Sleep disorders occur when an individual has problems with his/her sleep cycle. As a result, it may take patients longer to fall asleep, patients may wake up during the night, wake up early, they may fall asleep throughout the day, have severe nightmares (called night terrors), act out their dreams, or stop breathing during sleep.
The most common types of sleep disorders include delayed sleep phase syndrome (DSPS), insomnia, narcolepsy, night terrors, REM sleep behavior disorder (RBD), and sleep apnea.
There are two phases of sleep: non-rapid eye movement (NREM) sleep and rapid eye movement sleep (REM). The first hour or two of sleep is called NREM sleep. During this phase, the brain waves slow down.
After one to two hours of NREM sleep, the brain activity increases, and REM sleep begins. This is when most dreaming occurs. During REM sleep, the eyes (although closed) move rapidly, breathing becomes irregular, blood pressure rises, and individuals are in a state of temporary sleep paralysis. This temporary immobility prevents individuals from acting out their dreams.
Most sleep disorders can be managed with lifestyle changes and/or medications.
Apnea, biological clock, cataplexy, circadian rhythm, delayed sleep phase syndrome, DSPS, insomnia, non-rapid eye movement, narcolepsy, night terrors, NREM, polysomnogram, rapid eye movement, RBD, REM, REM sleep behavior disorder, sleep, sleep apnea, sleep center, sleep disturbances, sleep paralysis.
delayed sleep phase syndrome (dsps)
Overview: Delayed sleep phase syndrome (DSPS), also called circadian rhythm sleep disorder- delayed sleep phase type, occurs when a person's internal clock is not in sync with the normal sleep patterns of most adults. The patient's sleep pattern is delayed by two or more hours, causing later bedtimes and wake times.
When patients follow their internal clocks and go to bed when they are tired, they get enough sleep. However, patients with DSPS have abnormal internal clocks, and they typically do not feel tired until 2:00 a.m. or later. Since this does not match normal school and work schedules, patients feel tired when they try to follow conventional sleeping schedules.
DSPS patients typically find that sleeping aids do not help them fall asleep any earlier.
DSPS is a long-term condition that is most common among adolescents. DSPS can develop suddenly or gradually. Symptoms generally go away spontaneously without treatment.
Causes: DSPS is not caused by jet lag, working late shifts, working irregular shifts, or other external factors. Instead, DSPS is caused by an abnormality in the patient's internal clock (called the circadian rhythm).
Symptoms: Patients with DSPS generally have difficulty falling asleep before 2:00 a.m. Individuals often feel tired upon waking. Individuals may continue to feel fatigued or drowsy throughout the day.
Diagnosis: If it is suspected that a patient has DSPS, the individual may be asked to keep a sleep log. In the log, the patient writes what time they fell asleep and woke up each day. In order for DSPS to be diagnosed, symptoms must last at least three months. However, DSPS is often misdiagnosed because symptoms of this disorder are very general and similar to insomnia or some types of mental illness (such as depression).
Treatment: There is currently no cure for DSPS, but symptoms generally go away on their own. Treatment is available to help manage symptoms by reprogramming the patient's internal clock. The goal is to synchronize the patient's sleep patterns with their work and/or school schedules. Treatment often includes light therapy and chronotherapy. Patients may also benefit from melatonin supplements taken 30 minutes to one hour before bed. Melatonin should be used cautiously because high doses may disturb sleep and cause nightmares and uncontrollable yawning the next day. If treatment does not help, patients may need to change their work and social lives to accommodate their internal clocks.
Overview: Insomnia occurs when individuals have difficulty falling or staying asleep, and they wake up too early in the morning. It is a common health problem that can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia may cause an individual to feel tired, depressed, or irritable. Individuals may also have trouble paying attention, learning, and remembering, which may prevent them from performing fully on the job or at school. Severe insomnia can result in neurochemical (brain chemical) changes that may lead to problems, such as depression and anxiety, further complicating the insomnia.
Causes: There are many potential causes of insomnia. Psychological disorders, such as stress, anxiety, depression, and bipolar disorder, may lead to insomnia. Certain health conditions, including arthritis, overactive thyroid glands, gastrointestinal disorders (such as diarrhea or ulcers), Alzheimer's disease, Parkinson's disease, sleep apnea (discussed in detail below), and restless legs syndrome (RLS), may cause insomnia. Other factors, such as taking certain medications (such as stimulants, nasal decongestants, and some antidepressants), consuming caffeine, jet lag, wake-sleep pattern disturbances, excessive sleep during the day, and excessive physical or intellectual stimulation before bed, may cause insomnia.
Symptoms: The main signs and symptoms of insomnia are trouble falling or staying asleep or waking early, followed by a distinct feeling of fatigue (tiredness) the following day. Most often, daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include anxiousness, irritability, fatigue, poor concentration and difficulty focusing, impaired memory, decreased motor coordination, irritability, impaired social interaction, and motor vehicle accidents because of fatigued, sleep-deprived drivers.
