Insomnia, Circadian Rhythm Disorder, Restless Legs Syndrome, Narcolepsy, and Problem Sleepiness
Other Sleep Disorders
Insomnia is the perception or complaint of inadequate or poor-quality sleep. Often those that suffer from insomnia report the following symptoms.
- Difficulty falling asleep
- Frequent waking during the night
- Earlier than normal waking times
Typical conditions seem to make individuals more likely to experience insomnia:
- Advanced age (insomnia occurs more frequently in those over age 60)
- Female gender
- A history of depression
- Stress, anxiety
- The use of certain medications
What Causes Insomnia?
Insomnia can be classified into three categories; transient (short term), intermittent (on and off), and chronic (constant). Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia is considered to be chronic if it occurs on most nights and lasts a month or more. There are many causes of insomnia. Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:
- Environmental noise
- Extreme temperatures
- Change in the surrounding environment
- Sleep/wake schedule problems such as those due to jet lag
- Medication side effects
Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders. A person with chronic insomnia should seek a medical evaluation by their physician, and may require the consultation of a specialist. Insomnia is a SYMPTOM of many disorders and not a disorder in itself.
How Is Insomnia Diagnosed?
Patients with insomnia are evaluated with the help of a medical history and a sleep history. Sleep history may be obtained from a detailed sleep journal written by the patient themselves or through an interview with the patient’s bed partner concerning the quantity and quality of the patient’s sleep. Specialized sleep studies may be recommended, but only if there is suspicion that the patient may have a primary sleep disorder such as sleep apnea (OSA) or narcolepsy.
How Is Insomnia Treated?
Transient and intermittent insomnia may not require treatment since episodes last only a few days at a time. Treatment for chronic insomnia consists of:
- Diagnosing and treating underlying medical or psychological problems
- Identifying behaviors that may aggravate insomnia
- Possibly using sleeping pills
A patient taking any sleeping medications should be under the supervision of a physician to closely evaluate effectiveness and minimize side effects. In general, these drugs are prescribed at the lowest dose and for the shortest duration needed to relieve the sleep-related symptoms. For some of these medicines, the dose must be gradually lowered as the medicine is discontinued because, if stopped abruptly, it can cause insomnia to occur again for a night or two. Behavior modifying techniques such as Cognitive Behavioral Therapy (CBT) instead of medications to improve sleep, and relaxation therapy, sleep restriction therapy, and reconditioning are methods recommended to combat insomnia episode. Relaxation Therapy. Using specific and effective techniques that can reduce or eliminate anxiety and body tension, the result is the mind is able to stop “racing,” muscles can relax, and restful sleep can occur. It usually takes consistent practice to learn these techniques and to achieve effective relaxation. Sleep Restriction. Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. They may benefit from a sleep restriction program that at first allows only a few hours of sleep during the night. Gradually the time is increased until a more normal night’s sleep is achieved. Reconditioning. Another treatment that may help some people with insomnia is to recondition them to associate the bed and bedtime with sleep. For most people, this means not using their beds for any activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy. If unable to fall asleep, the person is told to get up, stay up until sleepy, and then return to bed. Throughout this process, the person should avoid naps and wake up and go to bed at the same time each day. Eventually the person’s body will be conditioned to associate the bed and bedtime with sleep.
Where To Get More Information
- Talk to your doctor if you are having trouble getting good, refreshing sleep each night. Together you can identify possible reasons for your sleeping difficulty and then try appropriate measure to correct the problem.
