Sleep disorders: everything you need to know

Contents:

• What is sleep and why is it important?
• What are sleep disorders?
• Causes and risk factor
• Types and symptoms
• Treatment
• What should I do if I have symptoms?
• Life with diagnosis and self-help
• Guide for loved ones: what should I do if someone close to me has a sleep disorder?

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What is sleep and why is it important?

Sleep is a natural, universal and essential process. It is the period during the day when the brain enters a reversible state of loss of consciousness, responding mainly only to signals from within the body [1, 2]. Sleep itself is of two types – REM and non-REM sleep. During REM (Rapid Eye Movement) sleep, neuronal connections involved in learning, memorization and memory storage are strengthened; during non-REM sleep, tissue repair and regeneration, strengthening of bones and muscles, and strengthening of the immune system take place [3].When sleep is insufficient (generally less than 7 hours, with individual differences) or the quality of sleep is impaired, serious consequences for both physical and mental health can occur [4]. Lack of restful sleep makes it difficult to complete daily activities, due to a reduced ability to concentrate and alertness in decisions or actions. In addition, sleep difficulties have been associated with an increase in the frequency of depressive states [5], anxiety [6], aggression and the development of various behavioral problems [7].

What are sleep disorders?

Sleep disorders are a group of conditions that manifest themselves by altering the duration or quality of sleep, with a major impact on physical and mental health and quality of life, both in the short term and especially in the long term. Although about 35% of the population experience at least one episode of a sleep disorder during their lifetime, most sleep disorders are not diagnosed until they seriously impair the body’s functioning [8].

The immediate consequences of sleep disturbances are decreased ability to concentrate, increased stress, absenteeism (from school, work or other important activities), decreased productivity, and an increase in the frequency of accidents of all kinds [9].

In the long term, there is an important link between the quality of sleep and maintaining normal body functions. Insufficient or poor-quality sleep can lead to diseases such as angina pectoris (chest pain), acute myocardial infarction (blockage of the vessels that feed the heart tissue), hypertension, obesity and type 2 diabetes mellitus [10]. The impact is not only somatic (physical), but also psychological – people suffering from sleep disturbances may experience emotional lability, which can lead to or increase various mental disorders. It is important to know the main sleep disorders and their most common symptoms, the consequences of which can be prevented by correct diagnosis and early medication and/or psychotherapeutic treatment [11].

Causes and risk factor

Sleep disorders have multiple causes, both psychological and somatic. The main cause of insomnia is psychological and social stress, caused by worries about family, work, school or financial problems. Traumatic events can also have a major impact. The environment (a room that is too bright or noisy) or working hours can be predisposing factors for insomnia – for example, people working night shifts are at high risk of developing sleep disturbances because of an imbalance in the secretion of hormones involved in maintaining the usual sleep-wake alternation. Also, the use of psychoactive substances (such as coffee or alcohol), especially in the second half of the day, or even adverse reactions to certain medications can contribute to the development of sleep disturbances [8].

Somatic dysfunctions that can cause sleep disturbances include obstructive respiratory diseases (airway blockage), obesity, cardiovascular or neurological disorders, and within psychiatric disorders, anxiety and depression are most commonly associated with insufficient or poor sleep [9].

Another common cause nowadays is the use of technology, such as the TV, phone or computer, in the evening or at night, which leads to bedtime procrastination when other activities are prioritized over sleep [12, 13]. Adults aged 18 to 24 are the most active online, and are also the most likely to postpone sleep in exchange for extra hours spent on these devices [14, 15]. Young people may also postpone sleep because of social pressure to be online during the night, to keep up with information posted on social networks and to be connected to discussions in groups of friends [16, 17].

Types and symptoms

The most common sleep disorders in the population are:

1. Insomnia

Insomnia is by far the most common sleep disorder. It is characterized by a reduction in the total amount of sleep in a day compared to a person’s usual need [18]. There are two types of insomnia – falling asleep (people have difficulty falling asleep) and staying asleep (people have difficulty staying asleep and tend to wake up during the night), and they can occur together. The disorder is characterized by episodes of reduced sleep duration of 3-4 episodes per week for at least one month, with associated effects of reduced overall quality of sleep and difficulty with daytime activities due to accumulated fatigue. Insomnia may occur in isolated episodes (about 80% of the population) or as chronic insomnia (15% of the population). Most of the causes presented in the previous section are causes of insomnia. There is also idiopathic insomnia without an identifiable cause [19, 20].

2. Obstructive sleep apnea syndrome (OSA)

This syndrome is characterized by periods of breathlessness (apnea) followed by microwaking (waking from sleep lasting a few seconds, which is not perceived by the person) due to airway blockage during sleep. This syndrome mainly affects men and people suffering from obesity, who account for 70% of diagnosed patients. During episodes of apnea, a state of hypoxia (decreased oxygen concentration in the blood) occurs due to obstruction of the respiratory tract, resulting in poor quality sleep and, consequently, permanent exhaustion during the day. In the absence of appropriate treatment, symptoms do not remit [21]. Snoring is usually noticed by a partner or roommate and is the inconvenience for which patients most often present for consultation. At night, decreased breathing movements, dry mouth and excessive sweating may also be noted [22]. In addition to daytime hypersomnolence, the disorder may also present with personality changes, automatic behavior or amnesia [23].

