Sleep Disorders 101
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Insomnia can be defined as trouble falling asleep, trouble staying asleep, waking too early or not feeling refreshed by what seems should be an adequate amount of sleep. It is the most common sleep disorder in America with nearly half the respondents to National Sleep Foundation survey reporting some problem with insomnia at one time or another. Despite the apparent commonness of the disorder, most people never mention their struggle with sleep to their doctors.
There can be hundreds of reasons for insomnia. Not everyone is sensitive to the same kinds of triggers. Each of us has certain predispositions either inborn or from early circumstances. Furthermore, almost everyone has some difficulty falling asleep when there is something special or stressful going on in our lives. Before a big exam, a trip, a wedding or when the neighbors are having a rocking party without us. Trouble sleeping only becomes a sleep disorder when it becomes chronic and begins to affect our ability to function well during the day.
In general sleep specialists divide insomnia into either primary or secondary insomnia. Primary insomnia is also called psychophysiological or learned insomnia. This kind of problem can develop when a person suffering from chronic stress adopts a series of habits that condition him to sleep poorly. This can build slowly and insidiously so that it is often hard to determine how or when the problem actually started. It can be even harder to peel back the layers of dysfunction to break the insomnia pattern.
Another term is secondary insomnia. As you might guess this refers to an inability to sleep that is caused by, or secondary to, something else. In this case another sleep disorder such as sleep apnea or restless legs syndrome may be the cause of the sleeplessness. Medical conditions such as heart disease, diabetes, thyroid imbalance and pulmonary problems can cause insomnia. Insomnia is also a common symptom of depression and anxiety. Ironically many of the medications used to treat disease can also cause sleep disturbances. It is for these reasons you should always tell your doctor if you are not sleeping well.
With most cases of secondary insomnia, the secret to fixing the sleep problem is to properly address the medical or emotional problems that are at the root. Unless bad sleep habits have developed in the meantime, the insomnia should resolve as the condition that caused it does.
There are so many potential caused of insomnia it can be difficult to sort it all out. Max Hirshkowitz, PhD and Patricia B. Smith in their book “Sleep Disorders for Dummies” offer this list of the most common causes for wakefulness:
- Certain medications like diet pills, blood pressure and allergy and asthma medications
- Chronic medical conditions that cause pain or discomfort like arthritis or asthma
- Depression or other emotional problems
- Food and beverages that contain stimulants like caffeine, or the cause digestive upsets
- Poor sleep habits, such as going to bed at a different time each night, or sleeping in a bed with pets
To this I would add that there can be a host of environmental factors that may also interfere with a restful night. These include:
- A snoring or restless bed partner
- Poor light or temperature control in the bedroom
- TV, radio or computer in the bedroom
- Household members with differing schedules
I’m sure you can come up with your own lists, as well…
This brief discussion has only been enough to highlight the facts that insomnia is both common and complicated. To learn more you may explore the resource links below. If you have insomnia you should discuss it with your doctor, therapist and sleep coach. It may be complicated, but it doesn’t have to be hopeless!
Chainsaw. Fog horn. Angry bear. Freight train. A cow giving birth. An Ozzy Osbourne concert. A wounded warthog. These are but a few of the colorful (and sometimes painful) descriptions of the snoring sounds of otherwise loved and presumably lovable sleepers.
Snoring is a sound produced by air waves passing over loose tissue on its way from the tip of the nose or lips to the lungs. The looser the tissue and the more forceful the airflow, the louder and more remarkable the resulting noise will become. The loose tissue may be in the area of the nose (such as polyps), the nasopharynx (adenoids), the back of the mouth or throat (uvula, soft palate, tongue) or lower in the throat (vocal cord abnormalities). Thickened mucus in any of these areas can also cause or add to the noisy vibration.
It used to be thought that snoring was merely annoying or comical (depending on whether you could close the door or not…). We now know that snoring may be a sign of a very serious breathing disorder called obstructive sleep apnea. In this condition the same tissue that is loose enough to vibrate noisily can end up blocking the airway and prevent the air from reaching the lungs. This can lead to a decrease in oxygen in the blood and disturb the sleep of the victim. The biggest problem is that this repeats over and over throughout the night and continues night after night. Chronic sleep deprivation and life threatening medical conditions can be a result.
