Sleep Disorders

To Sleep, Perchance to Dream: A Guide to Facts and Information about Sleep Disorders

Sleep disorders have been around throughout recorded history. In Shakespeare’s time, sleep and dreams were surrounded by an array of rituals and remedies for curing sleep disorders, promoting sleep, and preventing nightmares. Today, sleep disorders continue to be a common problem among millions of people across the world.

What is Sleep… and why it is important?

If there are sleep disorders, there must also be normal sleep.

The onset of sleep is triggered by the release of melatonin, a natural body hormone. Toward dawn, melatonin shuts off as the hormone cortisol increases, signaling the body to wake up.

Normal sleep follows a 90 minute cycle that repeats throughout the night. In this cycle, there are periods of rapid eye movement (REM) sleep alternating with periods of non-rapid eye movement (NREM) sleep.

About 75% of this cycle is made up of NREM sleep during which the body temperature, breathing rate and heart rate all drop. It is also during this deep NREM sleep when energy is restored and tissue repair occurs.

REM sleep is when the brain is active and dreams occur. These periods of REM sleep help provide energy to the brain and prepare the body for daytime activities. Sleep is important because normal sleep patterns determine how energetic and healthy you feel.

How much sleep does a person need? That depends on a number of factors:

  • Age – young children need more sleep than adults and the child may sleep as much as 10 hours a night. A healthy adult will normally get about 7 to 8 hours of sleep each night… but may get as little as 5.
  • Physical condition – A healthy person needs less sleep than someone who is sick. Since body repairs occur during sleep, it is normal for a sick person to sleep more, and more often, than someone who is healthy.
  • Psychological health – If you are psychologically unhealthy, you may sleep much more or much less than when you are spiritually and mentally healthy.

If you feel good and are refreshed in the morning after sleeping, you are probably getting the right amount of sleep.


Definition

Definition and Prevalence of Sleep Disorders

So, if normal sleep is so important, what are sleep disorders?

According to WebMD, sleep disorders are conditions that affect how much or how well you sleep. It has been estimated that as many as 70 million Americans have some sort of sleep problem; of those, as many as 60 percent may have a chronic problem.

While many sleep disorders are not diagnosed, it is estimated that sleep problems add as much as $15.9 billion to the health care bill in the United States. This number does not even include other health problems (such as heart disease and stroke) that may be caused or made worse by sleep problems.

Other statistics about sleep disorders include:

  • Approximately 25% of all children aged 1 to 5 have some sort of sleep disorder;
  • More than half of all Americans over the age of 65 have a sleep problem;
  • One disorder, sleep apnea, affects over 20 million Americans;
  • It is estimated that by the year 2050, over 100 million Americans may have a sleep disorder.


Types, Causes, Symptoms, and Treatments

Types, Causes, Symptoms and Diagnosis of Sleep Disorders

The American Academy of Sleep Medicine in collaboration with other international sleep groups developed “The International Classification of Sleep Disorders (ICSD)” which classifies sleep disorders as either dyssomnias (disorders that produce insomnia or excessive sleepiness) or parasomnias (disorders that occur during sleep but do not produce insomnia or sleepiness).

There is also a separate classification that is associated with mental, neurological or medical disorders. In all, the ICSD identifies 83 discrete types of sleep disorders. We will look at some of the most common including what causes the disorder and the symptoms of the sleep disorder.

Diagnosis of any sleep disorder is handled best in a sleep clinic using polysomnographic monitoring; specific details of diagnosis and treatment for each disorder are outlined below.

Dyssomnias

This category of sleep disorders includes many types of well-known sleep disorders. Some of which include:

Insomnia

Insomnia is the most common form of sleep disorder and involves an inability to go to sleep or stay asleep.

