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Module 4.4: Sleep Problems and Disorders

Disruptions of Normal Sleep

Regardless of one's chronotype, there are situations in which a person's circadian clock gets out of synchrony with the external environment. Traveling across multiple time zones, we often experience jet lag, a collection of symptoms that results from the mismatch between our internal circadian cycles and our environment. These symptoms include fatigue, sluggishness, irritability, and insomnia.

Individuals who do rotating shift work are also likely to experience disruptions in circadian cycles. Rotating shift work refers to a work schedule that changes from early to late on a daily or weekly basis. For example, a person may work from 7:00 a.m. to 3:00 p.m. on Monday, 3:00 a.m. to 11:00 a.m. on Tuesday, and 11:00 a.m. to 7:00 p.m. on Wednesday. In such instances, the individual's schedule changes so frequently that it becomes difficult for a normal circadian rhythm to be maintained. This often results in sleeping problems, and it can lead to signs of depression and anxiety. These kinds of schedules are common for individuals working in health care professions and service industries, and they are associated with persistent feelings of exhaustion and agitation that can make someone more prone to making mistakes on the job.

Rotating shift work has pervasive effects on the lives and experiences of individuals engaged in that kind of work, which is clearly illustrated in stories reported in a qualitative study that researched the experiences of middle-aged nurses who worked rotating shifts. Several of the nurses interviewed commented that their work schedules affected their relationships with their family. One of the nurses said,

If you've had a partner who does work regular job 9 to 5 office hours . . . the ability to spend time, good time with them when you're not feeling absolutely exhausted . . . that would be one of the problems that I've encountered. (West et al., 2009, p. 114)

There are things we can do to help us realign our biological clocks with the external environment. The use of a bright light have been shown to alleviate some of the problems experienced by individuals suffering from jet lag or the consequences of rotating shift work. Because the biological clock is driven by light, exposure to bright light during working shifts and dark exposure when not working can help combat insomnia and symptoms of anxiety and depression.

Table 4.1 Sleep Needs at Different Ages

Age Nightly Sleep Needs

0–3 months

12–18 hours

3 months–1 year

14–15 hours

1–3 years

12–14 hours

3–5 years

11–13 hours

5–10 years

10–11 hours

10–18 years

8–10 hours

18 and older

7–9 hours

Insufficient Sleep

When people have difficulty getting sleep due to their work or the demands of day-to-day life, they accumulate a sleep debt. A person with a sleep debt does not get sufficient sleep on a chronic basis. The consequences of sleep debt include decreased levels of alertness and mental efficiency. Interestingly, since the advent of electric light, the amount of sleep that people get has declined. While we certainly welcome the convenience of having the darkness lit up, we also suffer the consequences of reduced amounts of sleep because we are more active during the nighttime hours than our ancestors were. As a result, many of us sleep less than 7–8 hours a night and accrue a sleep debt. While there is tremendous variation in any given individual's sleep needs, the National Sleep Foundation cites research to estimate that newborns require the most sleep (between 12 and 18 hours a night) and that this amount declines to just 7–9 hours by the time we are adults. Table 4.1 shows amounts of sleep at different ages.


Links to Learning

Watch this brief video describing sleep deprivation in college students.

Here's another brief video describing sleep tips for college students.

Given that college students are notorious for suffering from significant sleep debt, chances are you and your classmates deal with sleep debt-related issues on a regular basis.

Sleep debt and sleep deprivation have significant negative psychological and physiological consequences. As mentioned earlier, lack of sleep can result in decreased mental alertness and cognitive function, and often results in depression-like symptoms. These effects can occur as a function of accumulated sleep debt or in response to more acute periods of sleep deprivation. It may surprise you to know that sleep deprivation is associated with obesity, increased blood pressure, increased levels of stress hormones, and reduced immune functioning. Furthermore, individuals suffering from sleep deprivation can also put themselves and others at risk when they put themselves behind the wheel of a car or work with dangerous machinery. Some research suggests that sleep deprivation affects cognitive and motor function as much as, if not more than, alcohol intoxication.

Link to Learning

To assess your own sleeping habits, read this article about sleep needs.

Sleep Disorders

Many people experience disturbances in their sleep at some point in their lives. Depending on the population and sleep disorder being studied, between 30% and 50% of the population suffers from a sleep disorder at some point in their lives. This section will describe.

Use the slideshow below to learn more about several sleep disorders as well as some of their treatment options. Click the arrows to move from one disorder to the next.

