
It
18:39
is
18:40
a
18:40
very
18:40
big
18:41
diagnostic
18:41
elephant
18:42
in
18:42
the
18:42
room
18:42
if
18:43
your
18:43
patient's
18:43
depressed.
18:44
And
18:44
it's
18:44
always
18:44
something.
18:45
When
18:45
I
18:45
ask
18:45
about
18:45
medical
18:46
history,
18:46
I
18:46
make
18:47
sure
18:47
to.
18:48
To.
18:48
To
18:48
ask
18:49
and
18:49
prod
18:49
if
18:50
they
18:50
have
18:50
obstructive
18:51
sleep
18:51
apnea.
18:51
Okay?
18:52
This
18:52
is
18:53
also
18:53
diagnosed
18:53
via
18:54
polysonography
18:55
or
18:55
a
18:55
home
18:55
sleep
18:56
apnea
18:56
test.
18:56
They
18:56
can
18:57
do
18:57
that
18:57
too,
18:58
right?
18:58
If
18:58
your
18:58
patient's
18:59
busy
18:59
and
18:59
they
18:59
can't
18:59
do
18:59
an
19:00
overnight,
19:00
you
19:00
can
19:00
do
19:01
a
19:01
home
19:01
sleep
19:02
apnea
19:02
test.
19:03
Okay?
19:04
This,
19:04
of
19:04
course
19:04
involves
19:05
snoring.
19:06
Usually
19:07
the
19:07
spouse
19:07
or
19:08
significant
19:08
other
19:08
will
19:09
witness
19:09
apnea,
19:10
witness
19:10
the
19:11
patient
19:11
gasping,
19:12
the
19:12
bed
19:13
even
19:13
actually
19:14
the
19:14
bed
19:14
partner
19:15
usually
19:15
reports
19:15
it
19:16
first.
19:16
Obesity
19:17
is
19:17
the
19:17
number
19:17
one
19:18
risk
19:18
factor
19:18
for
19:19
this.
19:19
The
19:19
airway
19:19
is
19:20
physically
19:20
collapsing.
19:21
Okay?
19:21
There
19:21
is
19:21
a
19:22
respiratory
19:22
effort,
19:23
the
19:23
chest
19:23
and
19:24
abdomen
19:24
are
19:24
moving,
19:24
but
19:25
no
19:25
airflow.
19:26
Right.
19:26
There's
19:26
a
19:26
lack
19:26
of
19:26
airflow
19:27
and
19:27
obesity
19:28
is
19:28
the
19:28
biggest
19:29
factor.
19:29
Okay?
19:30
They're
19:30
sleepy
19:31
the
19:31
next
19:31
day,
19:32
they
19:32
have
19:33
comorbid
19:33
hypertension,
19:34
mood
19:34
issues
19:35
in
19:35
the
19:35
morning,
19:35
headaches
19:36
in
19:36
the
19:36
morning.
19:36
And
19:36
the
19:36
issue
19:36
again
19:37
is
19:38
the
19:38
airway
19:39
collapsing.
19:40
Okay?
19:40
CPAP
19:40
is
19:41
first
19:41
line.
19:41
Patient
19:42
should
19:42
lose
19:42
weight,
19:43
etcetera,
19:43
etcetera.
19:44
Obstructive
19:44
sleep
19:45
apnea.
19:45
Exactly
19:46
what
19:46
the
19:46
name
19:46
says.
19:46
Easy
19:47
to
19:47
think
19:47
about.
19:48
You
19:48
can't
19:48
just
19:48
diagnose
19:49
that
19:49
with
19:49
a
19:49
magic
19:49
wand
19:50
though.
19:50
You
19:50
need
19:50
polystynography.
19:51
Okay,
19:52
Central
19:53
sleep
19:53
apnea.
19:53
That's
19:54
our
19:54
next
19:54
big
19:55
dragon
19:55
to
19:55
sleigh.
19:56
Very
19:56
simple.
19:56
The
19:57
brain
19:57
is
19:57
just
19:58
not
19:58
giving
19:58
the
19:59
message
19:59
to
19:59
breathe.
20:00
Okay?
20:01
This
20:01
is
20:01
also
20:01
a
20:02
polysonography
20:03
requirement.
20:03
You're
20:04
not
20:04
going
20:04
to
20:04
be
20:04
able
20:04
to
20:05
really
20:05
tell
20:05
in
20:06
session
20:06
that
20:07
a
20:07
patient
20:07
has
20:07
central
20:08
sleep
20:08
apnea
20:08
unless
20:09
they've
20:09
been
20:09
diagnosed
20:10
via
20:10
polysonography.
20:11
Okay?
20:12
So
20:12
if
20:12
they're
20:12
waking
20:13
up
20:13
feeling
20:14
unrefreshed
20:15
and
20:15
they
20:16
suspect
20:17
that
20:17
they're
20:17
not
20:17
breathing
20:18
or
20:19
their
20:19
spouse
20:21
suspects
20:21
that
20:22
as
20:22
well,
20:23
then
20:24
definitely.
20:25
Just
20:25
when
20:26
in
20:26
doubt,
20:26
get
20:26
a
20:26
polystynography.
20:28
There
20:28
might
20:28
be
20:29
underlying
20:30
causes
20:30
of
20:30
this
20:30
like
20:31
heart
20:31
failure
20:31
or
20:31
opioid
20:32
use
20:32
that's
20:33
depressing
20:33
the
20:33
respiratory
20:34
drive.
20:35
But
20:36
you
20:36
definitely
20:36
want
20:37
to
20:37
figure
20:37
out,
20:38
Work
20:38
with
20:38
medical,
20:39
collaborate
20:40
with
20:40
sleep
20:40
medicine
20:40
folks
20:41
and
20:41
figure
20:41
out
20:42
whether
20:42
this
20:43
is
20:43
obstructive
20:43
or
20:44
central
20:44
sleep
20:44
apnea.
20:45
But
20:45
you
20:45
in
20:45
your
20:45
clinic
20:46
are
20:46
not
20:46
going
20:46
to
20:46
be
20:46
able
20:47
to
20:47
understand
20:47
that.
20:48
You
20:49
can
20:49
only
20:49
tee
20:49
them
20:49
up
20:49
for
20:50
the
20:50
diagnosis.
20:50
Okay?
20:51
Then
20:51
there's
20:51
a
20:51
sleep
20:52
related
20:52
hypoventilation.
20:53
A
20:53
lot
20:54
of
20:54
you
20:54
may
20:54
not
20:54
even
20:54
know
20:55
this
20:55
exists
20:55
in
20:55
the
20:55
dsm.
20:56
Well,
20:56
it
20:57
does.
