Sleep Disorder

What is Sleep Disorder?

Sleep disorders are conditions that cause disruptions to normal sleep. They are quite common and can lead to physical, mental, social, and emotional problems due to poor or insufficient sleep. Overall health, safety, and quality of life are impacted by sleep disorders. For instance, studies have shown that those suffering from insomnia experience a significant drop in quality of life.

There are numerous types of sleep disorders. The International Classification of Sleep Disorders (ICSD) is a system that organizes and defines these disorders. In its third edition (ICSD-3), it lists and describes these types of sleep disorders:

* Insomnia (trouble falling or staying asleep)
* Sleep-disordered breathing (breathing disruptions during sleep)
* Central disorders of hypersomnolence (excessive sleepiness despite getting enough sleep)
* Circadian rhythm sleep-wake disorders (failure to sleep and wake at the correct times)
* Parasomnias (abnormal behaviors during sleep)
* Sleep-related movement disorders (unwanted movements during sleep)

It’s important to note that both adults and children can experience sleep disorders. However, children may show different symptoms, such as hyperactivity, lack of focus, irritability, or defiance, instead of clear sleepiness. This summary focuses on sleep disorders in adults; sleep disorders in children will be covered separately.

What Causes Sleep Disorder?

Sleep disorders arise from different causes. Each kind of sleep disorder has its own unique causes.

Insomnia

We aren’t yet completely sure what directly causes insomnia. But we do know that things like your environment, genes, thoughts and feelings, and behaviors can contribute to it. These can all lead to a state of being overly alert or “hyperaroused”, which can prevent sleep.

Sleep-Disordered Breathing (SDB)

Sleep-disordered breathing can be due to issues with control of breathing, the upper airway, and chest wall. This condition can range from mild forms to more serious ones like obstructive sleep apnea (OSA) and central sleep apnea (CSA). Obesity is often a key factor in this condition, especially in case of OSA.

Central Disorders of Hypersomnolence

Central hypersomnolence, or excessive sleepiness, is usually due to irregularities in how the central nervous system controls sleep and being awake. There are three main types: narcolepsy type 1, narcolepsy type 2, and idiopathic hypersomnia. Other causes include certain medical or psychiatric disorders, and the use of medications or substances.

Circadian Rhythm Sleep-Wake Disorders (CRSD)

CRSD can have two major types of causes: one type happens when the environment does not align well with your body’s internal “clock” or circadian rhythm (like shift work or jet lag), and the other type occurs when this internal “clock” itself gets out of sync with the external environment (like having difficulty falling asleep until very late at night).

Parasomnias

Parasomnias, or abnormal behaviors during sleep, can be caused by environmental factors, genetic factors, or a combination of both. Parasomnias include conditions like sleepwalking, night terrors, and sleep-related eating disorders, as well as nightmares and REM (rapid eye movement) sleep behavior disorder.

Sleep-Related Movement Disorders

These disorders are characterized by abnormal movements during sleep, often related to issues with controlling motor function. The cause depends on the type of disorder. For example, restless legs syndrome could be caused by genetics or iron deficiency. There are also other types of sleep-related movement disorders which are categorized based on the type of movements.

Risk Factors and Frequency for Sleep Disorder

Sleep disorders vary greatly in how common they are depending on the specific type. Certain conditions like Sleep-Disordered Breathing (SDB), short sleep duration, and non-restorative sleep are often connected. Poor sleep quality has also been linked to other sleep disorders. For example, in a study of people with diabetes, 61% reported poor sleep, 47% tested positive for Restless Leg Syndrome (RLS), and 51% had a high risk of Obstructive Sleep Apnea (OSA).