  • Causes and predisposing factors. Individuals who develop insomnia may have a history of being a “light sleeper”. A few nights of poor sleep may cause you to “learn” how to be an insomniac. As the disorder develops, you become tenser which leads to less sleep. Short periods of insomnia may also be caused by anxiety, pain, or many of the other disorders that will be discussed.
  • Symptoms. Feelings of decreased well-being during the day with decreased attention span and energy. Your mood may eventually be depressed as increased fatigue develops.
  • Diagnosis. Most commonly found in females, some forms of insomnia may be learned. Typically, the diagnosis will be made based on a complaint of being unable to sleep. You may also complain about a feeling of tension.
  • Treatment. The main focus of treatment for insomnia should be directed towards finding the cause. Cognitive behavioral therapies and controlling the sleep environment may also improve sleep for the insomniac.

Hypersomnia

Hypersomnia is sleepiness that recurs in episodes that last several days or weeks. These episodes usually occur only a few times a year and may alternate with binge eating. Between the episodes, the person seems to be fine and does not have any of the symptoms.

  • Causes and predisposing factors. The episodes of sleepiness may be caused by a fever or other severe health problem.
  • Symptoms. May include weight gain, disorientation, depression, forgetfulness, and impulsive behaviors.
  • Diagnosis. More common in males than females, the chief complaint is sleepiness over several days that occurs periodically and is not constant.
  • Treatment. May include lifestyle modifications and stimulants to help you stay awake during the day.

Narcolepsy

Narcolepsy is also called excessive sleepiness, sleep paralysis, Kleine-Levin syndrome and cataplexy.

  • Causes and predisposing factors. The cause of narcolepsy is not known but there does seem to be a genetic component to the disorder. Some doctors think there may be a chemical in the brain that is at least partly to blame for narcolepsy.
  • Symptoms. Narcoleptics take frequent and sudden naps lasting an hour or less. With a good deal of effort, the narcoleptic can sometimes overcome the sleepiness, but will fall sound asleep without that extra effort. Cataplexy, or sudden loss of muscle tone caused by strong emotion, is a unique feature of narcolepsy. The severity of cataplexy may be minor in which the head droops to very severe with a total body collapse. This state may be followed by sleep.
  • Diagnosis. The tendency to narcolepsy tends to be inherited in families. Without the presence of cataplexy, it is very difficult to make a definitive diagnosis of narcolepsy.
  • Treatment. Narcolepsy may improve over time due to better coping abilities of the individual, but you may also be advised to use stimulants to stay awake during the day.

Sleep Apnea

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts.

  • Causes and predisposing factors. Sleep apnea occurs when the muscles in your throat relax and your airway closes. When your oxygen level gets low because air is not getting in, your brain wakes you up so you can reposition yourself and reopen your airway.
  • Symptoms. You may have sleep apnea if you snore loudly and you feel tired even after a full night’s sleep. You may not be aware that you have this disorder; however, if you sleep with another person, they may be very aware that you stop breathing during the night.
  • Diagnosis. May involve time in a sleep center with a monitor; there are also portable monitors available that your doctor may prescribe for use at home.
  • Treatment for sleep apnea. Mouth piece that is worn at night or Continuous positive airway pressure (CPAP) both of which work to keep your upper airway open. If sleep apnea becomes a big problem, you can also have surgery to remove excess tissue from your nose or throat that blocks the airway.

Restless Legs Syndrome

Restless legs syndrome (RLS) is a feeling in the legs that causes an irresistible urge to move your legs.

  • Causes and predisposing factors. RLS may be caused by physical conditions such as anemia and lifestyle choices such as smoking and drinking caffeine.
  • Symptoms. While the tingling or painful sensations are most commonly felt in the legs, you may also feel them in your arms. These sensations are most noticeable at night when trying to sleep.
  • Diagnosis. Diagnosing RLS depends on the presence of four conditions: the irresistible urge to move your legs; the urge increases when you are resting; the symptoms may be relieved by stretching or moving; and the symptoms are worse at night. In a sleep lab, the monitors may watch you for periodic limb movements or twitching as you sleep.
  • Treatment. Treating RLS may be as simple as modifying your lifestyle and increasing your exercise. If the RLS is caused by a medical condition, treatment will be focused on treating the underlying cause. Drugs may be used if symptoms do not improve with other treatment.

