Sleep Disorders

Sleep Disorders Overview

Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep People with insomnia have one or more of the following symptoms:

• Difficulty falling asleep
• Waking up often during the night and having trouble going back to sleep
• Waking up too early in the morning
• Feeling tired upon waking

Types of Insomnia

The e are two types of insomnia: primary insomnia and secondary insomnia.

Primary insomnia: Primary insomnia means that a person is having sleep problems that are not directly associated with any other health condition or problem.
Secondary insomnia: Secondary insomnia means that a person is having sleep problems because of something else, such as a health condition (like asthma, depression, arthritis, cancer, or heartburn); pain; medication they are taking; or a substance they are using (like alcohol).

Acute vs. Chronic Insomnia

Insomnia also varies in how long it lasts and how often it occurs. It can be short-term (acute insomnia) or can last a long time (chronic insomnia). It can also come and go, with periods of time when a person has no sleep problems. Acute insomnia can last from one night to a few weeks. Insomnia is called chronic when a person has insomnia at least three nights a week for three months or longer.

Causes of Insomnia

Causes of acute insomnia can include:

• Significant life stress (job loss or change, death of a loved one, divorce, moving)
• Illness
• Emotional or physical discomfort
• Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep
• Some medications (for example those used to treat colds, allergies, depression, high blood pressure, and asthma) may interfere with sleep
• Interferences in normal sleep schedule (jet lag or switching from a day to night shift, for example)

Causes of chronic insomnia include:

• Depression and/or anxiety
• Chronic stress
• Pain or discomfort at night

Symptoms of Insomnia

Symptoms of insomnia can include:

• Sleepiness during the day
• General tiredness
• Irritability
• Problems with concentration or memory

Diagnosing Insomnia

If you think you have insomnia, talk to your health care provider. An evaluation may include a physical exam, a medical history, and a sleep history. You may be asked to keep a sleep diary for a week or two, keeping track of your sleep patterns and how you feel during the day. Your health care provider may want to interview your bed partner about the quantity and quality of your sleep. In some cases, you may be referred to a sleep center for special tests.

Treatment for Insomnia

Acute insomnia may not require treatment. Mild insomnia often can be prevented or cured by practicing good sleep habits (see below). If your insomnia makes it hard for you to function during the day because you are sleepy and tired, your health care provider may prescribe sleeping pills for a limited time. Rapid onset, short-acting drugs can help you avoid effects such as drowsiness the following day. Avoid using over-the-counter sleeping pills for insomnia, because they may have undesired side effects and tend to lose their effectiveness over time.

Treatment for chronic insomnia includes first treating any underlying conditions or health problems that are causing the insomnia. If insomnia continues, your health care provider may suggest behavioral therapy. Behavioral approaches help you to change behaviors that may worsen insomnia and to learn new behaviors to promote sleep. Techniques such as relaxation exercises, sleep restriction therapy, and reconditioning may be useful.

Good Sleep Habits for Beating Insomnia

Good sleep habits, also called sleep hygiene, can help you get a good night’s sleep and beat insomnia. Here are some tips:

• Try to go to sleep at the same time each night and get up at the same time each morning. Try not to take naps during the day, because naps may make you less sleepy at night.
• Avoid prolonged use of phones or reading devices (“e-books”) that give off light before bed. This can make it harder to fall asleep.
• Avoid caffeine, nicotine, and alcohol late in the day. Caffeine and nicotine are stimulants and can keep you from falling asleep. Alcohol can cause waking in the night and interferes with sleep quality.
• Get regular exercise. Try not to exercise close to bedtime, because it may stimulate you and make it hard to fall asleep. Experts suggest not exercising for at least three to four hours before the time you go to sleep.
• Don’t eat a heavy meal late in the day. A light snack before bedtime, however, may help you sleep.
• Make your bedroom comfortable. Be sure that it is dark, quiet, and not too warm or too cold. If light is a problem, try a sleeping mask. If noise is a problem, try earplugs, a fan, or a “white noise” machine to cover up the sounds.
• Follow a routine to help you relax before sleep. Read a book, listen to music, or take a bath.
• Avoid using your bed for anything other than sleep or sex.
• If you can’t fall asleep and don’t feel drowsy, get up and read or do something that is not overly stimulating until you feel sleepy.
• If you find yourself lying awake worrying about things, try making a to-do list before you go to bed. This may help you to not focus on those worries overnight.