Let’s look at the prevalence or how common various major sleep disorders are, as per the ICSD-3 classification:

Insomnia affects around one-third of adults, with severe cases causing daytime problems in about 10% of adults. Women are more affected, with 17.6% of them having insomnia compared to 10.1% of men. The condition can last for more than five years in about 40% of severe cases.
Sleep-Disordered Breathing is more common in older adults, with about 50% reporting sleep issues. The specific prevalence of types like obstructive, central, upper airway resistance syndrome, sleep-related hypoventilation syndrome, or obesity hypoventilation can be found in their respective articles.
Narcolepsy affects around 142,600 people (44.3 per 100,000). It has increased by 14% in recent years. The prevalence of idiopathic hypersomnia also increased by 32%, with similar rates for men and women.
CRSD affects between 0.13% to 0.17% of the population. It is more common in people with psychiatric illnesses. The most common type, DSPD, affects between 7% to 16% of adolescents and young adults.
Parasomnia, which includes sleepwalking, sleep terrors, sleep talking, and nightmares, is frequent. It affects around 3% of people without OSA and 43.8% of people who have nightmares. The prevalence of RBD is estimated to be 8.7 per 100,000 people, with men more affected than women (3:1 ratio).
Restless leg syndrome and periodic limb movement disorder are also more common in older adults. Women above the age of 50 have higher rates of primary insomnia than men. The prevalence of PLMD is around 40 per 100,000, which has increased by about 30% in the past decade.

Sleep disorders also differ by gender. Women tend to experience insomnia and Restless Leg Syndrome more often than men, while men tend to have more Sleep-Disordered breathing than premenopausal women. It’s also important to note racial and ethnic differences, with Hispanic and Chinese individuals experiencing more SDB and short sleep than white individuals, while black individuals have a higher chance of developing sleep apnea syndrome.

Signs and Symptoms of Sleep Disorder

Sleep disorders can manifest in several ways, impacting people’s sleep patterns and overall health. These disorders generally result in symptoms such as insomnia, hypersomnia, and unusual sleep-related behaviors. To identify and treat these disorders, a comprehensive background check, including sleep habits, work routine, medication list, and family and social history, is essential.

Insomnia is characterized by difficulty in falling asleep or maintaining sleep. People with insomnia may require around thirty minutes or more to fall asleep or wake up for extended periods during the night. Daytime fatigue, attention problems, increased accident frequency, aggression, low motivation, and energy are common. Insomnia can be short-term or chronic and tends to worsen due to health and psychosocial stressors.

To diagnose chronic insomnia, clinicians generally look for three signs. These include difficulty in initiating or maintaining sleep, the opportunity for adequate sleep, and daytime consequences of disrupted sleep. These symptoms must last for at least three months, occurring at least three times a week.

Hypersomnia is characterized by excessive daytime sleepiness to the point where it impacts daily functioning. People with hypersomnia struggle to maintain alertness during their waking hours and may even fall asleep unintentionally during the day. They often complain of “brain fog” and may suffer from depression and a poor quality of life. Severity is usually measured using specific questionnaires, and the condition can be confounded with fatigue.

As per the description of the condition by patients, narcolepsy, another form of hypersomnia, appears to result from the brain’s failure in maintaining a balance between sleep and wakefulness. Symptoms include excessive daytime sleepiness, muscle weakness triggered by strong emotions (cataplexy), hallucinations when falling asleep or waking up, and sleep paralysis.

Sleep-disordered breathing (SDB), such as sleep apnea, is another common sleep disorder resulting in daytime sleepiness, loud snoring, and bouts of stopped breathing during sleep.

Unusual sleep-related behaviors include distinct behaviors that occur before, during, or after sleep. These behaviors are often indicative of specific disorders such as restless leg syndrome, parasomnia, sleep drunkenness, and others. Examples of these behaviors include involuntary leg movements, confusional arousal, sexsomnia – abnormal sexual behaviour during sleep, etc.

Among these disorders, REM sleep behavior disorder (RBD) leads to physical movements such as kicking and punching in response to violent dreams. The patient can remember these dreams if they wake up during the episode. In children, nighttime terrors are common and typically resolve as they grow older. On the other hand, nightmares are often remembered by the person and can occur at any age.

