Fibromyalgia
Fibromyalgia (also know as fibromyalgia syndrome) is principally characterized by chronic widespread pain, fatigue and heightened response to tactile pressure. This chronic condition results in marked daytime distress and dysfunction. Poor, non-restorative sleep and insomnia are very common in patients with fibromyalgia (in as many as 95% of diagnosed patients), along with impairments in cognition (especially concentration and memory), headaches, and depression.
Causes of fibromyalgia
Approximately 2-4% of the population experience fibromyalgia, and the condition is more common in women. Although the underlying cause(s) of fibromyalgia is not yet clear, a number of theories exist, and include altered pain processing, changes in levels of specific neurotransmitters, stress reactivity, and psychological factors.
Treatments for fibromyalgia
Common treatment avenues might include exercise, cognitive behavioral therapy and pharmacotherapy (anti-depressants).
Objective changes to sleep have been documented, most commonly reflected in increased alpha activity (alpha intrusions) during NREM sleep, thought to indicate the presence of hypervigilance during sleep. Reduced slow-wave (deep) sleep has also been reported.
As problems with initiating and maintaining sleep are very common in patients with fibromyalgia, research has been conducted to see if cognitive behavioral methods for insomnia (CBT-I) can be applied to this patient group. One study published in 2005 found that individual CBT in fibromyalgia patients led to a 50% reduction in wake time during the night and roughly 60% of treated patients had a clinically important improvement in insomnia symptoms (Edinger et al., 2005). What still needs to be determined is whether improving sleep can have meaningful changes to the experience of pain, fatigue and other measures of well-being and quality of life.
The broader relationship between sleep and pain is also an important area of ongoing research. For example, it has been shown that both restricting sleep time and fragmenting sleep in healthy adults can lead to increased pain sensitivity, supporting a potential bi-directional relationship between pain and sleep: pain can disturb sleep, and fragmented sleep can exacerbate daytime pain. Indeed, it was recently shown that those with chronic sleep disturbance (without a diagnosed pain disorder) have altered sensitivity to experimentally-induced pain (Haack et al., 2012).
References:
Edinger, J.D., Wohlgemuth, W.K., Krystal, A.D., Rice, J.R. (2005). Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial. Archives of internal medicine, 165(21), 2527-2535.
Haack, M., Scott-Sutherland, J., Santangelo, G., Simpson, N.S., Sethna, N., Mullington, J.M. (2012). Pain sensitivity and modulation in primary insomnia. European Journal of Pain, 16(4), 522-533.
What is a sleep disorder?
At some point in their lives, it's likely that everyone will have trouble sleeping. Whether it's getting to sleep in the first place, or staying asleep throughout the night, we've all spent nights becoming increasingly frustrated, staring at the ceiling and willing ourselves to “just go to sleep”. Indeed sleeping may seem like the easiest, most natural thing in the world, until you can't. However, it's when these odd nights of bad quality or little sleep begin to trouble you on a daily basis, and have consequences for your daytime functioning, that you may need to seek help for a sleep disorder.
Disordered sleep comes in many forms, the main sleep disorders include:
- Insomnia
- Narcolepsy
- Sleep apnoeas
- Circadian rhythm disorders such as delayed sleep phase disorder
- Sleep-related movement disorders such as restless legs syndrome
- Parasomnias such as night terrors
There are, of course, those who don't spend long hours lying awake in the middle of the night, but simply fail to wake up feeling rested and refreshed by their sleep. What all sleep disorders tend to have in common however is a negative impact on daytime function. In general, sleep disorders come with a whole host of potential daytime problems which can ultimately impair quality of life, making their assessment, diagnosis and treatment imperative.
How common are sleep disorders?
It's estimated that 25-30% of the population suffers from a sleep disorder (National Institutes of Health, USA). In fact, sleep disturbance is the most common symptom of mental ill-health in the UK, being around twice as common as anxiety and depressive symptoms. Insomnia is the most common sleep disorder, and its prevalence increases with advancing age.
Treating sleep disorders
Despite poor sleep having become one of the most common complaints at GPs' surgeries, the average time devoted to training in sleep and sleep disorders in UK medical schools is incredibly brief. Indeed one study published in 1998 revealed it was roughly 5 minutes! (Stores & Crawford, 1998). This means that understanding, recognition, and treatment of sleep disorders in primary care may lag behind other common illnesses.
