How are sleep disorders treated?
A sleep disorder is called a parasomnia. Treatment of parasomnias, of course, depends on the specific disorder, which ends up being an itemized bullet list of “If A, then B” (see below).
Sleep disorders discussed below include:
- Sleep-related breathing disorders
- Sleep apnea
- Pulmonary ds
- Hypoventilation disorders
- REM-related sleep disorders
- REM disorder
- NREM disorder
- Circadian disorders
The need for sleep and the need to fix sleep disorders
Itemized bulleted lists can fan out the differences among them, but what unifies all of the sleep disorders is the end-result on the person who suffers with inadequate sleep. Lack of alertness is dangerous. Daytime fatigue makes more likely poor judgement (deficits in information processing), delayed reaction time when microseconds count, and reduced vigilance which can result in an overcorrection when suddenly startled awake by a crisis. One needn’t operate heavy machinery to be in harm’s way. The National Highway Traffic Safety Administration reports that each year there are 100,000 fatigue-related car crashes. This is a conservative estimate, because there is no forensic way to measure one’s alertness or sleepiness1. Also, fatigue is often hidden or overlooked when superseded by alcoholism or drug abuse, cited as the primary cause of an accident.
Another startling aspect of sleep disorders is that being sleepy all day may be the least of one’s problems. Psychopathology such as schizophrenia, depression, anxiety, and attention deficit disorder all include sleep disturbance as a risk factor2. Migraine headaches3, heart disease, hypertension, chronic pain, and gastrointestinal problems are all considered comorbidities (associated simultaneous illnesses) 4.
There is another penalty—one that is seldom considered. The majority of adults sleep with a partner. This sleep benefit is an often overlooked intangible, but it is important in a relationship. There is an ambience—a camaraderie of intimacy in feeling the presence of another human being, dear to the sleeper, all night long and feeling this presence and closeness during the multiple sleep transitions throughout the night. Sleep disorders take an unappreciated toll on the marital bed; relationship quality is dependent on sleep quality and vice versa5. It is more than waking the partner up with movements, gasps, or starts; it is the loss of the sleep-intimacy.
How are sleep disorders treated?
The following disorders are explored and explained in the previous article. Herein, as promised, is the bulleted list of treatments:
A third of people with narcolepsy will also have cataplexy, a sudden, fleeting episode of muscle weakness, with full consciousness, triggered by emotions or laughing.
- Behavioral therapy: adhering to a rigid sleep-wake time, avoidance of certain medications that can cause either sleepiness in the day or wakefulness at night, and scheduled 20-minute daytime naps. Behavioral therapy is usually insufficient alone, as most narcoleptics will require medication, too.
- Pharmacological: with a goal to attain normal alertness,
Non-amphetamines: Modafinil (Provigil), a non-amphetamine drug that promotes wakefulness.
- Amphetamines: Methylphenidate (Ritalin, Concerta) and amphetamines, central nervous system stimulants. Dextroamphetamine (Dexedrine), Adderall (a combination of amphetamine and dextroamphetamine) , and lisdexamfetamine (Vyvanse) are the most commonly prescribed.
Vigilence is necessary because of a higher risk for hypertension, cardiomyopathy, arrhythmias, and in high doses, psychosis, with amphetamines.
REM sleep behavior disorder (RBD)
This is not to be confused with the little jerks common during the transition from wakefulness to sleep. This is a dream-enactment eruption during REM sleep, ranging from hand gestures to violent thrashing or kicking. Bed partners make the diagnosis first! Because normal REM sleep is accompanied by a muscle paralysis of skeletal muscle, the abnormal volatile physicality seen in RBD may be a warning signal for Parkinson disease or other related disorders, because both involve a degeneration of neurons. Treatment of RBD is typically with
- Melatonin—suppresses REM sleep.
- Clonazepam (Klonopin)—suppresses REM sleep.
- Discontinue medicine known to increase REM sleep and worsen RBD, such as tricyclic and other antidepressants.
- A safe sleeping environment, both for the patient and if necessary, the partner, to avoid physical injury.
REM-related disorders, including nightmares
Nightmares are a mix of complex visual imagery and emotional investment in them while sleeping. Post-traumatic Stress Disorder (PTSD) is a cause of nightmares. Occasional nightmares are normal, but those of PTSD involve intrusive thoughts that can carry on into wakefulness. For the PTSD variety of nightmares, because of their interference with PTSD management, the following are noteworthy:
- CBT (Cognitive Behavior Therapy) should be done first, before considering medication.
- Alpha-blockers, such as prazosin (Minipress)
- Beta-blockers, such as propranolol, are possibly helpful, but this is still being studied.
