Sleep disorders, insomnia

Sleep disorders are among the most common problems for which people visit doctors. Almost 48% of the population suffers from intermittent or persistent sleep disorders; 10 – 15% of the population suffers from severe insomnia. Sleep disorders become more common as people get older: more than half of people over 65 suffer from them.

A healthy rhythm of wakefulness and sleep

Sleep serves the body’s regeneration and is therefore necessary for life. An adult needs an average of 7-8 hours of sleep a day, a three-year-old child an average of 12 hours. An individual’s need for sleep can vary from the average by 1-2 hours. The stages of wakefulness and sleep are controlled by the regulatory circuits of different brain regions . Sleep as one of the types of changes in consciousness is caused by the active action of deep brain centers on the cerebral cortex, and sleep goes through different stages with different depths of sleep.

The normal sleep rhythm consists of several wavelike phases. A distinction is usually made between paradoxical sleep, which is characterized by rapid eye movements (also called REM (Rapid-Eye-Movement) sleep), and orthodox sleep, in which the eyes do not move. REM stages are repeated 3 to 4 times a night and last an average of 20 minutes. A sleeper who is currently in the REM phase is thought to be dreaming. Orthodox sleep occupies the longest time of the time belonging to sleep. It is divided into four parts, the falling asleep stage, the light sleep stage, the moderately deep sleep stage and the very deep sleep stage. The sleeper passes through these stages several times each night, with these stages alternating in waves. After falling asleep, the sleeper enters the very deep sleep stage very quickly and remains in it for some time. He enters this stage once or twice more during the night. Most of the night is spent in the medium-depth sleep stage or the light sleep stage, with older people reaching only the light sleep stage much more often than younger people during the night. In the light sleep stage, the sleeper responds more easily and quickly to external stimuli and awakens more easily than from the very deep sleep stage.

Causes/risk factors for sleep disorders

Internal causes

The most common causes of sleep disorders are mental factors. These are usually problems caused by a stressful lifestyle with constant internal tension and insufficient time for rest. A person with sleep disorders is simply not able to be calm and not think about their daily problems. Sleep disturbances can also be caused by conflicts in a relationship or at work, leading to mental tension and sleep-disrupting ruminations on how to solve these problems. It is different for children. For them, sleep problems occur primarily as a manifestation of unprocessed fear.

Another large percentage of patients with sleep disorders are people with physical and mental illnesses. The list of physical illnesses is long: asthma, diabetes, dementia, heart and circulatory diseases, circulatory problems, thyroid hyperfunction, joint problems, all forms of acute illness with temperature and pain, and many others. Also parasomnias such as nightmares, night terrors or sleepwalking disturb sleep and prevent proper rest. Few patients with a depressive disorder sleep well, very often there are especially early morning awakenings.

External causes

External causes that cause or contribute to sleep disturbances include noise, unsuitable sleeping space or simply the wrong bed (a mattress that is too flat), sleeping too long in the afternoon, shift work and frequent time zone changes for people who travel frequently by plane. Medications (such as antidepressants) and drugs can also cause sleep disturbances. Irregular sleeping hours, excessive smoking and poor eating habits (eating during the night or having a ‘nightcap’) exacerbate sleep problems.

Progress of sleep disorders

Traditionally, sleep disorders are divided into three categories: insomnia, hypersomnia and sleep-related phenomena (parasomnias) such as sleepwalking, gnashing of teeth, etc.

Different types of sleep disorders

Insomnias are by far the most common. Insomnias include well-known phenomena such as inability to fall asleep, sleep disturbances, night wakings, and continuous sleep or waking too early. Insufficient sleep duration and/or poor sleep quality cause familiar problems occurring the next day, fatigue, poor mood and concentration problems, discomfort and poor performance. Problems with falling asleep and staying asleep are the most significant of all sleep disorders.

The term hypersomnia (sleepiness) refers to sleep disorders that are manifested by daytime sleepiness despite adequate sleep at night. Sleepiness that occurs without obvious causes (primary) is a largely unexplored phenomenon. A psychological contribution in the sense of escape from the psychological stresses of everyday life is very likely. Sleepiness that has disease causes (secondary) may result from brain tumors, brain injury and inflammation, and other neurological diseases.

Parasomnias are manifested by sleepwalking, nightmares, night terrors (pavor nocturnus), gnashing of teeth (bruxism) and other manifestations.

Various sleep disorders are attributed to disturbances in the rhythm of wakefulness and sleep, in which natural or, in some cultures, established sleep and wakefulness patterns are mixed. Examples include people with shift work, frequent air travellers, or patients with psychological disturbances of wake-sleep rhythms. Of physical origin are diseases such as narcolepsy and cataplexy, in which sleep fits occur during the day.

