Adult Sleep Disorders

Obstructive sleep apnea (OSA) is a breathing disorder whereby individuals stop breathing or have shallow breathing recurrently during sleep. Apneas are usually associated with snoring and produce changes in heart rate, blood pressure and blood oxygen, typically ending with an arousal. Recurrent apneas prevent patients from entering deep stages of sleep, leading to unrefreshing sleep and daytime sleepiness.

View the Obstructive Sleep Apnea (OSA) Fact Sheet

Although sleepiness and snoring are the most common symptoms, patients may experience nighttime choking, headaches, insomnia, night sweats, thrashing, nighttime urination and sexual dysfunction. Cardiovascular presentations include uncontrolled high blood pressure, abnormal heart rhythms at night, and unexplained right heart dysfunction.

OSA occurs in about 25% percent of adult males and 9% percent of females. It is nearly as common as asthma, but usually unrecognized. One out of three overweight male snorers have OSA. The diagnosis is made by an overnight sleep study. Treatments for mild OSA include weight loss, avoiding alcohol and sedatives, sleeping off the back, and/or nasal sprays. In patients with more significant disease, the treatment of choice is positive airway pressure (PAP) therapy. The device consists of a mask or tubing around or under the nose or mouth connected to a blower that is powered by an electrical outlet. Continuous positive airway pressure (CPAP) delivers air under a constant pressure, thereby acting as an air splint to keep the airway open. Bilevel PAP therapy delivers different pressures during inhalation and exhalation to improve comfort and tolerance. Bilevel PAP is the preferred initial treatment for some patients with sleep-related breathing disorders.

About Insomnia: Will You Sleep Again?

Insomnia is a disorder characterized by difficulty initiating or maintaining sleep. Approximately 50% of adults experience intermittent insomnia, and one in ten complain of chronic insomnia. Insomnia is approximately twice as common in women as in men, and is more common in older than younger people. There are many causes of insomnia. These include significant life stress (job loss or change, death of a loved one), medical illness, medications, pain or discomfort at night, depression, environmental factors such as noise, light, or extreme temperatures, and things that interfere with a normal sleep schedule including jet lag and shift work.

View the Insomnia Fact Sheet

Because sleep is very sensitive to psychological stress and physical ailments, nearly all people at some time in their lives experience sleepless nights. Usually sleep patterns return to normal over time. However, in some cases, insomnia may persist and become chronic. Such individuals often develop maladaptive thoughts and behaviors which maintain their insomnia. For example, they may spend too much time in bed, try too hard to sleep, worry too much about the effects of missing sleep, or turn to remedies such as alcohol or over-the-counter sleep aids. In essence, these people become desperate to sleep which only serves to worsen the problem and they develop performance anxiety with regard to sleep. Since sleep is a natural process that can not be forced, the harder one tries to "make sleep happen" the more sleep becomes elusive and the worse the insomnia becomes.

Psychophysiological insomnia is the most common form of insomnia. This is a disorder of learned, sleep-preventing associations, such as not being able to sleep because either your body or your mind is not relaxed. People with psychophysiological insomnia usually have excessive, daily worries about not being able to fall or stay asleep and make intense efforts to fall asleep that are accompanied by marked apprehensions that their efforts will be unsuccessful. They are usually unable to fall asleep when they desire. And they may fall asleep when trying to stay awake, such as when they are watching TV or reading.

Stress is the most common cause of psychophysiological insomnia. While it is common to have sleep disturbances when someone is going through stress, some people continue to have sleep disturbances long after the stress has abated. Sometimes the stress and sleep disturbances worsen one another, creating a vicious cycle. Many people with this condition are concerned that they will never have a good night of sleep again. The fact is that sleep will improve; however, treating this form of insomnia requires that you make some changes in the way you think and worry about sleep. It also requires some changes in your behavior.

