- Sleep Apnea (obstructive): sleepy or tired during day, snores at night; problem of sleep quality
- Sleep Deprivation: does not want to sleep but can; problem of sleep quantity
- Restless Legs Syndrome: leg discomfort relieved by movement, worse at night
- Insomnia: wants to sleep but cannot
- Parasomnias: abnormal actions during sleep that are disruptive to patient or family
- Circadian Rhythm Disorders: lack of harmony and synchrony with surrounding social or environmental sleep patterns
Sleep apnea refers to the lungs not receiving air during sleep. It results from obstruction in the throat that blocks the air (obstructive sleep apnea) or the brain failing to give the command to breathe (central sleep apnea). By far the most common of the two, particularly in the young and middle aged, is obstructive sleep apnea (OSA). Although obesity is the greatest risk factor for OSA (especially in middle-aged males), women, children, and the elderly need not be obese to suffer from OSA.
The most common symptoms of OSA are night time snoring that results from throat obstruction and daytime sleepiness that results from non-refreshing, poor quality sleep at night. Patients with OSA may not be aware that the quality of their sleep is poor because they are able to fall asleep and often do spend 7 to 8 or more hours sleeping. However, these same patients will often take naps during the day to try to compensate for the poor quality of their nighttime sleep. They don't equate this with a "sleep problem" because they think of a "sleep problem" as "insomnia" (inability to sleep at all). Another reason patients with OSA fail to recognize their sleep apnea is because it usually comes on gradually. The patient adapts to the gradual changes and either doesn't notice their harmful effects or rationalizes them. It's usually the bed partner who notices the changes more readily. The bed partner is therefore a more reliable source of information about the patient's true symptoms.
In addition to snoring, patients with OSA during sleep can gasp for air, hold their breath for long periods, or suddenly snort (as the throat opens). Sometimes they wake up, although usually they don’t know why. OSA occurs more when the patient is in deep sleep, especially dreaming, and when the patient is on his back or supine. Hypoxemia or low oxygen is a very important consequence of OSA that can be very harmful to the heart and brain. Fearful of OSA, the brain often will not allow the patient go into deep sleep, and this compounds the lack of refreshing sleep that then results in daytime fatigue and sleepiness.
Other consequences of OSA include not allowing the bed partner to sleep and poor performance at work, at school, or with sex (impotence). The patient can feel depressed and tired all the time. A particularly important consequence of OSA is an increase in accidents, especially motor vehicle accidents. OSA is a risk factor for heart disease and strokes, just like high cholesterol. OSA can worsen obesity, diabetes, atrial fibrillation, hypertension, asthma, COPD, headaches, and dementia. Recently, sleep apnea has been shown to be associated with more wrinkles in women (poor skin healing, especially from sun damage) as well as with various eye problems including glaucoma, floppy eyelids, eye irritation, vision loss, and retinopathy (particularly in diabetics and hypertensives). Also, sleep apnea has recently been shown to be associated with kidney disease among diabetics and hypertensives. Basically, the self strangulation and intermittent low oxygen caused by sleep apnea leads to tremendous stress which harms almost all the major organs of the body.
Sleep apnea needs a sleep study for diagnosis, and control is usually achieved.
In summary, sleep apnea is a very common, dangerous illness that was long ignored, but today is easily diagnosed and easily treated.
Sleep deprivation is the second most prevalent sleep disorder. This disorder is characterized by people who can sleep but do not want to because they want to stay up and work, study, party etc. Sleep deprivation is rampant among our younger people: high school, college, and late twenties and early thirties. Many of these young people believe sleep is downright boring and will deprive themselves of the necessary time for sleep, preferring to use that time to work hard and party hard. These hardy, trendy, up-and-coming folks often believe that sleeping 7 to 8 hours is for weak slobs or for the older, sedate crowd.
Unfortunately, these self-proclaimed "smart people" do not understand the basics of the science of sleep (see www.sleepfoundation.com and Dr. Dement’s book The Promise of Sleep) and are actually dangerously ignorant. A very important concept is sleep debt, which is accumulated if one does not sleep the adequate amount of time. The higher the sleep debt, the greater the probability that the person will experience fatigue, mood disorders, social problems and performance problems at work or at school.