Furthermore, sleep disorders and their symptoms may worsen due to factors like sleep deprivation, physical or emotional stress, traumatic events, and usage of certain substances or medications like antipsychotics, sedatives, and hypnotic agents.

Testing for Sleep Disorder

To evaluate sleep problems, a thorough medical history, list of medications, and physical examination are required. There are also useful questionnaires and tests to help doctors identify the type of sleep disorder.

The Epworth sleepiness scale (ESS) is a questionnaire that asks eight questions to measure how sleepy a person feels throughout their day-to-day life.

The Fatigue severity scale (FSS) is a nine-question tool that helps doctors tell the difference between sleepiness and fatigue, and estimate how severe the fatigue is.

The Insomnia Severity Index (ISI) is the most commonly used tool to identify and monitor how severe a person’s insomnia is.

A sleep diary or sleep log, is a record of a person’s sleep and wakefulness habits over weeks or months. This includes details like bedtime, how long it took to fall asleep, the number of times the person woke up, how long these awakenings lasted, and nap times.

Sleep studies are tests that measure your sleep. This can be done at home (home sleep apnea testing – HSAT) or in a sleep laboratory (polysomnography or PSG). During PSG, several monitoring devices are connected to you, that measure different aspects of your sleep including your breathing, the stages of your sleep, heart rhythm, and body movements. This test is used to diagnose various sleep disorders, including sleep apnea.

Additional lab testing can also be useful when investigating sleep disorders. These tests might include arterial blood gases (measuring the gases in the blood), thyroid function tests, drug and alcohol toxicity screening, iron and ferritin level tests (to determine if iron deficiency is a factor), and cerebrospinal fluid testing (checking for deficiency in certain sleep-related hormones).

Actigraphy is a test where a device like a watch is worn on the wrist. The device detects movement and provides information on sleep-wake cycles. This data can help diagnose conditions where a person’s sleep times are out of alignment with the normal 24-hour day.

Multiple sleep latency testing, also known as a nap study, is a test that measures sleepiness. The day after an overnight sleep study, the person is asked to take several 20-minute naps over an 8 to 10-hour period. This test is helpful in identifying the causes of excessive sleepiness during the day, which could be a symptom of various sleep disorders like sleep apnea, hypersomnia, and narcolepsy.

Treatment Options for Sleep Disorder

The treatment of sleep disorders depends on the specific type of disorder. For example, insomnia treatment is usually separated into non-drug treatments and drug treatments.

Non-drug treatments for insomnia often involve cognitive-behavioral therapy (CBT-I), a type of therapy that uses psychological techniques and behavior changes to improve sleep. CBT-I is shown to increase sleep time and reduce the severity of insomnia. This therapy method is especially important for people who may not be able to safely take medication, such as older people, due to the risk of side effects and addiction.

Non-drug treatments can also include changes to your sleep habits and your sleep environment. For example, you may have to limit your time in bed or only use your bed for sleeping, not for other activities like watching TV. Certain relaxation techniques like meditation can also be helpful. Lifestyle factors that affect sleep like light, noise, and temperature are also important to consider. However, we should note that these interventions alone are usually less effective than when used with CBT-I.

On the other hand, drug treatments for insomnia can include types of medications like histamine type 1 receptor blockers, benzodiazepines, non-benzodiazepine hypnotics, and melatonin receptor agonists. Each type of medication works differently to induce sleep and treat insomnia. However, each of these medications can have side effects and can be unsafe for some people to use.

Obstructive Sleep Apnea (OSA), another type of sleep disorder, is usually treated with positive airway therapy (PAP), lifestyle changes, oral appliances or surgical procedures. For OSA patients who still experience excessive daytime sleepiness despite their standard treatment, medications that promote wakefulness can be considered.

Narcolepsy, a condition characterized by excessive daytime sleepiness, can also be treated with various medications. Modafinil, a non-addictive medication that promotes wakefulness, is the preferred treatment. For narcolepsy patients experiencing sudden episodes of muscle weakness (cataplexy), doctors might recommend certain antidepressants and sodium oxybate.

