Definition

Sleep disorders are a group of syndromes characterized by disturbance in a person's amount of sleep, quality or timing of sleep, or in behaviors or physiological conditions associated with sleep. There are about 70 different sleep disorders. To qualify for the diagnosis of sleep disorder, the condition must be a persistent problem, cause an individual significant emotional distress, and interfere with social or occupational functioning. The text revision of the fourth edition (2000) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) specifically excludes temporary disruptions of sleeping patterns caused by travel or other short-term stresses.

Although sleep is a basic behavior in animals as well as humans, researchers still do not completely understand all of its functions in maintaining health. In the past 30 years, however, laboratory studies on human volunteers have yielded new information about the different types of sleep. Researchers have learned about the cyclical patterns of different types of sleep and their relationships to breathing, heart rate, brain waves, and other physical functions. These measurements are obtained by a technique called polysomnography.

There are five stages of human sleep. Four stages have non-rapid eye movement (NREM) sleep, with unique brain wave patterns and physical changes occurring. Dreaming occurs in the fifth stage, during rapid eye movement (REM) sleep.

• Stage 1 NREM sleep. This stage occurs while a person is falling asleep. It represents about 5% of a normal adult's sleep time.
• Stage 2 NREM sleep. In this stage, (the beginning of "true" sleep), the person's electroencephalogram (EEG) will show distinctive wave forms called sleep spindles and K complexes. About 50% of sleep time is stage 2 NREM sleep.
• Stages 3 and 4 NREM sleep. Also called delta or slow wave sleep, these are the deepest levels of human sleep and represent 10-20% of sleep time. They usually occur during the first 30-50% of the sleeping period.
• REM sleep. REM sleep accounts for 20-25% of total sleep time. It usually begins about 90 minutes after a person falls asleep, an important measure called REM latency. It alternates with NREM sleep about every hour and a half throughout the night. REM periods increase in length over the course of the night.

Sleep cycles vary with a person's age. Children and adolescents have longer periods of stage 3 and stage 4 NREM sleep than do middle aged or elderly adults. Because of this difference, a doctor will need to take a person's age into account when evaluating a sleep disorder. Total REM sleep also declines with age.

The average length of nighttime sleep varies among people. Most individuals sleep between seven and nine hours a night. This population average appears to be constant throughout the world. In temperate climates, however, people often notice that sleep time varies with the seasons. It is not unusual for people in North America and Europe to sleep about 40 minutes longer per night during the winter.

Description

The DSM-IV-TR classifies sleep disorders based on their causes. 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 a person 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. Individuals may then associate all sleep-related things (their bed, bedtime, etc.) with frustration, making the problem worse. They then become more stressed about not sleeping. Primary insomnia often begins in young adulthood or in middle age.

Hypersomnia is a condition marked by excessive sleepiness during normal waking hours. Affected persons either have lengthy episodes of daytime sleep or episodes of daytime sleep on a daily basis even though they are sleeping normally at night. In some cases, persons 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 people 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. Individuals with nocturnal myoclonus wake up because of cramps or twitches in the calves. These people feel sleepy the next day. Nocturnal myoclonus is sometimes called periodic limb movement disorder. RLS patients have a crawly or aching feeling in their calves that can be relieved by moving or rubbing the legs. RLS often prevents people 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. As of 2001, there is no cure for this disorder.

Narcolepsy is a dyssomnia characterized by recurrent "sleep attacks" that a person cannot fight. The sleep attacks are about 10–20 minutes long. A person 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 people with narcolepsy are 10 years old or younger. It is estimated that 0.02–0.16% of the general population suffers from narcolepsy. Men and women are equally affected.

Breathing-related sleep disorders are syndromes in which a person's sleep is interrupted by problems with 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. Persons 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 people 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. Their airway is not blocked, but 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 a person's daily sleep and 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 individuals who do not fit the pattern of these three disorders and appear to be the opposite of the delayed sleep phase type. These people 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 a person'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 a person 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 experience nightmares. They occur during REM sleep, usually in the second half of the night. A 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 gender 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 a person awakens screaming or crying. The individual 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. A person may be confused or disoriented for several minutes and cannot recall the content of the dream. There is usually a return to sleep without being able to remember the episode the next morning. Sleep terror disorder is most common in children four to 12 years old and is out-grown 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 a person 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 individuals are awakened during a sleepwalking episode, they may be disoriented and have no memory of the behavior. In addition to walking around, persons 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 people can remember what they were dreaming. The physical activities of such persons are often violent.