20:57
And
20:59
this
20:59
is
20:59
basically
21:01
unlike
21:01
obstructive
21:02
sleep
21:02
apnea
21:02
or
21:03
central
21:03
sleep
21:03
apnea,
21:04
where
21:04
breathing
21:04
repeatedly
21:05
stops
21:05
and
21:05
starts
21:06
Here,
21:06
breathing
21:07
never
21:07
really
21:07
stops,
21:08
it's
21:08
just
21:09
too
21:09
shallow.
21:09
So
21:09
the
21:10
patient
21:10
is
21:10
breathing,
21:10
but
21:11
it's
21:11
shallow.
21:11
CO2
21:12
is
21:12
building
21:12
up
21:13
in
21:13
the
21:13
system.
21:13
So
21:14
polysonography
21:16
with
21:16
CO2
21:17
monitoring
21:17
can
21:17
actually
21:18
show
21:18
that
21:18
their
21:18
CO2
21:19
is
21:19
being
21:19
elevated.
21:21
So
21:21
at
21:22
like
21:22
55
21:24
millimeters
21:24
of
21:25
mercury
21:25
or,
21:26
or,
21:26
or
21:27
basically
21:27
a
21:27
10
21:28
millimeter
21:29
of
21:29
mercury
21:29
difference
21:30
from
21:30
when
21:30
they're
21:30
awake.
21:30
Don't
21:31
get
21:31
too
21:31
hung
21:31
up
21:31
on
21:31
the,
21:32
the,
21:32
the
21:32
diagnostics
21:33
here.
21:33
But
21:33
basically
21:34
they
21:35
are
21:35
breathing,
21:35
but
21:35
it's
21:36
too
21:36
shallow.
21:36
They're
21:37
not
21:37
expelling
21:37
that
21:37
CO2
21:38
out.
21:38
It's
21:39
building
21:39
up.
21:40
Obesity
21:40
is
21:41
definitely
21:41
a
21:41
big
21:41
issue
21:41
here.
21:42
Neuromuscular
21:42
disease,
21:43
diseases,
21:43
als.
21:44
But
21:44
this
21:45
could
21:45
also
21:46
be,
21:47
this
21:47
is
21:47
one
21:47
of
21:48
the
21:48
sleep
21:48
disorders.
21:49
BIPAP
21:49
is
21:50
a
21:50
treatment,
21:50
weight
21:51
loss,
21:51
treat
21:52
the
21:52
underlying
21:52
neuromuscular
21:53
or
21:53
chest
21:53
wall
21:54
disease.
21:54
Don't
21:55
let
21:55
this
21:55
intimidate
21:55
you.
21:55
It's
21:56
radically
21:57
uncommon.
21:58
I
21:58
don't
21:58
see
21:58
it
21:58
very
21:58
often,
21:59
ever
21:59
in
21:59
clinic.
22:00
But
22:00
it
22:00
does
22:00
exist.
22:01
And
22:01
now
22:01
it's
22:02
demystified
22:02
for
22:03
you
22:03
a
22:03
little
22:03
bit.
22:03
Right.
22:03
Shallow
22:04
breathing,
22:04
CO2
22:05
builds
22:05
up,
22:05
it's
22:06
not
22:06
being
22:06
exhaled
22:07
forcefully
22:07
enough.
22:08
Out.
22:08
Obesity
22:09
is
22:09
a
22:09
cause.
22:10
Sleep
22:10
related
22:10
hypoventilation.
22:11
You
22:11
need
22:11
polysomnography.
22:12
So
22:13
now
22:13
we've
22:13
already
22:13
talked
22:13
about
22:14
obstructive
22:15
sleep
22:15
apnea,
22:15
central
22:16
sleep
22:16
apnea,
22:16
and
22:17
sleep
22:17
related
22:18
hypoventilation.
22:19
You
22:19
need
22:19
polysomnography.
22:20
You
22:21
also
22:21
need
22:21
it
22:21
narcolepsy
22:23
with
22:23
that
22:23
multiple
22:24
sleep
22:24
latent
22:24
latency
22:25
test.
22:26
Okay.
22:27
You
22:27
also
22:27
need
22:28
it
22:28
in
22:28
hypersomnolence
22:29
disorder
22:29
to
22:29
kind
22:29
of
22:29
rule
22:30
out
22:30
that
22:30
it's
22:30
not
22:30
narcolepsy.
22:31
Okay.
22:32
And
22:32
that's
22:32
kind
22:33
of
22:33
a
22:33
diagnosis
22:33
of
22:34
exclusion
22:34
to
22:34
some
22:34
extent.
22:35
But
22:35
notice
22:36
insomnia
22:36
disorder,
22:37
you
22:37
can
22:37
diagnose
22:37
that
22:38
in
22:38
your
22:38
clinic.
22:39
You
22:39
don't
22:39
need
22:39
to
22:40
necessarily
22:41
use
22:41
a
22:41
polysonography
22:42
there.
22:42
You
22:42
can
22:43
actually
22:43
take
22:43
their,
22:45
their
22:45
diagnostic
22:46
history.
22:46
And
22:46
if
22:46
they
22:47
cannot
22:47
fall
22:47
asleep,
22:48
stay
22:48
asleep,
22:49
or
22:49
wake
22:49
up
22:50
too
22:50
early
22:51
and
22:51
they've
22:51
unrefreshing
22:52
sleep,
22:52
you
22:52
can
22:53
certainly
22:53
start
22:53
to
22:53
diagnose
22:54
it
22:54
and
22:54
start
22:54
cbti.
22:55
Okay,
22:56
what
22:56
do
22:56
we
22:56
have
22:56
left
22:57
here?
22:57
We
22:57
have
22:57
circadian
22:58
rhythm
22:58
sleep
22:58
wake
22:59
disorders.
22:59
Okay.
23:01
This
23:01
would
23:01
be
23:02
misalignment
23:03
between
23:03
kind
23:03
of
23:03
the
23:04
internal
23:04
clock
23:04
and
23:04
the
23:05
patient's
23:05
desired
23:05
schedule.
23:06
Um,
23:07
this
23:07
can
23:07
really
23:07
jack
23:07
people
23:08
up.
23:08
I've
23:08
seen
23:08
people
23:08
on
23:09
like
23:09
night
23:09
shifts
23:09
for
23:10
a
23:10
very
23:10
long
23:10
time.
23:11
They
23:11
can't
23:11
quite
23:12
get
23:12
back
23:12
to
23:12
the
23:12
daytime
23:13
pattern
23:13
for
23:14
years.
23:14
They're
23:15
just
23:15
misaligned.
23:16
Their
23:16
sleep
23:17
is
23:17
normal.
23:19
And,
23:19
but
23:19
they
23:19
just,
23:20
maybe
23:20
they
23:20
go
23:20
to
23:20
bed
23:21
way
23:21
too
23:21
late.
23:22
They're
23:22
falling
23:23
asleep
23:23
at
23:23
2
23:23
to
23:23
4am
23:24
they
23:24
can't
23:25
wake
23:25
up
23:25
for
23:25
school.
