Common Sleep Disorders

A number of sleep disorders can disrupt your sleep quality and leave you with excessive daytime sleepiness, even if enough time was spent in bed to be well rested. More than 70 sleep disorders affect at least 40 million Americans and account for an estimated $16 billion in medical costs each year, not counting costs due to lost work time and other factors. The four most common sleep disorders are insomnia, obstructive sleep apnea (sleep-disordered breathing), restless legs syndrome (RLS), and narcolepsy. Additional sleep problems include sleep walking, sleep paralysis, night terrors, and other “parasomnias” that cause abnormal arousals.

Insomnia

Insomnia is defined as having trouble falling asleep or staying asleep, or as having unrefreshing sleep despite having ample opportunity to sleep. Life is filled with events that occasionally cause insomnia for a short time. Such temporary insomnia is common and is often brought on by stressful situations such as work, family pressures, or a traumatic event. A National Sleep Foundation poll of adults in the United States found that close to half of the respondents reported temporary insomnia in the nights immediately after the terrorist attacks on September 11, 2001.

Chronic insomnia is defined as having symptoms at least 3 nights per week for more than 1 month. Most cases of chronic insomnia are secondary, which means they are due to another disorder or medications. Primary chronic insomnia is a distinct sleep disorder; its cause is not yet well understood. About 30–40 percent of adults say they have some symptoms of insomnia within any given year, and about 10–15 percent of adults say they have chronic insomnia. Chronic insomnia becomes more prevalent with age, and women are more likely than men to report having insomnia.

Insomnia often causes problems during the day, such as excessive sleepiness, fatigue, a lack of energy, difficulty concentrating, depressed mood, and irritability. Due to all of these potential consequences, untreated insomnia can impair quality of life as much as, or more than, other chronic medical problems.

Chronic insomnia is often caused by one or more of the following:

 Another disease or mood disorder. The most common causes of insomnia are depression and/or anxiety disorders.Neurological disorders such as Alzheimer’s or Parkinson’s disease can also have insomnia as a symptom. Chronic insomnia can result from arthritis, asthma, or other medical conditions in which symptoms become more troublesome at night, making it difficult to fall asleep or stay asleep.

 Various prescribed and over-the-counter medications that can disrupt sleep, such as decongestants, certain pain relievers, and steroids.

 Sleep-disrupting behavior such as drinking alcohol, exercising shortly before bedtime, ingesting caffeine late in the day, watching TV or reading while in bed, or irregular sleep
schedules due to shift work or other causes.

 Another sleep disorder, such as sleep apnea or restless legs syndrome.

Some people, however, have primary chronic insomnia. This condition is linked to a tendency toward being more “revved up” than normal (hyperarousal). These people may have heightened secretion of certain hormones, higher body temperatures, faster heart rates, and a different pattern of brain waves while they sleep.

Doctors diagnose insomnia based mainly on sleep history, often by reviewing a sleep diary. An overnight sleep recording may be required if another sleep disorder is suspected. Doctors also will try to diagnose and treat any other underlying medical or psychological problems as well as identify behaviors that might be causing the insomnia.

Often, people who have insomnia enter into a vicious cycle—because of having trouble sleeping in previous nights, they become anxious at the slightest sign that they may not be falling asleep right away. That anxiety can make it more difficult for them to fall asleep. The more time they spend in bed not sleeping, and watching the clock, the more their anxiety—and sleeplessness—increases.

To break that cycle of anxiety and negative conditioning, experts recommend going to bed only when you’re sleepy. If you can’t fall asleep (or fall back to sleep) within 20 minutes, get out of bed and go into another room where you can pursue a relaxing activity until you feel sleepy again. Then return to bed. This reconditioning therapy has been shown to be an effective way to treat insomnia.

Another effective behavioral strategy for some people is relaxation therapy. For example, progressively tense and then relax each of the muscle groups in your body before sleep. Another method is to focus on breathing deeply. Relaxation therapy can provide a needed slowing down period so that you are indeed sleepy when the desired bedtime arrives.