Sleep disorders related to other conditions

In addition to the primary sleep disorders, the DSMIV-TR specifies three categories of sleep disorders that are caused by or related to substance use or other physical or 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.

Some people 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.

The use of drugs, alcohol, and caffeine frequently produce disturbances in sleep patterns. Alcohol abuse is associated with insomnia. A 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, a person 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.

Causes and symptoms

The causes of sleep disorders have already been discussed with respect to the DSM-IV-TR classification of these disorders.

The most important symptoms of sleep disorders are insomnia and sleepiness during waking hours. Insomnia is by far the more common of the two symptoms. It covers a number of different patterns of sleep disturbance. These patterns include inability to fall asleep at bedtime, repeated awakening during the night, and/or inability to go back to sleep once awakened.

Diagnosis

Diagnosis of sleep disorders usually requires a psychological history as well as a medical history. With the exception of sleep apnea syndromes, physical examinations are not usually revealing. A person's gender and age are useful starting points in assessing the problem. A doctor may also talk to other family members to obtain information about a person's symptoms. A family's observations are particularly important to evaluate sleepwalking, kicking in bed, snoring loudly, or other behaviors that an individual cannot remember.

Sleep logs

Many doctors ask people to keep a sleep diary or sleep log for a minimum of one to two weeks in order to evaluate the severity and characteristics of the sleep disturbance. An individual records medications taken as well as the length of time spent in bed, the quality of the sleep, and similar information. Some sleep logs are designed to indicate circadian sleep patterns as well as simple duration or restfulness of sleep.

Psychological testing

A physician may use psychological tests or inventories to evaluate insomnia because it is frequently associated with mood or affective disorders. The Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the Beck Depression Inventory, and the Zung Depression Scale are the tests most commonly used in evaluating this symptom.

Self-report tests

The Epworth Sleepiness Scale, a self-rating form recently developed in Australia, consists of eight questions used to assess daytime sleepiness. Scores range from 0–24, with scores higher than 16 indicating severe daytime sleepiness.

Laboratory studies

If a doctor is considering breathing-related sleep disorders, myoclonus, or narcolepsy as possible diagnoses, an affected person may be tested in a sleep laboratory or at home with portable instruments.

POLYSOMNOGRAPHY. Polysomnography can be used to help diagnose sleep disorders as well as conduct research into sleep. In some cases a person is tested in a special sleep laboratory. The advantage of this testing is the availability and expertise of trained technologists, but it is expensive. As of 2001, however, portable equipment is available for home recording of certain specific physiological functions.

MULTIPLE SLEEP LATENCY TEST. The multiple sleep latency test (MSLT) is frequently used to measure the severity of a person's daytime sleepiness. The test measures sleep latency (the speed with which an individual falls asleep) during a series of planned naps during the day. The test also measures the amount of REM sleep that occurs. Two or more episodes of REM sleep under these conditions indicates narcolepsy. This test can also be used to help diagnose primary hypersomnia.

REPEATED TEST OF SUSTAINED WAKEFULNESS. The repeated test of sustained wakefulness (RTSW) measures sleep latency by challenging a person's ability to stay awake. In the RTSW, a person is placed in a quiet room with dim lighting and is asked to stay awake. As with the MSLT, the testing pattern is repeated at intervals during the day.

Treatment

Treatment for a sleep disorder depends on what is causing the disorder. For example, if major depression is the cause of insomnia, then treatment of the depression with antidepressants should resolve the insomnia.

Medications

Sedative or hypnotic medications are generally recommended only for insomnia related to a temporary stress (such as surgery or grief) because of the potential for addiction or overdose. Trazodone, a sedating antidepressant, is often used for chronic insomnia that does not respond to other treatments. Sleep medications may also cause problems for elderly persons because of possible interactions with their other prescription medications. Among the safer hypnotic agents are lorazepam, temazepam, and zolpidem. Chloral hydrate is often preferred for short-term treatment in elderly people because of its mildness. Short-term treatment is recommended because this drug may be habit forming.

