Sleep Disorders
Many physiological and biological problems can lead to disruptions in your ability to get a healthy night's sleep. Use the Table of Contents below to click on an area that interests you, or scroll to read the entire article.
DYSOMNIAS
PARASOMNIAS
DYSOMNIAS
Sleep disorders that make it difficult to get to sleep or stay asleep. One of the leading "dysomnias" is Sleep Apnea.
See more on Sleep Apnea >>
What is Insomnia?
Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep. People with insomnia have one or more of the following symptoms:
- Difficulty falling asleep
- Waking up often during the night and having trouble going back to sleep
- Waking up too early in the morning
- Feeling tired upon waking
TIP: Get regular exercise. Try not to exercise close to bedtime because it may stimulate you and raise your core body temperature and make it hard to fall asleep.
Types of Insomnia
There are two types of insomnia: primary insomnia and secondary insomnia.
- Primary insomnia
Primary insomnia means that a person is having sleep problems that are not directly associated with any other health condition or problem.
- Secondary insomnia
Secondary insomnia means that a person is having sleep problems because of something else, such as a health condition (like asthma, depression, arthritis, cancer, heartburn, or pain; medication they are taking; or a substance they are using (like alcohol).
Acute vs. Chronic Insomnia
Insomnia also varies in how long it lasts and how often it occurs. It can be short-term (acute insomnia) or can last a long time (chronic insomnia). It can also come and go with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has insomnia at least three nights a week for a month or longer.
What causes Insomnia?
Causes of acute insomnia can include:
- Significant life stress (job loss or change, death of a loved one, divorce, moving).
- Illness.
- Emotional or physical discomfort.
- Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep.
- Some medications (for example those used to treat colds, allergies, depression, high blood pressure and asthma) may interfere with sleep.
- Interferences in normal sleep schedule (jet lag or switching from a day to night shift, for example).
Causes of chronic insomnia include:
- Depression and/or anxiety.
- Chronic stress.
- Pain or discomfort at night.
- Poor habits (what sleep specialists call “sleep hygiene”): These habits start as strategies that patients enlist to help themselves through bouts of acute insomnia, but which actually perpetuate and exacerbate the problem, e.g. bringing a TV into the bedroom or spending more time in bed.
What are the symptoms of insomnia?
Symptoms of insomnia include:
- Sleepiness during the day.
- General tiredness.
- Irritability.
- Problems with concentration or memory.
- Worrying during the day about the upcoming night's sleep.
Who is affected by Insomnia?
Insomnia can affect children as well as adults. It does become more prevalent as we age. Women are more affected then men. They report insomnia symptoms twice as often. At any given moment, nearly 50% of the American population report insomnia; 10% have chronic insomnia that lasts for more then 1 month. Usually they have had insomnia for years.
How is insomnia diagnosed?
If you think you have insomnia, talk to your doctor. Often it is prudent to have a consultation with a sleep specialist because often other sleep disorders can masquerade as insomnia. An evaluation may include a physical exam, a medical history, and a sleep history. You may be asked to keep a sleep diary for a week or two, keeping track of your sleep patterns and how you feel during the day. The sleep doctor may want to interview your bed partner about the quantity and quality of your sleep. In some cases, you may be referred to a sleep center for special tests, such as an overnight sleep study if the doctor thinks that your symptoms suggest that another sleep disorder is present.
How is insomnia treated?
Acute insomnia may not require treatment. Mild insomnia often can be prevented or cured by practicing good sleep habits (see below). If your insomnia makes it hard for you to function during the day because you are sleepy and tired, your doctor may prescribe sleeping pills for a limited time. Rapid onset, short-acting medications can help you avoid effects such as drowsiness the following day. Avoid using over-the-counter sleeping pills for insomnia since they may have undesired side effects and tend to lose their effectiveness over time.
Treatment for chronic insomnia includes first treating any underlying conditions or health problems that are causing the insomnia. If insomnia continues, your sleep specialist may suggest cognitive behavioral therapy. Behavioral approaches help you to change habits that may worsen insomnia and to learn new behaviors to help promote sleep. Techniques such as relaxation, exercise, sleep restriction therapy, stimulus control and reconditioning may be useful.
