What is the cause?

Hypersomnia. The most common cause of sleepiness is not getting enough sleep. It is now known that even small reductions in sleep can cause reduced performance. This can be in the classroom, at work, or behind the wheel.

Obstructive Sleep Apnea. Obstructive sleep apnea occurs when the upper airway is closed off as your tongue and throat muscles relax during sleep. As breathing is blocked, the brain senses it is not getting enough oxygen and wakes you up. Because sleep is frequently interrupted, you feel very sleepy during the day. Obstructive sleep apnea often occurs in people who are loud snorers. Alcohol and sleeping pills can also increase the number and length of breathing pauses.

Narcolepsy. Narcolepsy happens more often in families with a history of excessive sleepiness. This genetic link is not fully understood. It appears genetics combine with an unknown environmental factor to cause narcolepsy.

Idiopathic Central Nervous System Hypersomnia. “Idiopathic” means the cause is not known.

Insomnia. Insomnia can be due to many conditions, including medical, psychiatric, or psychological. Insomnia has been linked to anxiety and/or depression, and there is growing proof that insomnia may cause psychiatric problems. Because insomnia has such an effect on mood and performance, it’s important to get treatment.

One of the most common causes of insomnia is “restless legs syndrome” (RLS). People with RLS experience an uncomfortable sensation and an irresistible urge to move their legs as they begin to fall asleep. RLS is a neurological movement disorder. Because it may cause insomnia, it is sometimes mistaken for a sleep disorder.

RLS is common in both men and women, and affects 5 to 10 percent of the population. It may begin in childhood, but is more common in adults. It sometimes runs in families. Hormones appear to be a factor for women, as RLS sometimes occurs more often during menstruation, pregnancy, or menopause. Up to 27 percent of pregnant women may experience RLS.

RLS has been linked to iron deficiency anemia and other neurological disorders. It affects 20 to 40 percent of patients on dialysis due to chronic kidney failure. There is no evidence that RLS is related to any mental problems.

Circadian Rhythm Disturbances. The sleep/wake schedule disorders fall into two categories:

· Primary: “malfunction” of your biologic clock (needing to go to sleep earlier than you usually do, sleeping longer than you usually do, or having to take naps when you normally do not need to take naps)

· Secondary: due to external changes imposed on your biologic clock (shift work and jet lag)

What are the symptoms? Symptoms vary by sleep disorder. Most sleep disorders include one or more of the following symptoms:

· Inability to fall asleep at night

· Inability to stay asleep at night

· Excessive daytime sleepiness

· Fatigue

· Loud snoring or gasping sounds when you sleep (sleep apnea)

· “Sleep attacks, ” loss of muscle control or inability to move (narcolepsy)

Unusual behaviors arising from sleep (Parasomnias). Parasomnias are unpleasant or undesirable behaviors or experiences that happen mostly or only during sleep. Most are not signs of mental health disorders. Although there are many different parasomnias, two are most common:

Disorders of arousal. Disorders of arousal occur when one appears to be partially asleep and partially awake. Sleepwalking and sleep terrors are two disorders of arousal that are common in children.

But they are common in adults as well. Sometimes they are mistaken for mental health disorders. If the behaviors are violent or harmful, treatment with drugs or hypnotherapy (practicing self-hypnosis before sleep) often helps.

REM sleep behavior disorder (RBD). People with RBD appear to be acting out their dreams. RBD occurs mainly in older males who do not experience the normal relaxation of muscles during REM sleep. Instead, they move about in bed, mirroring the movement in their life-like dreams. Because people with RBD can accidentally hurt themselves or their bed partners, medical help is often needed to manage the disorder.

RBD is diagnosed through an overnight sleep study. It is easily managed with the drug, clonazepam, which is taken before bedtime.

How is it diagnosed? Sleep medicine is a well-recognized field. Sleep specialists can diagnose and help you manage your sleep disorder. Evaluation starts with a visit to the sleep doctor’s clinic. It takes about an hour. The staff will ask you about your sleep problems and do a physical exam.

Other tests may be necessary to understand your sleep problem. This may include blood tests or an overnight sleep study. Sometimes a test for daytime sleepiness is done.

If you need to visit a sleep center, you can expect a physical exam and some diagnostic tests. You will be asked for a detailed history of your sleep/wake function. The doctor may also ask for information from your bed partner, other family members, co-workers, or caregivers. This will help understand your sleep behaviors. You or an observer may fill out a sleep/wake diary to record sleep/wake patterns not seen during the exam.

What is an overnight sleep study? An overnight sleep study evaluates the quality of your sleep by observing body functions as you sleep. These include heart rate, electrocardiogram, breathing, snoring, brain activity, eye movements, body movements, and oxygen level. Tests may involve applying sensors to your body that are easily removed the next morning. You may also be video taped so your doctor can see your sleep problem firsthand.

Overnight sleep tests can include:

Polysomnography (PSG). In PSG, simple electrodes are placed on your body to record brain activity, breathing, heart activity, muscle activity, eye movements, and body movements. An audio-video recording of the sleep is also done. PSG will determine if there are:

· Disruptions of normal brain wave activity during sleep

· Heart or breathing abnormalities

· Sleep-related movements

· Other sleep-related disorders

Multiple Sleep Latency Test (MSLT). The MSLT measures daytime sleepiness. It helps to understand different complaints of “sleepiness, ” “tiredness, ” and “fatigue.” It is designed to:

· Measure how quickly you fall asleep when you nap during the day

· Identify unusual REM sleep during a nap

This test is usually done the day after you have a PSG. The test measures the same factors as the PSG and compares daytime and night time results. Sleep is observed during four or five 20-minute naps over a two hour period.