When sleep disorders are related to circadian rhythm abnormalities, or issues with your internal body clock, exposure to bright light at specific times can help to normalize your sleep schedule.

Lastly, restless leg syndrome, a condition which interferes with sleep by causing an irresistible urge to move your legs, can be improved with a prodrug formulation of gabapentin, named gabapentin enacarbil.

When it comes to diagnosing sleep disorders, doctors would have to rule out several other conditions that might cause similar symptoms. These include:

Post-traumatic stress disorder (PTSD)
Depression
Anxiety disorder
Bipolar disorder
Opioid abuse
Alcoholism
Abuse of stimulants (such as amphetamine)
Chronic obstructive pulmonary disease (COPD)
Hyperthyroidism

What to expect with Sleep Disorder

Not getting enough sleep can lead to accidents at work or while driving, lower productivity at work, and problems with thinking and processing. The future health outcomes for someone with a sleep disorder heavily depend on what is causing the problem. For example, if you’re having trouble sleeping because of Obstructive Sleep Apnea (OSA, a condition where your breathing stops and starts while you’re sleeping), this is generally something that can get better with treatment. On the other hand, those who suffer from chronic insomnia (long-term difficulty sleeping) could face a higher risk of mental disorders like depression and anxiety, and it could also lower their overall quality of life.

Possible Complications When Diagnosed with Sleep Disorder

If you don’t properly treat sleep disorders, this can increase your chances of having accidents and facing serious complications. This could make you more likely to develop mood and anxiety disorders. Additionally, not getting enough sleep can lead to false memories and a drop in your thinking abilities.

People with periodic limb movement sleep disorder, a condition characterized by repetitive movements of the limbs during sleep, have a greater risk of having strokes.

Also, untreated Obstructive Sleep Apnea (OSA), particularly severe cases combined with excessive daytime sleepiness, can lead to different heart-related problems.

Common Risks and Complications:

Increased likelihood of accidents
Development of serious complications
Mood disorders
Anxiety disorders
False memory
Decline in thinking abilities
Risk of stroke in those with periodic limb movement sleep disorder
Ongoing untreated Obstructive Sleep Apnea could lead to heart problems

Preventing Sleep Disorder

All patients should understand and put into practice the concept of good sleep hygiene. “Sleep hygiene” simply means maintaining habits that promote good sleep. Here’s some handy advice for everyone to cultivate good sleeping habits:

Try to maintain a consistent schedule. This means going to bed and waking up at the same time every day.
Use your bed purely for sleeping and intimate activities. Try to avoid activities like watching TV, using your phone, or reading in bed.
While daily exercise is great, try not to do it right before you go to bed.
Try to avoid stimulants like caffeine or smoking, especially in the evening.
Keep your bedroom dark, quiet and peaceful. A calm environment helps promote better sleep.
If you’re struggling to fall asleep, don’t force it. If you can’t sleep, get up and do something else, or consider changing your bed.

On another note, if you need to take medications that make you drowsy (called sedative-hypnotic medications), it is crucial to be cautious. It’s important that this is included in your medical record. You should also avoid driving or operating machinery when you’re under the influence of these medications.

Frequently asked questions

Sleep disorders are conditions that cause disruptions to normal sleep, leading to physical, mental, social, and emotional problems due to poor or insufficient sleep.

