Sleep Disorders
Learning Objectives
By the end of this section, you will be able to:
- Describe the symptoms and treatments of insomnia
- Recognize the symptoms of several parasomnias
- Describe the symptoms and treatments for narcolepsy
Many people experience disturbances in their sleep at some point in their lives. Depending on the population and sleep disorder being studied, between 30% and 50% of the population suffers from a sleep disorder at some point in their lives (Bixler, Kales, Soldatos, Kaels, & Healey, 1979; Hossain & Shapiro, 2002; Ohayon, 1997, 2002; Ohayon & Roth, 2002). This section will describe several sleep disorders as well as some of their treatment options.
Insomnia
Insomnia, a consistent difficulty in falling or staying asleep, is the most common of the sleep disorders. Individuals with insomnia often experience long delays between the times that they go to bed and actually fall asleep. In addition, these individuals may wake up several times during the night only to find that they have difficulty getting back to sleep. As mentioned earlier, one of the criteria for insomnia involves experiencing these symptoms for at least three nights a week for at least one month’s time (Roth, 2007).
It is not uncommon for people suffering from insomnia to experience increased levels of anxiety about their inability to fall asleep. This becomes a self-perpetuating cycle because increased anxiety leads to increased arousal, and higher levels of arousal make the prospect of falling asleep even more unlikely. Chronic insomnia is almost always associated with feeling overtired and may be associated with symptoms of depression.
There may be many factors that contribute to insomnia, including age, drug use, exercise, mental status, and bedtime routines. Not surprisingly, insomnia treatment may take one of several different approaches. People who suffer from insomnia might limit their use of stimulant drugs (such as caffeine) or increase their amount of physical exercise during the day. Some people might turn to over-the-counter (OTC) or prescribed sleep medications to help them sleep, but this should be done sparingly because many sleep medications result in dependence and alter the nature of the sleep cycle, and they can increase insomnia over time. Those who continue to have insomnia, particularly if it affects their quality of life, should seek professional treatment.
Some forms of psychotherapy, such as cognitive-behavioural therapy, can help sufferers of insomnia. Cognitive-behavioural therapy is a type of psychotherapy that focuses on cognitive processes and problem behaviours. The treatment of insomnia likely would include stress management techniques and changes in problematic behaviours that could contribute to insomnia (e.g., spending more waking time in bed). Cognitive-behavioural therapy has been demonstrated to be quite effective in treating insomnia (Savard, Simard, Ivers, & Morin, 2005; Williams, Roth, Vatthauer, & McCrae, 2013).
EVERYDAY CONNECTION: Solutions to Support Healthy Sleep
Has something like this ever happened to you? My sophomore college housemate got so stressed out during finals sophomore year he drank almost a whole bottle of Nyquil to try to fall asleep. When he told me, I made him go see the college therapist.
Many college students struggle getting the recommended 7–9 hours of sleep each night. However, for some, it’s not because of all-night partying or late-night study sessions. It’s simply that they feel so overwhelmed and stressed that they cannot fall asleep or stay asleep. One or two nights of sleep difficulty is not unusual, but if you experience anything more than that, you should seek a doctor’s advice.
Here are some tips to maintain healthy sleep:
- Stick to a sleep schedule, even on the weekends. Try going to bed and waking up at the same time every day to keep your biological clock in sync so your body gets in the habit of sleeping every night.
- Avoid anything stimulating for an hour before bed. That includes exercise and bright light from devices.
- Exercise daily.
- Avoid naps.
- Keep your bedroom temperature between 60 and 67 degrees. People sleep better in cooler temperatures.
- Avoid alcohol, cigarettes, caffeine, and heavy meals before bed. It may feel like alcohol helps you sleep, but it actually disrupts REM sleep and leads to frequent awakenings. Heavy meals may make you sleepy, but they can also lead to frequent awakenings due to gastric distress.
- If you cannot fall asleep, leave your bed and do something else until you feel tired again. Train your body to associate the bed with sleeping rather than other activities like studying, eating, or watching television shows.