Nocturnal Eating & Drinking Disorder

Nocturnal eating and drinking disorder is also called night eating syndrome. The person with this disorder will awaken three to eight times throughout the night and can only go back to sleep after eating or drinking.

  • Causes and predisposing factors. In infants and young children, parents may be this biggest cause of this syndrome if limits are not set with the young child.
  • Symptoms. Periodic waking during the night — and the child will only go back to sleep after eating. Excessive weight gain may be an issue.
  • Diagnosis. Before making the diagnosis of nocturnal eating disorder, all other causes for nighttime wakening should be ruled out.
  • Treatment. By the age of 6 months, most children will sleep through the night.

Jet Lag Syndrome

Plane Taking Off

Jet lag syndrome is considered a circadian rhythm sleep disorder, which is a disruption of the internal body clock. Jet lag is usually a temporary disorder that is a result of air travel across time zones.

  • Causes and predisposing factors. The cause of jet lag is the inability of the body of a traveler to immediately adjust to the time in a different zone.
  • Symptoms. Common symptoms of jet lag include temporary insomnia, fatigue, irritability, and an impaired ability to concentrate.
  • Diagnosis. If you have travelled across multiple time zones, particularly if going East, you may feel much more tired than usual.
  • Treatment. Avoid alcohol and caffeine during travel to prevent some of the symptoms. Drink lots of water during travel and get up and move in the plane during long flights. If possible, break up your flight to spend a day or two at a point midway in the journey. When you get to your final destination, get on the local time schedule as soon as possible!

Shift Work Disorder

Shift work disorder (SWD) is another circadian rhythm disorder.

  • Causes and predisposing factors. This disorder occurs when your work schedule and internal clock are not in synch. Typically this happens when you work the night shift. As many as 25% of night shift workers might suffer from SWD.
  • Symptoms. Excessive sleepiness when you are forced to be awake and trouble sleeping when it is time to sleep. You may also be at risk for more accidents and decreased productivity at work.
  • Diagnosis. This disorder is tough to diagnose, but it should be suspected for anyone who works night shift and has problems sleeping.
  • Treatment. Make sure your sleep environment is dark, quiet and conducive to sleep. You may find that melatonin helps to sleep. Unfortunately, if you are one of the group of people who cannot adapt to the night shift, you might be forced to look for another job.

Parasomnias

This category of sleep disorders includes many disorders that interrupt or occur during sleep. Some of which include:

Sleepwalking and Sleeptalking

These are disorders that occur when you walk, talk or do another activity while you are still in a deep non-REM sleep. Sleepwalking and sleeptalking usually occur when you are extremely tired or anxious. These disorders may be increased if you use alcohol or sedatives to help you sleep. Symptoms include any activity that you do when you are actually sleeping. These activities may be as simple as sitting up and looking around or as complex as driving a car! A sleepwalker will wake up confused and without any memory of doing anything while asleep.

Sleep Terrors

Sleep terrors are also known as night terrors. Most of the time, these episodes happen within the first two hours of sleep. Sleep terrors occur more commonly in some families so there may be a genetic factor involved in this disorder. Sleepwalkers may also be more likely to have sleep terrors. There is some research that also indicates that sleep terrors may be associated with certain forms of epilepsy. Symptoms include sudden awakening (usually with a scream) with rapid heart rate and breathing and sweating. You will usually have no memory of the incident since sleep terrors are not caused by nightmares.

Nightmares

Nightmares differ from sleep terrors in that nightmares usually happen during the second part of the night and are caused by a specific dream that the dreamer remembers when awakening. Nightmares are most commonly caused by anxiety or stress. Symptoms include feelings of fear or distress that result from a remembered bad dream.

Sleep related sinus arrest

This is a condition in which the heart of an otherwise healthy person stops for brief periods of time during REM sleep. If the condition is detected, a pacemaker may be inserted to help control the heart’s rhythm.