Hypersomnia, which refers to either excessive daytime sleepiness or excessive time spent sleeping, is a condition in which a person has trouble staying awake during the day. People who have hypersomnia can fall asleep at any time — for instance, at work or while they are driving. They may also have other sleep-related problems, including a lack of energy and trouble thinking clearly.

According to the National Sleep Foundation, up to 40% of people have some symptoms of hypersomnia from time to time.

Causes of Hypersomnia

There are several potential causes of hypersomnia, including:

• The sleep disorders narcolepsy (daytime sleepiness) and sleep apnea (interruptions of breathing during sleep)
• Not getting enough sleep at night (sleep deprivation)
• Being overweight
• Drug or alcohol abuse
• A head injury or a neurological disease, such as multiple sclerosis or Parkinson’s disease
• Prescription drugs, such as tranquilizers or antihistamines
• Genetics (having a relative with hypersomnia)
• Depression

Diagnosing Hypersomnia

If you consistently feel drowsy during the day, talk to your doctor. In making a diagnosis of hypersomnia, your doctor will ask you about your sleeping habits, how much sleep you get at night, if you wake up at night, and whether you fall asleep during the day. Your doctor will also want to know if you are having any emotional problems or are taking any drugs that may be interfering with your sleep.

Your doctor may also order some tests, including blood tests, computed tomography (CT) scans, and a sleep test called polysomnography. In some cases, an additional electroencephalogram (EEG), which measures the electrical activity of the brain, is needed.

Treatment of Hypersomnia

If you are diagnosed with hypersomnia, your doctor can prescribe various drugs to treat it, including stimulants, antidepressants, as well as several newer medications (for example, Provigil and Xyrem).

If you are diagnosed with sleep apnea, your doctor may prescribe a treatment known as continuous positive airway pressure, or CPAP. With CPAP, you wear a mask over your nose while you are sleeping. A machine that delivers a continuous flow of air into the nostrils is hooked up to the mask. The pressure from air flowing into the nostrils helps keep the airways open.

If you are taking a medication that causes drowsiness, ask your doctor about changing to one that is less likely to make you sleepy. You may also want to go to bed earlier to try to get more sleep at night, and eliminate alcohol and caffeine.

Sleep Disorders and Parasomnias

• Nightmares
• Night Terrors
• Sleepwalking
• Confusional Arousals
• Rhythmic Movement Disorder
• Sleep Talking
• Nocturnal Leg Cramps
• Sleep Paralysis
• Impaired Sleep-Related Erections
• Sleep-Related Painful Erections
• Irregular Heart Rhythms
• REM Sleep Behavior Disorder (RBD)
• Sleep Bruxism (Teeth Grinding)
• Sleep Enuresis (Bedwetting)
• Nocturnal Paroxysmal Dystonia (NPD)

Parasomnias are disruptive sleep disorders that can occur during arousals from REM sleep or partial arousals from non-REM sleep. Parasomnias include nightmares, night terrors, sleepwalking, confusional arousals, and many others.

Nightmares

Nightmares are vivid nighttime events that can cause feelings of fear, terror, and/or anxiety. Usually, the person having a nightmare is abruptly awakened from REM sleep and is able to describe detailed dream content. Returning to sleep is usually difficult. Nightmares can be caused by many factors, including illness, anxiety, the loss of a loved one, or negative reactions to a medication. Call your doctor if nightmares occur more than once a week or if nightmares prevent you from getting a good night’s sleepfor a prolonged period of time.

Night Terrors

A person experiencing a night terror abruptly awakes from sleep in a terrified state, but is confused and unable to communicate. They do not respond to voices and are difficult to fully awaken. Night terrors last about 15 minutes, after which time the person usually lies down and appears to fall back asleep. People who have night terrors (sometimes called sleep terrors) usually don’t remember the events the next morning. Night terrors are similar to nightmares, but usually occur during deep sleep.