Insomnia

Insomnia, a consistent difficulty in falling or staying asleep, is the most common of the sleep disorders. Individuals with insomnia often experience long delays between the times that they go to bed and actually fall asleep. In addition, these individuals may wake up several times during the night and have difficulty getting back to sleep. One of the criteria for insomnia involves experiencing these symptoms for at least three nights a week for at least one month’s time.

It is not uncommon for people suffering from insomnia to experience increased levels of anxiety about their inability to fall asleep. Increased anxiety leads to increased arousal, which makes the prospect of falling asleep even more unlikely. Chronic insomnia is almost always associated with feeling overtired and may be associated with symptoms of depression. Factors that may contribute to insomnia include age, drug use, exercise, mental status, and bedtime routines. People who suffer from insomnia might limit their use of stimulants such as caffeine or increase their amount of physical exercise during the day. Treatment may include stress management techniques and changes in problematic behaviors that could contribute to insomnia. Additionally, cognitive-behavioral therapy, which focuses on cognitive processes and problem behaviors, may be helpful in treating insomnia.).
Sleepwalking

In sleepwalking, or somnambulism, the sleeper engages in relatively complex behaviors ranging from wandering about to driving an automobile. During periods of sleepwalking, sleepers often have their eyes open, but they are not responsive to attempts to communicate with them. Sleepwalking most often occurs during slow-wave sleep, but it can occur at any time during a sleep period in some affected individuals.

Historically, somnambulism has been treated with a variety of pharmacotherapies ranging from benzodiazepines to antidepressants. However, the success rate of such treatments is questionable. Guilleminault et al. (2005) found that sleepwalking was not alleviated with the use of benzodiazepines. However, all of their somnambulistic patients who also suffered from sleep-related breathing problems showed a marked decrease in sleepwalking when their breathing problems were effectively treated.
REM Sleep Behavior Disorder (RBD)

REM sleep behavior disorder (RBD) occurs when the muscle paralysis associated with the REM sleep phase does not occur. Individuals who suffer from RBD have high levels of physical activity during REM sleep, especially during disturbing dreams. These behaviors vary widely, but they can include kicking, punching, scratching, yelling, and behaving like an animal that has been frightened or attacked. As a result of these behaviors, people who suffer from this disorder can injure themselves or their sleeping partners. Furthermore, these types of behaviors ultimately disrupt sleep, although affected individuals have no memories that these behaviors have occurred.

This disorder is associated with a number of neurodegenerative diseases such as Parkinson's disease. Clonazepam, an anti-anxiety medication with sedative properties, is most often used to treat RBD. It is administered alone or in conjunction with doses of melatonin (the hormone secreted by the pineal gland). As part of treatment, the sleeping environment is often modified to make it a safer place for those suffering from RBD.
Restless Leg Syndrome

A person with restless leg syndrome has uncomfortable sensations in the legs during periods of inactivity or when trying to fall asleep. This discomfort is relieved by deliberately moving the legs, which, not surprisingly, contributes to difficulty in falling or staying asleep. Restless leg syndrome is quite common and has been associated with a number of other medical diagnoses, such as chronic kidney disease and diabetes. There are a variety of drugs that treat restless leg syndrome: benzodiazepines, opiates, and anticonvulsants.

Night Terrors
Night terrors result in a sense of panic in the sufferer and are often accompanied by screams and attempts to escape from the immediate environment. Although individuals suffering from night terrors appear to be awake, they generally have no memories of the events that occurred, and attempts to console them are ineffective. Typically, individuals suffering from night terrors will fall back asleep again within a short time. Night terrors apparently occur during the NREM phase of sleep. Generally, treatment for night terrors is unnecessary unless there is some underlying medical or psychological condition that is contributing to the night terrors.
Sleep Apnea

Sleep apnea is defined by episodes during which a sleeper's breathing stops for 10–20 seconds or longer. While individuals suffering from sleep apnea may not be aware of these repeated disruptions in sleep, they do experience increased levels of fatigue. Many individuals diagnosed with sleep apnea first seek treatment because their sleeping partners indicate that they snore loudly and/or stop breathing for extended periods of time while sleeping.

There are two types of sleep apnea: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea occurs when an individual's airway becomes blocked during sleep, and air is prevented from entering the lungs. In central sleep apnea, disruption in signals sent from the brain that regulate breathing cause periods of interrupted breathing.