Sleep disorders are often associated with diseases such as sleep-disordered breathing (sleep apnoea syndrome) or muscle restlessness (restless legs syndrome). People with sleep disorders often go to bed already worried about what their sleep will be like. They often lie in bed for hours without any sign of falling asleep, with their thoughts constantly revolving around the events or problems of the previous day. Physically exhausted and inwardly tense, they wait until the longed-for sleep finally arrives. The same picture – tired to death yet wide awake – is found in intermittent sleep problems. Many patients wake up too early after a restless night and cannot fall asleep again.

Only sleep disturbances lasting several days, for example before exams or in other unusual situations, do not constitute any reason for restlessness. Even if these sleep problems are related to a nervous strain (family/job) for 2-3 weeks, this may still not indicate a serious problem. There is cause for concern only if about half of the nights the person suffers from sleep disturbances and the problems persist for more than a month An urgent visit to a doctor is necessary if the person has already developed a fear of insomnia and/or is taking sleeping pills on his/her own without consulting a doctor.

Consequences

Chronic insomnia is not harmless. Its effects overshadow the entire course of the day and damage the overall enjoyment and quality of life, as well as the sufferer’s partner and family relationships and job performance.

Nervousness, depression and other psychological disorders can also occur because of sleep problems. There may also be physical problems such as feeling cold all the time, headaches, blood pressure fluctuations and more.

Many sufferers tend to “self-medicate” – solving sleep problems with alcohol or medication. However, this can lead to serious problems with addiction to these substances, even to dependence.

Recognition/examination

A detailed medical history will help to determine the type and severity of the sleep disorder.Keeping a sleep diary will also provide valuable information and help to find ways to avoid poor sleeping habits. Of course, all physical and psychological illnesses that come into consideration as possible causes of insomnia must be identified.

We speak of problems falling asleep if the time from going to bed to falling asleep is more than 30 minutes. A sleep disorder is then considered to be a condition where the patient wakes up earlier than after 6 hours of sleep. These symptoms must occur for at least three days a week and for at least one month. A sleep disorder may be diagnosed as insomnia if it distresses the patient greatly or adversely affects the patient’s social and occupational abilities.

The most accurate diagnosis can be made in a sleep laboratory using polysomnography. In this method, the patient spends one or two nights in hospital and has his eye movements (electrooculography), brain currents (electroencephalography), heart rate and respiration, blood pressure, body movements and muscle tension (electromyography), as well as blood oxygenation monitored and recorded with appropriate equipment to correctly identify the stages of sleep.

Treatment

If any physical or psychological illness (the “underlying illness”) appears to be the cause of sleep problems, it must be investigated and treated as a matter of priority.

The patient can pave the way to better and more restful sleep by taking a number of measures (sleep hygiene): regular sleeping hours, a quiet and dark room with a temperature of 15-18°C – these factors contribute greatly to proper sleep. It is also necessary, if possible, not to stay up too long and to reduce the consumption of stimulating snacks (coffee, black tea, energy drinks) after dinner. The same applies to nicotine, alcohol and late evening meals.

Education and counselling about sleep disorders are the foundations of any care for the patient. Above all, it must be clearly explained that waiting for sleep is the biggest mistake in chronic sleep problems. Relaxation practices such as autogenic training and progressive muscle relaxation, according to Jacobson, can help when sleep disturbances are caused by stressful or conflicting situations.

If there is long-term psychological distress due to unresolved conflicts or problems, psychotherapy may be needed. Herbal products such as valerian drops or extracts of hops, St. John’s wort and lemon balm can help with sleep disorders in milder cases. Other products should not be taken for prolonged periods without consulting a doctor.

The use of some sleeping medications (such as barbiturates or benzodiazepines) can lead to addiction or even dependence, while other drugs cause persistent fatigue (hang-over) the following day, associated with reduced concentration and attention. In contrast, some newer benzodiazepine-free drugs (e.g. zolpidem) appear to be beneficial; they affect the natural sleep pattern to a lesser extent, do not induce daytime fatigue and pose virtually no risk of addiction.

The hormone responsible for metabolism and maintenance of biorhythms, melatonin, is a frequently recommended sleep disorder treatment in the United States and is used primarily for sleep disturbances caused by shift work and to adapt to the crossing of time zones on overseas flights. However, it is not a medication that should be taken without consulting a doctor.

Important notice

Caution: alcohol is not a good sleep aid: it may promote falling asleep, but it disrupts the normal alternation of sleep stages (sleep architecture) later on. Sleep after alcohol therefore loses its restful significance.
Any long-term use of sleeping pills can be dangerous. Long-term therapy should only be used in exceptional and justified cases.

Frequently asked questions

Read more

Insomnia at Mayo clinic

The Importance of Restful Sleep for Your Health and Wellbeing