Tips for a better night's sleep…

• Think positive. Avoid going to bed with a negative mind set, such as "If I don't sleep for 8 hours, I will feel terrible tomorrow."
• If you find yourself lying awake worrying in bed, try to clear your mind by making a to-do list before you go to bed.
• Establish a routine for bedtime and wake up at the same time each morning, including days off.
• Relax before going to bed by reading a book, listening to music or taking a bath.
• Create a positive sleep environment by making sure that your bedroom is comfortable, quiet and dark.
• Stop clock watching. Turn the clock around and only use the alarm.
• Get out of bed and do something else if you can't sleep after 20 minutes.
• Avoid using your bed for anything other than sleep and sex.
• Avoid naps during the daytime.
• Avoid stimulants (coffee, teas and colas) for at least 4 hours before bedtime and heavy meals late in the day.
• Avoid alcohol and smoking.
• Exercise regularly, but not within 4 hours of bedtime.

If these simple strategies are not effective, consult your physician. You may benefit from a consultation with a psychologist with expertise in treating psychophysiological insomnia who can teach you some powerful techniques including cognitive-behavioral therapy, biofeedback, sleep restriction therapy and relaxation-based treatments to improve your sleep. While these techniques require some effort and take time to work, they do provide a means of coping with insomnia that help people return to more normal sleep patterns.

Recommended Reading

• Insomnia Cures: Sleep Hygiene Practice Makes Permanent by Barry Krakow
• Say Goodnight to Insomnia by Gregg Jacobs
• Desperately Seeking Snoozin' : The Insomnia Cure from Awake to Zzzzz by John Wiedman
• No More Sleepless Nights, Workbook, Revised Edition by Peter Hauri and Shirley Linde
• Mind Over Mood by Dennis Greenberger and Christine Padesky
• The Relaxation and Stress Reduction Workbook by Martha Davis, Elizabeth Eshleman and Matthew McKay

Restless legs syndrome (RLS) is a common disorder characterized by uncomfortable sensations in the legs which are often described as pulling, crawling, tingling, prickly, and sometimes painful. Symptoms are more pronounced in the evening or at night, and during periods of inactivity such as long car trips and long-distance flights. The sensations are associated with an urge to move the legs which may give temporary relief. Patients will keep moving their legs, pace the floor, and toss and turn in bed.

View the Restless Legs Syndrome (RLS) Fact Sheet

The cause of RLS is unknown and there is no cure. RLS affects women slightly more than men and, although it may begin at any age, most patients are middle-aged or older. RLS causes difficulty falling asleep and staying asleep, and most patients report periodic leg jerks during which cause repeated awakening and disrupted sleep. If untreated, patients experience severe daytime sleepiness or fatigue which can impair daytime function and concentration. RLS has been associated with iron deficiency anemia, kidney failure, diabetes and peripheral nerve disease. Pregnant women may experience RLS, especially in their last trimester, with symptoms usually disappearing within 4 weeks of delivery.

Often misdiagnosed, RLS has symptoms that are often attributed to anxiety, stress, arthritis, muscle cramps, growing pains or aging. The treatment of RLS is symptomatic. Taking a hot bath, massaging the legs, and application of a heating pad may provide temporary relief. Various types of medications have been effective in relieving symptoms, including dopaminergic agents (e.g. pramipexole, pergolide), benzodiazepines, opioids (like codeine), and anti-convulsants (e.g. carbamazepine, gabapentin). Dopaminergic agents, which are also used to treat Parkinson disease, are considered the initial treatment of choice.

Circadian rhythm disorders are disruptions in the circadian rhythm—a name given to the “internal body clock” that regulates the (approximately) 24-hour cycle of biological processes in animals and plants. The term “circadian” comes from Latin meaning “around the day.”

The key feature of circadian rhythm disorders is a continuous or occasional disruption of sleep patterns. The disruption results from either a malfunction in the “internal body clock” or a mismatch between the “internal body clock” and the external environment regarding the timing and duration of sleep. As a result of the circadian mismatch, individuals with these disorders usually complain of insomnia at certain times and excessive sleepiness at other times of the day, resulting in work, school, or social impairment.

The following is a brief description of the more common circadian rhythm disorders.