- Obtain a referral from your family physician to have sleep testing done
- Check out our Resources page for more informative books and websites
Restless Legs Syndrome
Restless legs syndrome (RLS) is a sleep disorder in which a person experiences unpleasant sensations in the legs described as creeping, crawling, tingling, pulling, or generalized pain. These sensations usually occur in the calf area but may be felt anywhere from the thigh to the ankle. One or both legs may be affected; for some people, the sensations are also felt in the arms. These sensations occur when the person with RLS lies down or sits for prolonged periods of time, such as at a desk, riding in a car, or watching a movie. People with RLS describe an irresistible urge to move the legs when the sensations occur. Usually, moving the legs, walking, rubbing or massaging the legs, or doing knee bends can bring relief, at least briefly. RLS symptoms worsen during periods of relaxation and decreased activity. RLS symptoms also tend to follow a set daily cycle, with the evening and night hours being more troublesome for RLS sufferers than the morning hours. People with RLS may find it difficult to relax and fall asleep because of their strong urge to move, walk or do other activities to relieve the sensations in their legs. Persons with RLS often sleep best toward the end of the night or during the morning hours. Because of less sleep at night, people with RLS may feel sleepy during the day on an occasional or regular basis. The severity of symptoms varies from night to night and over the years as well. For some individuals, there may be periods when RLS does not cause problems, but the symptoms usually return. Other people may experience severe symptoms daily. Many people with RLS also have a related sleep disorder called periodic limb movements in sleep (PLMS). Involuntary jerking and bending leg movements during sleep that typically occur every 10 to 60 seconds characterizes PLMS. Some people may experience hundreds of such movements per night, which can wake them and their sleeping partners, disturbing their sleep. People who have RLS and PLMS have trouble both falling asleep and staying asleep and may experience extreme sleepiness during the day. As a result of problems both in sleeping and while awake, people with RLS may have difficulties with their job, social life, and recreational activities.
- Unpleasant sensations in the legs (sometimes the arms as well), often described as creeping, crawling, tingling, pulling, or painful
Walking, stretching, knee bends, massage, or hot or cold baths relieves leg sensations
Leg discomfort occurs when lying down or sitting for prolonged periods of time
The symptoms are worse in the evening and during the night
Involuntary leg (and occasionally arm) movements while asleep
Difficulty falling asleep or staying asleep
Sleepiness or fatigue during the daytime
Cause of the leg discomfort not detected by medical tests
Family members with similar symptoms
What Causes It?
Although the cause is unknown in most cases, certain factors may be associated with RLS:
- Family history. RLS is known to run in some families–parents may pass the condition on to their children
- Pregnancy. Some women experience RLS during pregnancy, especially in the last months. The symptoms usually disappear after delivery
- Low iron levels or anemia. Persons with these conditions may be prone to developing RLS. The symptoms may improve once the iron level or anemia is corrected
- Chronic diseases. Kidney failure quite often leads to RLS. Other chronic diseases such as diabetes, rheumatoid arthritis, and peripheral neuropathy may also be associated with RLS
- Caffeine intake. Decreasing caffeine consumption may improve symptoms
Who Gets RLS?
RLS occurs in both sexes. Symptoms can begin any time, but are usually more common and more severe among older people. Young people who experience symptoms of RLS are sometimes thought to have “growing pains” or may be considered “hyperactive” because they cannot easily sit still in school.
How Is It Diagnosed?
There is no laboratory test that can make a diagnosis of RLS and, when someone with RLS goes to see a doctor, there is usually nothing abnormal the doctor can see or detect on examination. Diagnosis therefore depends on what a person describes to the doctor. The history usually includes a description of the typical leg sensations that lead to an urge to move the legs or walk. These sensations are noted to worsen when the legs are at rest, for example, when sitting or lying down and during the evening and night. The person with RLS may complain about trouble sleeping or daytime sleepiness. In some cases, the bed partner will complain about the person’s leg movements and jerking during the night.
To help make a diagnosis, the doctor may ask about all current and past medical problems, family history, and current medications. A complete physical and neurological exam may help identify other conditions that may be associated with RLS, such as nerve damage (neuropathy or a pinched nerve) or abnormalities in the blood vessels. Basic laboratory tests may be done to assess general health and to rule out anemia. Further studies depend on initial findings. In some cases, a doctor may suggest an overnight sleep study to determine whether PLMS or other sleep problems are present. In most people with RLS, no new medical problem will be discovered during the physical exam or on any tests, except the sleep study, which will detect PLMS if present.
How Is It Treated?
