Sleep Disorders: Insomnia, Sleep Apnea and Treatment
Insomnia, sleep apnea, narcolepsy and parasomnias. Specialized diagnosis and treatment of sleep disorders by psychiatrist Paschalis Gkikas.
Sleep Disorders: Insomnia, Sleep Apnea and Treatment
Sleep is not a luxury — it is a biological necessity. When it is chronically disrupted, the consequences extend far beyond fatigue: cognitive function, immunity, cardiovascular health and mental balance are affected. Paschalis Gkikas specializes in Sleep Medicine and in the management of complex cases that combine psychiatric and sleep-related pathology.
What are sleep disorders?
Sleep disorders are a broad category of conditions that affect the quality, duration or timing of sleep. ICD-10 (F51, G47) and DSM-5 distinguish the following main categories:
- Insomnia (F51.0 / G47.0): Difficulty initiating or maintaining sleep, or early-morning awakening, despite adequate opportunity for sleep. It is chronic when it persists at least 3 nights per week for more than 3 months.
- Sleep apnea (G47.3): Repeated pauses in breathing during sleep — obstructive (OSA) or central — resulting in fragmented sleep and hypoxemia.
- Narcolepsy (G47.4): Excessive daytime sleepiness, cataplexy, sleep paralysis and hypnagogic hallucinations — due to orexin/hypocretin deficiency.
- Restless Legs Syndrome / RLS (G25.81): An irresistible urge to move the legs, worsening in the evening and interfering with sleep.
- Parasomnias (F51.3–F51.5): Sleepwalking, night terrors, nightmares — unwanted behaviors that occur during sleep or during transitions into and out of sleep.
- Circadian rhythm disorders (F51.2): Mismatch between the internal “clock” and the social schedule — delayed sleep phase, jet lag, shift work disorder.
- Hypersomnia (F51.1): Excessive daytime sleepiness despite adequate nocturnal sleep, without an identifiable cause.
Clinical presentation and symptoms
Night-time symptoms
- Difficulty falling asleep (>30 minutes)
- Frequent awakenings or inability to return to sleep
- Early final awakening
- Snoring, breathing pauses (OSA)
- Sensation of “crawling” or “itching” in the legs (RLS)
- Sleep-related behaviors (parasomnias)
Daytime symptoms
- Fatigue and reduced energy
- Cognitive decline, difficulty with concentration and memory
- Irritability, emotional instability
- Excessive daytime sleepiness, with driving risk
- Poor decisions, reduced occupational performance
Neurobiological basis
- Circadian system: The suprachiasmatic nucleus (SCN) of the hypothalamus functions as the “master clock” — regulating melatonin secretion and the circadian distribution of sleep and wakefulness.
- Adenosine and sleep pressure: Adenosine accumulates during wakefulness and creates “pressure” for sleep — caffeine blocks its receptors.
- Orexina/hypocretin: A neuropeptide that stabilizes wakefulness. Its deficiency is the pathophysiological basis of narcolepsy.
- GABA system: The main inhibitory neurotransmitter that facilitates the transition to sleep — the target of benzodiazepines and Z-drugs.
- HPA axis and stress: Chronic cortisol hypersecretion from stress, depression or PTSD directly disrupts sleep — explaining the deep connection between psychiatric and sleep pathology.
- Glymphatic system: During deep sleep (slow-wave sleep), the brain’s glymphatic system clears toxic protein residues, including β-amyloid. Chronic insomnia is associated with increased risk of neurodegenerative disorders.
Treatment approach
Sleep is the hidden pillar of every treatment plan. In Paschalis Gkikas’ practice, assessment of sleep quality is an integral part of every psychiatric evaluation — even when the patient has not presented it as the main complaint.
First-line treatments
- CBT-I (Cognitive Behavioral Therapy for Insomnia): The internationally recognized gold standard for chronic insomnia — more effective than pharmacotherapy in the long term. It includes sleep restriction, stimulus control, cognitive restructuring and sleep hygiene education.
- PGx-guided pharmacotherapy: Selection of a hypnotic is not trivial. Paschalis Gkikas assesses the genetic metabolic profile to select the safest and most effective option — from melatonin agonists to Z-drugs and selected antidepressants.
- CPAP device: For obstructive sleep apnea — in collaboration with a pulmonologist.
- Treatment of comorbidity: Depression, anxiety disorders and PTSD are among the main causes of secondary insomnia — treating them often regulates sleep automatically.
Second-line and specialized interventions
- rTMS: Neuromodulation protocols are being investigated for primary insomnia and insomnia comorbid with depression, targeting networks that regulate the sleep-wake cycle.
- tDCS: Emerging option for neurological optimization of sleep networks in specialized settings.
- Pharmacological interventions for RLS: Dopamine agonists, gabapentin — selected according to clinical profile and PGx.
- Light therapy: For circadian rhythm disorders.
Frequently asked questions (FAQ)
When does insomnia need psychiatric assessment rather than simple sleep hygiene?
When it persists for more than 3 months, when it is accompanied by depressive or anxiety symptoms, when fatigue affects occupational or social functioning, or when medication has already been tried without satisfactory benefit.
Is long-term use of hypnotics dangerous?
Benzodiazepine hypnotics are associated with dependence and cognitive effects when used chronically. Newer classes, such as orexin antagonists and melatonin agonists, have a more favorable safety profile. Selection is always individualized.
Can sleep apnea be related to depression?
Yes — there is a strong bidirectional relationship. Undiagnosed sleep apnea often appears as treatment-resistant depression. In every case of depression with marked daytime fatigue and snoring, sleep apnea must be ruled out.
Is a sleep laboratory study (polysomnography) needed to diagnose insomnia?
For classic chronic insomnia, diagnosis is clinical. Polysomnography is mainly indicated when sleep apnea, narcolepsy, REM sleep behavior disorder or unexplained hypersomnia is suspected.
