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Many patients with fatigue do not visit a physician. In patients who do consult the general practitioner, the cause of their fatigue is explained in about a quarter: 8 percent has a somatic cause while psychosocial causes explain 16 percent. In about three quarters the cause of fatigue remains unexplained. Because of the low prevalence of somatic causes the general practitioner will be reluctant to perform additional examinations but a thorough physical examination is essential. In patients with a longer duration of fatigue (6 months) it is indicated to expand inquiries. This starts with extending history taking in the direction of consanguinity and hereditary diseases. More comprehensive blood tests and investigation of sleep are important further steps. Referral to a specialist is essential as specialists are more familiar with scripts of rare diseases. The prognosis of longer lasting fatigue is bad, especially in the case of fatigue meeting criteria for ME/CFS. Treatment of longer lasting fatigue could compromise of psycho-education, exercise and specific therapies for sleeping disorders.

Long-term usage of benzodiazepines for anxiety and sleeping disorders results in a decline in effectiveness and an increase in the risk of dependence and side-effects over time. For this reason, in 2009, benzodiazepines for anxiety and sleeping disorders were disinvested (i.e. reimbursement was discontinued) in the Netherlands. Several factors contributed to disinvestment: the broad support from involved actors for disinvestment, the possibility to keep reimbursing benzodiazepines for patients groups for whom long-term use is indicated, patient groups that were not well organized, and the fact that long-term benzodiazepine use for anxiety and sleeping disorders is not medically necessary as well as ineffective. In the first year following disinvestment, the usage of benzodiazepines decreased with 15%. In subsequent years, usage stabilized, after which it decreased again.

Sleep disorders are prevalent and have large impact on well-being and functioning. Based on the presenting symptoms, the general practitioner can often diagnose and treat uncomplicated sleep disorders. An overview of the most common sleeping complaints, underlying diagnoses and useful treatments is given. Furthermore, we discuss a structured approach for diagnosing sleep disorders, provide criteria for referring patients with sleep disorders to sleep centers, and discuss medication both as cause as well as option for treating sleeping problems.

A 61-year-old woman with suspected schizophrenia has been attending an outpatient geriatrics service for some time, initially with memory complaints and panic attacks. During treatment, the diagnosis schizophrenia was rejected and psychopharmaceuticals were largely phased out, which improved cognitive functions. Eventually, flashbacks of incest experienced in childhood remained together with REM sleep pathology. The flashbacks, nightmares and the REM sleep pathology were responsive to rivastigmine. Rivastigmine use for the treatment of REM sleep pathology is known in the literature, but it has never been described previously that rivastigmine also impacts on flashbacks and nightmares..

Behavioural interventions, such as developing positive sleep-related associations and gradual extinction, are common and proven methods to treat behavioural childhood sleep problems. Although behavioural interventions are safe and effective, controversy has arisen because of the impression that they are incompatible with sensitive parenting (i.e. cued care). The practice of extinction, however, does not preclude a sensitive parenting style. It stimulates autonomy and self-regulation in the child. Instead of counterposing behavioural interventions and cued care, we suggest it is more productive to start from their similarities, such as optimizing sleep hygiene and developing a fixed sleep-wake rhythm. Such measures could be the first steps in a stepped-care model that may be supplemented with additional treatment aimed at the underlying causes of insomnia. For this comprehensive approach it is necessary to have a diverse array of evidence-based treatment options that suits the needs of both children and parents.

One in ten parents in the Netherlands feels there is a problem with their baby's sleep. Healthy sleep is very important for children and parents. Because of the many questions asked by parents, professionals are in need of clear guidelines. The guideline 'Healthy sleep and sleep problems in children', provided by the Dutch centre for youth health (NCJ, Nederlands Centrum Jeugdgezondheid) provides information on promoting healthy sleep behaviour and sleep interventions. We argue in this article that: (a) parents may have doubts about the recommended interventions; (b) the interventions are often not compatible with the concept of 'sensitive parenting'; and (c) the guideline does not include all possible interventions. We are pleading for a broadening of the spectrum of interventions. It is in the interest of parents as well as infants that interventions aimed at the needs of the infant are included in the spectrum of sleep interventions being offered.

