Sleep Disorders

Overview :

Sleep disorders are classified based on what causes them. Primary sleep disorders are distinguished from those that are not caused by other mental disorders, prescription medications, substance abuse, or medical conditions. The two major categories of primary sleep disorders are the dyssomnias and the parasomnias.

Dyssomnias

Dyssomnias are primary sleep disorders in which the patient suffers from changes in the amount, restfulness, and timing of sleep. The most important dyssomnia is primary insomnia, which is defined as difficulty in falling asleep or remaining asleep that lasts for at least one month. It is estimated that 35% of adults in the United States experience insomnia during any given year, but the number of these adults who are experiencing true primary insomnia is unknown. Primary insomnia can be caused by a traumatic event related to sleep or bedtime, and it is often associated with increased physical or psychological arousal at night. People who experience primary insomnia are often anxious about not being able to sleep. The person may then associate all sleep-related things (their bed, bedtime, etc.) with frustration, making the problem worse. The person then becomes more stressed about not sleeping. Primary insomnia usually begins when the person is a young adult or in middle age.

Hypersomnia is a condition marked by excessive sleepiness during normal waking hours. The patient has either lengthy episodes of daytime sleep or episodes of daytime sleep on a daily basis even though he or she is sleeping normally at night. In some cases, patients with primary hypersomnia have difficulty waking in the morning and may appear confused or angry. This condition is sometimes called sleep drunkenness and is more common in males. The number of people with primary hypersomnia is unknown, although 5-10% of patients in sleep disorder clinics have the disorder. Primary hypersomnia usually affects young adults between the ages of 15 and 30.

Nocturnal myoclonus and restless legs syndrome (RLS) can cause either insomnia or hypersomnia in adults. Patients with nocturnal myoclonus wake up because of cramps or twitches in the calves. These patients feel sleepy the next day. Nocturnal myoclonus is sometimes called periodic limb movement disorder (PLMD). RLS patients have a crawly or aching feeling in their calves that can be relieved by moving or rubbing the legs. RLS often prevents the patient from falling asleep until the early hours of the morning, when the condition is less intense.

Kleine-Levin syndrome is a recurrent form of hypersomnia that affects a person three or four times a year. Doctors do not know the cause of this syndrome. It is marked by two to three days of sleeping 18-20 hours per day, hypersexual behavior, compulsive eating, and irritability. Men are three times more likely than women to have the syndrome. Currently, there is no cure for this disorder.

Narcolepsy is a dyssomnia characterized by recurrent "sleep attacks" that the patient cannot fight. The sleep attacks are about 10-20 minutes long. The patient feels refreshed by the sleep, but typically feels sleepy again several hours later. Narcolepsy has three major symptoms in addition to sleep attacks: cataplexy, hallucinations, and sleep paralysis. Cataplexy is the sudden loss of muscle tone and stability ("drop attacks"). Hallucinations may occur just before falling asleep (hypnagogic) or right after waking up (hypnopompic) and are associated with an episode of REM sleep. Sleep paralysis occurs during the transition from being asleep to waking up. About 40% of patients with narcolepsy have or have had another mental disorder. Although narcolepsy is often regarded as an adult disorder, it has been reported in children as young as three years old. Almost 18% of patients with narcolepsy are 10 years old or younger. It is estimated that 0.02-0.16% of the general population suffer from narcolepsy. Men and women are equally affected.

Breathing-related sleep disorders are syndromes in which the patient's sleep is interrupted by problems with his or her breathing. There are three types of breathing-related sleep disorders:

• Obstructive sleep apnea syndrome. This is the most common form of breathing-related sleep disorder, marked by episodes of blockage in the upper airway during sleep. It is found primarily in obese people. Patients with this disorder typically alternate between periods of snoring or gasping (when their airway is partly open) and periods of silence (when their airway is blocked). Very loud snoring is a clue to this disorder.
• Central sleep apnea syndrome. This disorder is primarily found in elderly patients with heart or neurological conditions that affect their ability to breathe properly. It is not associated with airway blockage and may be related to brain disease.
• Central alveolar hypoventilation syndrome. This disorder is found most often in extremely obese people. The patient's airway is not blocked, but his or her blood oxygen level is too low.
• Mixed-type sleep apnea syndrome. This disorder combines symptoms of both obstructive and central sleep apnea.