23:26
Or
23:26
maybe
23:26
they're
23:27
falling
23:27
asleep
23:27
way
23:28
too
23:28
early.
23:28
Like
23:28
the
23:28
elderly.
23:29
They
23:29
go
23:29
to
23:29
bed
23:29
at
23:30
7pm
23:30
they
23:30
wake
23:30
up
23:31
at
23:31
3am
23:31
that
23:32
would
23:32
be
23:32
the
23:32
advanced
23:33
type
23:33
of
23:33
again
23:33
versus
23:34
the
23:34
delayed
23:34
type,
23:35
where
23:35
you're
23:35
going
23:35
to
23:35
bed
23:36
too
23:36
late
23:37
versus
23:37
advanced
23:37
you're
23:38
going
23:38
to
23:38
bed
23:38
too
23:38
early.
23:39
You're
23:39
kind
23:39
of
23:40
getting
23:40
to
23:40
bed
23:40
in
23:41
advance,
23:42
right?
23:42
And
23:43
then
23:43
there's
23:43
shift
23:43
work
23:44
and
23:44
jet
23:44
lag
23:44
and
23:45
all
23:45
of
23:45
that.
23:45
These
23:45
are
23:45
just
23:46
folks
23:46
who
23:46
are
23:46
misaligned,
23:47
sometimes
23:48
due
23:48
to
23:48
extraneous
23:49
factors.
23:50
Okay.
23:51
Melatonin
23:51
is
23:51
pretty
23:52
good.
23:52
There's
23:52
bright
23:52
light
23:53
therapy,
23:54
but
23:54
that's
23:54
another
23:54
one
23:55
that's
23:55
pretty
23:55
straightforward.
23:58
This
23:58
can
23:58
cause
23:58
the
23:59
patient
23:59
to
23:59
have
23:59
insomnia,
24:00
they're
24:00
sleepy
24:00
throughout
24:00
the
24:01
day,
24:01
or
24:01
both.
24:01
It's
24:01
very
24:02
distressing,
24:02
it's
24:02
very
24:03
impairing,
24:04
and
24:04
that's
24:04
where
24:04
we're
24:04
at.
24:06
So
24:06
now
24:06
it's
24:06
time
24:07
that
24:07
we
24:07
pivot.
24:08
We're
24:08
almost
24:08
done
24:08
with
24:09
these,
24:09
believe
24:09
it
24:09
or
24:09
not.
24:10
And
24:11
it's
24:11
not
24:11
so
24:11
bad,
24:11
is
24:12
it?
24:12
It's
24:12
actually
24:12
pretty
24:12
good.
24:13
We're
24:13
going
24:13
to
24:13
talk
24:13
now
24:14
about
24:14
the.
24:16
The
24:16
kind
24:16
of
24:17
the
24:17
big
24:17
flashy
24:17
ones
24:18
you
24:18
see
24:18
in
24:19
session
24:19
a
24:19
lot.
24:20
These
24:20
would
24:20
be
24:20
the
24:20
non
24:21
REM
24:22
nightmare
24:23
disorder
24:23
and
24:23
REM
24:24
disorders.
24:24
These
24:25
are
24:25
very
24:25
simple
24:25
if
24:26
you
24:26
just
24:26
think
24:26
about
24:26
them
24:27
together
24:28
and
24:28
what
24:28
separates
24:29
them.
24:29
Okay,
24:30
very
24:30
interesting.
24:31
Now,
24:31
non
24:32
rem
24:32
is
24:33
typically
24:33
in
24:33
the
24:34
first
24:34
third
24:34
of
24:34
the
24:34
night.
24:35
Remember
24:35
we
24:35
talked
24:35
about
24:35
how
24:36
it's
24:36
important
24:36
to
24:36
know
24:36
the
24:37
kind
24:37
of
24:37
the
24:37
sleep
24:38
architecture.
24:38
Non
24:39
REM
24:39
happens
24:39
usually
24:40
in
24:40
the
24:40
beginning.
24:40
It's
24:41
the
24:41
first
24:41
third
24:42
of
24:42
the
24:42
night.
24:42
And
24:43
this
24:43
is
24:43
your
24:43
patients
24:43
who
24:44
are
24:44
going
24:44
to
24:44
be
24:44
sleepwalking.
24:45
They're
24:45
rising,
24:46
they're
24:46
kind
24:46
of
24:46
walking,
24:47
they
24:47
have
24:47
a
24:47
blank
24:47
stare,
24:48
they're
24:48
unresponsive,
24:49
or
24:49
they
24:49
have
24:50
sleep
24:50
terrors,
24:50
they
24:50
are
24:50
panicky,
24:51
they
24:51
scream,
24:52
fight
24:52
or
24:53
flighty.
24:53
Okay.
24:54
But
24:54
when
24:54
you
24:55
wake
24:55
them
24:55
up
24:55
and
24:56
jolt
24:56
them,
24:57
they
24:57
have
24:57
no
24:58
ability
24:58
to
24:58
really
24:59
recall
24:59
their
24:59
dreams.
24:59
That's
25:00
the
25:00
absolute
25:00
key.
25:01
You're
25:01
dealing
25:01
with
25:01
a
25:02
non
25:02
rem
25:02
arousal
25:03
disorder.
25:04
It's
25:04
happening
25:04
in
25:04
the
25:04
first
25:05
part
25:05
of
25:05
sleep,
25:05
the
25:05
first
25:06
stages
25:06
of
25:06
sleep,
25:07
kind
25:07
of
25:07
early
25:07
in
25:07
the
25:07
night.
25:08
And
25:08
when
25:08
you
25:08
wake
25:09
them
25:09
up,
25:09
they
25:09
have
25:10
no
25:10
idea
25:10
they
25:10
have
25:10
amnesia.
25:11
They
25:11
don't
25:11
understand,
25:12
they
25:12
can't
25:12
recall
25:12
the
25:13
dream.
25:13
As
25:14
opposed
25:14
to
25:14
REM
25:15
disorder
25:15
or
25:16
nightmare
25:16
disorder
25:16
where
25:17
they
25:17
absolutely
25:17
can
25:18
recall
25:18
the
25:18
dream.
25:19
So
25:19
just
25:19
think
25:19
of
25:19
that.
25:20
Non
25:20
means
25:20
no,
25:21
I
25:21
can't
25:22
remember
25:22
it.
25:22
No
25:23
non
25:23
rem,
25:24
I
25:24
can't
25:24
remember
25:24
the
25:24
dream.
25:25
I
25:25
have
25:25
amnesia,
25:26
but
25:26
I'm
25:26
still
25:26
panicked.
25:27
I'm
25:27
screaming,
25:28
I
25:28
have
25:29
autonomic
25:29
arousal,
25:30
tachycardia,
25:31
sweating.
25:31
It's
25:32
very
25:32
terrifying.