There is new evidence that snoring itself may be damaging to the large blood vessels in the neck. Just like using a jack hammer or electric sander for hours and hours on end can damage the nerves and vessels of the hands and wrist, the vibration of snoring may be causing similar damage in the area of the head and neck. One recent study has shown that in people who snore loudly, the blood vessels that carry blood to the brain were damaged and “roughed up” on the inside. This makes it more likely that a blood clot can form or that rough edges can break off and cause a blockage preventing blood from getting to the brain, causing a stroke.
Snoring can be improved or eliminated through many different approaches or a combination of them. Snorers should:
> Achieve and maintain a healthy weight > Avoid alcohol and sedatives near bedtime > Stop smoking > Perform nasal rinses to reduce mucus > Treat allergies as appropriate > Be evaluated and treated for obstructive sleep apnea > Sleep on their side or slightly elevated on a wedge > Avoid sleep deprivation > See a medical specialist for additional help if needed
Obstructive Sleep Apnea (OSA) is a condition in which you cannot sleep and breathe effectively at the same time. A combination of a narrow upper airway (nose and throat) and muscles that become overly relaxed when sleeping can lead to soft tissue closing off the flow of air to the lungs resulting repeated suffocation during a time that should be restful and peaceful. The only way to open the airway to get the next breath is to awaken for at least a second to increase the muscle tension in the throat. Once that breath is in you generally fall immediately asleep again only to have the whole process repeat again in a very short time.
Someone with OSA may awaken hundreds of times every night and have no recollection of any of it. They are generally tired during the day, however and are at increased risk of falling asleep behind the wheel. THe repeated awakenings and the drops in oxygen are hard on the whole body. OSA sufferers are alos more likely to develop heart disease, have strokes, diabetes and gain weight. Depression is also more common in people with OSA.
Most people with OSA snore loudly nearly every night. The best way to definitively diagnose OSA is through an overnight sleep test in a sleep medicine clinic. This test involves having wires taped to your head, face, chest and finger to monitor your brain waves, movements and breathing. This test can not only tell if you have OSA, but also how bad it may be and to some extent how much strain it is placing on your system. Some other conditions such as central sleep apnea, complex sleep apnea, restless legs syndrome, periodic limb movements of sleep and REM sleep behavior disorder may also show up during the sleep study.
OSA may be treated by a change in sleeping position, pre-sleep behaviors, losing weight or by addressing another condition that may be causing it, such as chronic sinusitus. Other treatments include customized dental devices that reposition the jaw and tongue to increase airflow, surgery to change the shape of the airway, or continuous positive airway pressure (CPAP) therapy, which is the use of a small compressor and mask worn during sleep to provide an "air splint" to keep the airway open without having to wake repeatedly.
OSA is a serious condition that should not be ignored. Having a proper diagnosis and learning about your treatment options can save your life. To learn more you can follow these links.
RESTLESS LEGS SYNDROME
Restless Legs Syndrome (RLS) is a common neurological disorder characterized by unpleasant sensations in the legs (and sometimes the arms) that are often described as "creepy-crawly" or "tingly". The feelings are usually worse when the person is at rest and are pronounced in the evening. Moving the legs, walking or rubbing can relieve the sensations, but the relief is often only temporary. This can lead to considerable difficulty getting to sleep or getting back to sleep after waking up during the night.
The cause of RLS is not known, but it does run in families. People with anemia or low blood iron are more likely to have symptoms as are people with kidney disease, varicose veins and pregnancy. Many people also find that caffeine, alcohol and many different prescription drugs also make the sensations worse or more frequent. There are several drugs used to treat RLS and each case is likely to be a bit different. This is something to discuss with your doctor.
PERIODIC LIMB MOVEMENTS OF SLEEP
We’ve all seen the bad movies with the sleepwalkers moving stiff-legged, arms outstretched in front of them, mumbling and moaning as they march, usually en masse, toward the town center. Real sleepwalking, or somnambulism, is rarely like that. When sleepwalking, the person appears to be awake and moving around but is actually sleeping. The eyes are open but there may be a blank look on the face. Sometimes family members don’t even realize the person is sleepwalking because they seem so normal. The tip-off can happen when the sleepwalker starts talking nonsense or does something more strange such as stand in front of an open closet door for an unusually long time.
Sleepwalking triggers include sleep deprivation, anxiety, new environments, alcohol, drugs and fever.
We can perform some fairly complicated activities when sleepwalking. People commonly go to the bathroom, change clothes, move light furniture around and talk to house mates. More dangerously, people may leave the house, climb out windows, drive cars or use cooking appliances. Famous case studies have cited sleepwalking as a defense for criminal acts such as battery and even murder.
