Sleep Disorders

WHAT ARE SLEEP DISORDERS?

A sleep disorder is any medical or psychological problem that interferes with a person’s sleep. The most common of these problems is insomnia; other sleep disorders include narcolepsy, sleep apnea, restless legs syndrome, nightmares, night terrors, and sleepwalking.

People struggling with insomnia don’t feel rested after sleep due to difficulty falling asleep (sleep onset insomnia), frequently waking during the night (sleep disruption insomnia), or generally feeling unrefreshed after sleep. The 2008 Sleep in America Poll, conducted by the National Sleep Foundation, discovered that 11 percent of working adults were at risk for having insomnia.¹

Insomnia is often caused by poor sleep habits, anxious thoughts, pain, illness, consumption of alcohol, or use of stimulants, such as caffeine, nicotine, amphetamines, and cocaine.

Narcolepsy is a disorder characterized by an irresistible urge to sleep. This can be potentially dangerous, since people have been known to fall asleep while driving or operating machinery. The exact causes of narcolepsy are unknown, but some research suggests that it might be due to a combination of genetic factors and environmental stress.²

Sleep apnea is a disorder caused by an inability to breathe during sleep. When this happens, the person is awoken as he or she reflexively gasps for air. Some people with sleep apnea have been observed to wake up hundreds of times during a single night. Recent research has shown a connection between the development of sleep apnea and other health problems, such as high blood pressure, stroke, and obesity. Nighttime sleep apnea can raise a person’s blood pressure and contribute to cardiovascular problems such as strokes, while obesity can make breathing more difficult during the night. In the 2008 Sleep in America Poll, 14 percent of the working adults interviewed were at risk for having sleep apnea.¹

Restless legs syndrome is a disorder characterized by urges to move one’s legs, as well as sensations of tingling and discomfort in the legs. Frequently, moving around or rubbing the legs can bring relief, but this often makes it very difficult to lie still, fall asleep, and stay asleep. According to the 2008 Sleep in America Poll, 11 percent of the working adults interviewed were at risk for having restless legs syndrome.¹

Nightmares are frightening dreams that awaken a person in the middle of the night. In adults, frequent stress and anxiety can sometimes lead to chronic nightmares.³ Similarly, night terrors cause a person to suddenly awake in a state of panic. The person may even yell in fear and quickly sit up in bed but recall very little of the frightening dream or image.

Sleepwalking occurs when a person physically wanders while still asleep. Typically, this problem occurs in children, but adults have been known to experience it. The cause of the disorder is unknown, but contrary to popular belief, it is safe to wake a sleepwalker, and advisable if necessary to prevent the person from wandering into a dangerous situation.

WHO IS AFFECTED BY SLEEP DISORDERS?

According to the 2008 Sleep in America Poll, 65 percent of working adults in the United States experience sleep problems at least a few nights every week and 44 percent experience them nearly every night.¹ According to estimates by the U.S. National Institutes of Health, that translates into nearly forty million Americans struggling with chronic sleep disorders like these every year, with another twenty million experiencing occasional sleep problems.⁴

Regrettably, most people don’t get the optimum amount of sleep they need each night. According to some estimates, 44 percent of working adults get less than seven hours of sleep during the workweek, and 16 percent get less than six hours.¹ Similarly, 45 percent of adolescents get less than eight hours of sleep on school nights.⁵ Much of this lack of sleep can be attributed to people’s attempts to cram more work and family time into their busy schedules, which cuts into their time for sleeping. But many people might also be struggling with sleep disorders and not even know it.

Why Is Sleep Important?

Refreshing sleep is essential for good health. Sleep provides the body a period of time to regain energy, grow, and repair itself; plus, sleep allows the brain an opportunity to dream, integrate newly learned information, and produce neurotransmitters that are vital to good mental health. Periods of sleeping and waking are controlled by circadian rhythms, which are twenty-four-hour biological cycles during which a person moves through different phases of alertness and body temperature that, among other things, make sleep more or less likely to occur.

Throughout the night, a person’s body and brain also cycle through five different phases of sleep, which create changes in activity levels in both the body and the brain. The most well-known of these phases is the period called rapid eye movement (REM) sleep, during which a person’s brain is active, dreams are vivid, and the eyes move steadily from side to side beneath the eyelids. As the duration of sleep progresses throughout the night, the length of REM sleep increases with each cycle.

As people age, their need for sleep changes. For example, infants can sleep ten to fifteen hours per day, but this declines as they age. Recent studies indicate that adolescents need approximately eight to nine hours of sleep each night to perform at optimal levels.⁵ Typically most adults need approximately eight hours of sleep. This need for sleep continues even into a person’s senior years, despite the fact that many older people experience periods of lighter sleep during the night and more frequent awakenings. However, seniors often make up for their interrupted nighttime sleep by taking naps throughout the day.