Narcolepsy is treated with stimulants such as dextroamphetamine sulfate or methylphenidate. Nocturnal myoclonus has been successfully treated with clonazepam.

Children with sleep terror disorder or sleepwalking are usually treated with benzodiazepines because this type of medication suppresses stage 3 and stage 4 NREM sleep.

Psychotherapy

Psychotherapy is recommended for persons with sleep disorders associated with other mental disorders. In many cases an individual's scores on the Beck or Zung inventories will suggest the appropriate direction of treatment.

Sleep education

"Sleep hygiene" or sleep education for sleep disorders often includes instructing a person in methods to enhance sleep. People are advised to:

• Wait until they feel sleepy before going to bed.
• Avoid using the bedroom for work, reading, or watching television.
• Get up at the same time every morning no matter how much or how little they have slept.
• Avoid smoking and avoid drinking liquids with caffeine.
• Get some physical exercise on a daily basis, early in the day.
• Limit fluid intake after dinner; in particular, avoid alcohol because it frequently causes interrupted sleep.
• Learn to meditate or practice relaxation techniques.• Avoid tossing and turning in bed; instead, people should get up and listen to relaxing music or read.

Lifestyle changes

People with sleep apnea or hypopnea are encouraged to stop smoking, avoid alcohol or drugs of abuse, and lose weight in order to improve the stability of the upper airway.

In some cases, individuals with sleep disorders related to jet lag or shift work may need to change employment or travel patterns. They may need to avoid rapid changes in shifts at work.

Children with nightmare disorder may benefit from limits on television or movies. Violent scenes or frightening science fiction stories appear to influence the frequency and intensity of children's nightmares.

Surgery

Although making a surgical opening into the wind-pipe (a tracheostomy) for sleep apnea or hypopnea in adults is a treatment of last resort, it is occasionally performed if a person's disorder is life threatening and cannot be treated by other methods. In children and adolescents, surgical removal of the tonsils and adenoids is a fairly common and successful treatment for sleep apnea. Most people with sleep apnea are treated with continuous positive airway pressure (CPAP). Sometimes an oral prosthesis is used for mild sleep apnea.

Alternative treatment

Some alternative approaches may be effective in treating insomnia caused by anxiety or emotional stress. Meditation practice, breathing exercises, and yoga can break the vicious cycle of sleeplessness, worry about inability to sleep, and further sleeplessness for some people. Yoga can help some people to relax muscular tension in a direct fashion. The breathing exercises and meditation can keep them from obsessing about sleep.

Homeopathic practitioners recommend that people with chronic insomnia see a professional homeopath. They do, however, prescribe specific remedies for at-home treatment of temporary insomnia: Nux vomica for alcohol or substance-related insomnia, Ignatia for insomnia caused by grief, Arsenicum for insomnia caused by fear or anxiety, and Passiflora for insomnia related to mental stress.

Melatonin has also been used as an alternative treatment for sleep disorders. Melatonin is produced in the body by the pineal gland at the base of the brain. This substance is thought to be related to the body's circadian rhythms.

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KEY TERMS

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Apnea—The temporary absence of breathing. Sleep apnea consists of repeated episodes of temporary suspension of breathing during sleep.

Cataplexy—Sudden loss of muscle tone (often causing a person to fall), usually triggered by intense emotion. It is regarded as a diagnostic sign of narcolepsy.

Circadian rhythm—Any body rhythm that recurs in 24-hour cycles. The sleep-wake cycle is an example of a circadian rhythm.

Dyssomnia—A primary sleep disorder in which the patient suffers from changes in the quantity, quality, or timing of sleep.

Electroencephalogram (EEG)—The record obtained by a device that measures electrical impulses in the brain.

Hypersomnia—An abnormal increase of 25% or more in time spent sleeping. Patients usually have excessive daytime sleepiness.

Hypnotic—A medication that makes a person sleep.

Hypopnea—Shallow or excessively slow breathing usually caused by partial closure of the upper airway during sleep, leading to disruption of sleep.

Insomnia—Difficulty in falling asleep or remaining asleep.