In mild cases of RLS, some people find that activities such as taking a hot bath, massaging the legs, using a heating pad or ice pack, exercising, and eliminating caffeine help alleviate symptoms. In more severe cases medications are prescribed to control symptoms. Unfortunately, no one drug is effective for everyone with RLS. Individuals respond differently to medications based on the severity of symptoms, other medical conditions, and other medications being taken. A medication that is initially found to be effective may lose its effectiveness with nightly use; thus, it may be necessary to alternate between different categories of medication in order to keep symptoms under control.
A non-drug approach called transcutaneous electric nerve stimulation may improve symptoms in some RLS sufferers who also have PLMS. The electrical stimulation is applied to an area of the legs or feet, usually before bedtime, for 15 to 30 minutes. This approach has been shown to be helpful in reducing nighttime leg jerking.
Due to recent advances, doctors today have a variety of means for treating RLS. However, no perfect treatment exists and there is much more to be learned about the treatments that currently seem to be successful.
Where To Get More Information
An individual’s description of symptoms to their doctor is essential in ensuring an accurate diagnosis. You may find it helpful to keep a sleep diary if you suspect you might be experiencing RLS and are experiencing problems sleeping. Noting changes in your diet, lifestyle, sleep habits and routine, might help your doctor or a sleep specialist make an accurate diagnosis.
Obtain a referral to UBC Sleep Disorders Clinic.
Check out these useful websites:
Books that have help for RLS:
- Sleep Thief, Restless Legs Syndrome by Virginia N. Wilson
- The Official Patient’s Sourcebook on Restless Leg Syndrome by Icon Health Publications
- Stopping Restless Leg Syndrome by Chet Cunningham
- Restless Legs Syndrome by K. Ray Chaudhuri (Editor)
Narcolepsy is a chronic sleep disorder with no known cause. The main characteristic of narcolepsy is excessive and overwhelming daytime sleepiness, even after adequate nighttime sleep. A person with narcolepsy is likely to become drowsy or to fall asleep, often at inappropriate times and places. Daytime sleep attacks may occur with or without warning and may be irresistible. These attacks can occur repeatedly in a single day. Drowsiness may persist for prolonged periods of time. In addition, nighttime sleep may be fragmented with frequent awakenings. Three classic symptoms of narcolepsy, which may not occur in all patients, are:
- Cataplexy: sudden episodes of loss of muscle function, ranging from slight weakness (such as limpness at the neck or knees, sagging facial muscles, or inability to speak clearly to complete body collapse. Attacks may be triggered by sudden emotional reactions such as laughter, anger, or fear and may last from a few seconds to several minutes. The person remains conscious throughout the episode
- Sleep paralysis: temporary inability to talk or move when falling asleep or waking up. It may last a few seconds to minutes.
- Hypnagogic hallucinations: vivid, often frightening, dream-like experiences that occur while dozing or falling asleep.
* Please not that daytime sleepiness; sleep paralysis, and hypnagogic hallucinations can also occur in people who do not have narcolepsy. In most cases, the first symptom of narcolepsy to appear is excessive and overwhelming daytime sleepiness. The other symptoms may begin alone or in combination months or years after the onset of the daytime sleep attacks. There are wide variations in the development, severity, and order of appearance of cataplexy, sleep paralysis, and hypnagogic hallucinations in individuals. Only about 20 to 25 percent of people with narcolepsy experience all four symptoms. The excessive daytime sleepiness generally persists throughout life, but sleep paralysis and hypnagogic hallucinations may not.
When Should You Suspect Narcolepsy?
The symptoms of narcolepsy, especially the excessive daytime sleepiness and cataplexy, often become severe enough to cause serious disruptions in a person’s social, personal, and professional lives, while severely limiting ones activities. You should be checked for narcolepsy if:
- You often feel excessively and overwhelmingly sleepy during the day, even after having had a full night’s sleep;
- You fall asleep when you do not intend to, such as while having dinner, talking, driving, or working;
- You collapse suddenly or your neck muscles feel too weak to hold up your head when you laugh or become angry, surprised, or shocked;
- You find yourself briefly unable to talk or move while falling asleep or waking up.
How Common Is Narcolepsy?