Sleepwalking occurs during deep sleep Stage N-3, or slow wave sleep. It is more common in children and tends to run in families. It is not dangerous to wake a sleepwalker, despite common myths, and may sometimes be the safest thing to do, especially if they are attempting risky behavior. Sleepwalkers should generally sleep on the first floor and it may be necessary to use alarms at doors and windows to keep them from going outside.
Childhood sleepwalking is very common between the ages of 4 and 8. It may recur for short bouts later in childhood in response to some change in environment or circumstances. In adults, sleepwalking may be associated with mental disorders, seizures, brain injuries or medication reactions. They may also occur for no apparent reason. If an adult is apparently sleepwalking but also reports dream content that goes along with the activities performed, it is actually likely REM Sleep Behavior Disorder and needs evaluation by a sleep specialist.
Sleeptalking is more common in children and in boys, just like night terrors. It can occur in any stage of sleep, though common thought is the lighter the sleep, the more intelligible the speech. Sleeptalk varies from moans and mangled gibberish to full sentences and even apparently lucid conversations.
Modern sleep science and U.S. law agree, however, that sleeptalking is not the product of a conscious or rational mind. Therefore things said during sleep are not legally binding or admissible in court. For the same reason, family members or loved ones should not take sleeptalkers at their word, whether they are being generous or apparently unfaithful!
Sleeptalking often occurs in association with other parasomnias such as sleepwalking and nightmares. It may be triggered by sleep deprivation, fever, stress or alcohol. Sleeptalking by itself is not generally considered harmful and does not require treatment unless it is causing distress or upsetting the sleep of housemates. The Sleeptalker does not usually remember the episode and the sleep is not disrupted by it.
Nightmares are dreams with vivid and disturbing content. The dreamer often wakes up in the middle of the nightmare and can recall intense images and details about what was happening. They my have trouble getting back to sleep because of the distressing memory of the dream.
Nightmares occur during REM sleep and are more prevalent during the early morning hours. Children have them more often but adults will have them as well. They may be caused by many external factors such as illness, anxiety, change in routine or environment or loss of a job or relationship. Nightmares can be a side effect of some common medications, too, like beta blockers, antidepressants and drugs used for Parkinson’s disease.
Occasional childhood nightmares are generally nothing to worry about and most children outgrow them by their teens. Parents should be aware, however, that new or sudden onset of nightmares may signal some distress in the child’s life and some exploration of that may be in order.
Severe nightmare disorder is often associated with Post Traumatic Stress Disorder (PTSD). These dreams may come late in the sleep session or at sleep onset. The dream images are often familiar, repetitive and represent real situations the sleeper has experienced in their past. Treatment of the underlying PTSD is required to tame the dream episodes.
If nightmares are preventing restful sleep, you should tell your doctor. A change in medications or a search for cause may help return quiet and peaceful slumber.
It is often far worse to witness someone having a night terror than to actually have one. A night terror, or sleep terror, is characterized by arousal, agitation, sweating, enlarged pupils and increased blood pressure. The child, (it occurs mostly in children) often wakes with a scream and is inconsolable, even to the point of trying to fight off someone trying to comfort them. The distress may last for many minutes and if accompanied by vigorous or violent activity may result in injury. As quickly as it begins, the child will again relax and return to sleep. There is usually no recollection of the event in the morning and if awakened during an episode the child will likely be bewildered at all the attention and only report partial images or brief scenes.
Unlike nightmares, night terrors occur during Sleep Stage N-3 or slow wave sleep. They are likely to begin within an hour of sleep onset and are almost exclusively seen in the first half of the night.
1-6% of children between the ages of 4 and 12 experience night terrors. It is more common in boys. They may be the result of stress, psychological disturbance, sleep deprivation or something as simple as sleeping in an unfamiliar room or bed. For children, medical attention is usually not required unless they persist into the teens or are frequent enough to cause chronic sleep deprivation for the child – or the rest of the family!
In adults, sleep terrors are almost always a sign of something more serious and should be evaluated by a sleep specialist. Sleep deprivation, depression, anxiety, post-traumatic stress disorder and medication withdrawal syndromes may result in adult sleep terrors.