3. Narcolepsy-cataplexy syndrome

Narcolepsy is a sleep disorder with onset in young people between the ages of 10 and 30. It manifests as an irresistible urge to fall asleep, so-called sleep attacks, lasting from a few seconds to several minutes. They can occur even during activities that require concentration, such as talking, running, eating or driving. Their frequency varies from daily attacks to one attack every few months. Narcolepsy may or may not be accompanied by cataplexy (loss of muscle tone), this combination of symptoms representing the Gélineau narcolepsy-cataplexy syndrome [18, 24, 25, 26, 27].

However, sleep attacks are perceived as restful. They persist throughout life, although with age their frequency decreases. Other symptoms that may alarm the patient are sleep paralysis, hypnagogic hallucinations (during the transition from wakefulness to sleep), and automatic behavior, in which the person performs tasks without remembering [25, 27].

4. Idiopathic hypersomnia

This is a disorder similar to the narcolepsy-cataplexy syndrome. The main difference is the lack of cataplexy (loss of muscle tone), and sleep is perceived as insufficient and of poor quality. The main manifestation is daytime (hyper)sleepiness, accompanied by some degree of amnesia [28].

5. Daytime sleepiness

With a prevalence of 5-15% in the population, daytime sleepiness is actually a symptom of several possible sleep disorders. The causes may be the disorders described above, such as obstructive sleep apnea syndrome, narcolepsy, idiopathic hypersomnia, but also other pathologies such as depression, Pickwick’s syndrome (daytime sleepiness associated with obesity and heart failure) or Kleine-Levin syndrome (hypersomnia associated with bulimia, irritability and hypersexuality) [18, 20].

6. Parasomnias

They are sleep-phase-dependent sleep disorders (REM or non-REM), the most common of which are sleepwalking, night terrors and repeated nightmares [29].

1. Somnambulism is a parasomnia with a genetic component, occurring most commonly in children aged 5-12 years, rarely beginning in adulthood. Episodes last less than 10 minutes and are manifested by automatic nocturnal ambulatory behavior – the person gets out of bed, moves around the house and does various activities – followed by amnesia of the episode. Factors that may precipitate the disorder include fatigue, sleep deprivation, and sedative-hypnotic (sleep-inducing) drugs [18, 30, 35].
2. Night terrors is most common in children aged 5-7 years old and is characterized by extreme agitation, screaming and terror. Patients are generally confused and terrified, and in severe cases, with recurrent episodes, physical injuries may occur. The frequency decreases with increasing age – in children it is about 3% and in adulthood 1% [27, 29].
3. Nightmares are terrifying dreams, accompanied by sudden awakening, sometimes even by palpitations (the sensation of a rapid, skipping or extra beating of the heart) and tachypnea (increased respiratory rate) [31]. They occur mainly in the second half of the night, generally during REM sleep, and are considered normal phenomena, occurring in about 50% of children, and are correlated with immaturity of the neural circuitry of the brain [29]. With increasing age, their frequency in the population decreases [30]. They occur as a common symptom in post-traumatic stress disorder or severe anxiety. Nightmares become pathologic when they occur with high frequency, their presence during the night disrupting the performance of daily activities, or exacerbating states such as anxiety and depression. [34]

Treatment

Sleep disorders are mainly diagnosed and treated by a psychiatrist. He or she assesses the causative and risk factors, determines the type of disorder and prescribes and monitors its treatment. Treatment is of several types – medication or psychological. Drug treatment is usually combined with non-pharmacological methods, such as cognitive therapies and sleep hygiene, to address both symptoms and causes [34]. If the sleep disturbance has an organic cause (e.g. a neurological or respiratory dysfunction), treatment of the underlying disease is the first attempt. If the causative factors are not organic, a psychological approach is initially preferred [35].

1. Insomnia

Drug treatment consists mainly of sedative-hypnotic drugs. The most commonly used drugs in this category are benzodiazepines (e.g., Xanax – alprazolam, Anxiar – lorazepam, etc.). However, their widespread use has declined because they can be addictive. Abrupt discontinuation of benzodiazepines leads to withdrawal syndrome, characterized by insomnia and anxiety and, in severe cases, seizures [36, 37].

Other drugs used in insomnia are antihistamines, especially first-generation antihistamines with a sedative effect [37].

Recently, benzodiazepine-like sedative drugs called “Z-drugs” have also appeared on the market, such as zolpidem (Ambien) and zaleplon (Sonata). The advantage compared with benzodiazepines is the much reduced side-effects; however, if administered incorrectly, they may also increase the risk of addiction [38].

2. Obstructive sleep apnea syndrome

OSA is mainly diagnosed and treated by your lung specialist. The main treatment is the administration of oxygen using a continuous positive airway pressure (CPAP) machine, which keeps the airways open throughout the night. Another important aspect of treatment is weight loss in overweight people, as excess fat around the face and neck is a cause of obstructed breathing at night. If these treatments are unsuccessful, there is the possibility of removing the causes of the obstruction by an ENT (ear, nose and throat) surgeon [20].

