Sleep Disorders

Common Sleep Disorders

Circadian Rhythm Disturbances

People with circadian rhythm disorders have their internal biologic clocks out of alignment with the usual 24 hour cycle of light and dark. These individuals cannot fall asleep until very late in the night or into the early morning hours and then have difficulty waking up for school or work in the morning. In some cases they can stay asleep until late morning or early afternoon. Others go to sleep early in the evening and then wake up in the early morning well before daybreak unable to fall back asleep.

Circadian rhythms influence body temperature, sleep and wakefulness, and a variety of hormonal changes. Sunlight and other time cues help to set circadian cycles so that they are consistent from day to day. Even if we didn’t have time cues from our environment, fluctuations in circadian rhythms would continue to occur within a period of a little more than one day (generally about 25 hours). As a consequence of this we “reset” our internal clocks on a daily basis by going to sleep at the same time each night and awakening at the same time each day.
Others have lost the ability to have a set sleep and wake-up time and they have unusual variability in sleep onset and waking (these are usually people with severe visual impairment or total blindness). This issue causes difficulties in maintaining a normal work and sleep schedule.

Many different treatment modalities are used to treat these body rhythm disorders. These include using such measures as exposure to bright light (natural or artificial) at certain times of the day or night depending on the specific complaint and in some cases the light exposure is used in conjunction with medications that help control the body’s internal clock. People who work night shifts and/or rotating shifts as well as people who travel across three (3) or more time zones (time zone changes) [jet lag] are especially prone to circadian rhythm disturbances.

Insomnia

Insomnia is defined as a condition manifested by difficulty falling asleep and/or staying asleep. It needs to last for more than three (3) weeks at a time and is associated with negative daytime consequences of the disturbed nocturnal sleep. These daytime symptoms include fatigue, lethargy, impaired thought processes, mood disturbance and non-specific physical complaints including headache, gastrointestinal disturbance or multiple aches and pains. For the most part, insomnia is a symptom of an underlying medical and/or psychological problem; it is not a diagnosis by itself. Treatment is always more effective when the underlying problem is addressed rather than just treating the sleep complaints. An extremely useful regimen is for the person to maintain good sleep habits (see Guidelines for Better Sleep). Treatment can include cognitive behavioral therapy aimed at promoting mental relaxation as well as muscle tension release at bedtime. Therapy can be aimed at controlling the patient’s physical as well as their emotional environment that they are contending with at the time of sleep onset, or in special cases the patient can be treated by restricting the number of hours that they spend in bed (time spent waiting to fall asleep as well as time spent asleep) and as the person’s sleep improves the time in bed is increased. In some cases judicious use of sleeping medications are employed. This occurs when a temporary aid is needed to allow the person to get their sleep back on track. In most cases sleep will re-establish itself and in the long run regular use of sleeping pills will do more harm than good.

Narcolepsy

Narcolepsy is one of the most under diagnosed illnesses that medicine of the twenty first century deals with. It is estimated that only one quarter of those actually suffering from this disorder have been properly diagnosed and treated. This leaves approximately 120,000 sleepy people who have been misdiagnosed and improperly treated or undiagnosed completely. For these people, the impact on their lives is considerable and at times completely disabling or fatal (auto accidents account for the majority of the fatalities). With the advent of modern sleep monitoring techniques and recent developments in genetics this number should drop significantly. Although no cure for narcolepsy has been found, recent advances in medications allow most people to lead normal or nearly normal lives.

Narcolepsy can be defined as uncontrollable attacks of REM (Rapid Eye Movement) Sleep also called dream or paradoxical sleep during what is considered daytime or “normal” waking hours. Between these episodes the person feels sleepy on a continual basis unrelated to the amount or type of nighttime sleep.

Excessive daytime sleepiness is just one of the symptoms of narcolepsy. There are three other symptoms that are closely associated with narcolepsy and are known as the ancillary symptoms. These include cataplexy, which is the sudden loss of muscle strength usually brought on by a strong emotional stimulus e.g. laughter, anger, and fright. Sleep Paralysis is the sensation that all of your muscles are paralyzed and occurs in the transition into or out of sleep. Many “normal” people experience a feeling of free falling generally after a full night’s sleep and occurs when waking up out of the last REM period (dream state) of the night. Sleep paralysis becomes pathologic when it occurs at sleep onset rather than sleep offset.
The third associated symptom is called Hypnagogic and Hypnopompic Hallucinations. Hypnagogic hallucinations are vivid still image mental pictures that occur when one first falls asleep and hypnopompic hallucinations are similar vivid frozen motion mental imagery at the point of awakening.

