Sleep Disorder

Common Sleep Disorders

  • Sleep Apnea - when a person stops and then starts breathing again many times a night. It can happen dozens to hundreds of times a night. Each time, the person stops breathing for 10 seconds or more, then suddenly gasps for air. Between each gasp and the next time breathing stops, the person almost always snores loudly. Deep sleep is vital to good physical and mental health, but people with sleep apnea often do not reach deep sleep. Chronic daytime sleepiness results.
  • Narcolepsy - when a person falls asleep suddenly many times a day.
  • Chronic insomnia - when a person has trouble falling asleep or staying asleep night after night.
  • Cataplexy - is a condition of sudden muscular weakness or fatigue.

Insomnia

Insomnia is a complaint of any of the following: difficulty initiating sleep, difficulty maintaining sleep, early-morning awakening with difficulty resuming sleep, or unrefreshing sleep. The patient must also report some degree of impairment in social, occupational, or other important areas of daytime functioning. Daytime symptoms may include morning grogginess, memory problems, poor concentration, irritability, mild depression, anxiety, somatic complaints such as headaches or aches and pains, and daytime fatigue. Insomnia lasting less than 4 weeks is considered to be transient. Insomnia lasting longer than 4 weeks is chronic.

Prevalence and Risk

Epidemiologic data suggest that transient insomnia is prevalent in up to 50% of the population. The incidence of chronic insomnia is estimated to be about 10% to 15%. Those at greatest risk for insomnia include the elderly, women, shift workers, and person with comorbid medical or psychiatric disorders. Nearly two thirds of adult psychiatric outpatients have disturbed sleep; chronic insomnia is, in turn, a significant risk factor for the development of psychiatric illness. Insomniacs are more than twice as likely as non-insomniacs to have psychiatric disorders and are more prone to subsequent depressive illness, anxiety, or to alcohol abuse.

Evaluation/Diagnosis

The intake interview is essential for a proper evaluation of insomnia. It is important to determine the onset, duration, and course of the sleep problem, as well as associated symptoms, in order to identify causal and perpetuating factors and select an appropriate treatment plan. Basic questions should be asked about evening routine, typical bedtime, time taken to fall asleep, frequency and duration of awakenings, activities during nocturnal awake time, morning rise time, and daytime napping. A 2-week sleep diary kept by the patient. The bed partner is also an invaluable source of information because patients are often unaware of their sleep-related behaviors.

Transient Insomnia

Transient or intermittent insomnia is usually triggered by acute or precipitating factors. Stress, environment, and sleep-wake schedule changes are the most common examples. These elements can be readily identified during the interview process. Patients experiencing transient insomnia will often try to remedy the situation on their own, using such methods as relaxation techniques, herbal remedies, or over-the-counter medications; if the problem persists and adverse daytime consequences occur, the patient is more likely to seek the help of a physician. For most people with transient insomnia, the duration of sleep disturbance is directly related to the duration of the precipitating influence. Once the stressor is resolved, the sleep pattern usually returns to normal. In many cases, however, sleep does not improve, and the person is at risk of developing a chronic condition.

Tips For Patients: Good Sleep Practices

  • Maintain a regular bedtime and wake-up time, even on weekends.
  • Avoid taking naps. If you do, nap in the early afternoon and keep it less than one hour.
  • Get exercise, but not within three hours before bedtime.
  • Don’t work late into the evening. Allow some time to wind down.
  • Limit nicotine to before the four hours preceding bedtime and caffeine to before the eight hours preceding bedtime.
  • Avoid heavy meals later than three hours preceding bedtime.
  • Don’t use alcohol to fall asleep
  • Make sure the bedroom is quiet, dark, and at a comfortable temperature.
  • Reserve the bedroom for sleep and sex only. Don’t work, eat, read or watch TV in bed.
  • Avoid watching the clock. Turn it so you can’t see it, and then don’t think about what time it might be or how much sleep you may be getting.
  • Decrease the amount of time spent awake in bed. If you can’t sleep, leave the bed until you feel sleepy again.
  • Don’t try too hard to fall asleep.
  • Associated Daytime Sleepiness

    The appropriate definition of sleepiness is critical for proper evaluation. Patients may describe sleepiness as feeling tired, fatigued, lazy, blah, sleep, etc. Excessive daytime sleepiness refers to the propensity to fall asleep, nod, or doze easily in relaxed or sedentary situations or the feeling that one must exert extra effort to avoid sleeping in these situations. Fatigue, low energy, etc, without a propensity for daytime sleep, should be excluded from the evaluation of sleepiness. In addition to frank sleepiness, excessive daytime sleepiness can cause related symptoms, including poor memory, reduced concentration or attention, and irritability. Studies indicate that insomniacs are no more sleepy during the day than non-insomniacs (based on objective measures). Furthermore, insomniacs are often unable to nap during the day if given the opportunity. By contrast, sleep apnea patients are profoundly sleepy and nap quite readily. Daytime sleep propensity may therefore help differentiate primary insomnia from comorbid disorders causing excessive sleepiness.

    Transient Insomnia

    The initial approach to treating the patient with transient insomnia is to provide understandable information about sleep, the causes of insomnia, and healthy sleep practices. Information about basic sleep needs, the influence of circadian rhythms on sleep, and the effects of aging help establish realistic expectations and goals for treatment. Precipitating and maintaining factors in the patient’s insomnia profile should be highlighted. Increasing awareness of these factors should help resolve the current episode and prevent chronic symptoms and relapse.