Sleep restriction therapy also works for some people who have insomnia. First, limit
your night’s sleep to 4 or 5 hours, then gradually add more sleep time each night until you achieve a more normal night’s sleep. Daytime naps should be avoided during this sleep restriction therapy because napping may prolong insomnia by making it harder to fall asleep at night. In addition, during sleep restriction therapy, avoid driving a car or operating dangerous machinery until you have obtained adequate nighttime sleep.

All these changes in behavior are part of what is called “cognitive behavioral therapy.” Cognitive behavioral therapy also can be used to replace negative thinking related to sleep, such as “I’ll never fall asleep without sleeping pills,” with more realistic positive thinking. Cognitive behavioral therapy is effective in most people who have chronic insomnia.

Some people who have chronic insomnia that is not corrected by behavioral therapy or treatment of an underlying condition may need a prescription medication. You should talk to a doctor before trying to treat insomnia with alcohol, over-the-counter or prescribed short-acting sedatives, or sedating antihistamines that induce drowsiness. The benefits of these treatments are limited, and they have risks. Some may help you fall asleep but leave you feeling unrefreshed in the morning. Others have longer-lasting effects and leave you feeling still tired and groggy in the morning. Some also may lose their effectiveness over time. Doctors may prescribe sedating antidepressants for insomnia, but the effectiveness of these medicines in people who do not have depression is not established, and there are significant side effects.

To treat their insomnia, some people pursue “natural” remedies, such as melatonin supplements or valerian teas or extracts. These remedies are available over the counter. There is little evidence that melatonin can help relieve insomnia. Studies with valerian have also been inconclusive, and the actual dose and purity of various supplements, extracts, or teas that contain valerian may vary from product to product. In addition, because melatonin, valerian, and other natural remedies are not regulated by the Food and Drug Administration, their safety is not scrutinized.

Sleep Apnea

In people who have sleep apnea (also referred to as sleep-disordered breathing), breathing briefly stops or becomes very shallow during sleep. This change is caused by intermittent blocking of the upper airway, usually when the soft tissue in the rear of the throat collapses and partially or completely closes the airway. Each breathing stop typically lasts 10–20 seconds or more and may occur 20–30 times or more each sleeping hour.

If you have sleep apnea, not enough air can flow into your lungs through the mouth and nose during sleep, even though breathing efforts continue. When this happens, the amount of oxygen in your blood decreases. Your brain responds by awakening you enough to tighten the upper airway muscles and open your windpipe. Normal breaths then start again, often with a loud snort or choking sound. Although people who have sleep apnea typically snore loudly and frequently, not everyone who snores has sleep apnea.

Because people who have sleep apnea frequently arouse from deeper sleep stages to lighter sleep during the night, they rarely spend enough time in deep, restorative stages of sleep. They are therefore often excessively sleepy during the day. Such sleepiness is thought to lead to mood and behavior problems, including depression, and such sleepiness more than triples the risk of being in a traffic or work-related accident.

The many brief drops in blood-oxygen levels can be associated with morning headaches and decreased ability to concentrate, think properly, learn, and remember. In sleep apnea, the combination of the intermittent oxygen drops and reduced sleep quality triggers the release of stress hormones. These hormones in turn raise your blood pressure and heart rate and boost the risk of heart attack, stroke, irregular heart beats, and congestive heart failure. In addition, untreated sleep apnea can lead to altered energy metabolism that increases the risk for developing obesity and diabetes.

Anyone can have sleep apnea. It is estimated that at least 12–18 million American adults have sleep apnea, making it as common as asthma. More than one-half of the people who have sleep apnea are overweight. Sleep apnea is more common in men. More than 1 in 25 middle-aged men and 1 in 50 middle-aged women have sleep apnea along with excessive daytime sleepiness. About 3 percent of children and 10 percent or more of people over age 65 have sleep apnea. This condition occurs more frequently in African Americans, Asians, Native Americans, and Hispanics than in Caucasians.