25:33
But
25:33
they
25:33
don't
25:33
remember
25:34
it.
25:34
Okay.
25:34
Their
25:35
eyes
25:35
can
25:35
be
25:35
open.
25:36
The
25:36
sleep
25:37
terrors
25:37
have
25:37
a
25:37
dramatic
25:38
autonomic.
25:39
Autonomic
25:40
arousal,
25:40
sweating.
25:41
Okay.
25:42
But
25:42
again,
25:43
it's
25:43
not
25:43
the
25:43
second
25:43
half
25:43
of
25:44
the
25:44
night.
25:44
It's
25:44
the
25:44
first
25:44
half
25:45
of
25:45
the
25:45
night.
25:45
And
25:45
that
25:45
is
25:45
a
25:46
good
25:46
way.
25:46
I
25:46
can
25:46
kind
25:46
of
25:47
feel
25:47
a
25:47
lot
25:48
Less
25:48
nervous
25:48
in
25:49
session
25:49
and
25:49
go,
25:49
okay,
25:50
wait
25:50
a
25:50
minute.
25:50
This
25:51
is
25:51
the
25:51
first
25:51
half
25:51
of
25:51
the
25:51
night.
25:52
I
25:52
can
25:52
ask
25:52
them,
25:52
do
25:53
you
25:53
remember
25:53
the
25:53
dream
25:53
you're
25:54
going
25:54
through?
25:54
And
25:55
they
25:55
can't.
25:55
They
25:55
tell
25:56
me
25:56
straight
25:56
up,
25:56
they
25:57
can't.
25:57
They
25:57
don't
25:57
know
25:58
their
25:58
wife
25:58
is
25:58
terrified.
26:00
But
26:01
they,
26:01
they,
26:01
that's
26:02
just
26:02
their
26:02
experience.
26:02
And
26:03
that
26:03
can
26:03
definitely
26:04
get
26:04
you
26:04
to,
26:05
to
26:05
look
26:05
at
26:05
the
26:06
non
26:06
REM
26:07
sleep
26:07
related
26:08
disorder,
26:09
okay?
26:09
As
26:09
opposed
26:09
to
26:10
maybe
26:10
PTSD
26:11
where
26:11
it's
26:12
a
26:12
traumatic
26:12
nightmare.
26:13
It's
26:13
specifically
26:13
tied
26:14
to
26:14
a
26:14
trauma
26:15
that's
26:15
being
26:15
relived
26:16
at
26:16
all
26:16
times.
26:17
They're
26:17
not
26:17
necessarily
26:18
acting
26:18
it
26:18
out
26:18
in
26:19
ptsd,
26:20
okay?
26:21
They
26:21
usually
26:22
do
26:22
remember
26:22
it.
26:23
So
26:23
it's,
26:23
it
26:24
doesn't
26:24
have
26:24
the
26:24
amnesia
26:25
as
26:25
in,
26:26
in
26:26
non
26:26
rem,
26:27
they
26:27
do
26:27
have.
26:28
They
26:29
can
26:29
recall
26:29
it
26:30
typically
26:30
in
26:30
ptsd.
26:31
Maybe
26:31
if
26:32
I
26:32
give
26:32
them
26:32
prazosin,
26:33
they
26:33
can't
26:33
remember
26:33
it
26:33
anymore.
26:34
Or
26:35
sometimes
26:35
if
26:35
you,
26:35
even
26:36
if
26:36
you
26:36
don't
26:36
give
26:36
them
26:36
prazosin,
26:37
they
26:37
know
26:37
they're
26:37
having
26:37
a
26:38
nightmare,
26:38
but
26:38
they
26:38
can't
26:38
recall
26:39
it.
26:39
But
26:39
you
26:39
see
26:39
how
26:40
that's
26:40
so
26:40
different
26:40
because
26:41
non
26:41
rem,
26:41
they're
26:42
doing
26:42
stuff,
26:42
right?
26:43
They're
26:43
screaming,
26:44
they're
26:45
in
26:45
fight
26:45
or
26:45
flight,
26:46
right?
26:46
They
26:46
might
26:46
walk
26:47
or
26:47
do
26:47
all
26:47
kinds
26:47
of
26:48
weird
26:48
things,
26:48
but
26:48
they
26:49
don't
26:49
remember
26:49
it.
26:50
And
26:50
in
26:50
nightmare
26:51
disorder,
26:51
which,
26:52
not
26:52
to
26:53
overwhelm
26:53
you,
26:53
but
26:53
it's.
26:54
I
26:54
swear
26:54
this
26:54
gets
26:54
easier
26:55
in
26:55
nightmare
26:56
disorder.
26:58
It
26:58
is
26:58
also
26:58
the
26:59
second
26:59
half
26:59
of
26:59
the
26:59
night,
26:59
like
27:00
rem.
27:00
But
27:01
the
27:01
key
27:01
is
27:02
they
27:02
are
27:02
not
27:03
acting
27:03
out
27:04
their
27:04
dreams,
27:04
okay?
27:05
That's
27:06
the
27:06
biggest
27:06
difference
27:06
between
27:07
nightmare
27:07
disorder
27:07
and
27:08
rem.
27:08
Nightmare
27:09
disorder,
27:09
second
27:09
half,
27:10
you're
27:10
having
27:10
nightmares,
27:12
okay?
27:12
It's
27:13
a
27:13
REM
27:13
heavy
27:14
period.
27:15
They,
27:16
if
27:16
you
27:16
wake
27:17
them
27:17
up,
27:17
they
27:18
are
27:18
alert,
27:18
they're
27:19
oriented,
27:19
they
27:19
can
27:19
describe
27:20
their
27:20
nightmare
27:20
in
27:21
vivid
27:21
detail.
27:23
But
27:24
this
27:24
is
27:24
different
27:24
than
27:25
sleep
27:25
terrors
27:25
or
27:26
non
27:26
REM,
27:27
because
27:27
this
27:27
is
27:28
happening.
27:29
Non
27:29
REM
27:29
happens
27:30
in
27:30
the
27:30
first
27:30
third
27:31
of
27:31
the
27:31
night.
27:32
And
27:32
there's
27:33
no
27:33
dream
27:33
recall
27:33
with
27:33
non
27:34
rem.
27:34
Remember,
27:34
we
27:34
talked
27:35
about
27:35
it.
27:35
They're
27:35
confused,
27:36
they're
27:36
inconsolable.
27:38
But,
27:39
but
27:40
in
27:40
nightmare
27:40
disorder,
27:41
they,
27:41
you
27:41
can
27:41
wake
27:42
them
27:42
up
27:42
and
27:42
they're
27:43
fully
27:43
alert
27:43
and
27:44
they
27:44
are
27:44
horrified
27:45
and
27:45
they
27:45
hate
27:45
the
27:45
nightmare,
27:46
okay?
