February 18, 2008

A video and a discussion of Sleep Disorders

or if the video above doesn't work try this link:

This post is about sleep disorders. The video covers insomnia and sleep phase disorders so I will not discuss those here, but will concentrate on Sleep Apnea, Narcolepsy and several other sleep disorders. This is not a comprehensive list. But I wanted to discuss the major problems associated with sleep because they are more common both in psychiatric patients and in the general population than is perhaps widely understood.

First of all, let’s discuss SLEEP APNEA, which is when a person has brief periods during the night when they stop breathing. Often they are loud snorers and an episode may be detected when the snoring is interrupted. Sleep apnea sufferers frequently do not get enough oxygen at night. There are two types of the disorder. Obstructive and central sleep apnea.

In Obstructive Sleep Apnea, or OSA, which is the most common type, there is an obstruction of some sort in the throat during sleep and a subsequent narrowing of the upper airway. The obstruction is usually excess tissue and might be a large tongue or large tonsils but usually includes the relaxation and collapsing of muscles during sleep. Air pushed past this excess tissue is what produces the sound of snoring. This sort of apnea may be due to inherent physical characteristics, excess weight or drinking alcohol before sleep.

Central Sleep Apnea or CSA is caused by a delay in the signal from the brain telling you to breathe. It may be due to a neuromuscular cause but there may be other sources of the problem. It is not as common as OSA and much more difficult to diagnose as there is no tell-tale snoring.

In both OSA and CSA a person wakes up frequently, sometimes 100s of times a night, in order to breathe. These awakenings are so brief that usually there is no memory of them, though the sufferer may find him or herself fatigued or sleepy during the day. In fact, daytime sleepiness is often the presenting symptom bringing them to the attention of a physician.

Some symptoms of Obstructive Sleep Apnea are:

. loud snoring
. morning headaches
. chest pulls in during sleep in young children
. high blood pressure
. overweight, but not always
. a dry mouth upon awakening
. depression
. difficulty concentrating
. excessive perspiring during sleep
. heartburn
. reduced libido
. insomnia
. frequent trips to the bath room during the night
. restless sleep
. rapid weight gain

OSA can be lifethreatening and the risks of it going undiagnosed include stroke, heart attack, irregular heartbeat, impotence, high BP, and heart disease. Daytime sleepiness can increase the risk for accidents and lower productivity as well as put a strain on interpersonal relationships. Symptoms may be mild, moderate or severe.

A sleep test known as a polysomnogram is done to diagnose sleep apnea, which usually requires an overnight stay in a sleep lab. Sometimes you can test at home with a computerized polysomnograph that you return to the Sleep Center in the morning. The sleep lab machines monitor brain waves, muscle tension, eye movement, respiration, oxygen levels in the blood, with audio monitoring for snoring, gasping etc. (*By the way, Joe had this test done because of his ALS, to see how his oxygen levels were and how well he was breathing at night. He probably had central sleep apnea, due to the motor neuron degeneration involved in Lou Gehrig’s disease, but they knew this going in.)

Mild OSA can be treated behaviorally, by losing weight or sleeping on one’s side. Oral mouth devices can help keep the airway open and reduce snoring by 1) bringing the jaw forward, 2) elevating the soft palate, or 3) retaining the tongue from falling back in the airway and stopping breathing. Note that OSA often gets worse as you age and so should not be ignored or taken lightly.

Moderate and severe apnea sufferers usually use a C-PAP or even a BiPAP machine. C-PAP stands for Continuous Positive Air Pressure, and the machine blows a continuous stream of air into the nose and/or mouth, keeping the airway open. In more severe cases, the BiLevel-PAP machine is used with a higher pressure for “in breaths” and a lower pressure for “out breaths.” (*BiPAP was was prescribed for Joe’s severe CSA.)
In some cases of facial deformities or very large tongue or tonsils, surgery may be the only solution. But usually this is a last resort.