WHAT TREATMENTS ARE EFFECTIVE FOR SLEEP DISORDERS?

Some sleep disorders, including nightmares, night terrors, and sleepwalking, usually occur only infrequently and therefore don’t require treatment. However, each of the other major sleep disorders requires its own unique treatment, which is usually medical in nature.

Narcolepsy can sometimes be treated with stimulant medications, like methylphenidate (Ritalin), to keep the person awake.

Restless legs syndrome is also treated with medications such as nervous system depressants (benzodiazepines), painkillers, and drugs that are used to treat Parkinson’s disease (dopaminergic agents). People might also experience some relief by engaging in soothing activities, like warm baths, before bedtime.

Medical care for sleep apnea often requires the use of a continuous positive airway pressure treatment (CPAP). People who wear a CPAP mask while they sleep receive a continuous flow of oxygen that not only reduces their nighttime symptoms, but also can help reduce their overall blood pressure. In addition, people with sleep apnea who are overweight often benefit from losing weight, while others might benefit from surgery to correct obstructed airways.

Insomnia is often treated with sleep medications known as hypnotics. These include nervous system depressants (benzodiazepines), antidepressants such as trazodone (Desyrel), and newer sleep medications such as zolpidem (Ambien). Each person will respond to these medications in a slightly different way, so anyone taking them should communicate closely with the medical professional who prescribed them.

In addition, people with insomnia and other sleep disorders frequently benefit from the following skills: ⁶

Sleep education
Sleep hygiene skills
Stimulus control skills
Stress reduction and relaxation skills
Cognitive coping skills

1. Sleep Education

The truth is, there are many possible causes of sleep problems. In addition to the ones already mentioned, stress can often cause temporary sleep loss, and women may face additional problems due to fluctuating hormone levels during their menstrual cycles, pregnancy, and menopause. For these reasons, it’s important for each person to educate himself or herself about the many possible causes of sleep problems and to seek professional help whenever necessary. (Click here for more information about the causes of sleep disorders.)

2. Sleep Hygiene Skills

Sleep hygiene skills are healthy habits that can help people fall asleep faster and stay asleep longer. These habits include avoiding caffeine, nicotine, recreational drugs, and alcohol before bedtime; avoiding heavy meals before bedtime; avoiding bright lights before going to bed (including television and computer screens); avoiding strenuous exercise before bedtime; and making the bedroom cool, comfortable, and quiet. (Click here for more information about sleep hygiene.)

3. Stimulus Control Skills

Stimulus control skills can also help people develop regular sleep habits.⁷ The truth is, most people use their beds and their bedrooms for many activities other than sleep, such as doing work, talking on the telephone, watching television, and reading. As a result, their brains mistakenly associate the bedroom with activity, rather than rest. The goal of stimulus control is to change this connection and retrain the brain to link the bedroom with only rest and sleeping.

The first step of stimulus control is to develop a soothing presleep routine. This might mean turning down the lights, drinking a cup of herbal tea, taking a soothing bath, reading a relaxing book, and so on. This habit will signal the brain that the time for sleeping is approaching.

The next step is to go to bed only when tired. Many people go to bed when they aren’t feeling tired, and as a result, they lie there restlessly. Again, this sends a mixed message to the brain about what the bedroom is used for. Instead, people should wait until they’re tired before going to bed, even if this is later than they would like it to be. Hopefully, with the use of these skills a person can eventually develop a regular sleep schedule.

The third step is to only use the bedroom for sleep and sexual activity. This sends a message to the brain that entering the bedroom means it’s time for rest (or sex), but not for work.

The fourth step is to immediately turn out the lights after getting into bed and allow sleep to occur naturally. However, when people can’t fall asleep within fifteen minutes of getting into bed, they should get out of bed, leave the bedroom, and engage in some form of relaxing activity, such as reading a boring book or listening to calm music. In general, it’s best to avoid watching television or browsing the Internet when unable to sleep, because the bright light from the screen can often have a stimulating effect and keep a person awake. Then, when the person feels tired again, he or she should get back into bed and, again, allow sleep to occur naturally. This should be repeated throughout the night if a person lies in bed for fifteen minutes without falling asleep, or wakes up in the middle of the night and is unable to fall asleep again. Remember, the goal is to help the brain learn to associate the bedroom with sleeping, not with lying restlessly in bed. Basically, this step can be summarized by the phrase “Don’t stay in bed if you’re not sleeping.”

And, finally, the last step of stimulus control is to avoid taking naps during the day and to establish regular hours for waking up in the morning and beginning a sleep routine in the evening. This can help reset a person’s natural sleep rhythms. (Click here for more information about stimulus control skills.)