Narcoleptic patients can have one, two or all three of the associated symptoms and sometimes there will be no other symptom, other than the daytime sleepiness. Most patients with narcolepsy start off with the daytime sleep attacks and then go on to develop the ancillary symptoms later on. The ancillary symptoms however such as cataplexy can be as troubling to the patient as the primary symptom of sleep attacks. Treatment of the sleep attacks and cataplexy for the most part require different medications.

Narcolepsy typically starts during a person’s teenage years and for this reason many patients are labeled; slow, unmotivated, daydreamers, drug users, or ADD (Attention Deficit Disorder) sufferers.

The exact cause is not known but narcolepsy appears to be a disorder of that part of the central nervous system that controls sleep and wakefulness. An almost identical syndrome occurs in dogs and a very recent discovery has identified a mutant gene that codes for a specific neurotransmitter receptor. This is very exciting because it may allow medical science to modify the gene so that the correct receptor is made and “cure” the condition. The ancillary symptoms: cataplexy, sleep paralysis and hypnagogic hallucinations can be thought of as REM (rapid eye movement) intrusion into wakefulness. During REM sleep all muscles of the body become paralyzed and dreaming occurs. In narcoleptics however this behavior is not confined to sleep during the night but occurs periodically throughout the day causing all the signs and symptoms described above. Narcolepsy is not caused by psychiatric or psychological or emotional problems.

Parasomnias

Parasomnias are unpleasant feelings or behaviors that take place during the night when non-dream or non-REM sleep is taking place. This usually happens within the first two hours of sleep onset and includes confusional arousals, where there is an abrupt partial awakening from sleep manifested by disorientation, slow speech confusion and amnesia for the event upon full awakening. Sleep-walking and sleep-talking are other examples of parasomnias. More disturbing is the parasomnia known as sleep terrors which are more frightening than dreams or nightmares and include crying out, feelings of extreme anxiety and impending doom. These disorders are common during childhood and generally disappear during the teenage years. They rarely require treatment but sometimes medication is used if the parasomnia causes the person to place themselves in harm’s way. Sexomnia is sexual activity while asleep without memory of such activity.

Periodic Limb Movements of Sleep (PLMS)

Periodic Limb Movements of Sleep (PLMS) is another disorder that affects the limbs during sleep. It frequently interferes with the person’s ability to get a full night of restful sleep. It has previously been called nocturnal myoclonus. Movements appear after sleep onset that can be seen and recorded in one or more limbs either individually or can occur on a unilateral or bilateral basis. They occur in runs of muscle contractions and can be strong enough to cause the limb to move and in rare cases to cause a flinging or jerking movement that can wake the patient or can disturb their bed partner. Generally speaking people with RLS have some degree of PLMS but patients with PLMS do not necessarily have RLS.

REM Sleep-Related Disturbances

Dream related abnormal sleep states include Recurring Nightmares, Sleep Paralysis, and REM Sleep Behavior Disorder (RBD). Nightmares and isolated sleep paralysis are common occurrences and do not constitute an abnormality unless they occur several times a week and disturb the patient’s sleep however RBD is a serious disorder that involves patients acting out their dreams and can include punching, kicking, leaping and running from their bed. The disorder is more common in middle aged and elderly males and there is a high statistical association with Parkinson’s Disease.

Restless Legs Syndrome (RLS)

Restless Legs Syndrome (RLS) is a sleep disorder, which often appears in otherwise healthy people, and is not related to emotional or psychiatric disorders. As the name implies this disorder affects the legs but it can involve the arms as well. People experience a restless sensation in many different ways, but all describe a particularly uncomfortable sensation in the muscles of the affected limbs whenever they try to relax in either a sitting or lying position. The sensation is relived by moving or walking, or in extreme cases my application of warm soaks or a hot bath. The sensation can be very painful and frequently leads to problems falling asleep because of the inability to “relax.” Careful questioning will differentiate the pain of leg cramps and the pins and needles sensation that diabetics or other patients with “peripheral neuropathies” experience.