More than one-half of all people who have sleep apnea are not diagnosed. People who have sleep apnea generally are not aware that their breathing stops in the night. They just notice that they don’t feel well rested when they wake up and are sleepy throughout the day. Their bed partners are likely to notice, however, that they snore loudly and frequently and that they often stop breathing briefly while sleeping. Doctors suspect sleep apnea if these symptoms are present, but the diagnosis must be confirmed with overnight sleep monitoring. This monitoring will reveal pauses in breathing, frequent sleep arousals, and intermittent drops in levels of oxygen in the blood.

Like adults who have sleep apnea, children who have this disorder usually snore loudly, snort or gasp, and have brief stops in breathing while sleeping. Small children often have enlarged tonsils and adenoids that increase their risk for sleep apnea. But doctors may not suspect sleep apnea in children because, instead of showing the typical signs of sleepiness during the day, these children often become agitated and may be considered hyperactive. The effects of sleep apnea in children may include diminished school performance and difficult,aggressive behavior.

A number of factors can make a person susceptible to sleep apnea. These factors include:

 Throat muscles and tongue that relax more than normal while asleep
 Enlarged tonsils and adenoids
 Being overweight—the excess fat tissue around your neck makes it harder to keep the throat area open
 Head and neck shape that creates a somewhat smaller airway size in the mouth and throat area
 Congestion, due to allergies, that can also narrow the airway
 Family history of sleep apnea

If your doctor suspects that you have sleep apnea, you may be referred to a sleep specialist. Some of the ways to help diagnose sleep apnea include:

 A medical history that includes asking you and your family questions about how you sleep and how you function during the day.
 Checking your mouth, nose, and throat for extra or large tissues—for example tonsils, uvula (the tissue that hangs from the middle of the back of the mouth), and soft palate (roof of your mouth in the back of your throat).
 An overnight recording of what happens with your breathing during sleep (polysomnogram, or PSG).

 A Multiple Sleep Latency Test (MSLT), usually done in a sleep center, is used to see how quickly you fall asleep at times when you would normally be awake. Falling asleep in only a few minutes usually means that you are very sleepy during the day. Being very sleepy during the day can be a sign of sleep apnea.

Once all the tests are completed, the sleep medicine specialist will review the results and work with you and your family to develop a treatment plan. Changes in daily activities or habits may help reduce your symptoms:

 Sleep on your side instead of on your back. Sleeping on your side will help reduce the amount of upper airway collapse during sleep.

 Avoid alcohol, smoking, sleeping pills, herbal supplements, and any other medications that make you sleepy. They make it harder for your airway to stay open while you sleep, and sedatives can make the breathing pauses longer and more severe. Tobacco smoke irritates the airways and can help trigger the intermittent collapse of the upper airway.

 Lose weight if you are overweight. Even a little weight loss can sometimes improve symptoms.

These changes may be all that are needed to treat mild sleep apnea. However, if you have moderate or severe sleep apnea, you will need additional, more direct treatment approaches.

Continuous Positive Airway Pressure (CPAP) is the most effective treatment for sleep apnea in adults. CPAP delivers air into your air-way through a specially designed nasal mask attached to a machine that acts as a pump. The mask does not breathe for you; the flow of air creates enough increased pressure to keep the airways in your nose and mouth more open while you sleep. The air pressure is adjusted so that it is just enough to stop your airways from briefly becoming too small during sleep. The pressure is constant and continuous. Sleep apnea will return if CPAP is stopped or if it is used incorrectly.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP. CPAP treatment can cause side effects in some people. Possible side effects include dry or stuffy nose, irritation of the skin on the face, bloating of the stomach, sore eyes, or headaches. If you have trouble with CPAP side effects, work with your sleep medicine specialist and support staff. Together, you can do things to reduce or eliminate these problems.

Currently, no medications cure sleep apnea. However, the prescription drug modafinil may help relieve the excessive sleepiness that sometimes persists even with CPAP treatment of sleep apnea.