People experiencing sleep terrors may pose dangers to themselves or others because of limb movements. Night terrors are fairly common in children, mostly between ages 3 and 8. Children with sleep terrors will often also talk in their sleep or sleepwalk. This sleep disorder, which may run in families, also can occur in adults. Strong emotional tension and/or the use of alcohol can increase the incidence of night terrors among adults.

Sleepwalking

Sleepwalking occurs when a person appears to be awake and moving around, but is actually asleep. He or she has no memory of the episode. Sleepwalking most often occurs during deep non-REM sleep (stages 3 and 4 sleep) early in the night and it can occur during REM sleep in the early morning. This disorder is most commonly seen in children between ages 5 and 12; however, sleepwalking can occur among younger children, adults, and seniors.

Sleepwalking appears to run in families. Contrary to what many people believe, it is not dangerous to wake a person who is sleepwalking. The sleepwalker simply may be confused or disoriented for a short time upon awakening. Although waking a sleepwalker is not dangerous, sleepwalking itself can be dangerous, because the person is unaware of his or her surroundings and can bump into objects or fall down. In most children, it tends to stop as they enter the teen years.

Confusional Arousals

Confusional arousals usually occur when a person is awakened from a deep sleep during the first part of the night. This disorder, which also is known as excessive sleep inertiaor sleep drunkenness, involves an exaggerated slowness upon awakening. People experiencing confusional arousals react slowly to commands and may have trouble understanding questions that they are asked. In addition, people with confusional arousal often have problems with short-term memory; they have no memory of the arousal the following day.

Rhythmic Movement Disorder

Rhythmic movement disorder occurs mostly in children under age 1. A child may lie flat, lift the head or upper body, and then forcefully hit his or her head on the pillow. Rhythmic movement disorder, which also has been called “head banging,” also can involve movements such as rocking on hands and knees. The disorder usually occurs just before a person falls asleep.

Sleep Talking

Sleep talking is a sleep-wake transition disorder. Although it usually is harmless, sleep talking can be disturbing to sleep partners or family members who witness it. Talk that occurs during sleep can be brief and involve simple sounds, or it can involve long speeches by the sleeper. A person who talks during sleep typically has no recollection of the actions. Sleep talking can be caused by external factors, including fever, emotional stress, or other sleep disorders.

Nocturnal Leg Cramps

Nocturnal leg cramps are sudden, involuntary contractions most commonly of the calf muscles during the night or periods of rest. The cramping sensation may last from a few seconds to 10 minutes, but the pain from the cramps may linger for a longer period. Nocturnal leg camps tend to be found in middle-aged or older populations, but people of any age can have them. Nocturnal leg cramps differ from restless legs syndrome, because the latter usually does not involve cramping or pain. The cause of nocturnal leg cramps is not known. Some cases of the disorder can occur without a triggering event, while other causes of leg cramps may be linked to prolonged sitting, dehydration, an overexertion of the muscles, or structural disorders (such as flat feet). Muscle-stretching, exercise, and adequate water intake may help prevent leg cramps.

Sleep Paralysis

People with sleep paralysis are not able to move their body or limbs either when falling asleep or waking up. Brief episodes of partial or complete skeletal muscle paralysis can occur during sleep paralysis. Sleep paralysis can run in families, but the cause of sleep paralysis is not known. This disorder is not harmful, but people experiencing sleep paralysis often are fearful, because they do not know what is happening. An episode of sleep paralysis often is terminated by sound or touch. Within minutes, the person with sleep paralysis is able to move again. It may occur only once in your lifetime or can be a recurring phenomenon.

Impaired Sleep-Related Erections

This disorder occurs among men who are unable to sustain a penile erection during sleep that would be sufficiently rigid enough to engage in sexual intercourse. Men usually experience erections as a part of REM sleep, and impaired sleep-related erections may indicate erectile dysfunction.

Sleep-Related Painful Erections

Erections are a normal component of REM sleep for men. In rare cases, however, erections become painful and cause a man to wake up. The treatment of sleep-related painful erections may involve drugs that suppress REM sleep (some antidepressants, for example).