• Delayed Sleep Phase Disorder is a circadian rhythm disorder most common in adolescents and young adults whose “night owl” tendencies delay sleep onset – often until 2 a.m. or later. If allowed to sleep in late (often as late as 3 p.m.), sleep deprivation does not occur. However, earlier wake up times can lead to daytime sleepiness and impaired work and school performance. These individuals are often perceived as lazy, unmotivated, or poor performers who are chronically tardy for morning obligations. People with delayed sleep phase syndrome are often most alert, productive, and creative late at night.
• Advanced Sleep Phase Disorder is usually seen in the elderly. This disorder is identified by regular early evening bedtimes (6 p.m. – 9 p.m.) and early morning awakenings (2 a.m. – 5 a.m.). People with advanced sleep phase syndrome are “morning larks” and typically complain of early morning awakening or insomnia as well as sleepiness in the late afternoon or early evening.
• Jet Lag results from a conflict between the pattern of sleep and wakefulness between the internal biological clock and that of a new time zone. Individuals find it hard to adjust and function optimally in the new time zone. Eastward travel is more difficult than westward travel because it is easier to delay sleep than to advance sleep.
• Shift Work Sleep Disorder affects people who frequently rotate shifts or work at night. Work schedules conflict with the body’s natural circadian rhythm and some individuals have difficulty adjusting to the change. Shift work disorder is identified by a constant or recurrent pattern of sleep interruption related to the work schedule that results in insomnia or excessive sleepiness.

View the Shift Work Sleep Disorder Fact Sheet

The diagnosis of circadian rhythm disorders is challenging and often requires a consultation with a sleep specialist. Keeping a detailed sleep history and a sleep dairy for one to two weeks is essential. It is also important to exclude other sleep and medical disorders, including narcolepsy, which often mimics delayed sleep phase disorder. Sleep diaries are often complemented by actigraphy, a method of estimating sleep and wake using a wrist motion monitor for a period of days to weeks. Overnight and daytime sleep testing may be required. Sleep studies must be tailored to address the sleep pattern of the individual. This may require that testing be performed at unconventional times, for example, an ‘overnight’ sleep study might be performed during the day in a shift worker.

View theCircadian Rhythm Disorders Fact Sheet

Parasomnias are disruptive sleep-related disorders that can occur during arousals from rapid eye movement (REM) sleep or arousals from non-rapid eye movement (NREM) sleep.

Parasomnias:

• are characterized by undesirable physical or verbal experiences, such as walking or talking during sleep.
• occur in association with sleep, specific stages of sleep or sleep-wake transitions.
• can be divided into two groups—primary parasomnias and secondary parasomnias.

Types of Parasomnias:

• Nightmares: vivid nocturnal events that can cause feelings of fear, terror, and/or anxiety.
• Sleep terrors/night terrors: a person experiencing a night terror or sleep terror abruptly awakes from sleep in a terrified state.
• Sleepwalking (somnambulism): occurs when a person appears to be awake and moving around with eyes wide open but is actually asleep.
• Confusional arousals: usually occur when a person is awakened from a deep sleep during the first part of the night.
• Sleep paralysis: people with sleep paralysis are not able to move the body or limbs when falling asleep or waking up.
• REM sleep behavior disorder (RBD): people with REM sleep behavior disorder act out dramatic and/or violent dreams during REM sleep.
• Sleep enuresis: in this condition, also called bedwetting, the affected person is unable to maintain urinary control when asleep.

View the Parasomnias Fact Sheet

Narcolepsy is a clinical syndrome characterized by excessive sleepiness, cataplexy, hypnogogic hallucinations, and sleep paralysis. Cataplexy is the abrupt onset of muscle weakness precipitated by emotions such as laughter and anger. Hypnogogic hallucinations may be visual or auditory and occur just prior to sleep onset. Sleep paralysis describes the inability to move for several minutes on awakening. The cataplexy, hallucinations and sleep paralysis represent the occurrence of rapid eye movement (REM) sleep manifestations at inappropriate times.

View the Narcolepsy Fact Sheet

Narcolepsy affects 1 per 2,000 individuals in the general population. There is a genetic tendency with the risk of narcolepsy in an immediate family member of 1 per 100. Rarely, narcolepsy is triggered by infection or head injury. The human leukocyte antigen HLA DQB1*O602 is the genetic marker for narcolepsy in almost all individuals. Exciting new research is beginning to elucidate the abnormalities in the brain that may predispose a person to narcolepsy.

Excessive sleepiness is treated with stimulants (methylphenidate and amphetamines). Recently a new stimulant, modafinil (Provigil), was approved by the FDA, the first in 25 years. Modafinil has less side effects than the other stimulants and frequently is effective in a single daily dose. Cataplexy is treated with a tricyclic anti-depressant (protriptyline, imipramine or clomipramine) or one of the SSRI anti-depressants (fluoxetine).