Sleep deprivation helps to explain such spectacular and tragic disasters as the Exxon Valdez oil spill in Alaska, the Challenger Space Shuttle explosion, the Chernobyl Nuclear Plant meltdown in the Soviet Union, and the 2006 commuter plane crash in Fayette County, Kentucky. In each of these situations there were highly competent professionals who had performed their jobs well for years and then went through a period where unusually high work demands deprived them of much sleep. They then committed very simple, dumb mistakes that were not caught in time, nor even suspected, and resulted in tremendous public health disasters.
Approximately 33% of fatal truck accidents result from sleep deprivation. In fact, when truck accidents were initially studied by the federal government, the assumption was that many were caused by driving under the influence of alcohol, and thus the prediction was that accidents would cluster around midnight, when the bars would close. However, the accidents actually clustered long after that, around 4 am, when the sleep-deprived drivers finally dozed off behind the wheel. In addition to truck accidents, 10% of fatal car accidents are due to sleep deprivation. It has been shown that the impairment is the same whether one is drunk, is sleep-deprived (sleeping less than 4 to 6 hours), or has sleep apnea. In many states now, statutes severely punish drivers who are involved in accidents caused by their own sleep deprivation. The trend to pass such laws is growing throughout the country.
Sleep deprivation also leads to obesity and less control of diabetes. People who sleep less eat more salty, fatty and sweet snacks. Lower body weight correlates with good sleep habits, particularly in those who are middle-aged. Sleep is intimately related to eating and exercise. At present, this topic is undergoing very intensive research, particularly in the area of hormones (such as leptin) that help control both hunger and sleep.
Another important but less common sleep disorder that can lead to sleepiness during the day is narcolepsy. This disorder usually begins during the teenage years or in the early twenties. Tragically, it often goes undiagnosed and untreated for years or even decades, causing the patient enormous suffering.
Besides relentless daytime sleepiness, the other hallmark symptom of narcolepsy is sudden muscle weakness (cataplexy) that can affect the eyes, neck, throat, tongue, legs and arms (but without loss of consciousness), lasting minutes at a time. Together with muscle weakness or paralysis, dreaming actually intrudes into wakefulness. In fact, narcolepsy represents a mixing of sleep and wake states. Another frightening symptom of narcolepsy is morning paralysis, in which the patient wakes up but cannot move for several minutes. Again, this represents the paralysis of the dream state lingering too long. (See www.sleepfoundation.com)
Sudden dreaming during the day can lead the patient to describe what appear to be hallucinations, and this can lead to the erroneous diagnosis of a serious psychiatric illness. Unfortunately, the wrong medications can then be prescribed, after which the symptoms of narcolepsy will not improve. They might even worsen.
Fortunately, modern medications can adequately manage this devastating illness. The problem remains its timely diagnosis. Sleep studies are necessary to diagnose narcolepsy.
Restless Legs Syndrome:
Restless Legs Syndrome (RLS) is an irresistible urge to move the legs, and this movement temporarily relieves a leg discomfort that is worse at night and during periods of inactivity. It is also a very common disorder, like sleep apnea, that is easily diagnosed and treated, but also easily missed.
Although RLS is a disease of awake patients, this illness can cause insomnia, at times severely. RLS can also be disruptive in social situations when the patient must sit for extended periods of time, such as at a public function or during long travel in a plane, bus, or car. RLS is usually mild and may not have to be treated with drugs. In some cases, it can be very severe and can require expert care and multiple medications.
Restless Legs Syndrome can be familial and usually arises before age 30, often in childhood, where it can be confused with ADHD (Attention Deficit Hyperactivity Disorder). RLS can also be associated with other disorders: iron deficiency, pregnancy, renal failure, and peripheral neuropathy. Treating or resolving the associated disorder can greatly improve or cure the RLS.
Unfortunately, many medicines can worsen RLS, including antidepressants, antihistamines, anti-nausea drugs, and major tranquilizers. Alcohol and caffeine are also offenders.
Insomnia describes the most common sleep disorder. This condition is characterized by the person wanting to sleep and allowing the necessary time to sleep in a comfortable environment, yet being unable to sleep the desired amount. Insomnia may involve the inability to initiate sleep (onset), the inability to stay asleep (maintenance), or the problem of waking up too early. It is accompanied by some degree of frustration at night and impairment during the day.
