Disturbed Sleep: Causes and Treatments
In the Diagnostic and Statistical Manual of Mental Disorders 5, sleep-wake disorders encompass 10 conditions manifested by disturbed sleep, distress, and impairment in daytime functioning.1 Sleep disorders include insomnia, narcolepsy, restless leg syndrome, and breathing-related disorders (obstructive sleep apnea).
Excessive daytime sleepiness, or sudden somnolence, is a symptom that can occur with several sleep disorders. Excessive daytime sleepiness may include mild sleepiness, unrecognized episodes of “micro-sleep” or uncontrolled sleep attacks that result in falling asleep while in conversation, reading or watching television, or even while driving. Excessive daytime sleepiness may be caused by not getting enough hours of sleep or enough hours of quality sleep. On average, adults between 26 and 64 years of age need 7 to 9 continuous hours of sleep per day.2
Disturbed sleep can have many adverse health consequences, including fatigue, decreased cognitive focus, and altered mood, and can be a potential warning sign for medical issues—researchers believe that a lack of sleep may trigger inflammatory pathways that exacerbate arthritis pain.3 About two-thirds of patients who suffer from chronic pain also report poor or non-refreshing sleep due to a mutually reinforcing relationship between these 2 conditions.4,5
The problem of pain and sleep becomes even more complicated because many medications commonly prescribed to relieve pain, such as oxycodone (OxyContin, others), morphine (MS Contin, others), and codeine, can fragment sleep, or break up the sleep cycle.6 If a patient experiences poor sleep due to pain one night, he or she is likely to experience more pain the next night and so on, creating a vicious cycle. Chronic pain frequently is associated with a sleep-wake disorder, and these coexisting problems can be difficult to treat.
Sleep-wake disorders are diagnosed through a comprehensive assessment that includes a detailed patient history, physical exam, questionnaires, sleep diaries, and sleep studies. During a typical sleep study, patients are connected to testing equipment that measures various biological functions, including brain activity, muscle activity, respiratory effort, eye movements, heart rhythm, oxygen saturation, and sleep latency, duration, and efficiency.7 The temperature of the room is maintained at a comfortable level, and the lights are turned off. After the study is completed, the patient follows up with a specialist to review the outcomes and develop a treatment plan.
Narcolepsy is a neurologic disorder involving the loss of the brain’s ability to regulate sleep cycles normally. Patients with narcolepsy experience frequent excessive daytime sleepiness and disturbed nocturnal sleep, which often is confused with insomnia. Patients with narcolepsy generally experience the rapid eye movement (REM) stage of sleep within 5 minutes of falling asleep, but they tend to experience difficulties staying asleep. Patients with narcolepsy also have cataplexy, a sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions, such as laughing, crying, terror, etc. Some patients with narcolepsy also may suffer from sleep paralysis, or the temporary inability to move or speak while falling asleep or waking, accompanied by hallucinations. After developing narcolepsy, many patients suddenly gain weight, which can be prevented by active treatment.8
Restless Leg Syndrome
Another common sleep-wake neurological disorder is restless legs syndrome (RLS). RLS often is described as a creeping, crawling, tingling, aching, burning, pulling, or cramping sensation in the calves, thighs, feet, or arms. The sensations commonly are relieved by moving the legs or walking around. When movement stops, however, the sensations frequently return. The abnormal sensations are more common in the late afternoon or evening hours. RLS can disrupt sleep, leading to daytime drowsiness. RLS affects 10% of the U.S. population.9 Prescription and over-the-counter (OTC) medications are available to reduce the restlessness. For example, OTC pain relievers (acetaminophen), nonsteroidal anti-inflammatory drugs (ibuprofen and naproxen), a trial of gabapentin, opioids, muscle relaxants, or sleep aids, as well as medications intended for certain other diseases (Parkinson’s disease and epilepsy) may be helpful.10 Also, self-care, coping skills, and avoidance of caffeine can help reduce symptoms.
The most common type of sleep-wake disorder is insomnia, which may cause difficulty falling asleep, staying asleep, or awakening. Many people have experienced a period of transient insomnia for less than 1 week due to stress or environmental changes, but if this persists it becomes acute insomnia (<1 month duration) or evolves into what specialists call chronic insomnia (>1 month duration).
There are several potential causes of chronic insomnia, including chronic pain or other physical illness, shift work, poor sleep habits, consuming too much alcohol or caffeine, certain medications, and certain psychiatric conditions.11 In primary insomnia, in which no clear environmental, psychiatric, or medical cause can be identified, individual differences in brain function may result in an overactive alerting signal that continues long after a patient would like to fall asleep. If underlying health issues or environmental factors cannot be identified or changed, then there are a variety of treatment options (besides medications) that are available to help patients with disturbed sleeping. These include biofeedback,12 meditation,13 and cognitive-behavioral therapy (CBT).
What is CBT for Insomnia?
CBT for insomnia is a psychological intervention (typically lasting 8-12 weeks) in which a provider will perform a series of sleep assessments, ask patients to complete a sleep diary, and work with the patient in session to help change the way he/she sleeps.14 During the 2005 National Institute of Health state-of-the science meeting on insomnia, panelists concluded that CBT is a safe and effective means of managing chronic insomnia.15 This program can help patients who suffer from insomnia even if their sleep problems have a biological etiology. The program does not use sleep medications but instead teaches patients how to improve their sleep by changing their behaviors.
The CBT intervention includes relaxation training (progressive muscle relaxation, diaphragmatic breathing, and guided imagery), cognitive restructuring (identifying and correcting inappropriate thoughts and beliefs that contribute to insomnia), stimulus control (associating bed only with sleep and sex), sleep restriction (decreasing excess time in bed awake), and sleep hygiene (instituting practices, habits, and environmental factors important for sound sleep).