Sleep related behavior disorder

This is a condition in which the muscle paralysis normally seen in REM sleep is not there and the person begins to act out his dreams. This acting out may include hitting, kicking, or biting and may result in injuries to others.

Bruxism

Worn Teeth Due to Bruxism. The front teeth would naturally be longer but have been ground down over time. The image also shows a deviated midline or "midline discrepancy".

Grinding of teeth at night that may cause headaches or jaw pain.

Enuresis

Enuresis is also called bedwetting in a person over 5 years old. Until that age, accidents at night are common; after the age of five, the condition should be evaluated by your doctor since the cause may be an allergy, breathing problem, or seizure disorder.

Snoring

Can be diagnosed when you snore without any other signs or symptoms of a sleep related breathing disorder.

Sleep Apnea

Sleep apnea in children is usually caused by a very small airway. These children will be placed on an apnea monitor until their respiratory systems grow and mature.

Sudden unexpected nocturnal death

This condition is often associated with sleep terrors. Death occurs in young, healthy people (usually males of Southeast Asian heritage) during sleep. The death is usually preceded by choking and the person cannot be aroused from sleep.

Sudden Infant Death Syndrome (SIDS)

Unexpected death of an infant (less than 3 months old) without an apparent medical cause.

Sleep Disorders Associated with Mental, Neurologic or Medical Disorders

The sleep disorders in this classification are those that are caused by another medical, mental or neurological disorder. When the underlying disorder is managed, the sleep disorder normally disappears.

Sleep disorders in this category include those related to dementia, Parkinsonism, anxiety and panic disorders, epilepsy and seizures, headaches, respiratory and breathing problems, gastrointestinal problems, and fibromyalgia. When sleep is affected due to any of those conditions, the first thing you must do is get treatment for the medical or psychological condition that is causing the sleep disorder.


In the Life Cycle

Sleep Disorders through the Life Cycle

Some disorders are more prevalent in one age group than another or may develop during one stage of development. Common disorders in various stages of development include:

Infancy and Early Childhood

  • Nocturnal eating and drinking syndrome. Typically occurs in infancy and early childhood.
  • Sudden Infant Death Syndrome (SIDS). Only occurs in infancy. The cause of the death typically cannot be determined.
  • Sleep terrors and nightmares. These disorders seem to peak during early childhood through school age but may occur into adulthood as well.
  • Sleep apnea. Can occur in infants and children and is usually related to the immaturity of the child’s respiratory system.

School Age

  • Narcolepsy. Typically starts around the age of 10 with excessive sleepiness as the first symptom.
  • Sleepwalking. Generally starts in childhood and decreases as the child ages.
  • Risk for sleep related sinus arrest. Typically starts in the school age child.

Adolescence

Hypersomnia occurs most often in adolescence. This is probably due to the fact that it is during this stage that students’ hormones are causing them to naturally stay up later — while school schedules are forcing them to be up early.

Young Adulthood

  • Insomnia. Often begins in young adulthood.
  • Shift work disorder. May start when you begin a job that forces you to work at night. This disorder may get worse as you move into middle adulthood.

Middle Adulthood

  • Sleep apnea. Usually becomes problematic for individuals between the ages of 40 and 60.
  • Restless Legs Syndrome. Commonly starts in middle adulthood and worsens with age.
  • Sleep related behavior disorders. These type of disorders are normally seen in middle aged men.

Elderly

While medical and neurological conditions may start in middle adulthood, dementia, Parkinsonism, anxiety and panic disorders, epilepsy and seizures, headaches, respiratory and breathing problems, and gastrointestinal problems may peak in the elderly population causing an increase in sleep problems for this group.

When Should You Worry about Sleep Disorders?

All of us experience occasional sleep problems at some point. However, if you experience chronic sleep loss, other problems can develop. Some of which include weight gain, decrease in the immune system, and high blood pressure.

You should consult your doctor if your sleep problem happens consistently — or if you feel that your safety or health is at risk.


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