- Benzodiazepines, used because of their reduction of anxiety.
- Mood stabilizers, such as Tiagabine, Topiramate, and Valproic Acid (Depakene), have only produced mixed results and should not be a first choice.
Sleep-related movement disorders
Such as restless leg syndrome.
- Behavioral strategies, initially. Avoiding aggravating factors such as drugs known to contribute to the emergence of sleep movement disorders (sedating antihistamines and antidepressants).
This is a different, independent disorder altogether. It was formerly thought to be a sleep disturbance due to other health conditions, but this is false, as treating the suspected underlying conditions may not improve the insomnia. Nevertheless, when there are other conditions related to it, treatment of both yields the best results.
It can be associated with psychiatric disorders or provoked by time mismanagement of one’s day, overachieving and as such, being overexcited.
In today’s laptop and handheld world of devices, it can also be aggravated by late-night photostimulation (bright light interference that confuses the mind’s light/dark circadian sensitivities). Remembering our evolution, we evolved to go to sleep when it got dark. Keeping the lights on messes with our clocks and the right tumblers won’t line up to allow falling asleep. Cognitive-behavioral therapy (CBT) for insomnia has been shown to have a positive impact on both sleep and symptoms of depression and anxiety2, 6.
CBT consists of stimulus control (turning off the TV, radio, or lights for reading); avoiding caffeine, nicotine, and drugs that stimulate; resolving worries before bedtime; a rigid sleep-wake schedule (sleep “hygiene”); and daily exercise.
When severe and chronic, medications for insomnia include either a single agent are combination medications:
- Melatonin agonists (remelteon). Melatonin figures prominently in our circadian rhythm, governed by our pineal gland, which some consider to be an evolutionary vestige of a third eye.
- Antidepressant doxepin (Sinequan), using its sedating side effect, in low doses. Andepressants other than low dose doxepin are not recommended.
- Barbiturates. These have a significant abuse potential and many side effects, so these are not recommended for routine use.
- Short-acting hypnotics, formulated to leave your system so that the normal sleep cycle can emerge, include zolpidem (Ambien), zalepion, trazolam, and lorazepam.
- Over the counter remedies, such as sedating antihistamines (diphenhydramine), often the first self-remedy tried, may be problematic with hangovers, decreasing next day alertness, which defeats the purpose.
It is noteworthy that any drug or substance that impacts falling asleep may also interfere with your sleep cycle, which can bring about new problems. Alcohol, especially, although shortening the time to fall asleep, interferes with the sleep cycle later into the night. Marijuana (cannabis), a politically charged topic, has been shown to shorten the time for sleep, but may have effects on awakenings during the night7.
Sleep disorders (parasomnias) are a major phenomenon of modern living. As life demands more from us, especially during the hours we were meant to be sleeping, the hours we are meant to be awake are at stake. Treatment of sleep disorders that interfere with one’s quality of life, from conservative to aggressive treatments, should always be considered. A normal sleep/wake cycle is life as we know it, and anything less is destructive.
- Alberti A, Mazzotta G, Gallinella E, et al. Headache characteristics in obstructive sleep apnea syndrome and insomnia. Acta Neurol Scand. 2005;111(5):309–16.
- Daniel J. Taylor, PhD, Laurel J. Mallory, BA, Kenneth L. Lichstein, PhD, H. Heith Durrence, PhD, Brant W. Riedel, PhD, Andrew J. Bush, PhD; Comorbidity of Chronic Insomnia With Medical Problems, Sleep, Volume 30, Issue 2, 1 February 2007, Pages 213–218.
- Troxel WM, Robles TF, Hall M, Buysse DJ. Marital quality and the marital bed: Examining the covariation between relationship quality and sleep. Sleep medicine reviews. 2007;11(5):389-404. doi:10.1016/j.smrv.2007.05.002.
- Rachel Manber, PhD, Jack D. Edinger, PhD, Jenna L. Gress, BA, Melanie G. San Pedro-Salcedo, MA, Tracy F. Kuo, PhD, Tasha Kalista, MA. Cognitive Behavioral Therapy for Insomnia Enhances Depression Outcome in Patients with Comorbid Major Depressive Disorder and Insomnia. Sleep, Volume 31, Issue 4, 1 April 2008, Pages 489–495. https://doi.org/10.1093/sleep/31.4.489.
- Levin KH, Copersino ML, Heishman SJ, et al. Cannabis withdrawal symptoms in non-treatment-seeking adult cannabis smokers. Drug Alcohol Depend 2010; 111:120.
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