Jet lag—A temporary disruption of the body's sleep-wake rhythm following high-speed air travel across several time zones. Jet lag is most severe in people who have crossed eight or more time zones in 24 hours.

Kleine-Levin syndrome—A disorder that occurs primarily in young males, three or four times a year. The syndrome is marked by episodes of hypersomnia, hypersexual behavior, and excessive eating.

Narcolepsy—A life-long sleep disorder marked by four symptoms: sudden brief sleep attacks, cataplexy, temporary paralysis, and hallucinations. The hallucinations are associated with falling asleep or the transition from sleeping to waking.

Nocturnal myoclonus—A disorder in which the patient is awakened repeatedly during the night by cramps or twitches in the calf muscles. Nocturnal myoclonus is sometimes called periodic limb movement disorder (PLMD).

Non-rapid eye movement (NREM) sleep—A type of sleep that differs from rapid eye movement (REM) sleep. The four stages of NREM sleep account for 75–80% of total sleeping time.

Parasomnia—A primary sleep disorder in which a person's physiology or behaviors are affected by sleep, the sleep stage, or the transition from sleeping to waking.

Pavor nocturnus—Another term for sleep terror disorder.

Polysomnography—Laboratory measurement of a person's basic physiological processes during sleep. Polysomnography usually measures eye movement, brain waves, and muscular tension.

Primary sleep disorder—A sleep disorder that cannot be attributed to a medical condition, another mental disorder, or prescription medications or other substances.

Rapid eye movement (REM) sleep—A phase of sleep during which a person's eyes move rapidly beneath the lids. It accounts for 20–25% of sleep time. Dreaming occurs during REM sleep.

REM latency—After a person falls asleep, the amount of time it takes for the first onset of REM sleep.

Restless legs syndrome (RLS)—A disorder in which a person experiences crawling, aching, or other disagreeable sensations in the calves that can be relieved by movement. RLS is a frequent cause of difficulty falling asleep at night.

Sedative—A medication given to calm agitated individuals; sometimes used as a synonym for hypnotic.

Sleep latency—The amount of time that it takes to fall asleep. Sleep latency is measured in minutes and is important in diagnosing depression.

Somnambulism—Another term for sleepwalking.

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Practitioners of Chinese medicine usually treat insomnia as a symptom of excess yang energy. Cinnabar is recommended for chronic nightmares. Either magnetic magnetite or "dragon bones" is recommended for insomnia associated with hysteria or fear. If the insomnia appears to be associated with excess yang energy arising from the liver, a practitioner will suggest oyster shells. Acupuncture treatments can help bring about balance and facilitate sleep.

Dietary changes such as eliminating stimulant foods (coffee, cola, chocolate) and late-night meals or snacks can be effective in treating some sleep disorders. Nutritional supplementation with magnesium, as well as botanical medicines that calm the nervous system, can also be helpful. Among the botanical remedies that may be effective for sleep disorders are valerian (Valeriana officinalis), passionflower (Passiflora incarnata), and skullcap (Scutellaria lateriflora).

Prognosis

Prognosis depends on the specific disorder. Children usually outgrow sleep disorders. People with Kleine-Levin syndrome usually get better by age 40. Narcolepsy is a life-long disorder. The prognosis for sleep disorders related to other conditions depends on successful treatment of the substance abuse, medical condition, or other mental disorder. The prognosis for primary sleep disorders is affected by many things, including a person's age, gender, occupation, personality characteristics, family circumstances, neighborhood environment, and similar factors.

Health care team roles

Sleep experts are often trained in physiology, medicine or psychology. Such professionals often administer tests and make initial diagnoses. Physicians prescribe drugs for some forms of sleep disorders. Surgeons are occasionally called upon for surgical intervention. Nurses take part in any testing as well as providing pre-test patient education. Family members are often key members of a health care team when they provide information and help to make changes in the home. An affected person may become a member of the health care team when making dietary modifications, seeking alternative employment or deciding to undertake a course of therapy.

Prevention

Sleep disorders are difficult to prevent. Recognition of potential causes and avoidance of such situations or substances can prevent many forms of sleep disorders. Since many sleep disorders are relatively common and transitory, a good attitude about occasional problems with sleep is very helpful. This can prevent worrying.

L. Fleming Fallon, Jr., MD, DrPH