Anxiety and depression in Parkinson's disease (PD) are often unrecognized, partially due to a complex relationship with sleep disorders and other PD-related symptoms.br/AIM: To gain more insight in anxiety, depression and sleep disorders in PD, their reciprocal interaction and relationship with other (non)motor symptoms.br/METHOD: With three epidemiological studies in this thesis article we describe: the symptom dimensions of anxiety, motor symptoms and autonomic failure; predictors of the course of anxiety; and the temporal relationship between anxiety, depression and insomnia in PD.br/RESULTS: Anxiety in PD has one affective and various somatic symptom dimensions. There is a symptomatic overlap between anxiety and symptoms of motor and autonomic dysfunctions. Anxiety, depression and impulsive-compulsive behaviors in de novo PD show a parallel course. Cognitive dysfunctions and REM-sleep behaviour disorder are risk factors for anxiety in PD patients. The relationship between insomnia and anxiety and depression is bi-directional.br/CONCLUSION: There is an overlap, co-morbidity and interaction between anxiety, depression, sleep disorders and (non)motor symptoms, which warrants a multi-disciplinary approach to PD. Sleep disorders and cognitive dysfunctions may provide starting points for treatment and preventions of anxiety in PD.

Sleep disorders are a frequent problem with an important impact on the quality of life. Given its physiological properties, melatonin is often associated with sleep disorders and their treatment. In addition, melatonin has been recognized by the European Medicines Agency (ema) since 2007 for primary insomnia in adults over 55 years of age for a maximum of 13 weeks.br/AIM: Analysis of the international literature on the indication statements and effectiveness of melatonin for sleep disorders and their testing against practical use.br/METHOD: A narrative literature study in PubMed, Cochrane and Web of Science, supplemented with a retrospective study of prescribing behavior within a university psychiatric hospital.br/RESULTS: The current evidence for the use of melatonin for insomnia and circadian arrhythmias is low. We also noted that the effectiveness of melatonin for the recognized indication of primary insomnia was questioned by some guidelines and that the various studies were also heterogeneous in terms of outcome measures, indication statements and formulated advice. In addition, only 19.6% of the requirements in the retrospective study met the official ema indication.br/CONCLUSION: This study shows that melatonin is mainly used off-label. Overall, there appears to be limited effectiveness of melatonin, which has an impact on the indication statements.

The negative consequences of sleep-wake disorders in the general population and in children with an autism spectrum disorder (ASD) are well-established. However, little is known about sleep-wake disorders in adults with ASD.br/AIM: To study and measure sleep-wake disorders and sleep-wake patterns in adults in a clinical facility who have been diagnosed primarily as having ASD without any comorbid intellectual disability.br/METHOD: We assessed the sleep patterns of 19 patients in a residential facility. We asked patients to provide their sleep history, answer questionnaires and keep a sleep diary (subjective measurement). We also asked patients to collect actigraphy data (objective measurement) for seven days and to provide information about comorbid symptoms of anxiety and depression and use of medication.br/RESULTS: Nine patients (47%) had undiagnosed comorbid sleep-wake disorders. Patients in our study overrated their sleep efficiency (diary) compared to objective data (actigraphy). However, patients' subjective sleep quality did match patients' sleep efficiency. Only two out of 14 patients with symptoms of anxiety and/or depression were diagnosed with a comorbid depressive disorder, 15 patients were treated with medication.br/CONCLUSION: Sleep-wake disorders and comorbid symptoms of anxiety and depression might be more prevalent in adults with ASD in a residential facility than reported so far. This possibility needs to be considered more carefully during the diagnostic process and during treatment.

The incubus phenomenon is a paroxysmal condition characterised by sleep paralysis coinciding with a sensed presence and the frightening sensation that something or somebody is exerting pressure on the thorax.To present an overview of the literature on the incubus phenomenon and to provide practical advice regarding diagnosis and treatment.To obtain information for our paper we carried out a search in PubMed and the historical literature.The incubus phenomenon is a relatively unknown condition, even though, world-wide, it has a lifetime prevalence rate of 30% in the general population. The prevalence is even higher among students, psychiatric patients and patients with narcolepsy. It is attributed to a dissociation of the rem sleep phase and the subsequent intrusion of endogenously mediated percepts. The condition rarely requires treatment because it is self-limiting, and generally occurs only once in a lifetime. Repeated attacks, however, may warrant additional diagnostic testing with the aid of polysomnography and may require treatment with anxiolytics, antidepressants, anticholinergics or anti-epileptics.The incubus phenomenon is an intrusive condition, but, as far as we currently know, it is benign. Nevertheless, it is important that the condition is recognised and not confused with a psychotic disorder or any other type of severe mental illness. When necessary, it should be treated lege artis.

