The Clinical Picture

When physical illnesses present as psychological problems

In Search of a Good Night's Sleep

Do you have an undiagnosed primary sleep disorder?

Young Man--Asleep at his Laptop
Tired During the Day?
By Shanghai killer whale (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

If you can’t get a good night’s sleep, perhaps you have an undiagnosed primary sleep disorder. Sleep disorders are extremely common and come in many varieties. They are also treatable!

Let’s walk through a night of sleep and see where things can go awry. 

Falling Asleep

You snuggle under the covers. You relax. Then sleep “switches” on, but only if you’ve gone to sleep at the right time for your biological clock. If you have a disorder of circadian rhythm, you may lie awake with sleep-onset insomnia until bio-signals for sleep kick in. 

Alternatively, you might find that you can’t get comfortable in bed. You have strange sensations in your legs that only go away when you move them. You have restless legs syndrome.

Or, perhaps you cannot get to sleep without eating. Do you consume most of your daily caloric intake in the hours after dinner and before sleep? You might have night-eating syndrome. Doctors believe that the timing of eating and sleep are biologically out of synch in this disorder.

Do you have vivid hallucinations associated with falling asleep? These hallucinations may be seen or heard. They also might be felt. For example, you might sense that someone is standing nearby or that you are levitating. These are hypnagogic hallucinations and could be one sign of the sleep disorder narcolepsy.

Unusual Behaviors During Sleep

Now you’ve fallen asleep. 

Your sleep deepens, and your body muscles relax. This relaxation may lead to partial collapse of your breathing airway. Airway collapse is associated with short periods of time when breathing halts (apnea). Naturally, this sets off “biological alarms” that disrupt deep sleep, waking you into lighter sleep. When breathing resumes, you force air through your collapsed airway–this is snoring. Your snoring may wake your bed partner, yet you may be entirely unaware it. Sounds like you have obstructive sleep apnea.          

Nighttime episodes of breathing cessation without snoring can be due to disturbances in the biological controls of breathing during sleep. This is central sleep apnea.

Deep sleep may also be disrupted in association with repetitive limb movements, including restless legs. You might have no memory of kicking your bed partner or rumpling the sheets during sleep, but you could have periodic limb movements of sleep. 

Have you fallen out of bed during the night? Have you injured yourself or your bed-partner during sleep? You may have REM sleep behavior disorder. During normal dreaming sleep, voluntary muscles are partially paralyzed, making it impossible for people to act on their dream content. This mechanism fails, however, in REM sleep behavior disorder. 

Night terrors involve awakening in a state of intense fear but, unlike nightmares, these episodes are not associated with dreaming. Sleepwalking and/or sleep-talking also are not associated with dreaming. Sleepwalking can be dangerous because the sleeper is not able to use good judgment while moving about. 

Awakening

When you first awaken, are you ever briefly unable to move? Sleep paralysis may be associated with narcolepsy. Or, do you have hallucinations upon awakening? These hypnopompic hallucinations and are also associated with narcolepsy.

Many individuals have trouble waking up when their alarm rings. Any sleep disorder that causes non-restful sleep could be responsible for this. However, it is also possible that you have a circadian rhythm disorder in which your biological clock is set for a late-in-the-day time of awakening.

What You Find in the Morning

In the morning do you find evidence that you have gotten out of bed and eaten during the night? Do you have no memory or only a vague memory of these nighttime binges? Sleep-related eating disorder involves eating during the night while asleep or in a partially asleep state.

Or, in the morning to you find that you have urinated or bitten your tongue during sleep? You may be having nocturnal seizures. Although these are not a true sleep disorder, they may disrupt sleep and may cause nightmares.

During the Day

All of the sleep disorders are associated with excessive daytime sleepiness. But individuals with narcolepsy have episodes of daytime sleepiness that intensify until they cannot resist napping. Do you fall asleep at times that are unsafe or not socially appropriate? Do short naps rejuvenate you? Narcolepsy could be the problem, especially if you also have sleep paralysis, sleep-related hallucinations, and restless nighttime sleep.

What to Do

If you think you might have any of these sleep disorders, speak with your doctor. Get a thorough medical work-up. With treatment that is targeted to your specific sleep disorder, finally, you may be able to get a good night’s sleep.

Young Man--Asleep at his Laptop

Photo: Wikimedia Commons

 

Barbara Schildkrout, M.D., an Assistant Clinical Professor of Psychiatry at Harvard Medical School, is the author of Masquerading Symptoms.

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