Parasomnias
A parasomnia is one of a group of sleep disorders in which unwanted, disruptive motor activity and/or experiences during sleep play a role. Parasomnias can occur in either REM or NREM phases of sleep. Sleepwalking, restless leg syndrome, and night terrors are all examples of parasomnias (Mahowald & Schenck, 2000).
Sleepwalking
In sleepwalking, or somnambulism, the sleeper engages in relatively complex behaviours ranging from wandering about to driving an automobile. During periods of sleepwalking, sleepers often have their eyes open, but they are not responsive to attempts to communicate with them. Sleepwalking most often occurs during slow-wave sleep, but it can occur at any time during a sleep period in some affected individuals (Mahowald & Schenck, 2000).
Historically, somnambulism has been treated with a variety of pharmacotherapies ranging from benzodiazepines to antidepressants. However, the success rate of such treatments is questionable. Guilleminault et al. (2005) found that sleepwalking was not alleviated with the use of benzodiazepines. However, all of their somnambulistic patients who also suffered from sleep-related breathing problems showed a marked decrease in sleepwalking when their breathing problems were effectively treated.
DIG DEEPER: A Sleepwalking Defense?
On January 16, 1997, Scott Falater sat down to dinner with his wife and children and told them about difficulties he was experiencing on a project at work. After dinner, he prepared some materials to use in leading a church youth group the following morning, and then he attempted to repair the family’s swimming pool pump before retiring to bed. The following morning, he awoke to barking dogs and unfamiliar voices from downstairs. As he went to investigate what was going on, he was met by a group of police officers who arrested him for the murder of his wife (Cartwright, 2004; CNN, 1999).
Yarmila Falater’s body was found in the family’s pool with 44 stab wounds. A neighbor called the police after witnessing Falater standing over his wife’s body before dragging her into the pool. Upon a search of the premises, police found blood-stained clothes and a bloody knife in the trunk of Falater’s car, and he had blood stains on his neck.
Remarkably, Falater insisted that he had no recollection of hurting his wife in any way. His children and his wife’s parents all agreed that Falater had an excellent relationship with his wife and they couldn’t think of a reason that would provide any sort of motive to murder her (Cartwright, 2004).
Scott Falater had a history of regular episodes of sleepwalking as a child, and he had even behaved violently toward his sister once when she tried to prevent him from leaving their home in his pajamas during a sleepwalking episode. He suffered from no apparent anatomical brain anomalies or psychological disorders. It appeared that Scott Falater had killed his wife in his sleep, or at least, that is the defense he used when he was tried for his wife’s murder (Cartwright, 2004; CNN, 1999). In Falater’s case, a jury found him guilty of first degree murder in June of 1999 (CNN, 1999); however, there are other murder cases where the sleepwalking defense has been used successfully. As scary as it sounds, many sleep researchers believe that homicidal sleepwalking is possible in individuals suffering from the types of sleep disorders described below (Broughton et al., 1994; Cartwright, 2004; Mahowald, Schenck, & Cramer Bornemann, 2005; Pressman, 2007).
Night Terrors
Night terrors result in a sense of panic in the sufferer and are often accompanied by screams and attempts to escape from the immediate environment (Mahowald & Schenck, 2000). Although individuals suffering from night terrors appear to be awake, they generally have no memories of the events that occurred, and attempts to console them are ineffective. Typically, individuals suffering from night terrors will fall back asleep again within a short time. Night terrors apparently occur during the NREM phase of sleep (Provini, Tinuper, Bisulli, & Lagaresi, 2011), typically during stages 3 and 4. Generally, treatment for night terrors is unnecessary unless there is some underlying medical or psychological condition that is contributing to the night terrors (Mayo Clinic, n.d.).