CIRCADIAN RHYTHM DISTURBANCES
DELAYED SLEEP PHASE SYNDROME
ADVANCED SLEEP PHASE SYNDROME
SHIFT WORK SLEEP DISORDER
REM SLEEP BEHAVIOR DISORDER
REM behavior disorder (RBD) is characterized by complex motor behaviors occurring during REM sleep. Our muscles are usually extremely relaxed, right to the point of paralysis when we are in REM sleep. This is thought to be a protective mechanism that keeps us from physically acting out our dreams. People with RBD lack this protective paralysis to some degree and can carry out complex motor behaviors while they are dreaming. RBD usually occurs during the second half of the night, when REM is more prevalent. Movements may be violent and may harm the sleeper and/or the sleeper's bed partner. Often, the person may be unable to recollect these actions in the morning. RDB spans various age groups but is more prevalent in older men.
The cause of RBD is unknown. Some reports have suggested acute RBD is associated with the intake of tricyclic antidepressants, fluoxetine, and monoamine oxidase inhibitors, and withdrawal from alcohol or sedatives. In contrast, chronic RBD has been associated with narcolepsy and other idiopathic neurodegenerative disorders such as certain types of dementia and Parkinson's Disease.
To protect the sleeper and the bed partners from harm, RBD is often treated by low dose medication that decreases the amount and degree of movement during the night.
EXPLODING HEAD SYNDROME
Sleep Paralysis may be one of the most frightening, least dangerous things one can experience in sleep. It usually happens just when falling asleep or right at awakening and is the distinct sensation that one cannot move or speak. The feeling is caused by a slight mismatch in the brain and body, in that one is awake and the other still “asleep”. It usually only remains for a few seconds, but can last minutes, which for the uninformed can be terrifying. The episode is usually ended by a sound or movement in the room that can “break the spell”. I have told patients in the past to just concentrate on moving one tiny muscle, like an eyelid or pinky finger. This usually allows full movement to return quickly.
When sleep paralysis occurs at the onset of sleep it is called “hypnopompic sleep paralysis”. In this situation the body is relaxing more and more while the mind is kind of surfing between wake and sleep. If the mind wakes up and finds the body far more relaxed than when it last checked it can lead to a startling feeling of being hard to move.
When it happens upon waking in the night or morning it is referred to as “hypnogogic paralysis”. This is more likely when waking out of REM or dreaming sleep. During REM sleep it is natural and normal that our big muscles should be completely limp or paralyzed. This keeps us from acting out our dreams all night – which is a good thing! However if we again have that mismatch and the brain wakes up from REM just a fraction before the muscles wake up we will “catch ourselves” in that paralyzed state.
Sleep paralysis happens more often if we’re not getting enough sleep or if our schedules are really irregular. A change in time zones can be a trigger as can some medications that alter sleep cycles or timing. It may occur only once in a lifetime or become a recurring experience. It is usually harmless and once one knows what is happening it can be kind of entertaining. It’s the only time we ever get to watch ourselves sleeping!
If sleep paralysis is frequent enough to interfere with refreshing sleep it can be addressed by improving sleep habits, catching up on sleep and working on some general stress relief. There are some antidepressant medications that change sleep stages in such a way that sleep paralysis would be less likely, though this would be reserved for a fairly severe case. It can be associated with Narcolepsy, though, so if sleep paralysis is a common occurrence and there is significant daytime sleepiness, an evaluation by a sleep specialist would be advised.
Bruxism involves the involuntary grinding, biting or clenching during sleep. Teeth grinding in sleep is very common among children, but chronic bruxism in adults is less common. Most teethgrinders are unaware of their condition unless advised by their bed partners. They may, however wake with sore jaws, teeth or a headaches. Some have the unpleasant experience of being jolted awake when they suddenly chomp down on their own tongue!
Some specialists have said it is associated with stress, depression or other mental health disorders, however there is not universal agreement on this. Stress reduction and relaxation techniques can help though. Mouth guards worn when sleeping are sometimes necessary to protect the teeth and jaw. In extreme cases, muscle relaxant medications have been used to reduce the incidence of clenching.
Patients with obstructive sleep apnea have been shown to stop grinding their teeth when their sleep related breathing disorder was well managed, so there may some association there. Parkinson’s disease, Huntington’s disease and some medications may also pre-dispose to bruxism.
Bruxism can be hard on the teeth. Worn enamel, increased tooth sensitivity, tooth fractures, temporal mandibular joint pain, earaches, headaches and chew marks on the insides of the cheek can all result from this condition. If you’ve been told or suspect you grind your teeth while sleeping, see your dentist to find out if you may need extra protection for your dental health.