Despite the, often poor, provision of sleep disorder treatments within health care-systems, important research has and is currently being conducted to develop and assess treatments that improve sleep quality. However, advancements are being made in the development of non-drug treatments for many sleep disorders. Support for the effectiveness of Cognitive Behavioral Therapy (CBT) to improve even long-term poor sleep is growing.
Please consult your doctor if you suspect that you might be suffering from a sleep disorder.
Reference:
Stores, G., Crawford, C. (1998). Medical student education in sleep and its disorders. Journal of the Royal College of Physicians of London, 32(2), 149-153.
What is Narcolepsy?
Narcolepsy is a nervous system disorder with a typical onset between the ages of 15 – 25 years which affects around 0.02% – 0.18% of the population. Although the condition is relatively rare, the daytime consequences of narcolepsy can be severely debilitating.
Symptoms of narcolepsy
Narcolepsy is a disorder most strongly characterized by periods of excessive and extreme sleepiness during the day. During these periods, a powerful urge to sleep develops, often resulting in a short nap or 'sleep attack'. These sleep attacks generally last for around 15 minutes, but may last longer, and result in the sufferer feeling refreshed and able to continue their day as normal. Patients with narcolepsy also tend to fall asleep much faster than healthy individuals and may experience the condition alongside other forms of sleep disturbance, for example, sleep paralysis and sleep fragmentation.
Narcolepsy may also present with 'cataplexy', a sudden loss of muscle tone, which prevents movement of body parts. Attacks of cataplexy are most often triggered by strong emotions such as laughter or anger and usually last for 30 seconds or less, meaning that they may be missed all together. During these attacks, jaw muscles become slack, the head will suddenly fall forward and the knees will buckle. In the most severe cases cataplexy may last much longer, leaving the person paralyzed for several minutes.
Normal sleep patterns will see people going through 2 main stages as they fall asleep, 'non-rapid eye movement' (NREM) first, and then 'rapid eye movement' (REM) sleep after a couple of hours. However, people with narcolepsy do not experience NREM sleep initially, and instead enter REM sleep, immediately. This can result in vivid dreams very shortly after falling asleep. REM sleep is the phase of sleep characterized by muscle atonia and intense dream content.
Scheduled daytime naps (called the multiple sleep latency test) at a sleep laboratory can help with the diagnosis of narcolepsy, where there are REM-sleep onsets in at least 2 out of 4 nap opportunities.
Causes of narcolepsy
Much remains to be discovered about the precise causes of narcolepsy, but some research suggests that it may be a genetic disorder, meaning that it is passed down through family members in their DNA. In particular, research has shown that people with narcolepsy, on average, tend to have lower levels of a protein called 'hypocretin' in their brains. The chemical hypocretin has an important role in regulating sleep patterns which has lead to the theory that narcolepsy could be an autoimmune disease, where the immune system attacks the body's own cells, in this case those responsible for producing 'hypocretin'.
It is likely though, that other, environmental factors, also contribute to the development of the disorder. Other known factors associated with the onset of narcolepsy include pregnancy, changes in sleep pattern, brain damage and severe stress. These are considered to be potential contributory factors as more than 50% of people with narcolepsy see events of this kind shortly before their symptoms develop.
Treatments for narcolepsy
At this point, there is no known 'cure' for narcolepsy but the sleep disorder may still be managed effectively and its symptoms controlled. Treatment includes a variety of lifestyle changes including eating lighter or vegetarian meals during the day and scheduling naps to control daytime sleep and reduce the number of unplanned, sudden sleep attacks.
Alongside these lifestyle changes, people may be prescribed stimulant drugs to boost energy during the day or antidepressants to help deal with symptoms of cataplexy and REM-related features such as sleep paralysis and hypnagogic hallucinations.
What is Delayed Sleep Phase Disorder (DSPD)?