27:47
And
27:47
yet
27:48
they
27:48
are
27:48
not
27:49
acting
27:49
out
27:49
the
27:50
dream.
27:50
Because
27:51
in
27:51
REM
27:51
sleep
27:52
behavior
27:52
disorder,
27:53
they
27:53
are
27:53
in
27:54
fact
27:54
acting
27:54
out
27:55
the
27:55
dream.
27:55
And
27:55
that
27:55
is
27:55
what
27:56
makes
27:56
it
27:56
unique.
27:57
REM
27:58
is
27:58
acting
27:58
out
27:59
the
27:59
dream.
27:59
Again,
28:00
it
28:00
is
28:00
in
28:01
the
28:01
second
28:01
half
28:01
of
28:01
the
28:01
night.
28:01
We
28:02
talked
28:02
about
28:02
REM
28:02
being
28:03
in
28:03
the
28:03
second
28:03
half
28:04
and
28:05
absolutely
28:06
they
28:06
are
28:06
acting
28:07
out
28:07
the
28:07
dream.
28:07
They're
28:08
physically
28:08
fighting,
28:09
they're
28:10
doing
28:10
all
28:10
I've
28:11
had
28:11
people
28:11
rip
28:11
out
28:11
their
28:12
own
28:12
furniture,
28:12
their
28:13
TV
28:13
cables,
28:14
their
28:14
Internet.
28:15
These
28:16
people
28:16
are
28:16
in
28:16
a
28:16
REM
28:17
dream,
28:17
and
28:18
they
28:18
don't
28:18
have
28:18
the
28:18
atonia.
28:19
They
28:19
don't
28:19
have
28:19
the
28:19
lack
28:20
of
28:20
muscle
28:20
tone.
28:20
They
28:20
are
28:21
actively
28:21
punching,
28:22
kicking,
28:22
yelling,
28:22
jumping
28:23
out
28:23
of
28:23
bed.
28:24
Okay?
28:25
And
28:25
unlike
28:25
nightmare
28:26
disorder,
28:26
where
28:26
they're
28:27
not
28:27
acting
28:27
it
28:28
out,
28:28
they're
28:28
having
28:28
the
28:28
nightmares
28:29
and
28:29
nightmare
28:29
disorder,
28:29
but
28:30
they're
28:30
not
28:30
acting
28:30
out
28:31
REM
28:31
sleep
28:31
behavior
28:32
disorder.
28:32
They
28:33
are
28:33
absolutely
28:34
acting
28:34
out
28:35
the
28:35
dreams,
28:35
okay?
28:36
And
28:36
they
28:36
can
28:37
recall
28:37
them.
28:37
When
28:37
you
28:38
do
28:38
wake
28:38
them
28:38
up,
28:38
they
28:38
can
28:39
actually
28:39
recall
28:39
the
28:40
dream.
28:40
Okay.
28:41
And
28:41
this
28:41
is
28:42
actually
28:43
a
28:43
big
28:43
problem.
28:44
Typically
28:44
in
28:44
older
28:45
males,
28:45
80%
28:46
will
28:46
eventually
28:46
develop
28:46
Parkinson's
28:47
disease.
28:48
Okay?
28:49
So
28:49
this
28:49
is
28:49
like
28:49
a.
28:51
Or
28:51
Lewy
28:52
Body
28:52
dementia.
28:53
So
28:53
this
28:53
is
28:53
a
28:53
very
28:54
kind
28:54
of
28:54
scary
28:54
prognosis,
28:55
potentially.
28:56
You
28:57
need
28:57
to
28:57
make
28:57
sure
28:57
the
28:57
bedroom
28:58
is
28:58
safe.
28:59
Um,
28:59
you
28:59
know,
29:00
the
29:00
mattresses
29:01
on
29:01
the
29:01
floor.
29:02
Remove
29:02
sharp
29:03
objects.
29:03
Melatonin
29:04
might
29:04
be
29:04
good.
29:04
Clonazepam
29:05
may
29:05
be
29:06
good.
29:07
But
29:07
you
29:07
might
29:07
have
29:07
to
29:07
get
29:08
counsel
29:08
here
29:08
about
29:08
neurodegenerative
29:09
issues.
29:10
Again,
29:10
REM
29:11
sleep
29:11
behavior
29:12
disorder.
29:12
This
29:12
is
29:12
the
29:12
second
29:13
half
29:13
of
29:13
the
29:13
night.
29:13
It's
29:14
REM
29:14
heavy,
29:14
and
29:14
the
29:15
patient
29:15
is
29:15
acting
29:15
out
29:16
their
29:16
dreams.
29:17
Non
29:17
rem,
29:18
they.
29:18
It's
29:18
in
29:18
the
29:18
first
29:19
half
29:19
of
29:20
the
29:20
night.
29:20
They
29:21
have
29:21
terrors,
29:22
but
29:22
they
29:22
don't
29:23
recall
29:23
their
29:23
dreams.
29:23
They
29:23
don't
29:24
know
29:24
what's
29:24
happening.
29:24
They
29:24
have
29:25
no
29:25
idea
29:25
what's
29:25
happening.
29:25
Okay.
29:26
Okay.
29:26
They're
29:27
not
29:27
really
29:27
acting
29:27
out
29:27
their
29:28
dream
29:28
per
29:28
se.
29:29
They're
29:29
just.
29:29
They
29:30
have
29:30
no
29:30
idea
29:30
what
29:30
their
29:30
dream
29:31
is,
29:31
and
29:31
they're
29:31
just
29:31
kind
29:32
of
29:32
in
29:32
fight
29:32
or
29:33
flight
29:33
and
29:33
confused
29:34
when
29:34
you
29:34
wake
29:34
them
29:34
up.
29:35
That's
29:35
the
29:35
big
29:36
distinguisher
29:36
here.
29:37
All
29:37
right,
29:38
now
29:38
let's
29:38
talk
29:38
about
29:38
restless
29:39
leg
29:39
syndrome
29:40
real
29:40
quick.
29:42
With
29:42
restless
29:43
leg
29:43
syndrome,
29:44
okay,
29:45
you
29:45
have
29:45
the
29:46
urge
29:46
to
29:46
move
29:46
your
29:47
legs.
29:47
You
29:48
have
29:48
uncomfortable
29:49
sensations.
29:49
It's
29:50
worse
29:50
when
29:50
you're
29:50
at
29:50
rest,
29:51
when
29:51
you're,
29:51
like,
29:51
sitting
29:52
or
29:52
lying
29:52
down.
29:53
And
29:53
it's
29:54
relieved
29:54
by
29:55
moving.
29:56
Okay.
29:56
Stretching
29:57
or
29:57
walking.
29:57
It's
29:58
usually
29:58
worse
29:58
at
29:58
night
29:59
or
29:59
in
29:59
the
30:00
evening.
30:00
Okay.
30:01
And
30:01
it's
30:01
very
30:01
impairing.