One of the most common treatments for sleep apnea involves the use of a special device during sleep. A continuous positive airway pressure (CPAP) device includes a mask that fits over the sleeper's nose and mouth, which is connected to a pump that pumps air into the person's airways, forcing them to remain open, as shown in the imaged above.

SIDS

In sudden infant death syndrome (SIDS) an infant stops breathing during sleep and dies. Infants younger than 12 months appear to be at the highest risk for SIDS, and boys have a greater risk than girls. A number of risk factors have been associated with SIDS, including premature birth, smoking within the home, and overheating. There may also be differences in both brain structure and function in infants that die from SIDS.

The substantial amount of research on SIDS has led to a number of recommendations to parents to protect their children. The Safe to Sleep campaign, sponsored in part by the National Institute of Child Health and Human Development, educates the public about how to minimize risk factors associated with SIDS:

  • Infants should be placed on their backs when put down to sleep
  • Cribs should not contain any items which pose suffocation threats, such as blankets, pillows, or padded crib bumpers
  • Infants should not sleep with caps placed on their heads in order to prevent overheating.

Recommendations like these have helped to decrease the number of infant deaths from SIDS in recent years.

Narcolepsy

Narcolepsy

A person with narcolepsy cannot resist falling asleep at inopportune times. These sleep episodes are often associated with cataplexy, which is a lack of muscle tone or muscle weakness, and in some cases involves complete paralysis of the voluntary muscles. Around one third of individuals diagnosed with narcolepsy experience vivid, dream-like hallucinations during narcoleptic attacks.

Narcoleptic episodes are often triggered by states of heightened arousal or stress. The typical episode can last from a minute or two to half an hour. Once awakened from a narcoleptic attack, people report that they feel refreshed. Obviously, regular narcoleptic episodes could interfere with the ability to perform one's job or complete schoolwork, and in some situations, narcolepsy can result in significant harm and injury.

Generally, narcolepsy is treated using psychomotor stimulant drugs, such as amphetamines. However, there is a tremendous amount of variability among sufferers, both in terms of how symptoms of narcolepsy manifest and the effectiveness of currently available treatment options.

Access a printable copy of this slideshowPDF 

Dig Deeper

A Sleepwalking Defense?

On January 16, 1997, Scott Falater sat down to dinner with his wife and children and told them about difficulties he was experiencing on a project at work. After dinner, he prepared some materials to use in leading a church youth group the following morning, and then he attempted repair the family's swimming pool pump before retiring to bed. The following morning, he awoke to barking dogs and unfamiliar voices from downstairs. As he went to investigate what was going on, he was met by a group of police officers who arrested him for the murder of his wife.

Yarmila Falater's body was found in the family's pool with 44 stab wounds. A neighbor called the police after witnessing Falater standing over his wife's body before dragging her into the pool. Upon a search of the premises, police found blood-stained clothes and a bloody knife in the trunk of Falater's car, and he had blood stains on his neck.

Remarkably, Falater insisted that he had no recollection of hurting his wife in any way. His children and his wife's parents all agreed that Falater had an excellent relationship with his wife and they couldn't think of a reason that would provide any sort of motive to murder her.

Scott Falater had a history of regular episodes of sleepwalking as a child, and he had even behaved violently toward his sister once when she tried to prevent him from leaving their home in his pajamas during a sleepwalking episode. He suffered from no apparent anatomical brain anomalies or psychological disorders. It appeared that Scott Falater had killed his wife in his sleep, or at least, that is the defense he used when he was tried for his wife's murder. In Falater's case, a jury found him guilty of first degree murder in June of 1999; however, there are other murder cases where the sleepwalking defense has been used successfully. As scary as it sounds, many sleep researchers believe that homicidal sleepwalking is possible in individuals suffering from the types of sleep disorders described above.

Good Sleep

Good sleep is important to our health and longevity. It is no surprise that we sleep more when we are sick, because sleep works to fight infection. Sleep deprivation suppresses immune responses that fight off infection. As we studied earlier, when we sleep well, our cognitive functions are increased, we are mentally alert, our blood pressure and stress hormones are decreased, and our overall health is maintained. Psychosomatic Medicine found that older adults who had better sleep patterns also lived longer.

Check Your Knowledge

As you read your assignment for this lesson, pay close attention to the key terms and phrases PDF listed throughout the chapter. These terms and concepts are important to your understanding of the information provided in the lesson.