A note about snoring: much snoring is benign, but “All snorers have an partial obstruction of the upper airway. Many habitual snorers have complete episodes of upper airway obstruction where the airway is completely blocked for a period of time, usually 10 seconds or longer. This silence is usually followed by snorts and gasps as the individual fights to take a breath. When an individual snores so loudly that it disturbs others, obstructive sleep apnea is almost certain to be present.” (

NARCOLEPSY – Information cribbed from the NINDS.NIH.GOV site with additions from yours truly drawn from personal experience.

What is Narcolepsy?

Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experience fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In rare cases, some people may remain asleep for an hour or longer. (*Pam: it really depends on where one falls asleep. If you can sleep in a bed, you might in fact sleep for an hour or more. If you fall asleep in a chair, a few minutes or a few seconds might suffice but only for a short time. In the case of the chair, you will fall asleep again in a short while, because in fact you have not slept “enough.”) In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy, or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening (*Pam:I found that I would have vivid visual and dreamlike hallucinations at any time of the day, whether I felt sleepy or not – all this is in past tense because of Xyrem. See below); and brief episodes of total paralysis at the beginning or end of sleep. Narcolepsy is not definitively diagnosed in most patients until 10 to 15 years after the first symptoms appear. The cause of narcolepsy remains unknown. It is likely that narcolepsy involves multiple factors interacting to cause neurological dysfunction and sleep disturbances.

Is there any treatment?

There is no cure for narcolepsy. In 1999, after successful clinical trial results, the FDA approved a drug called modafinil for the treatment of EDS. (*Pam: Provigil seems to be more effective for normal people than for most of the people I know with narcolepsy. Though one of them is happy with it, Another takes a whole cocktail of stimulants just to get through the day...I myself still take the old stand-by of methylphenidate.) Two classes of antidepressant drugs have proved effective in controlling cataplexy in many patients: tricyclics (including imipramine, desipramine, clomipramine, and protriptyline) and selective serotonin reuptake inhibitors (including fluoxetine and sertraline). Drug therapy should be supplemented by behavioral strategies. For example, many people with narcolepsy take short, regularly scheduled naps at times when they tend to feel sleepiest. Improving the quality of nighttime sleep can combat EDS and help relieve persistent feelings of fatigue. Among the most important common-sense measures people with narcolepsy can take to enhance sleep quality are actions such as maintaining a regular sleep schedule, and avoiding alcohol and caffeine-containing beverages before bedtime.

On July 17, 2002, the FDA approved Xyrem (sodium oxybate or gamma hydroxybutyrate, also known as GHB) for treating people with narcolepsy who experience episodes of cataplexy. (*Pam:This has been the single most effective anti-narcolepsy drug I’ve taken. I have halved my Ritalin intake and often take less than that. I no longer have REM episodes while I am awake, that is, visual hallucinations that are really dream states intruding into waking hours. I don’t need to take 3-4 unwanted naps a day, usually if I take the methylphenidate on time I can make it through the day without them, though I do regularly get sleepy... But all in all, it has improved my life immeasurably.) Due to safety concerns associated with the use of this drug, the distribution of Xyrem is tightly restricted.

What is the prognosis?

None of the currently available medications enables people with narcolepsy to consistently maintain a fully normal state of alertness. But EDS and cataplexy, the most disabling symptoms of the disorder, can be controlled in most patients with drug treatment. Often the treatment regimen is modified as symptoms change. Whatever the age of onset, patients find that the symptoms tend to get worse over the two to three decades after the first symptoms appear. Many older patients find that some daytime symptoms decrease in severity after age 60.