Insomnia can be classified as acute, or lasting less than one month and associated with some temporary stressful event, illness, perception, or thought. Sleeping pills for a short duration work well in these situations, and the patient usually recovers the normal sleep routine.
Chronic insomnia is different. It lasts longer than one month, usually for years. Chronic insomnia is more ingrained and difficult to manage than acute insomnia. Over 60% of chronic insomnia cases involve psychological issues such as anxiety, depression, stress, alcohol or drug use, etc. Many also involve medical illnesses such as pain syndromes at night (e.g. arthritis), gastroesophageal reflux (heartburn), lung (e.g. asthma) or heart problems. Other sleep disorders may be involved such as sleep apnea,restless legs, or shift work disorder (a kind of circadian rhythm disorder).
Whether psychological issues are present or not, chronic insomnia 100% of the time involves the acquiring of bad sleep habits that perpetuate and aggravate the problem (see Good Sleep Hygiene). Sleeping pills are often attempted by the patient to try to solve the problem. They'll usually work for a short time before their effect wears off, which frustrates the patient even more. Sometimes the patient's expectations are unrealistic, such as the patient who wants to sleep 12 hours per night. Therapy by a trained expert with experience in managing sleep problems is usually the best initial approach to treating insomnia. (See Resources.)
Parasomnias represent a group of abnormal activity or behaviors during sleep that are disruptive to the patient or to the bed partner, the family, or even to the neighbors. Parasomnias are very common in childhood and include sleep walking, talking, night terrors, nightmares, grinding teeth, head rolling/banging, and urinating in bed.
In adults, an important parasomnia is REM Behavior Disorder, during which patients act out their violent dreams and at times injure themselves or their bed partners. As mentioned above in the section on Narcolepsy, we are ordinarily paralyzed while dreaming for this very reason: so we will not act out our dreams. Luckily, these patients respond well to medications.
Well-trained sleep experts need to diagnose and manage parasomnias. First of all, parasomnias must be distinguished from seizures or convulsions, or recognized as a secondary phenomenon to another sleep disorder such as sleep apnea. In these cases it is important to treat the seizure or the sleep apnea directly. Often no treatment at all is necessary (especially in children who grow out of the condition), but at other times treatment is mandatory for dangerous and disruptive conditions. At times, patients can engage in offensive acts that can lead to problems with the police and the courts. Diagnosis and treatment can be difficult under these circumstances.
Circadian Rhythm Disorders:
This interesting group of disorders involves the body’s internal clock not being in harmony or synchrony with the external light/dark cycle or the social cycle. The hallmark of these disorders is that the same patient complains of sleepiness during one part of the day and then insomnia during another part of the day.
There are two basic types of circadian rhythm disorders: internally driven and externally driven. The internal types include a disorder common in teenagers: Delayed Sleep Phase Disorder (DSPD). In this illness, the internal clock of these teenagers shifts several hours into the night, such that instead of going to sleep at 10pm they now need to begin sleep at 1 or 2am. Thus, they tend to wake up late. During school days they become sleep deprived, with all the attendant complications such as doing poorly in their early morning classes.
A similar internal type found in the elderly (but in the opposite time period) is Advanced Sleep Phase Disorder (ASPD): in which the person needs to go to sleep earlier in the evening, usually around 8pm, but then wakes up at 4am. Thus, the patient complains of sleepiness in the evening, which disrupts his social schedule, but then complains of insomnia in the early morning. Sleeping pills do not work in this situation.
The main externally driven disorder is Shift Work Syndrome that affects more than 10% of nighttime workers. Unfortunately, the patient becomes sleepy and tired during work hours and job performance is affected. At the same time, this patient suffers from insomnia when he or she does want to sleep. It is the worst of both worlds. Even though this very common disorder has plagued nighttime workers for centuries, it has only begun to be studied extensively within the last 20 years. Thankfully, there are various management techniques and medications available to control this disorder.
Jet lag is another externally driven disorder that is common in this age of business globalization and world travel. If only a few time zones are traversed (particularly if one travels east), a little patience is usually all that's required for the body to naturally return to its correct circadian rhythm. At other times, medications may be necessary.
An interesting aspect of the treatment of circadian rhythm disorders is the use of light therapy, since light so deeply influences the body's internal clock.