Although it is estimated that narcolepsy afflicts as many as 200,000 Americans, fewer than 50,000 are diagnosed. It is as widespread as Parkinson’s disease or multiple sclerosis and more prevalent than cystic fibrosis, but it is less well known. Narcolepsy is often mistaken for depression, epilepsy, or the side effects of medications.
Who Gets Narcolepsy?
Narcolepsy can occur in both men and women at any age, although its symptoms are usually first noticed in teenagers or young adults. There is strong evidence that narcolepsy may run in families; 8 to 12 percent of people with narcolepsy have a close relative with the disease.
What Happens In Narcolepsy?
Normally, when an individual is awake, brain waves show a regular rhythm. When a person first falls asleep, the brain waves become slower and less regular. This sleep state is called non-rapid eye movement (NREM) sleep. After about an hour and a half of NREM sleep, the brain waves begin to show a more active pattern again, even though the person is in deep sleep. This sleep state, called rapid eye movement (REM) sleep, is when dreaming occurs. In narcolepsy, the order and length of NREM and REM sleep periods are disturbed, with REM sleep occurring at sleep onset instead of after a period of NREM sleep. Thus, narcolepsy is a disorder in which REM sleep appears at an abnormal time. Also, some of the aspects of REM sleep that normally occur only during sleep–lack of muscle tone, sleep paralysis, and vivid dreams–occur at other times in people with narcolepsy. For example, the lack of muscle tone can occur during wakefulness in a cataplexy episode. Sleep paralysis and vivid dreams can occur while falling asleep or waking up.
How Is Narcolepsy Diagnosed?
Diagnosis is relatively easy when all the symptoms of narcolepsy are present, but if the sleep attacks are isolated and cataplexy is mild or absent, diagnosis is more difficult. Two tests that are commonly used in diagnosing narcolepsy are the polysomnogram and the multiple sleep latency test and a qualified sleep specialist usually performs both of these tests. The polysomnogram involves continuous recording of sleep brain waves and a number of nerve and muscle functions during nighttime sleep. When tested, people with narcolepsy fall asleep rapidly, enter REM sleep early, and may awaken often during the night. The polysomnogram also helps to detect other possible sleep disorders that could cause daytime sleepiness. For the multiple sleep latency tests, a person is given a chance to sleep every 2 hours during normal wake times. Observations are made of the time taken to reach various stages of sleep. This test measures the degree of daytime sleepiness and also detects how soon REM sleep begins. Again, people with narcolepsy fall asleep rapidly and enter REM sleep early.
How Is Narcolepsy Treated?
Although there is no cure for narcolepsy, treatment options are available to help reduce the various symptoms. Treatment is individualized depending on the severity of the symptoms, and it may take weeks or months for an optimal regiment to be worked out. Complete control of sleepiness and cataplexy is rarely possible. Treatment is primarily by medications, but lifestyle changes are also important. The main treatment of excessive daytime sleepiness in narcolepsy is with a group of drugs called central nervous system stimulants. For cataplexy and other REM-sleep symptoms, antidepressant medications and other drugs that suppress REM sleep are prescribed. Caffeine and over-the-counter drugs have not been shown to be effective and are not recommended. In addition to drug therapy, an important part of treatment is scheduling short naps (10 to 15 minutes) two to three times per day to help control excessive daytime sleepiness and help the person stay as alert as possible. It is important to note that daytime naps are not a replacement for nighttime sleep. Ongoing communication among the physician, the person with narcolepsy, and family members about the response to treatment is necessary to achieve and maintain the best control. Individuals with narcolepsy, their families, friends, and potential employers should know that:
- Narcolepsy is a life-long condition that requires continuous medication.
- Although there is not a cure for narcolepsy at present, several medications can help reduce its symptoms.
- People with narcolepsy can lead productive lives if they are provided with proper medical care.
- If possible, individuals with narcolepsy should avoid jobs that require driving long distances or handling hazardous equipment or that require alertness for lengthy periods.