Sleep problems are a common feature of many psychiatric disorders and untreated sleep disorders can increase the risk of developing psychiatric conditions, such as depression, later in life. Recent reports found that as many as two-thirds of patients referred to sleep disorder centers have a psychiatric disorder. The most common psychiatric disorders associated with sleep complaints include depression, anxiety, and substance (illicit drugs and alcohol) abuse. Treating sleep disorders has been shown to improve the co-existing psychiatric condition and overall quality of life.

Sleep and Depression

Depression is a mood disorder characterized by low mood and/or lack of interest in activities previously found to be enjoyable. Depression affects one's appetite, concentration, energy level, and motivation. People with depression report feelings of helplessness, hopelessness, worthlessness, and suicidal thoughts. The majority experience symptoms of insomnia, consisting of difficulty in falling asleep, staying asleep, early morning awakening, or non-refreshing sleep. Studies of depressed patients demonstrate prolonged sleep latency (time to fall asleep), lack of slow wave sleep (also known as deep sleep), reduced REM sleep latency (time to REM sleep from sleep onset), and increased amount of REM sleep.

There is a substantial body of evidence linking depression with sleep disorders. The relationship between insomnia and depression is bi-directional; Insomnia increases the risk of depression and depression can cause insomnia. In a 34-year follow-up study of medical students at Johns Hopkins Medical Center, the risk of developing depression among students with insomnia was twice that of those without insomnia. Of all the symptoms of depression, insomnia is often the last to respond to medications. Failure to treat insomnia increases the risk of a depression relapse.

Rarely, people with depression report excessive daytime sleepiness. This is more common in patients with Seasonal Affective Disorder, also known as "winter depression".

View the Sleep and Psychiatric Disorders Fact Sheet

Sleep and Anxiety Disorders

People with anxiety disorders feel nervous, tense, have difficulty controlling worrying, and find it hard to relax. Sleep disorders are found in over 50% of patients with generalized anxiety disorder. Difficulty in falling and staying asleep is the most common sleep disturbance. People with anxiety disorders report a high level of psychological distress and are unable to relax sufficiently to sleep at night. Insomnia in turn can elevate anxiety levels. Nocturnal panic attacks are also common; these are characterized by sudden awakening from sleep with intense anxiety, shortness of breath, and heart palpitations and usually lead to difficulty falling back asleep.

Sleep and Substance Abuse

People who abuse alcohol and other illicit drugs frequently experience sleep problems. In addition, many people abuse alcohol and illicit drugs to promote sleep. However, they are not effective in the long run and can lead to a variety of serious adverse consequences, including psychiatric and medical disorders and psychosocial problems such as impaired performance at school or work. Though many believe in its sleep-promoting benefits, alcohol actually disrupts sleep, causing recurrent awakenings and a reduced amount of REM sleep. Other substances cause similar problems. The use of alcohol and other illicit drugs to treat insomnia is strongly discouraged.

Treatments

The treatment of co-existing psychiatric and sleep disorders requires a thorough evaluation by experts with knowledge in both sleep medicine and psychiatry. Medications to treat depression and anxiety must be chosen carefully, as some promote wakefulness while others cause drowsiness. Cognitive Behavioral Therapy (CBT) is a structured and focused treatment for insomnia, typically provided by an experienced psychologist. CBT refers to a variety of behavioral strategies aiming to correct maladaptive thought patterns and behaviors that can cause or worsen insomnia. This type of therapy is not only effective, but its benefits outlast those of medications. Examples of CBT include relaxation therapy and biofeedback. People with insomnia should also adopt healthy habits and rituals that promote a good night's sleep. These include:

• Think positive
• Establish fixed bed and wake times
• Relax before going to bed
• Maintain a comfortable sleeping environment
• Avoid clock watching
• Follow a 20 min "Toss and Turn" rule
• Use the bedroom for sleep and sex only
• Avoid daytime naps
• Avoid caffeine, alcohol, nicotine within 6 hours of sleep
• Exercise regularly, but not within 3 hours of sleep

Resources

National Sleep Foundation
1522 K Street NW Suite 500
Washington D.C. 20077-1680

National Alliance on Mental Illness
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042