30:03
Okay?
30:03
It's
30:03
very,
30:04
very
30:04
impairing.
30:06
So
30:06
you
30:07
don't
30:07
need
30:07
polysenography
30:08
for
30:08
that.
30:09
But
30:09
a
30:09
lot
30:10
of
30:10
clinicians
30:10
like
30:10
to
30:11
check
30:11
serum
30:11
ferritin
30:12
and
30:12
transfer
30:13
in
30:13
saturations.
30:14
Okay.
30:15
That,
30:16
you
30:16
know,
30:16
low
30:17
brain
30:17
iron
30:17
can
30:17
kind
30:18
of
30:18
drive
30:18
the
30:18
pathophysiology
30:19
of
30:19
restless
30:20
leg
30:20
syndrome.
30:20
I'll
30:21
be
30:21
honest
30:21
with
30:21
you.
30:21
I
30:21
haven't
30:22
yet
30:22
had
30:22
one
30:22
patient
30:23
come
30:23
to
30:23
me
30:23
and
30:23
go,
30:23
hey,
30:24
I
30:24
have
30:24
restless
30:24
leg
30:24
syndro
30:25
syndrome.
30:25
Can
30:25
you
30:25
please
30:25
help
30:25
me?
30:26
I
30:26
find
30:26
that
30:27
the
30:27
vast
30:27
majority
30:27
of
30:28
my
30:28
patients
30:28
tend
30:28
to
30:28
get
30:29
Treated
30:29
in
30:29
primary
30:29
care
30:30
with
30:30
this.
30:31
And
30:31
usually
30:32
it
30:32
looks
30:32
like
30:33
gabapentin
30:33
or
30:34
Lyrica,
30:36
but
30:36
I
30:36
won't
30:36
speak
30:37
to
30:37
that
30:37
too
30:37
much
30:37
because
30:38
I
30:38
don't
30:38
really
30:38
treat
30:38
this
30:39
as
30:39
often.
30:39
I
30:39
don't
30:40
see
30:40
it
30:40
as
30:40
often
30:41
and
30:41
it's
30:41
usually
30:42
already
30:42
treated
30:42
by
30:43
the
30:43
time
30:43
it
30:43
gets
30:43
to
30:43
me,
30:44
so
30:44
I'll
30:44
kind
30:44
of
30:45
defer
30:45
that.
30:45
But
30:45
it
30:45
is
30:45
in
30:46
the
30:46
DSM
30:46
and
30:47
you
30:47
should
30:47
be
30:47
aware
30:47
to
30:47
the
30:48
dsm
30:48
and
30:48
because
30:49
it's
30:49
in
30:49
the
30:49
DSM
30:49
we
30:50
shouldn't
30:50
be
30:50
oblivious
30:50
to
30:51
it.
30:51
Getting
30:51
those
30:52
serum
30:53
ferritin
30:53
and
30:53
transferrin
30:54
levels
30:54
would
30:55
really
30:55
be
30:55
important
30:55
to
30:55
check
30:56
on
30:56
iron
30:56
stores.
30:57
Again,
30:57
it
30:57
drives
30:58
the
30:58
pathophysiology
30:59
of
30:59
this
30:59
and
31:00
to
31:00
check
31:00
the
31:01
protein
31:01
that
31:01
transfers
31:02
or
31:02
delivers
31:02
iron
31:03
that
31:03
would
31:03
be
31:04
the
31:04
transferrin
31:05
saturation.
31:05
And
31:06
to
31:06
make
31:06
sure
31:06
those
31:06
levels
31:07
all
31:07
look
31:07
good
31:08
would
31:08
be
31:08
very
31:08
important.
31:09
Last
31:09
but
31:09
not
31:10
least,
31:10
my
31:10
friends,
31:10
we
31:10
won't
31:11
spend
31:11
a
31:11
lot
31:11
of
31:11
time
31:11
on
31:11
this
31:12
one,
31:13
but
31:13
we
31:13
have
31:14
the
31:14
substance
31:15
or
31:15
medication
31:16
into
31:16
sleep
31:17
disorders.
31:18
Um,
31:18
that's
31:19
something
31:19
again
31:19
that
31:20
you're
31:20
probably
31:20
going
31:21
to
31:21
get
31:21
a
31:21
good
31:21
clinical
31:22
history
31:22
and
31:22
understand
31:23
a
31:23
clear
31:23
temporal
31:24
relationship
31:25
between
31:25
their
31:25
sleep
31:26
problem
31:26
and
31:26
them
31:27
just
31:27
starting
31:27
a
31:28
drug
31:28
or
31:28
substance
31:29
or
31:29
during
31:29
withdrawal.
31:30
Don't
31:30
underestimate
31:31
they
31:32
just
31:32
stopped
31:32
smoking
31:34
cannabis.
31:36
I
31:36
see
31:36
that
31:36
a
31:36
lot.
31:37
They
31:37
don't
31:37
always
31:37
realize
31:38
it
31:38
or
31:38
draw
31:38
the
31:38
conclusions.
31:39
It
31:39
can
31:40
get
31:40
very
31:40
muddy.
31:40
I've
31:41
called
31:41
cannabis
31:42
diagnostic
31:42
mud
31:43
over
31:43
and
31:43
over.
31:44
So
31:45
it
31:45
can
31:45
really
31:46
look
31:46
different
31:46
depending
31:47
on
31:48
what
31:48
they're
31:48
doing.
31:48
They
31:49
might
31:49
have
31:49
stopped
31:49
some
31:50
supplement
31:51
they
31:51
got
31:51
on
31:52
Amazon.
31:52
They
31:53
might
31:53
be
31:53
changing
31:54
their
31:54
caffeine
31:55
intake
31:55
without
31:56
really
31:56
telling
31:56
you
31:56
or
31:57
thinking
31:57
that
31:57
they
31:57
have
31:57
to
31:57
tell
31:58
you.
31:59
Right.
31:59
They
31:59
might
31:59
be
32:00
drinking
32:00
more
32:00
or
32:00
drinking
32:01
less
32:01
or
32:01
stopping
32:02
alcohol
32:02
altogether.
32:03
And
32:03
maybe
32:04
it's
32:04
not
32:04
this
32:04
like
32:04
medically
32:05
complicated
32:05
withdrawal,
32:06
but
32:06
it
32:06
is
32:07
causing
32:07
some
32:07
rebound
32:08
anxiety
32:08
that's
32:09
trickling
32:09
into
32:09
their
32:10
ability
32:10
to
32:10
sleep.
32:10
Regardless
32:11
of
32:12
definitely
32:12
be
32:13
mindful
32:13
that
32:13
not
32:14
everything
32:14
you're
32:14
looking
32:14
at
32:15
is
32:15
going
32:15
to
32:15
require
32:16
polysonography
32:17
or
32:17
might
32:17
be
32:18
as
32:18
clear
32:18
as
32:18
a
32:18
night
32:19
terror
32:19
or
32:20
acting
32:20
out
32:20
a
32:20
dream.