What habits promote a good night's sleep?
Check out Dr. Shive's Tips to Promote a Good Night's Sleep >>
Restless Leg Syndrome: What is Restless Leg Syndrome?
Restless legs syndrome (RLS) is a disorder of the part of the nervous system that affects movements of the legs. Because it usually interferes with sleep, it also is considered a sleep disorder.
What causes Restless Leg Syndrome?
RLS patients have been shown to have low iron storage in the brain. We know iron is necessary for the proper synthesis and functioning of Dopamine which is an important neurotransmitter.
Symptoms of Restless Legs Syndrome
People with RLS have strange sensations in their legs (and sometimes arms) and an irresistible urge to move their legs to relieve the sensations. The sensations are difficult to describe: they are usually not painful, but are reported to be uncomfortable, "itchy," "pins and needles," or "creepy crawly" feeling deep in the legs. The sensations are usually worse at rest, especially when lying in bed. Symptoms usually occur only in the evening. The sensations lead to discomfort, sleep deprivation, and stress.
The severity of RLS symptoms ranges from mild to intolerable. Symptoms get gradually worse over time in about two thirds of people with the condition and may be severe enough to be disabling. Most people have these symptoms only intermittently but in severe cases, they can occur nightly. The symptoms are generally worse in the evening and night and less severe in the morning. While the symptoms are usually quite mild in young adults, by age 50 the symptoms may cause severe nightly sleep disruption that can significantly impair a person's quality of life.
Who is affected by Restless Legs Syndrome?
RLS affects about 10% of the U.S. population to some degree. Only a small percentage has severe RLS. It affects both men and women and may begin at any age, even in infants and young children. It is common in pregnancy affecting on average 20% of pregnant women. Most people who are affected severely are middle-aged or older. Other medical conditions such as anemia or kidney disease can put you at greater risk for RLS.
RLS is often unrecognized or misdiagnosed. In many people, the condition is not diagnosed until 10-20 years after symptoms begin.
How is RLS diagnosed?
RLS is a clinical diagnosis which means it is not based on any given test, but on your symptoms, medical history and physical exam.
How is RLS treated?
Once correctly diagnosed, RLS can often be treated successfully with medications. Sometimes people with RLS have low iron, therefore, iron supplements can help relieve the symptoms. Before a treatment plan is decided on, your sleep specialist should do a blood test to look at iron levels in your blood, in particular, Ferritin, which is a marker of iron storage levels. If Ferritin is low and symptoms are mild or intermittent then most sleep specialists will try iron replacement first. If iron is not the problem or iron therapy is not effective or symptoms are causing great sleep disruption, then there are 4 classes of medication that are used:
- Dopamine agonists, e.g. pramipexole (Mirapex), ropinirole (Requip)\
- Anti-epileptics, e.g. gabapentin (Neurontin)
- Benzodiazepines, e.g. clonazepam (Klonopin)
- Opioids, e.g. Methadone
Narcolepsy: What is Narcolepsy?
Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. It is characterized by slippage between 2 states of being: wake and REM sleep. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the day usually every 2-3 hours. These sudden sleep attacks may occur during any type of activity at any time of day.
Many narcolepsy patients are diagnosed, usually erroneously with psychiatric disorders such as depression, malingering, or even schizophrenia. In many cases, narcolepsy is undiagnosed and, therefore, untreated.
What causes Narcolepsy?
The cause of narcolepsy is not known; however, it results in a loss of neurons in the brain that produce a chemical called hypocretin. Hypocretin is a neurotransmitter and is thought to be a wake-promoting agent. In addition, researchers have discovered abnormalities in various parts of the brain involved in regulating sleep which seem to contribute to symptom development.
It is likely narcolepsy involves multiple factors that interact to cause neurological dysfunction and sleep disturbances.
What are the symptoms of Narcolepsy?