A study with 1050 people over the age of 50 years with mild to severe intellectual disabilities showed that the health of this group declined at a much younger age than in the general population of the same age. The cardiovascular risk was often higher and depression and sleep disorders were more common in people aged over 50 years with intellectual disabilities, but these were often not diagnosed. Recognising the underlying causes and determining which approach to take to them require specialist knowledge. The accumulation of unfavourable factors from childhood may lead to people becoming frail at an earlier age, which in this population is predictive of a decline in health and independence and a high risk of death within 3 years. The prevalences of multimorbidity and polypharmacy in people over 50 with intellectual disabilities are comparable to those of the Dutch nursing home population. In order to maintain the health and independence of people with an intellectual disability for longer, an improvement in vocational training for carers, development of multidisciplinary guidelines, and enhancement of the quality and availability of outpatient clinics with intellectual disability specialists are required.

To determine the sensitivity, specificity and the positive and negative predictive value of taking a detailed sleep history for making the diagnosis of psychophysiological insomnia.Retrospective case file study.We examined 767 patients referred to the Amsterdam Centre for Sleep and Wake Disorders, and who underwent polysomnography for the first time between 1 January and 31 December 2010. We compared the probable diagnosis made following history-taking with the final diagnosis made after polysomnography. In this we differentiated between organic and non-organic insomnia. The sensitivity, specificity, positive and negative predictive values of the sleep history were calculated.In 24.8% of the 303 patients whose histories did not indicate organic insomnia, polysomnography showed there to be an organic cause. Primary causes were obstructive sleep apnoea (13.2%), upper airway resistance syndrome (5.4%), and periodic limb movement disorder (4.0%) or a combination of these. In the histories of 464 patients there were indications that the insomnia had an organic cause and in 325 of them this was confirmed by polysomnography. The sensitivity of detailed history taking to psychophysiological insomnia was 62.1%, the specificity 81.3%, the positive predictive value was 75.2% and the negative predictive value was 70.0%. In patients under the age of 40 with a score on the Epworth sleepiness scale10 (i.e. no hypersomnolence), a BMI25 kg/m2 and indications of psychophysiological insomnia, organic insomnia could not be demonstrated, with the exception of one parasomnia.History-taking only meant that the organic cause was missed in a substantial percentage of patients with insomnia, in particular in older patients with hypersomnolence and a high BMI.

Most individuals with mental disorders complain about the problems they experience with sleeping and waking. It is becoming evident that careful diagnosis of sleep-wake disorders is of great importance for the prevention and treatment of mental disorders. Since the introduction of the DSM-IV, clinical scientific research has provided important new insights in this field.To find out whether the new classification of sleep-wake disorders in DSM-5 is likely to improve the diagnosis of disorders of this type.We discuss the main changes in the DSM-5 classification of sleep- wake disorders, comparing the new version with the version in DSM-IV.Because considerable attention is being given to the symptom-orientated and dimensional approach, the classification of sleep-wake disorders in the DSM-5 is closer to current psychiatric practice and it does justice to the current scientific insights into the dimensional nature of psychiatric disorders.The DSM-5 classification takes recent scientific insights into account and might help to improve the diagnosis of sleep-wake disorders in psychiatry.

There are many different types of sleep disorders. The majority of sleep-related breathing disorders can be attributed to sleep apnoea syndrome. Nocturnal choking sensation is a different symptom, for which we present two cases. Nocturnal choking sensation is a terrifying symptom for the patient and the diagnostic approach can be challenging. Aside from sleep choking syndrome, this symptom may appear with nocturnal laryngospasm, insular epilepsy and nocturnal gastro-oesophageal reflux. A thorough patient history and observation of the nocturnal event, sometimes supported by EEG findings, may provide the clue to the diagnosis. These kinds of nocturnal symptoms are best analyzed in a clinic specialized in both epilepsy and sleep disorders.