Another treatment approach that may help some people is the use of a mouthpiece (oral or dental appliance). If you have mild sleep apnea or do not have sleep apnea but snore very loudly, your doctor or dentist may also recommend this. A custom-fitted plastic mouth-piece will be made by a dentist or an orthodontist—a specialist in correcting teeth or jaw problems. The mouthpiece will adjust your lower jaw and tongue to help keep the airway in your throat more open while you are sleeping. Air can then flow more easily into your lungs because there is less resistance to breathing. Following up with the dentist or orthodontist is important to correct any side effects and to be sure that your mouthpiece continues to fit properly.

Some people who have sleep apnea, depending on the findings of the evaluation by the sleep medicine specialist, may benefit from surgery. Removing tonsils and adenoids that are blocking the airway is done frequently, especially in children. Uvulopalatopharyngoplasty (UPPP) is a surgery for adults that removes the tonsils, uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and part of the soft palate (roof of the mouth in the back of the throat). Tracheostomy is a surgery used rarely and only in severe sleep apnea when no other treatments have been successful. A small hole is made in the windpipe, and a tube is inserted. Air will flow through the tube and into the lungs, bypassing the obstruction in the upper airway.

Restless Legs Syndrome (RLS)

Restless legs syndrome (RLS) causes an unpleasant prickling or tingling in the legs, especially in the calves, that is relieved by moving or massaging them. This sensation creates a need to stretch or move the legs to get rid of these uncomfortable or painful feelings. As a result, a person may have difficulty falling asleep and staying asleep. One or both legs may be affected. In some people, the sensations are also felt in the arms. These sensations can also occur with lying down or sitting for prolonged periods of time, such as while at a desk, riding in a car, or watching a movie.

Many people who have RLS also have brief limb movements during sleep, often with abrupt onset, occurring every 5–90 seconds. This condition, known as periodic limb movements in sleep (PLMS), can repeatedly awaken people who have RLS and reduce their total sleep time. Some people have PLMS but have no abnormal sensations in their legs while awake.

RLS affects 5–15 percent of Americans, and its prevalence increases with age. RLS occurs more often in women than men. One study found that RLS accounted for one-third of the insomnia seen in patients older than age 60. Children also can have RLS. This condition can be difficult to diagnose in children, and it often is confused with hyperactivity or “growing pains.”

RLS is often inherited. Pregnancy, kidney failure, and anemia related to iron or vitamin deficiency can trigger or worsen RLS symptoms. Researchers suspect that these conditions cause insufficient iron that results in a lack of dopamine. The brain uses dopamine to control limb movements. Doctors usually can diagnose RLS by patients’ symptoms and a telltale worsening of symptoms at night or while at rest. Some doctors may order a blood test for iron, although many people who have RLS have normal levels of iron in their blood but abnormal levels in the fluid that bathes their brain. Doctors may also ask people who have RLS to spend a night in a sleep lab where they are monitored to rule out other sleep disorders and to document the excessive limb movements.

RLS is a treatable but not curable condition. Dramatic improvements are seen quickly when patients are given dopamine-like drugs. Alternatively, people who have milder cases may be treated successfully with sedatives or by behavioral strategies. These strategies include stretching, taking a hot bath, or massaging the legs before bedtime. Avoiding caffeinated beverages can also help reduce symptoms. If iron or vitamin deficiency underlies RLS, symptoms may improve with prescribed iron, vitamin B12, or folate supplements. Some people may require anticonvulsant medications to stem the creeping and crawling sensations in their limbs. Others who have severe symptoms may need to be treated with pain relievers, such as codeine or morphine, or a combination of drug treatments.

Narcolepsy

Narcolepsy’s main symptom is excessive and overwhelming daytime sleepiness, even after adequate nighttime sleep. In addition, night-time sleep may be fragmented by frequent awakenings. People who have narcolepsy often fall asleep at inappropriate times and places. Although television sitcoms occasionally feature these individuals to generate a few laughs, narcolepsy is no laughing matter. People who have narcolepsy experience daytime “sleep attacks” that last from seconds to more than one-half hour, can occur without warning, and may cause injury. These embarrassing sleep spells can also make it difficult to work and to maintain normal personal or social relationships.