Symptoms of narcolepsy include:
- Excessive daytime sleepiness (EDS)
This symptom is the sinequanon of narcolepsy. In general, EDS interferes with normal activities on a daily basis, whether or not a person with narcolepsy has sufficient sleep at night. People with EDS report mental cloudiness, a lack of energy and concentration, memory lapses, a depressed mood, and/or extreme exhaustion. Furthermore, people with narcolepsy have actual sleep attacks many times during the day.
- Cataplexy
This symptom consists of a sudden loss of muscle tone that leads to feelings of weakness and a loss of voluntary muscle control. It can cause symptoms ranging from slurred speech to total body collapse depending on the muscles involved and is often triggered by intense emotion, for example surprise, laughter or anger.
Click this link to watch Rusty, the narcoleptic dog >>
- Hallucinations
Usually, these delusional experiences are vivid and frequently they are frightening. They occur as the person is falling asleep or just waking up and likely represent REM intrusion with dream mentation. The content is primarily visual, but any of the other senses can be involved.
- Sleep paralysis
This symptom involves the temporary inability to move or speak while falling asleep or waking up which is very frightening to the patient. These episodes are generally brief lasting a few seconds to several minutes. After episodes end, people rapidly recover their full capacity to move and speak.
Narcolepsy: Who is affected?
The peak age at which symptoms occur is 15-25 years. A second smaller peak of onset has been noted between 35-45 years, and near menopause in women.
Narcolepsy: How is it diagnosed?
Sometimes, the diagnosis of Narcolepsy is fairly apparent from the patient's complaints, especially if the patient or a family member describes cataplexy which is a phenomenon unique to narcolepsy. Still, the American Academy of Sleep Medicine recommends that the diagnostic work-up for Narcolepsy include an overnight sleep study (polysomnogram) followed by a Multiple Sleep Latency Test, which is a daytime nap study that attempts to quantify daytime sleepiness and document a shortened REM latency which means REM occurs very shortly after falling asleep. In rare cases, cerebro-spinal fluid is taken from the patient via a lumbar puncture in order to analyze the levels of Hypocretin (AKA Orexin) which are typically very low and undetectable in patients with Narcolepsy. Even less often, a genetic test can be run. This is rarely considered to impart additional information, because a large percentage of patients without Narcolepsy have the same biologic markers.
How is it treated?
There are medications that can be quite effective and can help people with narcolepsy lead normal lives. Stimulants such as Modafanil (Provigil) are used to improve day time alertness and hypnotics such as sodium oxybate (Xyrem) are used to consolidate sleep. Sodium Oxybate is also effective at treating Cataplexy. Other medications useful for treating Cataplexy are anti-depressants such as SSRIs (Serotonin selective re-uptake inhibitors).
PARASOMNIAS
Sleep disorders characterized by arousal, partial arousal, or sleep stage transitions. They are marked by abnormal behaviors during sleep.
REM Behavior Disorder (RBD)
Normal sleep has 2 distinct states: non–rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep is divided into 3 stages (N1, N2, N3). During REM sleep, rapid eye movements occur, breathing becomes irregular, blood pressure rises, and there is loss of muscle tone (paralysis). However, the brain is highly active, and the electrical activity recorded in the brain by EEG during REM sleep is similar to that recorded during wakefulness. REM sleep is usually associated with vivid dreaming. Normally REM sleep accounts for 20-25% of the sleep period, and this percentage remains fairly stable throughout the human life span.
In a person with REM behavior disorder (RBD), the paralysis that normally occurs during REM sleep is incomplete or absent, allowing the person to "act out" his or her dreams. RBD is characterized by the acting out of dreams that are vivid, intense, and violent. Dream-enacting behaviors include talking, yelling, punching, kicking, sitting, jumping from bed, arm flailing, and grabbing. An acute form may occur during withdrawal from alcohol or sedative-hypnotic drugs.
RBD is usually seen in middle-aged to elderly people. It is 9 times more common in men than in women.
What causes RBD?