Delayed sleep phase disorder (DSPD) belongs to a group of sleep disorders known as circadian rhythm sleep disorders whereby individuals experience a chronic pattern of sleep disturbance due to changes or misalignment in the circadian timing of their sleep, relative to what their social and physical environment dictate. It is this conflict that leads the expression of a problem. For example, an individual whose circadian rhythm, or 'body clock', is delayed may find that their ideal time for sleep is 4am with a rise time of 12 noon. This schedule does not match the typical sleep window of most adults; and thus the main problems of those with DSPS relate to attempting to fall asleep (before their body clock is ready to) and attempting to wake up in the morning (before their body clock is ready to). The latter can be an important problem if the individual has to commence work at 8 or 9am, rendering them with partial sleep deprivation
Circadian rhythm sleep disorders in general, lead to excessive daytime sleepiness as well as periods of insomnia, due to the shift in the natural, circadian timing of an individual's sleep window. DSPD in particular, tends to describe sleep-wake schedules which are delayed by two or more hours from the 'normal' so, for example, if an individual found themselves becoming sleepy at 4am and waking naturally at 12 noon. Other than this offset, DSPD does not cause 'abnormal sleep' and tends to follow a reliable pattern over a 7 day period.
Symptoms of DSPD
To meet the diagnostic criteria for DSPD according to the official DSM-IV manual of psychiatric disorders, the sleep disturbance must cause 'clinically significant' distress or impairment in an individual's social or occupational functioning or in any other important areas of their life. As in the diagnosis of other sleep disorders, this disturbance must not occur as a result of another sleep or mental health disorder or due to the physiological effects of any substances.
People with DSPD are commonly referred to as night owls, however, those with DSPD do not choose their waking hours, generally falling asleep very late at night and waking in the late morning or afternoon. DSPD will often lead to individuals being labeled as having insomnia but, importantly, they have no difficulty falling asleep if allowed to follow their internally set sleep pattern.
Treating DSPD
Treatment for DSPD includes a variety of lifestyle changes such as improvement in sleep hygiene habits, for example restricting caffeine intake in the hours before bed, keeping to a regular schedule and only using your bedroom for sleeping. Alternatively, 'bright light therapy' may help to reset the body clock, using controlled exposure to strong light levels shortly after awakening, or prescribed melatonin.
What is Sleep Apnoea?
'Sleep apnoea', or 'sleep apnea', is a general term covering three distinct conditions: 'Obstructive sleep apnoea' (OSA), 'Central sleep apnoea' (CSA) and 'Complex' or 'Mixed' sleep apnoea.
Intermittent or mild bouts of sleep apnoea may occur during periods of illness, for example as a result of a throat infection, and tend not to require treatment. However, forms of long-term or severe sleep apnoea can result in dangerously low levels of blood oxygen and therefore require prompt medical attention.
Obstructive sleep apnoea is…
OSA is the most commonly diagnosed form of sleep apnoea, being characterized by things such as restlessness during sleep, snoring and sleepiness during the daytime amongst other, less common symptoms.
Snoring – the vibration of respiratory structures due to obstructed air movement while asleep – is often considered to be the most recognizable symptom in those suffering from sleep apnoea. However, it is actually when snoring stops that breathing may be most obstructed, with the throat becoming too constricted to allow enough air to flow through the airway to make a sound. These breathing events (called apnoeas [complete cessation of airflow] or hypopneas [50% reduction in airflow]) may occur several times per hour, and can result in arousal from sleep. It is for this reason that snoring is not a sure sign of sleep apnoea and that louder snoring is not necessarily more likely to be caused by severe obstruction due to OSA.
Risk factors for developing obstructive sleep apnoea include having a Body Mass Index (BMI) of 40 or more, a neck circumference (in men over 17in), smoking and drinking alcohol regularly. Older adults, men, and people with diabetes are also known to be more likely to suffer from OSA, although it may still be found in both women and children.
How to sleep with sleep apnoea?
Simply implementing lifestyle and behavioral changes may help improve OSA; however, the most effective treatment is seen as a result of the use of a Continuous Positive Airway Pressure or 'CPAP' machine. CPAP machines are used to open up the airways and keep blood oxygen at a healthy level by maintaining a flow of air to the lungs delivered through a facial mask.
Individuals whose OSA isn't helped by the use of a CPAP machine, or find the machines too uncomfortable, may be offered a range of surgical procedures to widen their airway or remove and tighten soft-tissue in the throat.