Irregular Heart Rhythms

A cardiac arrhythmia — the medical term for an irregular heart rhythm — is a change from the normal rate or control of the heart’s contractions. People who have coronary artery disease and whose blood oxygen is lowered by sleep-disordered breathing may be at risk for arrhythmias, which take place during REM sleep. Continuous positive airway pressure (CPAP) treatment may reduce this risk.

REM Sleep Behavior Disorder (RBD)

People with rapid eye movement (REM) sleep behavior disorder act out dramatic and/or violent dreams during REM sleep. REM sleep usually involves a state of sleep paralysis (atonia), but people with this condition move the body or limbs while dreaming. Usually, RBD occurs in men aged 50 and older, but the disorder also can occur in women and in younger people. It differs from sleepwalking and sleep terrors, in that the sleeper can be easily awakened and can recall vivid details of the dream. In the diagnosis and treatment of RBD, potentially serious neurological disorders must be ruled out. Polysomnography(sleep tests) and drug treatments also can be involved in the diagnosis and treatment of this disorder.

Sleep Bruxism (Teeth Grinding)

Sleep bruxism — or teeth grinding — involves the involuntary, unconscious, excessive grinding or clenching of teeth during sleep. It may occur along with other sleep disorders. Sleep bruxism may lead to problems, including abnormal wear of the teeth and jaw muscle discomfort. The severity of bruxism can range from mild to severe enough to cause dental injury. In some cases, grinding can be prevented with the use of a mouth guard. The mouth guard, supplied by a dentist, can fit over the teeth to prevent them from grinding against each other.

Sleep Enuresis (Bedwetting)

In this condition, the affected person is unable to maintain urinary control when asleep. There are two kinds of enuresis — primary and secondary. In primary enuresis, a person has been unable to have urinary control from infancy onward. Primary bedwettingappears to run in families. Children are more likely to have it if their parents or siblings had it as children. In secondary enuresis, a person has a relapse after previously having been able to have urinary control. Enuresis can be caused by medical conditions (for example, diabetes, urinary tract infections, and sleep apnea) or by psychiatric disorders. Some treatments for bedwetting include behavior modification, alarm devices, and medications.

Nocturnal Paroxysmal Dystonia (NPD)

This disorder is sometimes marked by seizure-like episodes during non-REM sleep. Most evidence points to NPD being a form of epilepsy. Episodes of NPD typically recur several times per night.

Normal sleep has two distinct states: non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep is divided into four stages. During REM sleep, rapid eye movements occur, breathing becomes irregular, blood pressurerises, and there is a loss of muscle tone (paralysis). However, the brain is highly active, and the electrical activity recorded in the brain by EEG during REM sleep is similar to that recorded during wakefulness. REM sleep is usually associated with dreaming. REM sleep accounts for 20%-25% of the sleepperiod.

In a person with REM sleep behavior disorder (RBD), the paralysis that normally occurs during REM sleep is incomplete or absent, allowing the person to “act out” his or her dreams. RBD is characterized by the acting out of dreams that are vivid, intense, and violent. Dream-enacting behaviors include talking, yelling, punching, kicking, sitting, jumping from bed, arm flailing, and grabbing. An acute form may occur during withdrawal from alcohol or sedative-hypnotic drugs.

RBD is usually seen in middle-aged to elderly people (more often in men).

Causes of REM Sleep Disorder

The exact cause of REM sleep behavior disorder (RBD) is unknown, although the disorder may occur in association with various degenerative neurological conditions such as Parkinson’s disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. In 55% of persons the cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine, sertraline, or paroxetine) or other types of antidepressants (mirtazapine).

RBD often precedes the development of these neurodegenerative diseases by several years. In one study, 38% of patients diagnosed with RBD subsequently developed Parkinson’s disease within an average time of 12-13 years from the onset of RBD symptoms. Also, RBD is seen in 69% of those with Parkinson’s disease and multisystem atrophy. The relationship between RBD and Parkinson disease is complex; however, not all persons with RBD develop Parkinson’s disease.