The exact cause of REM behavior disorder (RBD) is unknown, although the disorder may occur in association with various degenerative neurological conditions such as Parkinson’s disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. In 55% of persons the cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine, sertraline, or paroxetine) or other types of antidepressants (mirtazapine).
What are the symptoms of RBD?
Patients ”Act Out” their dreams causing harm to themselves and/or bed partners. Their sleep is disturbed only if they are awakened by a frightened spouse or they fall out of bed. Patients and their bed partners have had serious injuries and some deaths have been attributed to this disorder.
Who is affected?
RBD often precedes the development of neurodegenerative disease such as Parkinson’s Disease by several years. In one study, 60% of patients diagnosed with RBD subsequently developed Parkinson’s disease with a lag time that can be as long as 12-13 years from the onset of RBD symptoms. The prevalence of RBD is increased in persons with Parkinson’s disease and in multisystem atrophy where it is observed in 69% of these patients. The relationship between RBD and Parkinson’s disease is complex and not yet well-understood, but it behooves a patient with RBD to be followed closely by a neurologist.
How is RBD diagnosed?
Often, the patient gives a history of acting out dreams and this gives the sleep specialist a strong suspicion of RBD, but the American Academy of Sleep Medicine strongly recommends an overnight sleep study where decreased muscle tone during REM may be observed as well as frank dream enactment.
How RBD is treated?
The good news is that this disorder is easily treated in 90% of cases with a low dose benzodiazepine such as Clonazepam. Patients often get relief after 1 night of treatment and most within one week.
Nightmares
Nightmares are vivid nocturnal events that can cause feelings of fear, terror, and/or anxiety. Usually, the person having a nightmare is abruptly awakened from REM sleep and is able to describe detailed dream content. Typically, they occur more during the early morning hours. Usually, the person having a nightmare has difficulty returning to sleep.
Nightmares can be caused by many factors including illness, anxiety, the loss of a loved one, or negative reactions to a medication. Extreme cases are usually associated with Post-traumatic Stress Disorder (PTSD). Call your doctor if nightmares occur more often than once a week or if nightmares prevent you from getting a good night's sleep for 1 month or more. There are medications such as alpha-blockers that can be useful.
Night Terrors
Night Terrors are to be distinguished from nightmares in the following ways: (1.) They are more common in children; (2.) The person is inconsolable and does not usually awaken; (3.) The person has no memory of the event in the morning; (4.) Usually they occur during the first 2-3 hours of sleep; (5.) They do not disturb the sleep or daytime function of the patient, but are quite distressful to the rest of the household.
Sleepwalking
Sleepwalking occurs when a person appears to be awake and moving around but is actually asleep. They have no memory of their actions. Sleepwalking most often occurs during deep non-REM sleep (stage 3) early in the night. This disorder is most commonly seen in children ages eight to twelve; however, sleepwalking can occur among younger children, adults and elderly patients.
Sleepwalking appears to run in families. Contrary to what many people believe, it is not dangerous to wake a person who is sleepwalking. The sleepwalker simply may be confused or disoriented for a short time upon awakening. Although waking a sleepwalker is not dangerous, sleepwalking itself can be dangerous because the person is unaware of his or her surroundings and can bump into objects or fall down. In most children, it tends to stop as they enter the teen years. Keeping the person safe is the primary consideration. It may be necessary to place alarms on doors and windows and to never allow the sleepwalker to sleep above the first floor.
Confusional Arousals
Confusional arousals usually occur when a person is awakened from a deep sleep during the first part of the night. This disorder, which also is known as excessive sleep inertia or sleep drunkenness, involves an exaggerated slowness upon awakening. People experiencing confusional arousals react slowly to commands and may have trouble understanding questions that they are asked. In addition, people with confusional arousal often have problems with short-term memory and have no memory of doing these things the following day.
Sleep Talking
Sleep talking is a sleep-wake transition disorder. Although it usually is harmless, sleep talking can be disturbing to sleep partners or family members who witness it. Talk that occurs during sleep can be brief and involve simple sounds, or it can involve long speeches by the sleeper. A person who talks during sleep typically has no recollection of the actions. Sleep talking can be caused by external factors including fever, emotional stress or other sleep disorders.