- Parents, teachers, spouses, and employers should be aware of the symptoms of narcolepsy. This will help them avoid the mistake of confusing the person’s behavior with laziness, hostility, rejection, or lack of interest and motivation. It will also help them provide essential support and cooperation.
- Employers can promote better working opportunities for individuals with narcolepsy by permitting special work schedules and nap breaks.
Where To Get More Information
Talk to your doctor if you feel excessively sleepy during the day, or if you fall asleep when you do not intend to. Together you can identify possible reasons for your sleeping difficulty and then try appropriate measure to correct the problem. Obtain a referral to UBC Sleep Disorders Clinic. Check out these useful websites:
Books related to Narcolepsy:
- Hla in Narcolepsy , Y. Honda, T. Juji (Editor)
- Narcolepsy , C. Guilleminault (Editor)
- Narcolepsy: A Funny Disorder That’s No Laughing Matter , Marguerite J. Utley
- Narcolepsy and Hypersomnia, Bedrich Roth
- Psychosocial Aspects of Narcolepsy, Meeta Goswami (Editor), et al Sleep Disorders: Insomnia and Narcolepsy , Henry Kellerman
Everyone feels sleepy at times. However, when sleepiness interferes with daily routines and activities, or reduces the ability to function, it is called “problem sleepiness.” A person can be sleepy without realizing it. For example, a person may not feel sleepy during activities such as talking and listening to music at a party, but the same person can fall asleep while driving home afterward.
You may have problem sleepiness if you:
- Consistently do not get enough sleep, or get poor quality sleep;
- Fall asleep while driving;
- Struggle to stay awake when inactive, such as when watching television or reading; have difficulty paying attention or concentrating at work, school, or home;
- Have performance problems at work or school;
- Are often told by others that you are sleepy;
- Have difficulty remembering;
- Have slowed responses;
- Have difficulty controlling your emotions;
- Must take naps on most days.
What Causes Problem Sleepiness?
Sleepiness can be due to the body’s natural daily sleep-wake cycles, inadequate sleep, sleep disorders, or certain drugs.
Each day there are two periods when the body experiences a natural tendency toward sleepiness: during the late night hours (generally between midnight and 7 am) and again during the midafternoon (generally between 1 pm and 4 pm). If people are awake during these times, they have a higher risk of falling asleep unintentionally, especially if they haven’t been getting enough sleep.
The amount of sleep needed each night varies among people. Each person needs a particular amount of sleep in order to be fully alert throughout the day. Research has shown that when healthy adults are allowed to sleep unrestricted, the average time slept is 8 to 8.5 hours. Some people need more than that to avoid problem sleepiness; others need less. If a person does not get enough sleep, even on one night, a “sleep debt” begins to build and increases until enough sleep is obtained. Problem sleepiness occurs as the debt accumulates. Many people do not get enough sleep during the work week and then end up sleeping longer on the weekends or days off to reduce their sleep debt. If too much sleep has been lost, sleeping in on the weekend may not completely reverse the effects of not getting enough sleep during the week.
Sleep disorders such as sleep apnea, narcolepsy, restless legs syndrome, and insomnia can cause problem sleepiness. Sleep apnea is a serious disorder in which a person’s breathing is interrupted during sleep, causing the individual to awaken many times during the night and experience problem sleepiness during the day.
People with narcolepsy have excessive sleepiness during the day, even after sleeping enough at night. They may fall asleep at inappropriate times and places. Restless legs syndrome (RLS) causes a person to experience unpleasant sensations in the legs, often described as creeping, crawling, pulling, or painful. These sensations frequently occur in the evening, making it difficult for people with RLS to fall asleep, leading to problem sleepiness during the day. Insomnia is the perception of poor-quality sleep due to difficulty falling asleep, waking up during the night with difficulty returning to sleep, waking up too early in the morning, or un-refreshing sleep. Any of these sleep disorders can cause problem sleepiness.
