by Edward Bruce Bynum, Ph.D., Director of Behavioral Medicine
It is not unusual occasionally for most of us to experience a sleepless night or nights of troubled sleep. These are usually associated with common stress or worry. Occasionally they may be due to medication. Sometimes it may be due to reaction to alcohol. This is called alcohol rebound syndrome. These almost always pass with time, a little rest, and occasional over-the-counter medication. There are some problems associated with medical disorders. These are known to initiated or prolong sleep disturbances. These can be chronic pain, a recent injury, or ongoing mild or even serious depression. Environmental blocks to sleep can be many. In a dormitory there can be excessive noise, there can be a strain in interpersonal relationships, and again a preoccupation with a current personal or family crisis.
It is important to know some basic knowledge about the structure of sleep. Sleep researchers today commonly divide sleep into four stages. They have also noted that all mammals sleep. In fact, the inhibition of sleep is referred to as sleep onset delay. It occurs in human beings when there is more than an hour between laying down to go to sleep and actually falling off to sleep. Sleep is a circadian rhythm and has a neurophysiological basis. This has been studied in laboratories with appropriate EEG and other monitoring equipment. It is known that sleep occupies a significant portion of our live when we are very young and also when we are of an advanced age. It goes on a long curve. Sleep also helps considerably with exercise. Therefore, there is a clearly established need for sleep. Also, when we are deprived of sleep there are consequences for our physical, emotional and psychological behavior.
Of course sleep and dreams go together. During sleep live there is a phenomenon of rapid eye movement (REM). Rapid eye movement is almost always associated with story-like imagery, emotional arousal, and a sense of meaningfulness about the phenomenon. When there is no opportunity for the person to experience REM for some prolonged period of nights, there is a phenomenon of REM rebound where in succeeding nights the person attempts to make up for the REM time that is lost with excessive REM activity. Also during sleep there is a phenomena of non REM activity, which indeed is most of the time in sleep. When one is awakened during a REM period, there is a story-like, dream-like, reverie-like experience. Sometimes extremely intense emotionally. However, when one is awakened during non REM, there is occasional mentation, it is fragmentary, and of relatively little emotional import.
Sleep is often interrupted by some of the afore mentioned activities. In situations like this and on a limited basis medication is helpful in restoring sleep. However there are positive and negatives aspects to sleep medication. Sleep also can be interrupted by poor eating habits and indigestion.
It is noteworthy that in all the higher mammals, but particularly in men and women, sleeping and dreaming is associated with physiological sexual arousal and occasionally the recognition of this arousal in dream experiences.
While most of us enjoy regular sleep and do not think about it much except when we go to get a good night’s sleep, occasionally individuals do experience significant interruptions in their normal sleep cycle. These constitute some of sleep disorders that are more troublesome. A sleep disorder that is troublesome is one in which one experiences a significant alteration in ones mood and capacity to function in the waking state. Some of the more primary sleep disturbances include narcolepsy. Narcolepsy involves the symptoms to irresistible daytime sleep. Also at times there is a transient weakness in the body referred to as cataplexy. Sometimes with narcolepsy occurs a brief sleep paralysis. Also occasional hypnogogic hallucinations which can be unsettling.
Another one of the primary sleep disorders is sleep apnea, of which there are three kinds. These are associated with neurological problems. They involve the interruption of the smooth inhalation-exhalation process. These can be referred to as central sleep apnea, upper airway sleep apnea, and mixed. Prolonged disruption between inhalation and exhalation and sleep can have cardiovascular repercussions in certain individuals, usually significantly overweight males.
Also in the primary sleep disorders are the phenomenon of primary insomnia. Primary insomnia is a difficulty in falling off to sleep. Here there is a persistent and consistent sleep onset delay sometimes of many hours. Often a person feels that they’ve gone through the whole night and slept very little or not at all. The other end of the spectrum expresses itself in primary hypersomnia. This is the tendency to sleep much, much more than is necessary. For the average person, between five and eight hours constitutes the widest range. Below four hours of sleep and above ten hours of sleep constitute cause for at least clinical consultation.
Some of the more unusual forms of primary sleep disturbance include nocturnal myoclonus. This is associated with a phenomenon of “restless legs” syndrome. This is where literally during the sleep cycle ones legs are moving. This can be particularly irritating to ones sleeping partner. In this disorder, the place of exercise and a physical massage and self-care cannot be underestimated.