Sleep and Circadian Rhythm Disorders

Circadian rhythm disorders are disruptions in a person’s circadian rhythm — a name given to the “internal body clock” that regulates the (approximately) 24-hour cycle of biological processes. The term circadian comes from Latin words that literally mean around the day. There are patterns of brain wave activity, hormone production, cell regeneration, and other biological activities linked to this 24-hour cycle.

The circadian rhythm is important in determining sleeping patterns such as when we sleep and when we wake, every 24 hours.The normal circadian clock is set by the light-dark cycle over 24 hours.

What Causes Circadian Rhythm Disorders?

Circadian rhythm disorders can be caused by many factors, including:

• Shift work
• Pregnancy
• Time zone changes
• Medications
• Changes in routine such as staying up late or sleeping in
• Medical problems including Alzheimer’s or Parkinson disease
• Mental health problems
• Menopause

Common Circadian Rhythm Disorders

Jet Lag or Rapid Time Zone Change Syndrome: This syndrome consists of symptoms that include excessive sleepiness and a lack of daytime alertness in people who travel across time zones.
Shift Work Sleep Disorder: This sleep disorder affects people who frequently rotate shifts or work at night.
Delayed Sleep Phase Syndrome (DSPS): This is a disorder of sleep timing. People with DSPS tend to fall asleep very late at night and have difficulty waking up in time for work, school, or social engagements.
Advanced Sleep Phase Syndrome (ASPD): This is a disorder in which a person goes to sleep earlier and wakes earlier than desired. ASPD results in symptoms of evening sleepiness, going to bed earlier (for example, between 6 p.m. and 9 p.m.), and waking up earlier than desired (for example, between 1 a.m. and 5 a.m.)
Non 24-Hour Sleep Wake Disorder: This disorder frequently affects those that are totally blind since the circadian clock is set by light-dark cycle over a 24 hour period. In non-24 hour sleep wake disorder the cycle is disturbed. The disorder result in drastically reduced sleep time and sleep quality at night and problems with sleepiness during daylight hours.

How Are Circadian Rhythm Disorders Treated?

Circadian rhythm disorders are treated based on the kind of disorder diagnosed. The goal of treatment is to fit a person’s sleep pattern into a schedule that allows him or her to meet the demands of their lifestyle. Therapy usually combines proper sleep hygiene techniques and external stimulus therapy, such as bright light therapy or chronotherapy. Chronotherapy is a behavioral technique in which the bedtime is gradually and systematically adjusted until a desired bedtime is achieved. Bright light therapy is designed to reset a persons circadian rhythm to a desired pattern. When combined, these therapies may produce significant results in people with circadian rhythm disorders.

Melatonin is sometimes used to help insomnia and to prevent jet lag. Ask your doctor about it if you are traveling between time zones.

What Is Non-24-Hour Sleep-Wake Disorder?

Thanks to an internal body clock, most people get sleepy and wake up at roughly the same times every day. But if you have Non-24-hour sleep-wake disorder (Non-24), you may find yourself gradually going to bed later every night and waking up later each day.

Eventually, your sleep schedule goes all the way around the clock. For example, you might fall asleep at 11 p.m. one night and then can’t get to sleep until 1 a.m. the next night. The delay gets worse until you’re going to sleep at 2 a.m., 4 a.m., and later each night.

Non-24 is a circadian rhythm disorder and occurs because our internal clock is not synched with light and dark cycles of the day and night. Most individuals with this disorder are totally blind. That’s because your internal clock gets its cue from seeing light. But sometimes people who have normal vision also get it.

There’s no cure, but treatments, including hormones, medicine, and light therapy, can help get you closer to a normal sleeping pattern.

Ask your doctor to put you in touch with others who also have Non-24. You can get emotional support from those who are going through the same things you are.

You can also get advice in support groups about how to educate your friends, teachers, or bosses about your condition and how it affects your schedule. You might need to bust some myths about it. For example, some people may think all you need to do is “try harder” to get to sleep on time. Explain to them that you’ve got a very real disorder and that you’re getting medical help to try to bring it under control.

Causes

You get Non-24 because of a problem with your internal body clock, which controls your ability to sleep at night and stay awake during the day.

This “clock” is actually a group of thousands of nerve cells in your brain that sends signals to your body that it’s time to wake up or go to sleep.