Parkinson's disease has traditionally been viewed as a disease with only motor features. Nowadays, a wide variety of non-motor symptoms and signs are also recognised as being characteristic of the disease. Non-motor symptoms, most importantly autonomic dysfunction, neuropsychiatric symptoms and sleep problems, are prevalent in virtually all Parkinson's disease patients and influence the quality of life more than the motor symptoms. Patients may visit a variety of health care professionals, but non-motor symptoms are often missed, because physicians do not explicitly ask patients about them or do not recognise them as being part of the disease. Knowledge of non-motor symptoms is important to avoid unnecessary additional testing. Specific treatment options are available, as described in the Dutch multidisciplinary guidelines on Parkinson's disease.

Smith-Magenis syndrome is a generic disorder, characterised by physical, neurological and behavioural features and caused by a 17p11.2 deletion. Patients with this syndrome typically display an inversion of the sleep-wake cycle. In this article we describe clinical developments in a two-year-old girl with Smith-Magenis syndrome whose sleep problems were successfully treated with melatonin and beta-adrenergic blockers. We also mention relevant data obtained in our literature search.

The obstructive sleep apnea syndrome (OSAS) is characterized by repetitive upper airway obstructions during sleep. This sleep-related breathing disorder is associated with excessive daytime sleepiness and increased cardiovascular risk. Recently, the national multidisciplinary guidelines for the diagnosis and treatment of OSAS in adults have been thoroughly revised. In the guidelines an important place has been created for mandibular repositioning appliances. With these devices, which resemble activators, a widening of the upper airways is produced during sleep by advancing the mandible. According to the guidelines therapy with repositioning appliances should be considered a first-line treatment for patients with mild to moderate OSAS.

Nightmares and insomnia are experienced by 70% of patients suffering from post-traumatic stress disorder (PTSD). These sleep problems are often resistant to treatment and exert a strong negative influence on the quality of life. In the last few decades several studies have reported on the characteristics of sleep disturbances in PTSD.To provide an overview of objective features of sleep disturbances - as opposed to self-report methods - in patients with PTSD.Articles on this topic, published in peer-reviewed journals between 1980 and the present, were retrieved from Medline and Embase, using the search terms 'PTSD', 'sleep', 'nightmares', 'insomnia', 'polysomnography'.Studies reported on changes in sleep efficiency, arousal regulation, motor activity during sleep, rem characteristics and delta sleep activity during sleep. Also, correlations were found between nightmares and sleep apnoea in ptsd. In some studies on sleep disturbance no objective sleep disturbances were found in PTSD patients. However, most studies on PTSD related sleep disturbances were conducted in small, heterogeneous groups, and results were therefore inconsistent. Even the results of larger and more homogeneous studies were sometimes contradictory.There is a discrepancy between the clinical importance of sleep problems in PTSD and unambiguous objective sleep disorders. Future research should try to establish objective criteria for identifying the altered sleep patterns in PTSD. These criteria should help us to understand the neurobiological mechanisms of sleep disturbances in PTSD and develop new treatment strategies.

After successful completion of a benzodiazepine withdrawal programme it nevertheless is hard to remain abstinent in the long term.To determine to what extent the success of a benzodiazepine discontinuation programme for psychiatric patients with chronic benzodiazepine use (or = 3 months) can be predicted from the severity of the anxiety, sleep disorders and depressive symptoms, and from the level of benzodiazepine dependence. The predictive values of coping style and personality characteristics were also studied.A prognostic cohort study with patients of the Radboud University Nijmegen Medical Centre was conducted. Before entering the programme 92 patients were given a psychological assessment. Anxiety level, benzodiazepine dependence, coping style and personality traits were measured by means of psychological questionnaires. The DSM-IV axis I classification for each patient was known. Patients who had stopped their medication immediately after the discontinuation programme ended (n = 6o) were compared with patients who had not been successful in completing the programme (n = 32). Thereafter, patients who were still abstinent at the follow-up about 2 years later (n = 25) were compared with patients who at that time /used benzodiazepine (n = 43).Of all the variables examined, it was only a specific coping style whereby patients expressed their (negative) emotions which was associated with the short- and long-term success of the discontinuation programme. The more patients expressed their negative emotions, the greater the chance of a successful outcome and permanent abstinence. Coping style, however, predicted for only a small proportion of the variance in the success of the discontinuation programme.The psychological characteristics and the DSM-IV axis I classifications should not exert undue influence on the clinician's decision to advise the patient to stop or continue taking benzodiazepines.