4. Develop Stress Reduction and Relaxation Skills

Stress reduction and relaxation skills can also be helpful for sleep problems, and there are a variety of different techniques that a person can learn. Most of these techniques include focusing on slow, rhythmic abdominal breathing, which often produces a feeling of calmness. Often, people find relief using progressive muscle relaxation, which involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling. Similarly, other people find cue words and visualization techniques effective for helping them relax and fall asleep. (Click here for a full description of relaxation techniques and self-soothing methods.)

5. Develop Cognitive Coping Skills

Finally, many people with sleep problems are also suffering with mental health problems such as anxiety and depression. If a person suspects that this is the case, he or she should seek information and treatment for these problems, too.

Challenging problematic thoughts and irrational beliefs is central to the treatment of both anxiety and depression. This skill is also very helpful to people who cannot sleep because worrisome thoughts keep them awake at night or wake them in the middle of the night and prevent them from going back to sleep.

Irrational beliefs can take many forms. Often, people aren’t even aware that they have them until they stop to listen to the self-talk inside their head. Examples of irrational beliefs include “I’m not capable of handling my problems alone,” “I should always do everything perfectly,” and “I’m responsible for everyone else’s happiness.” Thoughts like these can certainly make a stressful situation even worse. And for many people, thoughts like these are constantly being replayed in their mind like an endless tape loop, making them even more vulnerable to the effects of stress.

Coping with these thoughts in an effective way takes practice. It also takes time to identify the irrational beliefs and refute them with actual evidence. For example, for the person who holds the belief “I’m not capable of handling my problems alone,” appropriate questions would be “What’s the evidence that contradicts that statement? Have I ever handled significant problems on my own? What were the results?” (Click here for instructions on refuting irrational beliefs.)

Other techniques can also be helpful, like using thought stopping to end nagging worries, and an eye movement technique in which moving the eyes from side to side in a specific way can break up troublesome thoughts and take the emotional sting out of them. (Click here for instructions on using thought stopping and the eye movement technique.)

Worry control skills are designed to help a person cope more effectively with the stress of chronic fears and worries. For example, problem-solving skills can help a person brainstorm new solutions to old problems and then test the effectiveness of using those solutions. (Click here for instructions on using problem-solving skills.)

A risk assessment can help people recognize the irrational beliefs they have about a stressful situation and then identify several possible coping strategies for dealing with the situation. The result is usually that a person’s fear and anxiety diminish after thinking about several alternative outcomes that hadn’t been considered. The steps of risk assessment include naming the triggering situation, rating the associated anxiety level, describing the related emotions, identifying the automatic thoughts, imagining the worst possible outcome, predicting a better outcome, and, finally, rating the anxiety level once again. (Click here for instructions on performing a risk assessment.)

Worry exposure actually requires that a person set aside time to worry on purpose. The goal of this exercise is to schedule twenty-five minutes a day to worry about something in full, vivid detail. Doing so helps many people recognize that their anxiety about the worrisome topic actually diminishes over time, especially after they start imagining alternative, more positive outcomes. (Click here for instructions on using worry exposure.)

And, finally, worry behavior prevention is designed to help people reduce behaviors that actually create more stress in their lives. For example, a man who worries about work might get to work an hour early and stay an extra hour to make sure everything is done perfectly, despite the fact that his boss doesn’t require him to do this, and despite the fact that the behavior is putting a strain on his relationship with his wife. Worry behavior prevention can help the person identify what actions lead to more stress and find ways to make needed changes. (Click here for instructions on worry behavior prevention.)

REFERENCES FOR SLEEP DISORDERS

1. National Sleep Foundation. 2008. Sleep in America Poll: Summary of Findings. Washington, DC: National Sleep Foundation.

2. Mignot, E. 2000. Pathophysiology of narcolepsy. In Principles and Practice of Sleep Medicine, 3rd ed., edited by M. H. Kryger, T. Roth, and W. C. Dement. Philadelphia: Saunders.

3. Berquier, A., and R. Ashton. 1992. Characteristics of the frequent nightmare sufferer. Journal of Abnormal Psychology 101: 246-250.

4. Patient Education Institute. 2005. Sleep disorders. www.nlm.nih.gov/medlineplus/tutorials/sleepdisorders/htm/_no_50_no_0.htm. Accessed March 3, 2008.

5. National Sleep Foundation. 2006. Sleep in America Poll. Washington, DC: National Sleep Foundation.

6. Wolfson, A. R. 2001. The Woman’s Book of Sleep. Oakland, CA: New Harbinger Publications.

7. Bootzin, R. R., D. Epstein, and J. M. Wood. 1991. Stimulus control instructions. In Case Studies in Insomnia, edited by P. J. Hauri. New York: Plenum Press.