Circadian rhythm sleep disorders are dyssomnias resulting from a discrepancy between the person's daily sleep/wake patterns and demands of social activities, shift work, or travel. The term circadian comes from a Latin word meaning daily. There are three circadian rhythm sleep disorders. Delayed sleep phase type is characterized by going to bed and arising later than most people. Jet lag type is caused by travel to a new time zone. Shift work type is caused by the schedule of a person's job. People who are ordinarily early risers appear to be more vulnerable to jet lag and shift work-related circadian rhythm disorders than people who are "night owls." There are some patients who do not fit the pattern of these three disorders and appear to be the opposite of the delayed sleep phase type. These patients have an advanced sleep phase pattern and cannot stay awake in the evening, but wake up on their own in the early morning.

PARASOMNIAS. Parasomnias are primary sleep disorders in which the patient's behavior is affected by specific sleep stages or transitions between sleeping and waking. They are sometimes described as disorders of physiological arousal during sleep.

Nightmare disorder is a parasomnia in which the patient is repeatedly awakened from sleep by frightening dreams and is fully alert on awakening. The actual rate of occurrence of nightmare disorder is unknown. Approximately 10-50% of children between three and five years old have nightmares. They occur during REM sleep, usually in the second half of the night. The child is usually able to remember the content of the nightmare and may be afraid to go back to sleep. More females than males have this disorder, but it is not known whether the sex difference reflects a difference in occurrence or a difference in reporting. Nightmare disorder is most likely to occur in children or adults under severe or traumatic stress.

Sleep terror disorder is a parasomnia in which the patient awakens screaming or crying. The patient also has physical signs of arousal, like sweating, shaking, etc. It is sometimes referred to as pavor nocturnus. Unlike nightmares, sleep terrors typically occur in stage 3 or stage 4 NREM sleep during the first third of the night. The patient may be confused or disoriented for several minutes and cannot recall the content of the dream. He or she may fall asleep again and not remember the episode the next morning. Sleep terror disorder is most common in children four to 12 years old and is outgrown in adolescence. It affects about 3% of children. Fewer than 1% of adults have the disorder. In adults, it usually begins between the ages of 20 and 30. In children, more males than females have the disorder. In adults, men and women are equally affected.

Sleepwalking disorder, which is sometimes called somnambulism, occurs when the patient is capable of complex movements during sleep, including walking. Like sleep terror disorder, sleepwalking occurs during stage 3 and stage 4 NREM sleep during the first part of the night. If the patient is awakened during a sleepwalking episode, he or she may be disoriented and have no memory of the behavior. In addition to walking around, patients with sleepwalking disorder have been reported to eat, use the bathroom, unlock doors, or talk to others. It is estimated that 10-30% of children have at least one episode of sleepwalking. However, only 1-5% meet the criteria for sleepwalking disorder. The disorder is most common in children eight to 12 years old. It is unusual for sleepwalking to occur for the first time in adults.

Unlike sleepwalking, REM sleep behavior disorder occurs later in the night and the patient can remember what they were dreaming. The physical activities of the patient are often violent.

Sleep disorders related to other conditions

In addition to the primary sleep disorders, there are three categories of sleep disorders that are caused by or related to substance use or other physical or mental disorders.

SLEEP DISORDERS RELATED TO MENTAL DISORDERS. Many mental disorders, especially depression or one of the anxiety disorders, can cause sleep disturbances. Psychiatric disorders are the most common cause of chronic insomnia.

SLEEP DISORDERS DUE TO MEDICAL CONDITIONS. Some patients with chronic neurological conditions like Parkinson's disease or Huntington's disease may develop sleep disorders. Sleep disorders have also been associated with viral encephalitis, brain disease, and hypo- or hyperthyroidism.

SUBSTANCE-INDUCED SLEEP DISORDERS. The use of drugs, alcohol, and caffeine frequently produces disturbances in sleep patterns. Alcohol abuse is associated with insomnia. The person may initially feel sleepy after drinking, but wakes up or sleeps fitfully during the second half of the night. Alcohol can also increase the severity of breathing-related sleep disorders. With amphetamines or cocaine, the patient typically suffers from insomnia during drug use and hypersomnia during drug withdrawal. Opioids usually make short-term users sleepy. However, long-term users develop tolerance and may suffer from insomnia.

In addition to alcohol and drugs that are abused, a variety of prescription medications can affect sleep patterns. These medications include antihistamines, corticosteroids, asthma medicines, and drugs that affect the central nervous system.

Sleep disorders in children and adolescents

Pediatricians estimate that 20-30% of children have difficulties with sleep that are serious enough to disturb their families. Although sleepwalking and night terror disorder occur more frequently in children than in adults, children can also suffer from narcolepsy and sleep apnea syndrome.