Sleep Apnea

It has been estimated that two out of three adult males snore some or all of the time during nocturnal sleep and almost that number of women following menopause also experience snoring. Of one hundred people who snore approximately one third will not have sleep apnea, one third will have mild to moderate sleep apnea and one third will have severe sleep apnea. All people who have sleep apnea snore but not all snorers have sleep apnea. Snoring is a sign that the airway is not fully open, and the distinctive sound of snoring comes from efforts to force air through a narrowed passageway in the throat.

The “typical” patient with sleep apnea exhibits loud snoring throughout the night because their upper airway either collapses under it’s own weight or the tongue and uvula (the small tissue that hangs on the soft palate in the back of the throat) close over the back of the throat causing air to be blocked. The person literally chokes himself or herself at the level of the upper airway.

In order to “break the blockage” the body chooses breathing over sleep and the person undergoes a brief awakening-usually without awareness, to allow the muscles of the throat to contract and open up the passage. This pattern can happen 5 to over one hundred times per hour. During the time they are not breathing, their oxygen level falls and carbon dioxide builds up. Because of this constant interruption of sleep the patient becomes chronically sleep deprived. This directly leads to daytime sleepiness, which can be severe. Other consequences of untreated sleep apnea are high blood pressure, heart failure, heart attacks and strokes. Chronic sleep deprivation leads to impaired concentration, poor memory and a significant increase in automobile accidents and fatalities. It is important to note that continued weight gain can make the apnea worse over a long period of time and ingestion of any sedative or tranquilizer including alcohol can turn mild apnea into severe apnea in one night.
One does not need to be overweight, middle aged, or male to have sleep apnea. Persons with enlarged tonsils, posterior displaced jaws, or masses in the throat can all experience the same symptoms and signs that the “typical” patient described above can exhibit.

Snoring loudly every night calls for a visit to your physician or referral to a sleep specialist connected with a sleep laboratory where overnight studies are performed to evaluate and treat the sleep apnea.

Warning signs include: Loud snoring, abnormal pattern of snoring with long relative periods of silence then resumption of the snoring with loud gasps or snorts, morning headaches, daytime sleepiness with problems concentrating or experiencing poor short-term memory, sexual dysfunction with loss of desire or impaired sexual functioning, and awakening during the night either gasping or choking.

Sleep Apnea can also be seen in children. As in adults these kids are usually overweight but also have enlarged tonsils and or adenoids and small throats. Children with sleep apnea may snore, squeak, have difficulty breathing, and sleep fitfully. School age children with sleep apnea typically have problems at school or at home with observations that they are sluggish, slow, lazy, on drugs, or seem to daydream. Many in fact are incorrectly diagnosed as attention deficit disorder and sometimes inappropriately treated with medication.

Diagnosis & Treatment of Sleep Disorders:

The evaluation consists of two parts. The first is a thorough history and physical examination that is done by our Sleep Medicine Consultant. At the time of the initial evaluation you will be asked to fill out questionnaires to get detailed information on your health, sleep habits, sleep environment and any current medications you are taking including prescription and over the counter or health food supplements.

The second part of the evaluation involves observing and monitoring your night-time sleep with either a home sleep test or an in-lab test (polysomnography) for one or two nights. During this monitoring session we will be recording brain waves, eye movements, air movement through the nose and mouth, muscle activity of your legs and sometimes your arms, breathing effort as measured by abdominal and rib cage muscle activity or movement, electrocardiogram, and pulse oximetery (measuring the amount of oxygen carried by the blood). All measurements are done with surface electrodes; there are no needles or skin punctures required. You will be sleeping in a comfortable room and in spite of the fact that you will be in darkness we will be recording your images on a digital recorder that makes it look as if you were sleeping in bright daylight.

Depending on your sleep problem, you may also be scheduled for a series of nap tests (Multiple Sleep Latency Test) on the day following a night study.

“Improving the Quality of Life by Improving the Quality of Sleep”

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