Central sleep apnoea is…
CSA, also known as 'Cheyne-Stokes respiration', differs from OSA in that it involves an imbalance of the brain's respiratory control centers during both sleep and wakefulness. Low blood oxygen therefore occurs as a result of failures in the brain's feedback mechanisms rather than being due to physical obstructions as seen in OSA. Sufferers of CSA do not struggle to breathe during sleep but may be seen to cycle between periods of fast and slow breathing in order to compensate for drops in blood oxygen known as 'hypoxaemia'.
The effects of CSA will differ between sufferers depending on how severe their apnea is but tends to present milder symptoms unless the condition exists alongside other health problems such as those with the heart or nervous system.
'Complex' or 'mixed' sleep apnoea is…
People seen to have a combination of OSA and CSA may receive a diagnosis of 'complex' or 'mixed' sleep apnoea. It is currently thought that it is possible for people suffering from long-term, severe OSA to develop CSA as a result of damage to the brain's feedback mechanisms. Research is ongoing into the relationship between OSA and CSA, with much left to be understood about 'complex' or 'mixed' apnoeas.
Please consult your doctor if you believe you might be suffering from sleep apnoea.
What is REM-sleep Behavior Disorder?
REM-sleep Behavior Disorder (RBD) is a parasomnia characterized by abnormal behaviors that emerge during REM sleep, potentially leading to injury. Prevalence of RBD has been estimated at 0.5%, being more common in males, with onset typically occurring in those aged 50 years and over.
Symptoms of RBD
Rapid eye movement (REM) sleep is the phase of sleep where we are most likely to experience intense and vivid dreaming. It is normally characterized by muscle atonia (a loss of muscle tone), meaning that we are essentially paralyzed during this phase of sleep and should therefore, be unable to initiate any motor movements. This loss of muscle tone can be measured through a technique called electromyography (EMG), as part of overnight sleep study or 'polysomnography' (PSG), which determines electrical activity in skeletal muscles. In those with RBD however, there is no loss of muscle tone during periods of REM sleep, leaving these patients able to act out their dreams.
In contrast to those with NREM (non-rapid eye movement) parasomnias, such as sleep-walking, patients with RBD often have good recall of the dream and are able to orient themselves to their surroundings relatively quickly after arousal. Dreams are often described by RBD patients as being vivid, intense and action-packed. In terms of behavior, dream-enacting episodes can typically feature confrontation and aggression, which can result in injury to the patient (e.g. diving from bed) and bed partner (e.g. choking/headlock). It is often the case therefore that RBD patients will first present to a sleep medicine specialist due to a history of sleep-related injury. Typically, these injuries will range from bruises and tooth chipping through to lacerations, fractures and subdural hematomas (Schenck & Mahowald, 2011).
What causes RBD?
There is evidence that brainstem areas of the brain are involved in regulating REM sleep and that damage to these areas may result in RBD-like symptoms. This is supported by research into lesions in certain brainstem areas (in particular the pontine tegmentum), which induced human-like RBD symptoms in cats.
Recent follow-up studies of patients diagnosed with RBD have also shown that more than half of all patients subsequently develop neurodegenerative disorders, particularly Parkinson's Disease and Dementia with Lewy Bodies. Effective pharmacological treatment usually involves Clonazepam, which appears to suppress excessive motor-behavioral activity during REM sleep. Melatonin is also used as a second-line therapy in RBD patients, which has been shown to restore normal REM muscle atonia in some patients. In conjunction with pharmacotherapy, maximizing the safety of the sleeping environment is also important e.g. move bed away from window, bed partner sleep in a different room, move hard objects away from bed area (Schenck & Mahowald, 2011).
What is Restless Legs Syndrome (RLS)?
Restless Legs Syndrome (RLS), also known as 'Ekbom syndrome', is thought to affect between 5-10% of adults. The syndrome is characterized by uncomfortable or painful feelings in the thighs, claves and feet, which result in overwhelming urges to move the legs. These feelings are often experienced as crawling or tickling sensations in the skin or leg muscles and range from the mildest of feelings, to the most severe and debilitating sensations. The symptoms of RLS may not be restricted to the nighttime and, in the most extreme situations, can significantly impact on daily quality of life.