Light plays a key role in this process. Your body clock doesn’t swing into action until light moves from your eyes to your brain.

If you’re totally blind, light doesn’t reach your brain, so your internal body clock may not work right. About half of all people who are completely blind have Non-24.

If you’re not blind and you have Non-24, it might be because there are problems in the way your brain is getting light from your eyes. You won’t have any vision trouble, but your body clock isn’t getting the start-up signal it needs to message your body that it’s time to wake up or go to sleep.

You could also get Non-24 if your body doesn’t make enough melatonin. Other causes include:

Developmental brain disorders, including autism spectrum disorder
Brain damage from head injury or tumors

Symptoms

When you have Non-24 you feel sleepy during the day and have trouble falling asleep at night.

Since your sleep schedule moves around the clock, you may feel normal for days and weeks at a time. But as your bedtime pattern shifts, you’ll go back to having problems in getting to sleep at night.

Getting a Diagnosis

Non-24 is often mistaken for sleep deprivation or psychiatric problems. Your doctor will ask about your medical history. He may suggest you keep a sleep diary for a few weeks, or even months, to help track your sleep patterns. You may also wear a sensor that tracks your movement and records your rest and activity patterns.

Your doctor may ask you questions such as:

1. How often do you fall asleep during the day?
2. Do you feel rested after sleeping?
3. How have your sleep patterns affected your work, personal, and social lives?
4. When was the last time you had a good night’s sleep?
5. When you sleep, do you wake up feeling rested?
6. How strong is your desire to sleep during the day, and how does it change from one day to the next?
7. How hard is it for you to concentrate?
8. What do you do to stay awake during the day?

Blood, urine, or saliva tests over several weeks can check for signs that your body clock runs on a non-24-hour rhythm.

Together, the sleep diary and test results will help your doctor diagnose Non-24-hour sleep-wake disorder.

Questions for Your Doctor

Do I have Non-24 or another circadian rhythm disorder?
What tests will I need?
How do I keep a sleep diary?
What is causing my Non-24?
What are the treatments? What do you recommend?
What lifestyle changes can help me manage my disorder?
Can I ask for accommodations at work or school?

Treatment

The goal is to get your internal body clock back into sync with the rest of the world’s 24-hour day-night cycle. You have several options.

Phototherapy. You are exposed to bright light early in the morning from a light box. Late in the day, you wear special goggles to avoid light.

Doctors usually try light therapy only after your sleep hours are back to normal, and it works only in people who have vision. It helps your eyes send the right signal to your brain about light and dark.

Melatonin. This is a hormone that controls the sleep-wake cycle. By taking doses at the right times, you might be able to shift your body clock earlier or later. If you have vision problems, you may need to take other treatments along with it, but it’s effective on its own for people who are totally blind.

Medication. Your doctor may recommend a prescription drug that targets the parts of the brain that control the timing of the sleep-wake cycle.

Taking Care of Yourself

Treatment is only part of what you can do to manage your condition. Look for creative ways to adjust to your shifting sleep patterns. Think about what’s important to you and how you can make positive changes in your life.

For instance, you may need to ask your boss for flexible working hours. If you’re a student, consider taking classes online or viewing lectures on video. Ask your school about getting a flexible exam schedule or taking a lighter course load.

Keep in mind that Non-24 is considered a disability under the Americans with Disabilities Act. Schools and employers must make reasonable accommodations for you, such as part-time or altered schedules.

What to Expect

It’s important to keep a regular schedule of phototherapy, melatonin, or medication to keep your body clock in tune with a 24-hour day-night cycle.

Treatment success varies from person to person. One survey found that a combination of therapies brought “moderate” or “marked” improvement in 31% of people.

If you still have some symptoms after treatment, get help from your doctor and family members about managing your lifestyle to fit your changing sleep-wake cycle. You may need advice from a mental health professional to help you work through the challenges of a shifting schedule.

Getting Support

Get the emotional backing you need by reaching out to family and friends. You can also get more information about Non-24, along with tips for managing the condition, on the web site of the Circadian Sleep Disorders Network.

For more information, please visit our LEARN section.