Diagnosis: A doctor will ask the individual experiencing insomnia questions to evaluate his/her medical history. Questions investigate mental health problems, medications (prescription and non-prescription drugs, herbs, and supplements), history of pain, leisure habits, work and home situation, and others. The doctor will also inquire about the individual's sleep history. Questions about length and severity of the sleeping problem, routines before sleeping, snoring, and noise levels may also be asked. The doctor will also give the individual a full physical exam, including blood tests for conditions (such as thyroid problems) that may interfere with sleep. A polysomnogram is a recording of the breathing, movements, heart function, and brain activity during sleep. For this study, the individual sleeps overnight at a sleep center or hospital. A sleep study will be recommended if there are signs of sleep apnea or restless legs syndrome (RLS).
Treatment: Treatment for insomnia depends on the underlying cause. For instance, if a psychological problem is causing symptoms, a healthcare provider may recommend psychotherapy or cognitive behavioral therapy. If a medication is the suspected cause, a healthcare provider may be able to recommend a different drug or dosage.
There are many sedative-hypnotic medications available to help patients fall asleep and stay asleep throughout the night. Commonly prescribed medications for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), triazolam (Halcion®), zolpidem (Ambien®), zaleplon (Sonata®), and eszopiclone (Lunesta®).
However, the U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep because they may cause serious side effects. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.
Over-the-counter (OTC) sleep aids may be used short-term to treat insomnia. For instance, diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid. It can be purchased alone (Benadryl®, Nytol®, or Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). OTC sleep aids are not intended for long term use, because dependency can develop.
Melatonin agonists, such as ramelteon (Rozerem®), have also been used to treat insomnia. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. These drugs are less likely to cause morning drowsiness than sedative-hypnotics. Side effects are generally mild and may include daytime sleepiness, dizziness, and fatigue.
Sedating antidepressants, including trazodone (Desyrel®), amitriptyline (Elavil®), and doxepin (Sinequan®), have been used to treat insomnia. When used to promote sleep, these medicines are used in lower doses than when used to treat depression. Side effects may include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.
Overview: Narcolepsy is a sleep disorder that occurs when individuals are overwhelmingly tired and spontaneously fall asleep throughout the day. Patients have a hard time staying away for extended periods of time, regardless of the circumstances or how much sleep they get.
The severity of narcolepsy varies among patients. Most patients are diagnosed between the ages of 10 and 25. It is uncommon for patients to be diagnosed with the disorder when they are older than 40 years of age.
Causes: Researchers are still performing studies to fully understand the causes of narcolepsy. Scientists believe that genetics may play a role in the disorder. However, since only about two percent of narcoleptic patients have family histories of the disorder, other factors besides genetics are probably involved.
Narcoleptic patients may have imbalances in the brain chemicals that help control sleep. For instance, one chemical called hypocretin has been shown to help individuals wake from sleep and stay awake. Patients with narcolepsy typically have low levels of this chemical. However, researchers do not know what causes individuals to have low levels of hypocretin. It has been suggested that the body's immune system might attack hypocretin-producing cells by mistake.
Symptoms: Patients with narcolepsy are excessively tired throughout the day. Individuals can fall asleep at any time or any place throughout the day. For instance, they may fall asleep in the middle of conversations with friends. These sleep attacks may last anywhere from a few minutes to a half hour. Individuals also experience decreased alertness and concentration.
About 70% of narcoleptic patients also experience periodic episodes of cataplexy, which is a sudden and temporary loss of muscle tone. This condition, which may last anywhere from a few seconds to a few minutes, may cause symptoms that range from slurred speech and drooling to complete muscle weakness. Laughter or strong emotions, especially excitement and sometimes fear or anger, typically trigger cataplexy. Some patients may only experience cataplexy a few times a year, while others may experience symptoms several times a day.
Sleep paralysis may also occur while the individual is falling asleep or awakening. This temporary inability to move typically lasts anywhere from a few seconds to several minutes. When sleep paralysis occurs, patients may feel scared because they are often aware of what is happening even though they cannot move.
Some patients may experience hallucinations. This occurs if the patient is semi-awake when he/she starts dreaming.
Additional symptoms may include restless nighttime sleep or sleepwalking. Some patients may also act out their dreams and talk or move their arms or legs.
Diagnosis: If narcolepsy is suspected, the patient may be required to spend the night at a sleep center. During the night, a team of specialists will observe the patient's sleep patterns and behavior. Electrodes may also be placed on the patient's scalp before he/she falls asleep. This test, called a polysomnogram, measures the electrical activity of the brain and heart, as well as the movements of the muscles and eyes.
Patients may also be asked to fill out a sleep questionnaire, called the Epworth Sleepiness Scale. This survey asks the patient to rank how tired they are during certain activities.
