Sleep Disorders

It can certainly feel like everyone else in the world is asleep and you are the only one awake. However, if you are awake when you’d like to be sleeping, you are not alone. Approximately 20-25% of people around the world are dissatisfied with their sleep.

There are about 70 sleep disorders in the International Classification of Sleep Disorders, 3^rd Edition. I describe here the most common ones that we encounter in the clinic.

If you have a bad night, you know how it affects you the next day. Some people are affected more than others. Many become more irritable. Daily activities, including tasks for work or school, and housework, may feel more challenging. You may feel somewhat discouraged. Sometimes, people feel like being alone rather than getting together with friends. You may also notice being more physically clumsy, for example, bumping into furniture more than usual.

The good news: Although things feel harder to do after a bad night, often people perform their work and home activities to near the same levels as after a good night.

The not-so-good news: When insomnia continues and becomes chronic, people may experience slowed reaction time, reduced attention, worsened short-term memory, and lower performance at work. Chronic insomnia also increases the risk of developing clinical depression.

More good news: With treatment of insomnia, mood improves and mental functioning is expected to return to normal.

Researchers who have studied groups of people with insomnia over a number of years and compared their health to groups without insomnia have made some interesting discoveries related to health. These “longitudinal” studies show that people with chronic insomnia have a higher risk of having car crashes and higher risk of developing cardiovascular disease (chance of heart attack or stroke) and type 2 diabetes.

The good news: There is little reason to believe that these risks cannot be reduced by effectively treating the insomnia. Research is underway to test this. In any event, it makes good sense to reverse the insomnia in order to—at the very least—improve sleep, mood and wellbeing. The best treatment we have is called cognitive behavioural therapy for insomnia (CBT-I). CBT-I effectively treats insomnia, and improves mood, functioning and quality of life.

Usual treatment: CBT-I

Where to start:  If you want to do CBT-I, you can either do it on your own, by following a book (e.g., Sink into Sleep), an online program (e.g., Sleepio, SHUT-i) or with the help from a clinician who is trained in behavioural sleep medicine. In addition, HALEO offers online CBT-I with 1:1 help from a therapist.

Note: Unless your physician suspects that you may have another sleep disorder, other than insomnia, there is no need to have an overnight sleep study. This will just confirm what you already know—that you have trouble sleeping!

Usual treatment: Treatment depends on the nature and severity of the disorder. Based on the diagnosis, some people are prescribed continuous positive airway pressure (CPAP), an oral appliance, or advised to avoid sleeping on their back, or to lose weight.

Where to start: See your family physician or primary care provider. You may be referred for an overnight study, either in at a sleep clinic or via a home sleep apnea test using a portable monitoring device.

Usual treatment: If the restless legs are severe, your physician may prescribe medication.

The non-pharmacologic approaches, although recommended as the first step in managing restless legs, have rarely been scientifically tested. They are safer than medications for the disorder. People with restless legs discover their own methods that usually involve movement. Experts generally recommend the following:

• • • Avoid the following because they worsen RLS:
      – sleep loss
      – alcohol
      – antihistamines (like diphenhydramine – found in many over-the-counter cold and sleep remedies)
      – caffeine
      – intense exercise within 2 hours of bed
  • • Stay active physically and mentally. Inactivity leads to more RLS.

During an episode, try the following:

• • • Walk
    • Stretch the legs. Various yoga or basic fitness stretches that involve the legs (calf, hamstring, quadriceps) may be helpful.
    • Massage the leg muscles.
    • Take a warm bath or shower (although some find cold is better).
    • If you are in a place where physical movement is limited, like a plane or a bus, engage in mentally engrossing activity such as conversation, video games, reading a fascinating book or doing a crossword.
    • In general, being physically, emotionally or mentally stimulated and alert seems to keep the restlessness at bay.

Where to start: You can start with the various non-pharmacologic strategies listed above.

If leg restlessness is interfering with your ability to sleep or to do things during the day (like travelling on buses, going to movies), describe your symptoms to your family physician or primary care provider.

Usual treatment:  The person with periodic limb movements is often not aware of them, although their bed partner may be. An overnight study in the sleep lab can detect them and the sleep specialist may recommend treatment, usually medication.

Where to start:  If you have restless legs syndrome and think you might also have periodic limb movements during sleep, try the strategies above and talk to your family physician or primary care provider.

Most nightmares occur in rapid eye movement (REM) sleep, although some traumatic nightmares may occur in other sleep stages, such as Stage N2. It is normal to have the occasional nightmare. If nightmares occur repeatedly, and interfere with mood or daytime functioning, then the term “nightmare disorder” is used.

Usual treatment: In some cases, physicians may prescribe medications. An effective non-pharmacologic treatment is called “dream imagery rehearsal.” This involves re-writing the dream and rehearsing the new one. Following a certain protocol, this treatment has been shown to reduce the frequency and the severity of nightmares.

Where to start: A health professional who works in sleep medicine or behavioural sleep medicine can help. You may need a referral from your family physician. You can also receive help from a psychologist or counsellor who is familiar with dream imagery rehearsal.

Specifically, the person is a late-night person. If they follow their preferred sleep-wake timing, they will fall asleep in the early morning hours and awaken in the late morning or in the afternoon, and there is no sleep problem. However, if the person must be at work or school at usual start times, there is great difficulty waking up on time. Similarly, if the person tries to go to bed earlier than the preferred bedtime, it takes a long time to go to sleep.

Usual treatment: strategically timed light treatment, strategically timed melatonin

Where to start:  These treatments are usually provided by sleep medicine specialists or experts in behavioural sleep medicine. Ask your family physician or primary care provider for a referral.