The phenomenon of nonrestorative sleep and “pseudoinsomnia” are also primary sleep disorders. In nonrestorative sleep, the person may indeed go to sleep but they do not experience that deep and satisfying sleep such as when they wake up in the morning they feel refreshed. These often occur during times of a prolonged stress. A person may awaken from a night of many dreams and feel tired and exhausted and even depresses during the day. They sleep but that sleep is just not restful. Also the person experiences a very, very light sleep such that they are not really sure if they fell asleep or if they were awake all night. This also can be very irksome.
There are also numerous medically related disorders involving sleep. Occasionally periodic hypersomnia is related to a medical disorder. The syndrome of Kleine-Levin syndrome is relatively rare but does occur. Here the person experiences a significant increase in food and sex drives and altered sleep habits. Occasionally ones REM sleep cycle is interrupted by intense anxiety. This can be the result of either a classical nightmare, in which imagery is remembered of a frightening nature, or a night terror. In the case of a night terror, one is suddenly awakened from sleep with a sense of intense dread and other worldliness and yet no memory of the content of one’s experience.
Rarer still is the phenomenon of painful nocturnal erections during sleep. This occurs almost exclusively in males. This is associated with a medical disorder. Also various thyroid dysfunctions are known to complicate the sleep cycle. Finally, excessive use of various stimulants such as caffeine and nicotine or in some cases alcohol are known to interrupt the normal flow of the sleep cycle. One also, therefore, has to be very cautious in one’s use of excess substances.
Finally, the sleep cycle can be greatly complicated by emotional and psychological difficulties. Clinical depression often results in difficulties falling asleep, many awakenings during the night, and excessive difficulty getting out of bed in the morning. In some cases, bipolar disorders exacerbate or create sleep disturbances. Schizophrenia in the beginning stages is often marked by significant changes in the sleep cycle. There is often REM deprivation accompanying difficulties in the waking state that occur during the initial or acute stages of schizophrenia. Alcoholism, alcohol rebound syndrome, conditioning and associations are a major factor in many sleep disturbances. Also psychiatrically speaking, paranoia, excessive vigilance, and recurrent experience of trauma memory are known to greatly disturb the sleep cycle.
There is the condition however of conditioned insomnia. This is when the environmental factors such as a very noisy living situation or expectations of difficulties at night can condition a person to have sleep onset delayed. Finally, there are various forms of sleep phobias. Some individuals experience difficulty falling asleep for fear of extremely bad dreams or even death.
There is a classification of sleep difficulties referred to as the parasomnias. Parasomnias are a phenomenon that occur during the waking state but are not associated with phenomenon that occur in the sleeping state. These are usually associated with the deepest level of the four stages of sleep, referred to as delta sleep. For instance, young children often experience not only nightmares but night terrors. The nightmare occurs during the regular REM sleep, but the night terror however, occurs during the deeper stages of delta sleep. Also the phenomenon of sleep walking or somnabulism occurs in the deepest level of sleep. The phenomemon of bedwetting or enuresis, mostly associated with young children, occurs in sleep. The phenomenon of soiling or encopresis is associated with neurological difficulties of adaptation in younger children and also difficulties in aging for older individuals. Nocturnal bruxism or grinding the teeth occurs during sleep. This is when during the REM cycle one is verbally working through or attempting to work through very psychological and emotional difficulties. The bruxism also occurs during the waking state.
Various therapeutic approaches to the difficulties of sleep cover the full spectrum. Often times the medical physician will prescribe a medication on a brief usage basis. Sometimes psychotherapy for anxiety and emotional disorders is a treatment of choice for sleep and other difficulties of the night. In some rare instances, when there is a differential or a complicated diagnosis, referral to a sleep laboratory if warranted. This information can be ascertained from one’s clinician. There are several excellent clinics in the area. Finally, there are various clinical medications to induce sleep, referred to as “hypnotics”. There are also behavioral methods to overcome primary and secondary insomnia. These often involve shifts in one’s life style, substance use, diet, and appropriate exercise to regulate one’s metabolism. The vast majority of sleep disturbances are transient and normal. It is when they are persistent and cause disturbances in one’s concentration during the day, mood, or expressions of prolonged anxiety, somatization and depression, that one should seek a professional consultation.
Peter Hauri, Ph.D., Sleep Disorders, Upjohn
Diagnostic and Statistical Manual of Mental Disorders (DSM IV)
Kingman P. Strohl, MD, The Biology of Sleep Apnea, Journal of Science and Medicine, Oct. 1996, pg. 32 – 41