A multiple sleep latency test may also be performed at a sleep center. The patient will be asked to take several naps that are about two hours apart. Narcoleptic patients will fall asleep quickly and enter rapid eye movement (REM) sleep almost immediately.
Treatment: Because narcolepsy is a neurological disorder, the condition does not improve if the patient gets more sleep. Although there is no cure for narcolepsy, medications can help manage symptoms. Patients typically receive medications called central nervous system (CNS) stimulants. These drugs help narcoleptic patients stay awake during the day. Modafinil (Provigil®), a newer stimulant, is less addictive and better tolerated than other older types of stimulants. However, some patients need treatment with methylphenidate (Ritalin®) or other types of amphetamines.
In addition, patients often take antidepressants, such as protriptyline (Vivactil®), imipramine (Tofranil®), and amitriptyline (Elavil®). These medications suppress REM sleep. As a result, they help control symptoms of cataplexy, hallucinations, and sleep paralysis.
Another prescription medication, called sodium oxybate (Xyrem®), may also be prescribed to some patients. This medication, which is taken at night, helps reduce symptoms of sleep paralysis, hallucinations, and cataplexy.
Even though this medication is taken at night, high doses may also help control daytime sleepiness. Serious side effects, including difficulty breathing during sleep, sleepwalking, and bedwetting, have been reported. Therefore, this medication is only taken when other medications are unsuccessful. Xyrem® is not sold in local pharmacies. Instead, a healthcare provider must enroll a patient in a restricted distribution risk-management program that offers the drug from a single centralized pharmacy, the Xyrem® Success Program™.
Overview: Night terrors are similar to nightmares. However, night terrors are scarier and more intense. Night terrors typically cause individuals to scream and thrash about during sleep. Individuals usually do not remember their night terrors when they wake in the morning.
Night terrors primarily affect young children, usually between the ages of four and 12. Night terrors during childhood are not usually a cause for concern, and most children outgrow night terrors by adolescence.
In rare cases, adults may experience night terrors, usually in response to extreme stress or anxiety. Adults may benefit from medications if they experience frequent night terrors.
Causes: Many factors, including fatigue, stress, illnesses (especially those that cause fevers) and medications that affect the brain or spinal cord (such as stimulants), may cause night terrors.
Symptoms: Night terrors typically occur two to three hours after an individual has fallen asleep. During sleep, the patient may scream or yell, sit up in bed, thrash around, sweat, or breathe rapidly. If a parent or bedmate tries to hold or comfort the patient during a night terror, the patient may unknowingly put up a fight. Adults, who are larger and stronger than children, may even injure their bedmate as they thrash around during night terrors. Most night terrors only last a few minutes. Once the individual wakes up, he/she probably will not remember the episode.
Diagnosis: Night terrors usually do not require a diagnosis. A healthcare provider may perform a physical and/or psychological exam to determine what might be triggering the terrors.
Treatment: Children who experience night terrors generally do not require any treatment. Parents may gently restrain their children to try and calm them down. Speaking softly and calmly is recommended because shouting or shaking the child awake typically worsens the episode.
Although rarely used, medications called benzodiazepines, such as clonazepam (Klonopin®) may be used short-term to reduce symptoms in children. Antidepressants, such as imipramine (Tofranil®), may also help if night terrors affect the child's performance at school.
Adults may also benefit from these medications if they experience frequent night terrors or if they are harming their bedmates during episodes. If stress or anxiety seems to be causing night terrors, a healthcare provider may recommend psychotherapy.
It is also important to ensure that the patient's bedroom is safe. For instance, children who experience night terrors should not sleep on the top of a bunk bed. Consider blocking stairways with a gate. Any sharp or unsafe objects should be out of the patient's reach.
rem sleep behavior disorder
Overview: REM sleep behavior disorder (RBD) occurs when patients do not experience temporary paralysis during REM sleep. As a result, patients act out their dreams, which are often intense, vivid, and violent. The patient may yell, punch, kick, jump up from bed, and punch the air.
RBD typically occurs in middle-aged to elderly patients. It is more common in men than women.
Causes: The exact cause of RBD remains unknown. However, the disorder has been linked to many degenerative neurological (brain) disorders, including Parkinson's disease. It is important to note that not all patients with RBD develop neurological disorders.
Symptoms of RBD may also occur during withdrawal from alcohol or sedative-hypnotic drugs. However, this form is only temporary and goes away once the person has gone through withdrawal.
Symptoms: Patients with RBD act out their dreams. This may include yelling, screaming, thrashing around, kicking, punching, sitting up in bed, or getting out of bed during sleep. In some cases, RBD may cause self injury or injury to the bed partner. If the person wakes up in the middle of an attack, he/she is often able to remember the dream in detail.
