Sleep problems? Talk to Dr. Z

Many of clients, perhaps not the majority but a significant number, complain about not sleeping enough hours in the night, about having difficulties in falling or staying asleep. Often, their psychological and physical symptoms are caused, at least in part, by their lack of adequate sleep. Lack of sleep can be very detrimental to physical, psychological and relational health. Lack of sleep, especially insomnia, can be treated with Cognitive Behavioral Therapy (CBT) as a first line of remedy. CBT should be tried before resorting to narcotics (medications that induces sleep) and, in particularly difficult cases, in conjunction with medication. Medication will help with the symptoms, but will do nothing about the causes of insomnia. CBT can directly address the causes, while helping to mitigate the symptoms. 

A primer on sleep problems

Sleep loss and sleep disorders are among the most common yet frequently overlooked and readily treatable health problems. It is estimated that 50 to 70 million Americans chronically suffer from a disorder of sleep and wakefulness, hindering daily functioning and adversely affecting health and longevity (NHLBI, 2003). About 80 to 90 percent of adults with clinically significant sleep-disordered breathing remain undiagnosed (Young et al., 1997b). The most visible consequences are errors in judgment contributing to disastrous events such as the space shuttle Challenger (Walsh et al., 2005). Less visible consequences of sleep conditions are far more prevalent, and they take a toll on nearly every key indicator of public health: mortality, morbidity, performance, accidents and injuries, functioning and quality of life, family well-being, and health care utilization. Some of these consequences, such as automobile crashes, occur acutely within hours (or minutes) of the sleep disorder, and thus are relatively easy to link to sleep problems. Others—for example, obesity and hypertension—develop more insidiously over months and years of chronic sleep problems. After decades of research, the case can be confidently made that sleep loss and sleep disorders have profound and widespread effects on human health (NCBI, 2006). The most common sleep conditions are sleep loss, sleep-disordered breathing, insomnia, narcolepsy, restless legs syndrome (RLS), parasomnias, sleep-related psychiatric disorders, sleep-related neurological disorders, sleep-related medical disorders, and circadian rhythm sleep disorders (NCBI, 2006).

Sleep Loss
Sleep loss generally, in adults, refers to sleep of shorter duration than the average basal need of 7 to 8 hours per night. The main symptom of sleep loss is excessive daytime sleepiness, but other symptoms include depressed mood and poor memory or concentration (Dinges et al., 2005). 
Sleep loss (less than 7 hours per night) may have wide-ranging effects on the cardiovascular, endocrine, immune, and nervous systems, including the following:
Obesity in adults and children (the shorter the sleep, the greater the obesity)
Diabetes and impaired glucose tolerance (which is a precursor to diabetes)
Cardiovascular disease and hypertension (heart attacks [myocardial infarction] and perhaps stroke)
Anxiety symptoms (excess mental distress, anxiety, and self-medication with alcohol)
Depressed mood
Alcohol use (lack of sleep induces alcohol consumption as the individual tries to induce sleep)

Sleep-disordered Breathing
The most common disorder is characterized by obstructive apneas and hypopneas (White, 2005), where repeated episodes of collapse (apneas) or partial collapse of the pharyngeal airway occur, usually a result of obstruction by soft tissue in the rear of the throat. Snoring, which is produced by vibrations of the soft tissues, is a good marker for Obstructive Sleep Apnea or OSA (Netzer, et al., 2003). OSA causes chronic elevation in daytime blood pressure (Young et al., 2002aYoung and Javaheri, 2005),  arrhythmias (Guilleminault et al., 1983); coronary artery disease (Andreas et al., 1996) and specifically, myocardial infarction (Hung et al., 1990D’Alessandro et al., 1990Mooe et al., 1996a,bMarin et al., 2005); and congestive heart failure (Javaheri et al., 1998). A polysomnogram, or sleep study, is necessary to properly measures your personal key metrics while asleep. These metrics are used to determine if you have obstructive apnea or another sleep related conditions such as central sleep apnea or restless leg syndrome. When indicated, your physician will recommend the use of a Continuous Positive Air Pressure device, or C-PAP.