3. Narcolepsy-cataplexy syndrome

The treatment for this syndrome is medication, with several options. One of the main options is sodium oxybate (sold as Xyrem). It can only be prescribed by a doctor, because of the risk of dependence, as well as the risk of respiratory depression (decreased respiratory rate, which can degenerate into respiratory arrest). It reduces fragmented sleep at night, but the mechanism of action is not yet fully elucidated [39]. Other drugs used in the treatment of narcolepsy include modafinil (Aspendos), pitolisantum (Wakix) or, more recently, solriamfetol (Sunosi).

4. Idiopathic hypersomnia

Treatment of idiopathic hypersomnia is similar to narcolepsy, using stimulants such as modafinil or amphetamines.

5. Daytime sleepiness associated with depression

In depression-associated daytime sleepiness, the first-line treatment is selective serotonin reuptake inhibitor (SSRI) antidepressants, which increase the availability and time of action of serotonin at the neuronal synapse. However, their adverse effects include (paradoxically) insomnia, anxiety and nightmares [37].

6. Parasomnias

These types of sleep disorders are most commonly treated with cognitive-behavioral psychotherapy or hypnosis, although medication can be used as an adjunct to psychological treatment [27, 40].

What should I do if I have symptoms?

If you are experiencing symptoms of a sleep disorder, the first step would be to see your GP. He or she will ask you about your symptoms and their possible causes, and then refer you to a specialist. If the sleep disorder is mainly psychological, the specialist is a psychiatrist. He or she will give you a treatment plan and/or refer you to a psychologist for some form of therapy. You can access free psychotherapy sessions if you have health insurance and a referral from the specialist.

An important element in getting quality sleep is good sleep hygiene. Even if you suffer from a somatic pathology that alters your sleep, following certain minimum rules before going to bed can improve the quality of your sleep [32].

1. Quality sleep is achieved by creating a routine. Try to have the same bedtime every night so as not to disturb the hormonal secretions involved in the sleep-wake alternation, for example the secretion of melatonin (a hormone involved in the transition from wakefulness to sleep) [41]. The period when melatonin is secreted at its peak is between 00:00 and 03:00 [42, 43]. Including this time in your rest routine can ensure good quality sleep.

2. The room you sleep in should be airy, with a suitable room temperature, and as little or no light as possible, as melatonin secretion is dependent on the amount of light exposure [41]. Avoid exposure to screens or other forms of artificial light as well as stimulants (coffee, chocolate, alcohol) 1-2 hours before bedtime [46].

If you work night shifts, exposure to artificial light during the night will decrease your normal melatonin secretion, your circadian rhythm will be disrupted, and sleep quality will be poorer [44]. Minimizing exposure to bright natural light after your work shift (e.g. by wearing sunglasses towards home) and taking melatonin supplements can help you get a balanced and more restful sleep despite your night-time schedule [45].

3. Practice relaxing activities before sleep, such as reading, meditation or breathing exercises, to clear your mind of intrusive thoughts that may be disturbing you [41]. One of the best breathing techniques for insomnia or anxiety is the 4-7-8 method, where you breathe in for 4 seconds, hold your breath for 7 seconds, and exhale quietly for 8 seconds [47].

4. You can keep a record of how many hours you slept or how restful your sleep was in a diary. This makes it easier to notice certain patterns, which you can correct or address later in therapy [48].

5. It is also important not to force yourself to fall asleep. By concentrating too much on the goal of falling asleep, a stress factor is unconsciously created that can jeopardize your intention, duration and quality of sleep [46].

Life with diagnosis and self-help

Although sleep disturbances can become a ‘regular’ part of your life, they can be kept under control and even treated. Below are some tips to help you navigate a sleep disorder diagnosis:

• Try to monitor the frequency with which symptoms occur and the correlation between their occurrence and stressful events in your life [49].
• It is important that when you receive a consultation, your communication with the specialist is governed by honesty and accuracy.
• Trust psychotherapy. Once you can find the hidden causes of your problem, you can replace the behaviors that got you to this point with behaviors that promote healthy sleep.
• If medication is available, follow it as prescribed by your doctor to avoid side effects with a negative impact on your mind and body.
• Communicate the problem to your loved ones to make sure they know what you’re dealing with and can support you in sensitive situations.
• Monitor your progress – it will improve your mood [50].
• Try to adhere to a healthy lifestyle with set bedtimes, exercise and sufficient but balanced meals.
• DO NOT turn to self-medication, alcohol or drugs, as these coping mechanisms only make the underlying problem worse.
• DO NOT consume ALCOHOL in combination with sedative drug therapy – this combination can have serious (even lethal) effects on your health [51].

Guide for loved ones: what should I do if someone close to me has a sleep disorder?

When a loved one suffers from sleep disturbances, the most striking effect is a change in mood. If someone close to you is experiencing such changes, be patient, ask in advance if they are willing to communicate with you about the cause of the problem, and offer support and transparent communication. Suggest that they seek specialized help and create a beneficial routine and a pleasant environment in which to rest. Last but not least, look after your own mental health so that you can continue to offer support.

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