The number of indications for the medical use of melatonin is slowly increasing. Melatonin is produced by the pineal gland and is a key signal in the circadian rhythm of the body. Melatonin plays an obvious role in the pathophysiology and treatment of sleep disorders and jetlag. Recent research has also demonstrated its favourable effect on blood-pressure regulation. By analogy, melatonin may play a role in a variety of other circadian processes. However, research into the precise effects is still insufficient.

In this publication a review is presented based on the findings resulting from sleep-wake investigations searching for sleep disorders associated with insomnia in relatively healthy elderly. 44 Relevant journal articles published between 1980-1998 were found. The four most important sleep disorders which can be accompanied by sleeplessness in relatively healthy elderly people are periodic leg movements disorder (PLM), restless legs syndrome (RLS), REM sleep behaviour disorder (RBD) and sleep apnea syndrome (SAS). Of these disorders, sleep apnea and periodic leg movements occur most frequently, in a quarter of the elderly. The latter, however, seldom complain about sleeplessness. Within the category of older people disorders characterized by movements during sleep increase significantly with age, nightly respiration disorders do not. SAS, PLM and RBD appear most frequently in men and RLS in women. The disorders characterized by movements during sleep (especially RLS and RBD) are often accompanied by sleeplessness. SAS, however, is more closely associated with day-time sleepiness than with sleeplessness. No combination of demographic variables and symptoms allows a reliable prediction of these sleep disorders. Fortunately, these disorders are not a major threat to the health of older people.

Description of driving behaviour of patients with excessive daytime sleepiness (EDS) and the influence on their driving of diagnosis, therapy, legal guidelines and advices.Inventory based on questionnaires.Centre for Sleep and Wake Disorders, The Hague, the Netherlands.All patients with EDS who were in a stable condition for at least 6 months after therapy were sent a questionnaire (n = 138). The questions concerned actual driving behaviour, EDS and the effects of diagnosis, therapy and advice given by the Centre.The response was 67% (n = 92). Eighteen patients had never driven a car. Eighteen of the other 74 patients quit driving or drove less. Fifty-six patients did not change their behaviour or drove even more. There was little effect on driving behaviour of diagnosis, therapy and advice to stop driving.Patients with EDS often participate as drivers in modern traffic. Legal guidelines and advice given by physicians have only little influence on this behaviour. As general measures seem to be ineffective, approaches tailored to the individual patient may lead to more acceptable results.

To study the family physician's role in the diagnosis and treatment of multiple sclerosis (MS) patients.Descriptive.Nederlands Instituut voor Onderzoek van de Gezondheidszorg, Utrecht, The Netherlands.In the Dutch National survey of morbidity and intervention in general practice, data were collected by 161 general practices throughout the Netherlands (161 family physicians) regarding contacts with patients during three months. These data were examined for contacts which resulted in the diagnosis of MS and for comorbidity.MS patients (n = 118) had 4.3 encounters per 3 months with their family physician and (or) the practice assistant. In 5 patients MS was diagnosed for the first time. Apart from neurological complaints characteristic of MS the family physician was consulted most frequently for sleeping disorders, urinary tract infections and urine incontinence. One-third of patients depended on social security and 26% had a paid job.The family physician was consulted relatively frequently by MS patients. Apart from sleeping disorders remarkably few psychic complaints were noted.

An inventory has been made on sleeping problems and the use of hypnotics in a nursing home. Contrary to general opinion, the results show that admission to a nursing home does not have to lead to an increase of hypnotics and neuroleptics used. One third of the total patient population revealed severe subjective sleeping problems, for which, however, a therapeutic intervention was not always necessary. In particular somatic revalidation patients showed high percentages of sleeping complaints and medical treatment. A communication hypothesis is presented as a possible explanation: somatic patients are able to ask for medication contrary to psychogeriatric patients, for whom the caregiving network often initiates therapeutic intervention. Attention is focussed on a few sleep disturbing stimuli that often occur in the setting of a nursing home. Prevention of these stimuli implicates changes in the nursing care organization.

The case is reported of a 47-year old female suffering from the exploding head syndrome. This syndrome consists of a sudden awakening due to a loud noise shortly after falling asleep, sometimes accompanied by a flash of light. The patient is anxious and experiences palpitations and excessive sweating. Most patients are more than fifty years of age. Further investigations do not reveal any abnormality. The pathogenesis is unknown, and no therapy other than reassurance is necessary.