Insomnia
Insomnia is the most commonly reported sleep problem (Ohayon, 2002). It is a highly prevalent disorder that often goes unrecognized and untreated despite its adverse impact on health and quality of life (Benca, 2005a) (see also Chapter 4). Insomnia is defined by having difficulty falling asleep, maintaining sleep, or by short sleep duration, despite adequate opportunity for a full night’s sleep. Other insomnia symptoms include daytime consequences, such as tiredness, lack of energy, difficulty concentrating, and/or irritability (Simon and VonKorff, 1997). The precise causes of insomnia are poorly understood but, in general terms, involve a combination of biological, psychological, and social factors. Insomnia is conceptualized as a state of hyperarousal (Perlis et al., 2005). Patients often attribute their difficulty sleeping to an overactive brain. The most common treatment for insomnia is medication (prescribed by your physician), preferably in conjunction with Cognitive Behavioral Therapy (CBT) to get to the causes of the insomnia. Medication will only treat the symptoms. As soon as you stop taking the medication, the symptoms will reappear. If you add CBT, working on the causes of the insomnia can prevent its recurrence.

Narcolepsy
Narcolepsy and idiopathic hypersomnia (sleeping too much) are characterized by a clinically significant complaint of excessive daytime sleepiness that is neither explained by a circadian sleep disorder, sleep-disordered breathing, or sleep deprivation, nor is it caused by a medical condition disturbing sleep (AASM, 2005).The most common treatment for narcolepsy is medication (prescribed by your physician).

Parasomnias
Parasomnias are unpleasant or undesirable behaviors or experiences that occur during entry into sleep, during sleep, or during arousals from sleep (AASM, 2005). 

Disorders of arousal manifest in a variety of ways, from barely audible mumbling, disoriented sleepwalking, to frantic bouts of shrieking and flailing of limbs (Wills and Garcia, 2002). Individuals who experience confusional arousals exhibit confused mental and behavioral activity following arousals from sleep. They are often disoriented in time and space, display slow speech, and blunted answers to questions (AASM, 2005). 

Sleep terrors are characterized by arousal from  SWS accompanied by a cry or piercing scream, in addition to autonomic nervous system and behavioral manifestations of intense fear (AASM, 2005). 

Sleepwalking is characterized by a complex series of behaviors that culminate in walking around with an altered state of consciousness and impaired judgment (AASM, 2005).Comorbid psychiatric and sleep disorders are treated by a combination of medication and/or psychotherapy (Krahn, 2005; Benca, 2005a).

Copyright © 2006, National Academy of Sciences.

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Get Help With Sleep
To make an appointment with Dr. Z, call (678) 554-5632 or click the blue button to request an appointment using the online form. We can go over your current situation, identify the ways in which lack of sleep is affecting your life and that of your loved ones, or how its effects are impairing important relationships. We will put some dimensions to the problem, and identify your current resources that may be applied toward meaningful and lasting change. If additional resources and skills are needed, we will treat your severe symptoms of insomnia with CBT and help you feel more rested and better able to function. Treating sleep problems with CBT it’s proven to be effective, and has helped many people who had a variety of different symptoms and challenges. Call and make your appointment today and we can get started!

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Circadian rhythm sleep disorder

Circadian rhythm sleep disorder arises from chronic alterations, disruptions, or misalignment of the circadian clock in relation to environmental cues and the terrestrial light-dark cycle. The 2005 update of the International Classification of Sleep Disorders designated nine different circadian disorders, including delayed sleep phase type, advanced sleep phase type, non-entrained sleep-wake type, irregular sleep-wake type, shift work type, and jet lag type (AASM, 2005). Treatment for delayed sleep phase syndrome requires resynchronizing to a more appropriate phase to the 24-hour light-dark cycle. In addition to a structured sleep-wake schedule and good sleep hygiene practices, potential therapies include resetting the circadian pacemaker with bright light, melatonin, or a combination of both. Treatment options for individuals with advanced sleep phase syndrome are limited. Bright light therapy in the evening has been used successfully in a limited study to reduce awakenings.

Restless leg syndrome

RLS is a neurological condition characterized by an irresistible urge to move the legs (it also may affect the arms, trunk, or head and neck). It is also associated with paresthesias—uncomfortable feelings—which individuals describe as creepy-crawly, jittery, itchy, or burning feelings. The symptoms are partially or completely relieved by movement. The urge to move and unpleasant sensations worsen during periods of rest or inactivity, especially in the evening and at night, causing most individuals difficulty falling asleep (Michaud et al., 2000). The discomfort associated with RLS also causes individuals to wake frequently during the night (Montplaisir et al., 1997) The most common treatment for RLS is medication (prescribed by your physician).