Certain medical conditions and drugs, including prescription medications, can also disrupt sleep and cause problem sleepiness. Examples include:
- Chronic illnesses such as asthma, congestive heart failure, rheumatoid arthritis, or any other chronically painful disorder;
- Some medications to treat high blood pressure, some heart medications, and asthma medications such as theophylline;
- Alcohol—Although some people use alcohol to help themselves fall asleep, it causes sleep disruption during the night, which can lead to problem sleepiness during the day. Alcohol is also a sedating drug that can, even in small amounts, make a sleepy person much more sleepy and at greater risk for car crashes and performance problems;
- Caffeine—Whether consumed in coffee, tea, soft drinks, or medications, caffeine makes it harder for many people to fall asleep and stay asleep. Caffeine stays in the body for about 3 to 7 hours, so even when taken earlier in the day it can cause problems with sleep at night; and
- Nicotine from cigarettes or a skin patch is a stimulant and makes it harder to fall asleep and stay asleep.
Problem Sleepiness & Adolescents
Many high school and college students have signs of problem sleepiness, such as:
- Difficulty getting up for school;
- Falling asleep at school; and/or
- Struggling to stay awake while doing homework.
The need for sleep may be 9 hours or more per night as a person goes through adolescence. At the same time, many teens begin to show a preference for a later bedtime, which may be due to a biological change. Teens tend to stay up later but have to get up early for school, resulting in their getting much less sleep than they need.
Many factors contribute to problem sleepiness in teens and young adults, but the main causes are not getting enough sleep and irregular sleep schedules. Some of the factors that influence adolescent sleep include:
- Social activities with peers that lead to later bedtimes;
- Homework to be done in the evenings;
- Early wake-up times due to early school start times; parents being less involved in setting and enforcing bedtimes; and
- Employment, sports, or other extracurricular activities that decrease the time available for sleep.
Teens and young adults who do not get enough sleep are at risk for problems such as:
- Automobile crashes;
- Poor performance in school and poor grades;
- Depressed moods’ and
- Problems with poor and adult relationships
Shift Work & Problem Sleepiness
About 20 million Americans (20 to 25 percent of workers) perform shift work. Most shift workers get less sleep over 24 hours than day workers. Sleep loss is greatest for night shift workers, those who work early morning shifts, and female shift workers with children at home. About 50 to 70 percent of shift workers have difficulty sleeping and/or problem sleepiness.
The human sleep-wake system is designed to prepare the body and mind for sleep at night and wakefulness during the day. These natural rhythms make it difficult to sleep during daylight hours and to stay awake during the night hours, even in people who are well rested. It is possible that the human body never completely adjusts to nighttime activity and daytime sleep, even in those who work permanent night shifts.
In addition to the sleep-wake system, environmental factors can influence sleepiness in shift workers. Because our society is strongly day-oriented, noise, light, telephones, family members, and other distractions often interrupt shift workers who try to sleep during the day. In contrast, the nighttime sleep of day workers is largely protected by social customs that keep noises and interruptions to a minimum.
What Can Help?
Many people simply do not allow enough time for sleep on a regular basis. A first step may be to evaluate daily activities and sleep-wake patterns to determine how much sleep is obtained. If you are consistently getting less than 8 hours of sleep per night, more sleep may be needed. A good approach is to gradually move to an earlier bedtime. For example, if an extra hour of sleep is needed, try going to bed 15 minutes earlier each night for four nights and then keep the last bedtime. This method will increase the amount of time in bed without causing a student change in schedule. However, if work or family schedules do not permit the earlier bedtime, a 30- to 60-minute daily nap may help.
In general, medications do not help problem sleepiness, and some make it worse. Caffeine can reduce sleepiness and increase alertness, but only temporarily. It can also cause problem sleepiness to become worse by interrupting sleep.
While alcohol may shorten the time it takes to fall asleep, it takes to fall asleep; it can disrupt sleep later in the night, and therefore add to the problem sleepiness.
Medications may be prescribed for patients in certain situations. For example, the short-term use of sleeping pills has been shown to be helpful in patients diagnosed with acute insomnia. Long-term use of sleep medication is recommended only for the treatment of specific sleep disorders.
If you think you are getting enough sleep, but still feel sleepy during the day, check with your doctor to be sure your sleepiness if not due to a sleep disorder.