32:21
Always
32:22
be
32:22
suspicious
32:22
of
32:22
an
32:23
underlying
32:23
issue,
32:24
in
32:24
this
32:25
case
32:25
a
32:25
substance.
32:26
So
32:26
have
32:26
a
32:26
very
32:26
clear
32:27
inventory
32:27
from
32:28
the
32:28
get
32:28
go
32:28
of
32:28
what
32:28
your
32:29
patient
32:29
does
32:29
and
32:29
doesn't
32:30
do.
32:30
And
32:30
to
32:31
have
32:31
them
32:31
notify
32:31
you
32:31
if
32:32
they
32:32
add
32:32
anything
32:32
or
32:33
remove
32:33
anything
32:33
because
32:34
it
32:34
will
32:34
affect
32:34
the
32:35
diagnostic
32:36
picture.
32:37
Okay.
32:38
So
32:38
I
32:38
hope
32:38
this
32:38
helped
32:39
you.
32:39
I
32:39
hope
32:39
there
32:39
are
32:40
certain
32:40
hard
32:40
and
32:40
fast
32:41
rules
32:41
that
32:41
make
32:42
this
32:42
a
32:42
lot
32:42
easier
32:43
for
32:43
you
32:43
to
32:43
understand.
32:45
Some
32:45
of
32:46
them
32:46
we've
32:46
talked
32:46
about.
32:46
Right?
32:47
When
32:47
in
32:47
the
32:47
night
32:48
is
32:48
such
32:49
a
32:49
great
32:49
parasomnia,
32:50
Pearl.
32:51
Because
32:51
the
32:51
first
32:52
third
32:52
is
32:52
usually
32:53
a
32:53
non
32:53
rem
32:53
based
32:54
sleepwalking
32:55
or
32:55
sleep
32:56
terror
32:56
Issue.
32:57
The
32:57
second
32:57
half
32:57
would
32:58
be
32:58
REM
32:58
based.
32:59
Again,
32:59
that's
32:59
like
32:59
a
33:00
nightmare
33:00
disorder
33:00
or
33:00
REM
33:01
sleep
33:01
behavior
33:02
disorder.
33:02
We
33:02
talked
33:03
about
33:03
whether
33:03
you're
33:03
alert
33:04
or
33:04
confused.
33:04
That's
33:05
an
33:05
instant
33:05
differentiator
33:06
for
33:06
you.
33:07
If
33:07
you're
33:08
alert
33:08
and
33:08
oriented
33:09
and
33:09
you
33:09
remember
33:09
your
33:10
dream,
33:10
that's
33:10
REM
33:11
based.
33:11
That's
33:11
a
33:12
nightmare
33:12
disorder
33:12
or
33:13
REM
33:13
based
33:13
disorder.
33:14
If
33:14
you're
33:14
confused,
33:15
disoriented,
33:15
you
33:15
don't
33:16
remember
33:16
stuff,
33:16
that's
33:16
usually
33:17
non
33:17
REM
33:17
based.
33:18
That's
33:18
the
33:18
sleep
33:19
waking
33:19
or
33:20
sleep
33:20
terror.
33:20
Excuse
33:21
me,
33:21
sleep
33:21
walking
33:22
or
33:22
sleep
33:22
terror
33:23
type
33:23
problem.
33:24
Okay.
33:25
And
33:26
remember
33:26
the
33:26
big
33:26
difference
33:27
between
33:27
nightmare
33:27
disorder.
33:28
You're
33:28
not
33:28
actually
33:29
acting
33:29
out
33:29
your
33:30
nightmares.
33:30
That
33:30
would
33:30
be
33:30
the
33:31
REM
33:32
sleep
33:33
disorder.
33:33
Okay.
33:34
Um,
33:35
that
33:35
would
33:35
be
33:35
rbd.
33:37
Okay.
33:37
And
33:37
you
33:37
do
33:38
need
33:38
a
33:38
polysonography
33:39
to
33:40
confirm
33:41
a
33:41
REM
33:41
based
33:42
sleep
33:42
disorder.
33:43
Okay.
33:44
We
33:44
talked
33:44
about
33:45
the
33:45
difference
33:45
between
33:45
hypersomnolins
33:46
and
33:46
narcolepsy.
33:47
They
33:48
both
33:48
require
33:48
polysonography
33:49
to
33:49
get
33:49
really
33:50
technical
33:50
and
33:50
to
33:50
understand
33:51
basically
33:52
to
33:52
just
33:52
figure
33:52
out
33:53
the
33:53
difference
33:53
between
33:53
the
33:54
two.
33:54
Remember,
33:54
narcolepsy
33:55
has
33:55
all
33:55
those
33:55
big,
33:55
flashy
33:56
extra
33:57
metrics
33:57
that
33:57
require
33:58
kind
33:58
of
33:58
a
33:58
more
33:59
detailed
34:00
diagnosis.
34:00
Right.
34:00
We
34:01
want
34:01
to
34:01
see
34:01
if
34:01
they're
34:01
entering,
34:02
remember,
34:03
in
34:03
under
34:03
15
34:03
minutes.
34:04
And
34:04
we
34:04
want
34:05
to
34:05
see
34:05
if
34:05
they're
34:05
falling
34:06
asleep
34:06
in
34:06
under
34:06
eight
34:07
minutes.
34:07
And
34:07
that
34:07
is
34:08
also
34:08
tested
34:09
not
34:09
just
34:09
with
34:09
polysonography,
34:10
but
34:10
with
34:10
that
34:11
multiple
34:11
sleep
34:11
latency
34:12
test.
34:12
Okay.
34:12
They're
34:13
losing
34:13
muscle
34:13
tone.
34:13
That's
34:14
type
34:14
one.
34:14
Don't
34:15
forget
34:15
that.
34:15
Right.
34:16
We
34:16
talked
34:16
about
34:16
the
34:17
three
34:17
different
34:17
breathing
34:18
disorders.
34:18
Okay.
34:19
It's
34:19
kind
34:19
of
34:19
the
34:19
same
34:19
symptom,
34:20
but
34:20
three
34:20
different
34:21
mechanisms.
34:21
Right?
34:22
Airway
34:22
collapse.
34:23
Airway,
34:24
the
34:24
brain
34:25
not
34:25
telling
34:26
the
34:27
body
34:28
to
34:28
breathe.
34:29
And
34:29
then
34:29
hypoventilation,
34:30
where
34:30
the
34:30
breathing
34:31
is
34:31
just
34:31
too
34:31
shallow.
34:32
It's
34:32
a
34:32
mechanical
34:32
problem.
34:33
CO2
34:33
is
34:34
building
34:34
up.
34:34
We
34:34
can
34:34
measure
34:35
it.