Now here is what said about “narcolepsy in depth”, since it adds to the info from NINDS:

Narcolepsy in Depth

Narcolepsy is a disabling disorder of sleep regulation that affects the control of sleep and wakefulness. It may be described as an intrusion of the dream sleep (called REM or rapid eye movement) into the waking state. Symptoms generally begin between the ages of 15 and 30. The four classic symptoms of the disorder are excessive daytime sleepiness; cataplexy (sudden, brief episodes of muscle weakness or paralysis brought on by strong emotions such as laughter, anger, surprise or anticipation); sleep paralysis (paralysis upon falling asleep or waking up); and hypnagogic hallucinations (vivid dreamlike images that occur at sleep onset). Disturbed nighttime sleep, including tossing and turning in bed, leg jerks, nightmares, and frequent awakenings, may also occur. The development, number and severity of symptoms vary widely among individuals with the disorder. There appears to be an important genetic component to the disorder as well.
Excessive sleepiness is usually the first symptom of narcolepsy. Patients with the disorder experience irresistible sleep attacks, throughout the day, which can last for 30 seconds to more than 30 minutes, regardless of the amount or quality of prior nighttime sleep. These attacks result in episodes of sleep at work and social events, while eating, talking and driving, and in other similarly inappropriate occasions. Although narcolepsy is not a rare disorder, it is often misdiagnosed or diagnosed only years after symptoms first appear. Early diagnosis and treatment, however, are important to the physical and mental well-being of the affected individual.

TREATMENT: There is no cure for narcolepsy; however, the symptoms can be controlled with behavioral and medical therapy. The excessive daytime sleepiness may be treated with stimulant drugs, while cataplexy and other REM-sleep symptoms may be treated with antidepressant medications. At best, medications will reduce the symptoms, but will not alleviate them entirely. Also, some medications may have side effects. Basic lifestyle adjustments such as keeping a good sleep schedule, improving diet, increasing exercise and avoiding "exciting" situations may also help to reduce the effects of excessive daytime sleepiness and cataplexy.

PROGNOSIS: Although narcolepsy is a life-long condition, most individuals with the disorder enjoy a near-normal lifestyle with adequate medication and support from teachers, employers, and families. If not properly diagnosed and treated, narcolepsy may have a devastating impact on the life of the affected individual, causing social, psychological, and financial difficulties.

Other Sleep Disorders

A Night Terror, also known as pavor nocturnus, is a parasomnia sleep disorder characterized by extreme terror and a temporary inability to regain full consciousness. The subject wakes abruptly from slow-wave sleep, usually in the first third of the night, with waking usually accompanied by gasping, moaning, or screaming. It is often impossible to fully awaken the person, and after the episode he or she normally settles back to sleep without waking. In the morning, the person usually will not recall the experience. Night terrors typically occur during non-rapid eye movement sleep.

Night terrors are not dreams. The lack of a dream itself leaves those awakened from a night terror in a state of disorientation much more severe than that caused by a normal nightmare. This can include a short period of amnesia during which the subjects may be unable to recall their names, locations, ages, or any other identifying features of themselves.
Night terrors can occur rarely or as often as every night, and may be associated with physical injury to the patient in the most severe cases. If you are concerned, consult a sleep specialist,

Finally, Sleepwalking.

Sleepwalking, or somnambulism, is by definition when a person carries out normal waking activities during sleep. It usually occurs earlier in the night than REM or dreaming sleep and is not in fact associated with a dream, contrary to popular belief. In fact, while it occurs most commonly with slow wave sleep it can happen in any stage of non-REM sleep. Because children and young adults spend far more time, up to 25%, in SWS than older adults, it may account for why sleepwalking is more common in the young than as we age. About 18% of the population are prone to sleepwalking, with it more prevalent in boys than girls and the highest incidence at age 11-12.

Sleepwalkers do not remember their somnambulistic behaviors and so most episodes are forgotten unless recorded by an onlooker or sleep lab.

A large range of behaviors may be indulged in during somnambulism, from standing up and walking to murder (the last has always been controversial) but some people will eat while they are asleep and wake in the morning only to find empty food containers and no memory of having eaten. Others may injure themselves because they trip and fall while walking through a darkened bedroom. Both hypnosis and medications have proved helpful.

Posted by pamwagg at February 18, 2008 09:11 PM | TrackBack


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