Nocturnal Leg Cramps
Nocturnal leg cramps are sudden, involuntary contractions most commonly of the calf muscles during the night or during periods of rest. The cramping sensation may last a few seconds or up to 10 minutes, but the pain from the cramps may linger for a longer period. Nocturnal leg camps tend to be found in middle-aged or older populations, but people of any age can have them. Nocturnal leg cramps differ from restless legs syndrome as the latter usually does not involve cramping.
The cause of nocturnal leg cramps is not known. Some cases of the disorder can occur without a triggering event, while other causes of leg cramps may be linked to prolonged sitting, dehydration, an overexertion of the muscles, or structural disorders (such as flat feet). Muscle-stretching, exercise and adequate water intake may help prevent leg cramps. Some physicians suggest an increase in minerals such as calcium, magnesium and potassium.
Sleep Paralysis
People with sleep paralysis are not able to move their body or limbs. It can occur either when falling asleep or waking up. Brief episodes of partial or complete skeletal muscle paralysis can occur during sleep paralysis. Sometimes sleep paralysis runs in families, but the cause of sleep paralysis is not known. This disorder is not harmful, but people experiencing sleep paralysis often are fearful because they do not know what is happening. An episode of sleep paralysis often is terminated by sound or touch. Within minutes, the person with sleep paralysis is able to move again. It may occur only once in a lifetime or can be a recurrent phenomenon. It is seen most commonly in people with narcolepsy.
Impaired Sleep-related Penile Erections
This disorder occurs among men who are unable to sustain a penile erection during sleep that would be sufficiently rigid enough to engage in sexual intercourse. Men usually experience erections as a part of REM sleep, and impaired sleep-related erections may indicate erectile dysfunction of organic, rather than psychological, origin.
Sleep-related Painful Erections
Erections are a normal component of REM sleep for men. In rare cases, however, erections become painful and cause a man to wake up. The treatment of sleep-related painful erections may involve drugs that suppress REM sleep (some antidepressants, for example).
REM Sleep Cardiac Arrhythmias
A cardiac arrhythmia is a change from the normal rate or rhythm of the heart’s contractions. People who have coronary artery disease and whose blood oxygen is lowered by sleep-disordered breathing may be at risk for arrhythmias, which often take place during REM sleep. Continuous positive airway pressure (CPAP) treatment may reduce this risk.
Sleep Bruxism
Sleep bruxism involves the involuntary, unconscious, excessive grinding or clenching of teeth during sleep. It may occur along with other sleep disorders. For example, it is often associated with sleep apnea. Sleep bruxism may lead to problems including abnormal wear of the teeth and jaw muscle discomfort. The severity of bruxism can range from mild cases to severe cases that involve evidence of dental injury. In some cases, bruxism can be prevented with the use of a mouth guard. The mouth guard, supplied by a dentist, can fit over the teeth to prevent teeth from grinding against each other.
Nocturnal Paroxysmal Dystonia (NPD)
This disorder is sometimes marked by seizure-like episodes during non-REM sleep. Most evidence points to NPD being a form of epilepsy. Episodes of NPD typically recur several times per night.
Nocturnal Seizures
Nocturnal seizures are difficult to distinguish from parasomnias. They might occur just after a person has fallen asleep, just before waking, during daytime sleep, or while in a state of drowsiness. People who experience nocturnal seizures may find it difficult to wake up or to stay awake. Although unaware of having had a seizure while asleep, they may arise with a headache, have temper tantrums, or other destructive behavior throughout the day. Nocturnal seizures and their mechanisms are poorly understood. The majority of people with nocturnal seizures have idiopathic epilepsy and there is evidence that sleep enhances epileptic discharges in the EEG, though their daytime recordings may appear to be normal. Any repetitive, stereotyped behavior during sleep could be a seizure and should be investigated with an overnight sleep study with extended EEG monitoring.
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