Diagnosis: A polysomnographic video recording is typically performed to diagnose RBD. During the test, the patient will spend the night at a sleep center. When the patient is asleep, researchers will monitor the electrical activity of the brain and heart, the movement of the muscles, the movements of the eyes, and breathing patterns. A video recording is also made to monitor the physical behavior of the patient during sleep. Patients with RBD will have an increase in muscle movements in association with increased brain activity.
Overview: Sleep apnea is a serious condition that occurs when the individual stops breathing for short periods of time during sleep. Because sleep apnea causes individuals to wake up frequently throughout the night, patients are often drowsy during the day.
Causes: There are two main types of sleep apnea: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea is the most common form that occurs when the muscles in the throat relax. These muscles support the soft palate, the small piece of tissue that hangs from the soft palate (called the ulva), the tonsils, and the tongue. When these muscles relax, the patient is unable to breathe.
The brain senses this inability to breathe and causes the individual to wake up and start breathing again. This process may occur 20 to 30 times or more each hour during sleep. Most patients do not even realize this happens.
Obstructive sleep apnea occurs most often in older adults. It is also twice as likely to occur in men as women. Obese individuals have an increased risk of experiencing obstructive sleep apnea because they have excess fat in their upper airways.
Central sleep apnea occurs when the brain does not send proper signals to the muscles that control breathing during sleep. This is usually caused by heart disease. They are more likely to remember waking up in the middle of sleep than patients with obstructive sleep apnea.
It is possible to have a combination of both types of sleep apnea, which is called complex sleep apnea. Central sleep apnea may develop at any age, and it affects males and females equally. Some evidence suggests that 15% of patients with sleep apnea have complex sleep apnea.
Symptoms: Many of the symptoms of obstructive sleep apnea and central sleep apnea are the same. Common symptoms of both of these disorders include loud snoring, waking from sleep abruptly, difficulty staying asleep, waking up with a dry mouth or sore throat, and drowsiness during the day
In addition, individuals with central sleep apnea often wake up with shortness of breath and headaches.
Patients with central sleep apnea may also experience shortness of breath and headaches when they wake up from sleep.
Diagnosis: If sleep apnea is suspected, the patient may be asked to spend a night at a sleep center. At a sleep center, the patient's sleep patterns will be observed and analyzed. Several tests, including a nocturnal polysomnography, oximetry, and portable cardiorespiratory test, may be performed to monitor the patient's conditions.
During a nocturnal polysomnography test, a specialist will monitor the electrical activity of the brain and heart, the movement of the muscles, the movements of the eyes, and breathing patterns of the patient during sleep.
During an oximetry test, a small machine monitors and records the oxygen level of the patient during sleep. A small sleeve is placed over one of the fingers. This test may be performed at a sleep center or at home. Patients with sleep apnea will have low levels of oxygen before each awakening.
A healthcare provider may give the patient a portable cardiorespiratory test to perform at home. These tests involve oximetry, measurement of breathing patterns, and the measurement of airflow.
Treatment: Milder cases of sleep apnea may be treated with lifestyle changes, including weight loss and smoking cessation. More severe cases may be treated with devices to open the airway and/or surgery.
A machine called a continuous positive airway pressure (CPAP) is the most common and effective treatment for patients with moderate to severe sleep apnea. This machine delivers air through a mask that is placed over the nose during sleep. The mask does not breathe for the patient. Instead, it pushes air into the patient's mouth when he/she inhales. This air movement keeps the airways open, preventing sleep apnea and snoring. Patients who use a CPAP should tell their doctors if their weight changes. If the patient loses or gains weight, the pressure settings may need to be changed.
Patients may also wear devices over their mouths to control sleep apnea. Some devices bring the jaw forward in order to open the throat and control symptoms of mild obstructive sleep apnea. Patients should talk to their dentists to determine the best oral appliance for them. Patients should visit their dentists every six months for the first year once they find an oral appliance that works for them. After the first year, patients should visit their dentists and healthcare provider annually to make sure that the device is effectively relieving symptoms of sleep apnea.
In addition to CPAP, patients with central sleep apnea may benefit from bilevel positive airway pressure (BiPAP). This device provides a higher air pressure when the patient inhales and a lower pressure when the patient exhales. The goal of this treatment is to strengthen the weak breathing pattern of central sleep apnea. Some machines can be set to automatically provide oxygen if the device detects a breath has not been taken in a certain amount of seconds.
Another airflow device, called an adaptive servo-ventilation (ASV) may be used to treat central sleep apnea and complex sleep apnea. This device detects the patient's normal breathing pattern and stores it in a built-in computer. When the patient falls asleep, the machine uses the stored information to regulate the patient's breathing pattern and prevent sleep apnea.
Moderate to severe sleep apnea may need to be treated with surgery. During surgery, the extra tissue from the throat or nose that is blocking the airway passage is removed.