34:35
Okay.
34:36
And
34:37
so
34:37
I
34:37
hope
34:37
you
34:38
enjoyed
34:38
this.
34:39
There's
34:39
many
34:40
different
34:40
treatments
34:41
depending
34:41
on
34:42
which
34:42
one
34:42
of
34:42
these
34:42
sleep
34:43
issues
34:44
are
34:44
going
34:44
on.
34:44
There's
34:45
CBTI
34:46
for
34:46
insomnia.
34:47
Then
34:47
we
34:48
talked
34:48
about
34:48
restless
34:48
leg
34:49
and.
34:50
And
34:50
you
34:50
know,
34:50
giving
34:51
iron
34:51
might
34:51
be
34:52
important
34:52
there,
34:52
or
34:53
gabapentin
34:53
or
34:53
Lyrica.
34:55
And
34:55
I'll
34:55
be
34:55
honest,
34:55
some
34:56
of
34:56
these
34:56
other
34:56
ones
34:56
get
34:56
kind
34:57
of
34:57
complicated.
34:57
Right?
34:58
You
34:59
even
34:59
have
34:59
SSRIs
35:00
that
35:00
can
35:00
contribute
35:01
to
35:01
REM
35:01
based
35:01
sleep
35:02
disorders.
35:03
Okay.
35:04
And
35:05
so
35:06
it's
35:06
just.
35:06
It
35:06
gets
35:07
kind
35:07
of.
35:07
You
35:07
really
35:07
got
35:07
to
35:08
get
35:08
in
35:08
the
35:08
evidence
35:08
and
35:08
get
35:08
in
35:09
the
35:09
weeds
35:09
with
35:09
some
35:09
of
35:09
these
35:10
as
35:10
to
35:10
how
35:10
to
35:10
fix
35:10
them.
35:11
And
35:11
there's
35:11
not
35:11
always
35:12
FDA
35:12
approved
35:13
medications
35:13
for
35:14
nightmare
35:14
disorder
35:15
or
35:17
REM
35:17
based
35:17
sleep
35:18
disorders
35:18
or
35:18
non
35:18
REM
35:19
based
35:19
sleep
35:20
disorder.
35:20
So
35:20
you
35:20
really
35:20
got
35:21
to
35:21
get
35:21
into
35:22
the
35:22
evidence,
35:22
figure
35:22
out
35:23
the
35:23
underlying
35:23
causes.
35:24
And
35:24
my
35:24
friends,
35:25
not
35:25
to
35:26
discourage
35:26
you,
35:26
because
35:26
I
35:27
think
35:27
if
35:27
anything,
35:27
you
35:27
have
35:28
more
35:28
of
35:28
a
35:28
mastery
35:28
now.
35:29
But
35:29
we
35:29
didn't
35:29
really
35:30
even
35:30
touch
35:30
on
35:30
PTSD
35:31
that
35:31
much.
36:26
And
36:26
of
36:26
course
36:27
PTSD
36:28
is
36:28
the
36:28
elephant
36:28
in
36:29
the
36:29
room
36:29
because
36:29
most
36:30
of
36:30
the
36:30
time
36:30
you
36:30
hear
36:30
nightmares
36:31
in
36:32
your
36:33
clinical
36:33
experience,
36:34
you're
36:34
going
36:34
to
36:34
be
36:34
dealing
36:34
with
36:35
PTSD
36:35
and
36:36
not
36:36
necessarily
36:36
this
36:37
stuff,
36:37
or
36:37
maybe
36:38
a
36:38
little
36:38
bit
36:38
of
36:38
PTSD
36:39
and
36:39
then
36:39
sometimes
36:40
sleep
35:45
terrors
36:40
in
36:41
addition
36:41
to
36:41
ptsd.
36:42
So
36:43
it
36:43
can
36:43
get
36:43
confusing
36:44
pretty
36:44
fast.
36:44
But
36:45
definitely
36:45
lean
36:46
back
36:46
on
36:46
this
36:46
episode.
36:47
It'll
36:47
all
36:47
make
36:47
sense
36:48
again.
36:48
And
36:48
we
36:49
also
36:49
if
36:49
you
36:49
are
36:49
a
36:49
Patreon
36:50
member,
36:50
you
36:51
go
36:51
to
36:51
patreon.com
36:52
pearlsandprep
36:53
if
36:53
you
36:53
are
36:54
a
36:54
Patreon
36:54
member,
36:55
go
36:55
into
36:55
our
36:56
Show
36:56
Notes,
36:56
become
36:56
one
36:57
and
36:57
you
36:57
will
36:58
get
36:58
a
36:58
beautiful
36:58
slide
36:59
deck
36:59
where
36:59
this
36:59
is
37:00
all
37:00
visual
37:00
and
37:01
sticky
37:02
and
37:03
simple
37:03
for
37:03
you
37:03
to
37:04
remember
37:04
and
37:04
have
37:04
at
37:04
your
37:05
fingertips
37:05
if
37:05
you
37:05
need
37:06
it.
37:07
Really,
37:07
the
37:07
difference
37:08
between
37:08
a
37:08
good
37:08
and
37:08
a
37:08
great
37:09
clinician
37:09
are
37:10
the
37:10
clinicians
37:10
that
37:10
understand
37:11
the
37:11
how
37:11
and
37:11
the
37:12
why
37:12
of
37:12
what
37:12
they're
37:12
doing.
37:12
And
37:13
that's
37:13
why
37:13
we
37:13
built
37:14
Patreon
37:15
so
37:15
that
37:15
you
37:15
have
37:16
it.
37:16
I
37:16
have
37:17
been
37:17
transformed
37:18
as
37:18
a
37:18
clinician
37:18
because
37:18
of
37:19
this
37:19
Patreon
37:19
library
37:20
that
37:20
just
37:20
makes
37:21
things
37:21
stick
37:22
so
37:22
quickly
37:23
and
37:23
it's
37:23
empowered
37:24
me
37:24
and
37:24
patients
37:24
can
37:24
really
37:25
smell
37:25
that
37:25
a
37:25
mile
37:26
away.
37:26
So
37:26
we
37:26
can't
37:26
urge
37:27
you
37:27
enough
37:27
to
37:28
become
37:28
a
37:28
Patreon
37:28
member
37:29
again.
37:29
Go
37:29
to
37:29
the
37:29
Show
37:30
Notes,
37:30
click
37:31
the
37:31
Patreon
37:31
link
37:32
and
37:32
become
37:32
a
37:32
member.
37:32
We'd
37:33
love
37:33
to
37:33
have
37:33
you.
37:33
Until
37:34
next
37:34
time,
37:34
my
37:34
friends.
37:35
We
37:35
will
37:35
see
37:35
you
37:35
and
37:35
have
37:36
a
37:36
great
37:36
week.
37:36
Bye
37:36
Bye.