RLS sufferers tend to begin experiencing the 'itching' or 'tickling' sensations in their legs during periods of rest, only finding relief by moving their legs and, whilst some may only experience RLS very rarely, others will report experiencing these symptoms every day.
RLS is most often discussed in relation to sleep as the urge to move the legs often proves to be strongest at rest. The majority (as much as 80%) of individuals with RLS experience several episodes of jerking leg movements during the night, called periodic limb movements (PLMs), which may seriously fragment their sleep and often without them knowing. Compromised sleep quality, sleep continuity and architecture ultimately impairs next-day functioning, through increased levels of sleepiness and fatigue.
What causes RLS?
There is still much debate and disagreement surrounding the causes of RLS, which may be associated with underlying health conditions, including anemia (iron deficieny), Parkinson's disease and reduced kidney function. In these cases, RLS would be given as a 'secondary diagnosis'. Alternatively, RLS may present on its own, being given as a 'primary diagnosis'. In these cases however, there is often no obvious cause of RLS and it may be seen to run in the individual's family.
Most research into the causes of restless legs indicates low levels of the neurotransmitter 'dopamine' to be key. Dopamine is important in the control of muscle movements meaning that low levels of the chemical may play a role in the involuntary leg movements seen in RLS.
Treatments for RLS
RLS may not require treatment if the symptoms experienced are very mild, however, several lifestyle changes may be advised. These include avoidance of caffeine and alcohol and participating regularly in exercise alongside stopping smoking if you do so.
In cases of RLS caused by other conditions, people may find that treatment for their primary diagnosis may also improve their RLS. However, in more severe cases of RLS, people may benefit from medication to adjust dopamine levels.
Please consult your doctor if you believe you might be suffering from restless legs syndrome.
What are Night Terrors?
Night terrors belong to a group of sleep disorders called 'Parasomnias' and are most commonly seen in children between the ages of two to seven years old. Night terrors are less often seen in adolescents and adults but may still occur during periods of deep sleep, in the first few hours of the night, continuing for anything up to 15 minutes at a time.
Parasomnias
Parasomnias include any undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep. They encompass sleep-related movements, emotions, perceptions, dreaming and changes in autonomic nervous system (ANS) functioning.
Parasomnias are relatively common in the general population, occurring in around 4 percent of the adult population and in almost 20 percent of all children and adolescents (Wills & Garcia, 2002). More specifically, Ohayon and colleagues found prevalence rates for night terrors of 2.2% of the general population and 2.2% reported sleep walking.
Symptoms of night terrors
Night terrors are fundamentally different from nightmares, which are relatively common in childhood and are characterized by bad dreams resulting in feelings of terror or horror in the night. Individuals waking from nightmares are often able to describe the contents of their nightmare in considerable detail. Night terrors, in contrast, are likely to result in little or no memory of the episode despite people showing signs of being awake, for example, having their eyes open.
Children having a night terror may be seen to sit suddenly upright or thrash about, they may also shout out, appearing to be in a state of inconsolable, confused panic. Despite being able to move about and even talk, they may not recognize the people around them and can become further agitated if forced to wake up. It is for this reason that people are advised not to try waking those experiencing a night terror unless they are in danger of harming themselves or others. Although it may be difficult to watch someone having a night terror, they are unlikely to remember anything the next day.
What causes night terrors?
It is thought that the likelihood of experiencing night terrors may be increased by any situation or chemical, which increases the quantity of deep sleep. This may include certain medications as well as being 'overtired'. These may also interact with situations in which people are more likely to wake during periods of deep sleep such as sudden or loud noises around them or raised feelings of excitement or worry.
What is Sleep Paralysis?
Sleep paralysis comes in many forms each of which may be characterized by the inability to carry out normal body movements, voluntarily, in the period just before sleep onset or during the time taken to awaken fully. These periods of paralysis are often seen to co-occur with visual and auditory hallucinations or vivid, dream-like states which, whilst harmless, can be very frightening experiences. Although these hallucinations may be interpreted as dreams, they may also be mistaken for reality provoking a strongly fearful response.