The signs and symptoms of sleep disorders include: - Insomnia: Difficulty falling asleep or maintaining sleep, taking longer than 30 minutes to fall asleep, waking up frequently during the night, daytime fatigue, attention problems, increased accident frequency, aggression, low motivation, and low energy. - Hypersomnia: Excessive daytime sleepiness, struggling to maintain alertness during waking hours, unintentional daytime sleep episodes, complaints of "brain fog," depression, and poor quality of life. - Narcolepsy: Excessive daytime sleepiness, muscle weakness triggered by strong emotions (cataplexy), hallucinations when falling asleep or waking up, and sleep paralysis. - Sleep-disordered breathing (SDB): Daytime sleepiness, loud snoring, and episodes of stopped breathing during sleep. - Unusual sleep-related behaviors: Involuntary leg movements, confusional arousal, sexsomnia (abnormal sexual behavior during sleep), and other behaviors that occur before, during, or after sleep. - REM sleep behavior disorder (RBD): Physical movements such as kicking and punching in response to violent dreams, with the ability to remember these dreams if waking up during the episode. - Nighttime terrors: Common in children and typically resolve as they grow older. - Nightmares: Often remembered by the person and can occur at any age. These symptoms can be worsened by factors such as sleep deprivation, physical or emotional stress, traumatic events, and the use of certain substances or medications like antipsychotics, sedatives, and hypnotic agents.

Sleep disorders can arise from various causes, including environmental factors, genetic factors, thoughts and feelings, behaviors, irregularities in the central nervous system, issues with control of breathing and the upper airway, chest wall, and motor function, as well as certain medical or psychiatric disorders, the use of medications or substances, and a misalignment between the body's internal "clock" or circadian rhythm and the external environment.

The other conditions that a doctor needs to rule out when diagnosing Sleep Disorder are: - Post-traumatic stress disorder (PTSD) - Depression - Anxiety disorder - Bipolar disorder - Opioid abuse - Alcoholism - Abuse of stimulants (such as amphetamine) - Chronic obstructive pulmonary disease (COPD) - Hyperthyroidism

The types of tests that may be needed to diagnose sleep disorders include: - Epworth sleepiness scale (ESS) questionnaire - Fatigue severity scale (FSS) questionnaire - Insomnia Severity Index (ISI) questionnaire - Sleep diary or sleep log - Sleep studies (polysomnography or home sleep apnea testing) - Additional lab testing (arterial blood gases, thyroid function tests, drug and alcohol toxicity screening, iron and ferritin level tests, cerebrospinal fluid testing) - Actigraphy - Multiple sleep latency testing (nap study)

The treatment of sleep disorders depends on the specific type of disorder. For example, insomnia treatment is usually separated into non-drug treatments and drug treatments. Non-drug treatments for insomnia often involve cognitive-behavioral therapy (CBT-I), which uses psychological techniques and behavior changes to improve sleep. CBT-I is shown to increase sleep time and reduce the severity of insomnia. Non-drug treatments can also include changes to sleep habits and the sleep environment. Drug treatments for insomnia can include various types of medications. Obstructive Sleep Apnea (OSA) is usually treated with positive airway therapy (PAP), lifestyle changes, oral appliances, or surgical procedures. Narcolepsy can be treated with medications such as modafinil. Circadian rhythm abnormalities can be treated with exposure to bright light at specific times. Restless leg syndrome can be improved with gabapentin enacarbil.

When treating sleep disorders, there can be side effects associated with certain medications. Some common side effects include: - Risk of side effects and addiction with certain insomnia medications - Side effects of histamine type 1 receptor blockers, benzodiazepines, non-benzodiazepine hypnotics, and melatonin receptor agonists used to treat insomnia - Side effects of medications used to promote wakefulness in patients with obstructive sleep apnea and narcolepsy, such as modafinil, antidepressants, and sodium oxybate - Side effects of gabapentin enacarbil, used to improve restless leg syndrome It is important to note that these medications can be unsafe for some individuals to use, and the specific side effects can vary depending on the medication and the individual.

The prognosis for sleep disorders varies depending on the specific type and underlying cause. Some sleep disorders, such as obstructive sleep apnea, can improve with treatment. However, chronic insomnia may increase the risk of mental disorders like depression and anxiety and lower overall quality of life. It is important to address and treat sleep disorders to improve prognosis and overall health outcomes.

You should see a sleep specialist or a sleep medicine doctor for sleep disorders.