Actigraphy. Some people have a hard time keeping an accurate sleep diary. In such cases, actigraphy may provide more reliable information on activity while you are awake and asleep.

An actigraph is a small device worn on the wrist. It records body activity and the time of day. It is usually worn for a week or two. Then the information is transferred to a computer. Many cases of severe insomnia require an actigraph for diagnosis and treatment.

Hypersomnia. Hypersomnia is diagnosed by taking a complete history. Voluntary sleep deprivation is the most common cause of hypersomnia. If the cause is not clear, then additional tests may be performed. This could include all-night sleep monitoring, a series of nap studies the next day, or blood tests.

Obstructive Sleep Apnea. Obstructive disorders are usually diagnosed through a sleep study.

Narcolepsy. Narcolepsy is diagnosed during an all-night sleep study followed by nap studies the next day. In the future, tests of fluid in the brain and spinal cord may be useful.

Idiopathic Central Nervous System Hypersomnia. Idiopathic Central Nervous System Hypersomnia is diagnosed with a sleep study.

Insomnia. Most cases of insomnia can be easily diagnosed and managed by your primary care doctor.

RLS. RLS is diagnosed in a sleep specialist’s office. Formal sleep studies are rarely needed. Blood tests may be done to look for mild degrees of anemia.

Circadian Rhythm Disturbances. The primary circadian rhythm disorders may be more difficult to diagnose because they are often similar to other disorders such as hypersomnia, insomnia, drug abuse, or mental health conditions. For example, the delayed sleep phase syndrome (people who go to sleep later than usual) is often similar to sleep onset insomnia or difficulty falling asleep. You try to go to sleep before your biological clock permits, and you lie in bed unable to sleep until your body clock says sleep.

Secondary disorders, arising from problems such as jet lag and shift work, are usually diagnosed from information about your work and travel routines.

What are the treatments? Once the tests are done, your sleep doctor will discuss these results with you and make a treatment plan. Most sleep problems are treatable. Select a specific disorder from the list below to find a treatment option.

Hypersomnia. Treatment depends on the cause. If you are sleep deprived, getting enough sleep is vital. So good sleep habits are important. Stimulant or wake-promoting medications such as mazindol, methylphenidate, methamphetamine, exedrine, or modafinil are treatments.

Obstructive Sleep Apnea. If you have sleep apnea, you have several medical and surgical treatment options. The preferred treatment is nasal continuous positive airway pressure. A small, toaster-size machine sits next to your bed. It delivers air under pressure through a mask. Wearing this mask over your nose keeps your airway open during sleep.

Several types of surgery are available, including:

· Tracheostomy: an opening is cut in the trachea and a tube is place in the opening. The patient breathes through the tube. This is an effective but extreme option

· Uvulopalatopharyngoplasty: a surgical procedure that removes the uvula and part of the palate to make the airway bigger

Another option is the use of oral/dental devices. They are similar to a small mouth guard athletes use while playing. They may work in mild cases.

Weight loss may help. However, the long-term success of weight reduction programs for any condition is very poor. And weight is only one factor in patients with sleep apnea.

Narcolepsy. There are many treatment choices. The hypersomnia in people with narcolepsy responds well to stimulant drugs. These include modafinil, methylphenidate, dextroamphetamine, or methamphetamine.

The symptoms of cataplexy, sleep paralysis, and hypnologic hallucinations respond to a group of medicines called tricyclic antidepressants or serotonin-specific reuptake inhibitors (fluoxetine or venlafaxine). Scheduled short naps can also be helpful for many people.

Idiopathic Central Nervous System Hypersomnia. This disorder is treated with stimulant drugs.

Insomnia. First, it’s necessary to identify and treat any medical or mental health conditions. Then, a combination of behavior changes and drug therapy is often successful. Sleep medication and hypnosis can relieve short-term insomnia. They may also prevent constant insomnia.

Effective medications include the benzodiazepines, as well as zolpidem and zaleplon. Beware that many drugs commonly given for insomnia (diphenhydramine, tricyclic antidepressants, or trazodone) are much less effective. The risk of drug tolerance, dependence, and abuse with these medications appears to have been greatly exaggerated.

Recently, melatonin has been touted as a “cure-all” for insomnia (as well as jet lag and shift work). More studies are needed.

RLS. Three classes of medications are used to treat RLS:

· Drugs that act on the brain neurotransmitter called dopamine, such as levodopa/carbidopa, bromocriptine, pergolide, pramipexole, and ropinirole

· Benzodiazepines such as clonazepam

· A wide variety of opiates including codeine, propoxyphene, oxycodone, and methadone

Circadian Rhythm Disturbances. Successful treatments are available for these disorders. They include:

· Chronotherapy (resetting the biological clock)

· Sedative/hypnotic drugs

· Phototherapy (bright light exposure at particular times of the day)

· Melatonin

Living with sleep disorders. Most sleep disorders are either treatable or preventable. There is no need to suffer and lose even more sleep over these disorders.

Prevention. Many sleep disorders cannot be prevented but may be linked to other preventable health conditions.

Overall good sleep practices. Good sleep practices may help you improve your sleep in general. They may also help with some sleep disorders. Try to:

· Sleep only when drowsy.

· Sleep only in the bedroom. Use the bedroom for sleeping only.

· Avoid napping.

· Avoid caffeine, drinking, and smoking.

· Avoid a large meal before bed.

· Exercise on a regular basis, but avoid strenuous exercise within six hours of bedtime.

· Make your bedroom comfortable with low light and noise levels.

· Consider relaxation techniques to reduce stress levels.