Those who suffer from sleep paralysis commonly report feeling immense pressure on their chests during episodes, adding to their feelings of anxiety during the paralyzed state and can result in breathlessness. Unlike the rest of the body however, which remains paralyzed throughout, the ability to move the eyes may in fact be preserved. It is completely normal to experience sleep paralysis from time to time, however when it becomes frequent and distressing or is associated with other symptoms of sleep-wake disorder, then it may require treatment.
What causes sleep paralysis?
Sleep paralysis is closely related to a normal part of the sleep cycle know as 'REM atonia', a paralysis which occurs as part of normal 'rapid eye movement', or REM, sleep. Sleep paralysis may take place either as the body enters REM sleep or once leaving REM sleep but before the full REM cycle has taken place. Paralysis can be very brief, ending after a matter of seconds, but in other cases may stretch into several minutes.
Sleep paralysis may be associated with other sleep disorders, such as narcolepsy, or else be present in otherwise entirely healthy people. In cases where sleep paralysis is the only symptom experienced, a diagnosis of 'isolated sleep paralysis' (ISP) may be given.
Although not strictly 'causes' of sleep paralysis, there are several factors which are known to increase the chances of experiencing an episode of sleep paralysis. These include:
- Sleeping in an upwards position on your back
- Increased levels of stress or sudden lifestyle changes
- Insufficient quantities of sleep
- Alcohol consumption
Treating sleep paralysis
As sleep paralysis is more common in people who are sleep deprived, getting the right amount of sleep may be seen to reduce the number of episodes of sleep paralysis. Keeping a regular schedule and taking frequent exercise alongside reducing caffeine and nicotine intake may also prove helpful in lowering the likelihood of sleep paralysis occurring.
I feel sleepy during the day
It is important to differentiate sleepiness from tiredness. When we feel sleepy, it is a conscious struggle to remain awake. On the other hand, when we are tired, we may feel fatigued but still remain relatively alert. You could think about this distinction by associating tiredness as a physical symptom experienced in the muscles in our body. Sleepiness however, is more like 'brain tiredness'.
It's a good idea to try to keep all your sleep for night-time, so if you feel mildly sleepy during the day do your best to counteract it. Exercise at lunchtime can be a good idea – a brisk walk perhaps. Getting out in the daylight is very important because natural light helps keep us alert. Then caffeinated drinks can also give us a much-needed 'boost' during daytime lulls.
The course helps to restore normal levels of sleepiness by increasing sleep pressure – This is a good thing and can be more pronounced during the course, which helps to get your sleep into shape. Often prior to the course, poor sleepers don't feel sleepy at all, night or day! Sleepiness will wear off as your sleep continues to evolve.
However if you feel very sleepy – so sleepy that you might fall asleep without warning – you should take it seriously as it can be dangerous, particularly when driving. In this case you should seek advice from your doctor as soon as possible.
Do sleep problems normally pass quite quickly?
Is it unusual to have an ongoing sleep problem? How common are sleep problems?
Occasional sleep disturbance is of course very common, and one might say very normal. Everyone experiences difficulty getting to sleep or staying asleep at some time in their lives. Often at times of change or times of stress. This is the way that nature intends things. Stressors are essentially 'threats' that our brain interprets as danger signs when we need heightened awareness. This makes it harder to down-regulate arousal into sleep and we experience that not only physiologically but also mentally when our mind is focused on the things that are going on in our lives.
These problems usually sort themselves out and end up being short-lived, and so is the poor sleep that goes with them. However, we know from leading sleep epidemiologists like Dr Maurice Ohayon of Stanford University that about 10 per cent of adults, that is 1 in 10 people, experience persistent sleep problems, and this can be as high as 1 in 5 (20 per cent) in people over 65 years of age. There are probably even more people out there who suffer with poor sleep but who do not seek help for it. The 3 P's model helps us to understand how persistent poor sleep can evolve from an acute sleep disturbance.
References:
Wilson, S., Argyropoulos, S. (2005). Antidepressants and sleep: a qualitative review of the literature. Drugs, 65(7), 927-947.
Mayers, A.G., Baldwin, D.S. (2005). Antidepressants and their effect on sleep. Human Psychopharmacology, 20(8), 533-559.