With narcolepsy, the usually sharp distinctions between being asleep and awake are blurred. Also, people who have narcolepsy tend to fall directly into dream-filled REM sleep, rather than enter REM sleep gradually after passing through the non-REM sleep stages first. In addition to overwhelming daytime sleepiness, narcolepsy has three other commonly associated symptoms, but these may not occur in all people:

 Sudden muscle weakness (cataplexy). This weakness is similar to the paralysis that normally occurs during REM sleep, but it lasts a few seconds to minutes while an individual is awake. Cataplexy tends to be triggered by sudden emotional reactions, such as anger, surprise, fear, or laughter. The weakness may show up as limpness at the neck, buckling of the knees, or sagging facial muscles affecting speech, or it may cause a complete body collapse.

 Sleep paralysis. People who have narcolepsy may experience a temporary inability to talk or move when falling asleep or waking up, as if they were glued to their beds.

 Vivid (hypnogogic) dreams. These dreams tend to surface when people who have narcolepsy first fall asleep. The dreams are so lifelike that they can be confused with reality.

Experts estimate that as many as 350,000 Americans have narcolepsy, but fewer than 50,000 are diagnosed. The disorder is as widespread as Parkinson’s disease or multiple sclerosis, and more prevalent than cystic fibrosis, but it is less well known. Narcolepsy is often mistaken for depression, epilepsy, or the side effects of medicines.

Narcolepsy can be difficult to diagnose in people who have only the symptom of excessive daytime sleepiness. It is usually diagnosed with the aid of an overnight sleep recording (PSG) and the MSLT. Both tests reveal signs of narcolepsy—the tendency to fall asleep rapidly and enter REM sleep early, even during brief naps.Narcolepsy can develop at any age, but the symptoms tend to appear first during adolescence or early adulthood. About 1 of every 10 people who have narcolepsy has a close family member who has the disorder, suggesting that one can inherit a tendency to develop narcolepsy. Studies suggest that a neurotransmitter called hypocretin plays a key role in narcolepsy. Most people who have narcolepsy lack hypocretin, which promotes wakefulness. Scientists believe that an autoimmune reaction, perhaps triggered by disease or brain injury, specifically destroys the hypocretin-generating cells in the brains of people who have narcolepsy.

Eventually, researchers may develop a treatment for narcolepsy that restores hypocretin to normal levels. In the meantime, most people who have narcolepsy find some to all of their symptoms relieved by various drug treatments. For example, central nervous system stimulants can reduce daytime sleepiness. Antidepressants and other drugs that suppress REM sleep can prevent muscle weakness, sleep paralysis, and vivid dreaming. Doctors also usually recommend that people who have narcolepsy take short naps (10–15 minutes) two or three times a day, if possible, to help control excessive daytime sleepiness.

Parasomnias (Abnormal Arousals)

In some people, the walking, talking, and other body functions normally suppressed during sleep emerge during certain sleep stages. Alternatively, the paralysis or vivid images usually experienced during dreaming may persist after awakening. These arousal malfunctions are collectively known as parasomnias and include confusional arousals, sleep talking, sleep walking, night terrors, sleep paralysis, and REM sleep behavior disorder (acting out dreams). Most of these disorders—such as confusional arousals, sleep walking, and night terrors—are more common in children, who tend to outgrow them once they become adults. People who are sleep-deprived also may experience some of these disorders, including sleep walking and sleep paralysis. Sleep paralysis also commonly occurs in people who have narcolepsy. Certain medications or neurological disorders appear to lead to other parasomnias, such as REM sleep behavior disorder, and these parasomnias tend to occur more in elderly people. If you or a family member has persistent episodes of sleep paralysis, sleep walking, or acting out of dreams, talk with your doctor.