Nightmares
Nightmares are disturbing and vivid, story-like dreams that typically occur during REM sleep and include a fear-related emotional component (Nielsen & Levin, 2007). Nightmares tend to be more prevalent in childhood and females consistently report more nightmares than males (Nielsen & Levin, 2007). The occasional nightmare is normal, with approximately 1 in 20 people reporting one nightmare a week (Reg, Sheaves & Freeman, 2017). Clinical populations (e.g., patients diagnosed with PTSD, schizophrenia, and/or borderline personality disorder) experience nightmares more frequently, which leads many scientists to believe that nightmares are a sign of emotional disturbance (Nielsen & Levin, 2007; Reg, Sheaves & Freeman, 2017). Milder forms of stress are also related to an increase in nightmares, such exam stress, natural disasters or bereavement.
Sleep Paralysis
Sleep paralysis is a temporary inability to move and typically occurs right after falling asleep or when waking up. An individual experiencing sleep paralysis will be consciously aware, often able to move their eyes but not the rest of their body (Sleep Foundation, 2020). These experiences can be frightening and are often accompanied by terrifying hallucinations that are distinct from typical dreams or nightmares; approximately “75% of sleep paralysis episodes involve hallucinations” (Sleep Foundation, 2020). Interestingly, the hallucinations seem to follow three general themes: the presence of malevolent intruders, physical/sexual assault (e.g., pressure on the chest like someone is sitting on you), and unnatural involuntary movements (e.g., levitation) (Sharpless & Barber, 2011; Sleep Foundation, 2020). Most people will experience sleep paralysis at least once in their lives, but some people experience it on a regular basis and it can become terrifying. One way to overcome sleep paralysis is to stick to a sleep schedule – going to sleep and waking up at consistent times every day.
Narcolepsy
Unlike the other sleep disorders described in this section, a person with narcolepsy cannot resist falling asleep at inopportune times. These sleep episodes are often associated with cataplexy, which is a lack of muscle tone or muscle weakness, and in some cases involves complete paralysis of the voluntary muscles. This is similar to the kind of paralysis experienced by healthy individuals during REM sleep (Burgess & Scammell, 2012; Hishikawa & Shimizu, 1995; Luppi et al., 2011). Narcoleptic episodes take on other features of REM sleep. For example, around one third of individuals diagnosed with narcolepsy experience vivid, dream-like hallucinations during narcoleptic attacks (Chokroverty, 2010).
Surprisingly, narcoleptic episodes are often triggered by states of heightened arousal or stress. The typical episode can last from a minute or two to half an hour. Once awakened from a narcoleptic attack, people report that they feel refreshed (Chokroverty, 2010). Obviously, regular narcoleptic episodes could interfere with the ability to perform one’s job or complete schoolwork, and in some situations, narcolepsy can result in significant harm and injury (e.g., driving a car or operating machinery or other potentially dangerous equipment).
Generally, narcolepsy is treated using psychomotor stimulant drugs, such as amphetamines (Mignot, 2012). These drugs promote increased levels of neural activity. Narcolepsy is associated with reduced levels of the signaling molecule hypocretin in some areas of the brain (De la Herrán-Arita & Drucker-Colín, 2012; Han, 2012), and the traditional stimulant drugs do not have direct effects on this system. Therefore, it is quite likely that new medications that are developed to treat narcolepsy will be designed to target the hypocretin system.
There is a tremendous amount of variability among sufferers, both in terms of how symptoms of narcolepsy manifest and the effectiveness of currently available treatment options. This is illustrated by McCarty’s (2010) case study of a 50-year-old woman who sought help for the excessive sleepiness during normal waking hours that she had experienced for several years. She indicated that she had fallen asleep at inappropriate or dangerous times, including while eating, while socializing with friends, and while driving her car. During periods of emotional arousal, the woman complained that she felt some weakness on the right side of her body. Although she did not experience any dream-like hallucinations, she was diagnosed with narcolepsy as a result of sleep testing. In her case, the fact that her cataplexy was confined to the right side of her body was quite unusual. Early attempts to treat her condition with a stimulant drug alone were unsuccessful. However, when a stimulant drug was used in conjunction with a popular antidepressant, her condition improved dramatically.
a consistent difficulty in falling or staying asleep
a type of psychotherapy that focuses on cognitive processes and problem behaviors
