What Do Sleep Problems Consist Of?

Many people, including children, have sleep problems; in fact they affect about 10 to 40% of the population.  They include such things as:

  • Frequent awakening during the night
  • Talking during sleep
  • Difficulty falling asleep
  • Waking up crying
  • Feeling sleepy during the day
  • Having nightmares
  • Sleep terrors (in children)
  • Bedwetting (in children)
  • Teeth grinding and clenching
  • Waking early
  • Narcolepsy

Many sleep problems are related to poor sleep habits.  Poor sleep habits tend to occur when an individual gets used to doing many things in their bed:  reading, watching TV, playing video games, talking on the phone, eating, etc.  The end result is that the mind and body lose perspective of what a bed is for, because in those individuals it can be anything and everything.  So when it is time to sleep, the body doesn’t have a different feeling than any other time and resists falling asleep.

Additionally some sleep problems may be symptoms of stress.  In children persistent sleep problems may be a symptom of emotional difficulties or a fear about going to bed and falling asleep.  “Separation anxiety” is a developmental landmark for young children. For all young children, bedtime is a time of separation, but some children will do everything they can to prevent a separation at bedtime.  To help minimize common sleep problems, a parent should develop consistent bedtime and regular bedtime and sleep routines for children. Parents often find that feeding and rocking help an infant to get to sleep. However, as the child leaves infancy, parents should encourage the child to sleep without feeding and rocking. Otherwise, the child will have a hard time going to sleep alone.  Simply put, the child will expect whatever they got used to when they first learned to fall asleep.

What Types Of Sleep Problems Are There?

Sleep disorders can be related to problems initiating sleep, maintaining sleep, or resulting in excessive sleep.  They can affect the amount, quality, or timing of sleep and even result in behavioral abnormalities that occur during sleep.

Advanced Sleep Phase Syndrome – is a condition in which a person falls asleep very early in the evening, usually between 6 and 9pm, and then wakes up in the middle of the night before sunrise, sometimes as early as 1 am.

Bedwetting – also known as enuresis, is a condition in which a person (usually a child) urinates on the bed while sleeping.

Bruxism – – is a condition in which a person grinds their teeth or clenches their jaw during sleep.  It is one of the most common sleep disorders affecting up to 40 million Americans. Bruxism can result in serious damage to the teeth so getting treatment is very important.  It can also lead to facial pain and headaches, and in severe and chronic cases, it can lead to deterioration of the temporomandibular joints. Most individuals with Bruxism are not aware of it and 5-10% go on to develop symptoms such as jaw pain and headache. While there is no cure for this disorder, doctors either recommend mouth guards or Botox injections.

Delayed Sleep Phase Syndrome – is a condition in which the person chronically stays up until very late, usually until 3 to 4 am, and then sleeps all morning, getting up at 10 to 11 am.

Hypersomnia – is a condition in which a person sleeps too much, either for prolonged periods at night or during the day.

Insomnia – is a condition in which a person has an inability either to fall asleep or to remain asleep during the course of the night.  Insomnia can be further classified into:  Early insomnia– taking more than 30 minutes to fall asleep, followed by a relatively normal night of sleep.  Middle insomnia– waking up one or more times during the course of the night and taking more than 30 minutes to fall back asleep after each awakening.  Late insomnia– waking up before sunrise and not being able to get back to sleep.

Klein-Levin Syndrome – is a very rare condition in which a person needs excessive amounts of sleep, sometimes for up to 20 hours a day.  This is normally accompanied with excessive food intake (compulsive hyperphagia) and an abnormally uninhibited sexual drive (hypersexuality).  While some researchers speculate that Klein-Levin syndrome has a hereditary cause, others believe the condition may be the result of an autoimmune disorder. There is no definitive treatment for Klein-Levin syndrome. Stimulants and wake-promoting medicines including amphetamines, methylphenidate, and modafinil are used to treat the sleepiness. Because of similarities between Klein-Levin syndrome and certain mood disorders, lithium and carbamazepine may be prescribed.  Responses to treatment have often been limited.

Narcolepsy – is a condition in which a person chronically experiences daytime sleepiness so extreme that they fall asleep at inappropriate times for anywhere from a few seconds to 30 minutes. See Below for Further Information.

Night / Sleep Terror – is a condition in which a sleeping person (usually a child) will scream uncontrollably and appear to be awake, but is confused and can’t communicate.  The sufferer usually has no recollection of the event. Sleep is divided into two categories: rapid eye movement (REM) and non-rapid eye movement (non-REM). Non-REM sleep is further divided into four stages, progressing from stages 1-4. Night terrors occur during the transition from stage 3 non-REM sleep to stage 4 non-REM sleep, beginning approximately 90 minutes after the person (usually a child) falls asleep.  Sleep terrors may be caused by:  stressful life events, fever, sleep deprivation, medications that affect the brain, and recent anesthesia given for surgery.  See Below for Further Information.

Nocturia – is a condition in which a person has a reoccurring need to go to the bathroom and urinate at night

Periodic Limb Movement Disorder – This often coexists with restless legs syndrome and is a condition in which a person has sudden, involuntary, and repetitive leg jerking that occurs at the onset of sleep as well as during the course of sleep.

REM Behavior Disorder – is a condition in which a person loses the whole body paralysis that normally occurs during the Rapid Eye Movement period.  As a result, their body is free to act out their dreams. These behaviors can be violent in nature and in some cases will result in injury to either the patient or their bed partner.  REM Behavior Disorder is a treatable condition. The standard therapy is the anti-convulsant drug Klonopin (clonazepam), and this is generally well tolerated.  While the exact reason for its effectiveness is unknown, it does restore the natural paralyzed state of a person in the REM stage of sleep.

Restless Legs Syndrome – is a condition in which a person feels creeping, crawling, prickling, burning, itching, or tugging sensations in the legs while resting or sitting for extended periods of time. Sometimes the arms and torso may be affected as well.   While this disorder is at its worst during sleep or periods of non-movement it can also affect a person who is awake.   Restless Legs Syndrome is characterized by an irresistible urge to move one’s body to stop uncomfortable or odd sensations by providing temporary relief.  For relief of this disorder, some doctors prescribe anticonvulsants, opioids (such as methadone), or Benzodiazepines.

Rhythmic Movement Disorder – is a condition in which a person has head banging, head rolling, body rocking, body rolling or other repetitive movements during sleep.

Situational Circadian Rhythm Sleep Disorder – also commonly known as jet lag, is a condition in which a person has trouble adjusting to their home time zone and regular sleep schedule.  It also occurs to shift workers who work irregular and often night shifts.

Sleep Apnea – is a condition in which a person momentarily stops breathing during sleep. The most common form of this condition is obstructive sleep apnea, in which the air passages become blocked, causing respiratory distress. Sleep apnea is characterized by pauses in breathing during sleep. Each episode lasts long enough so that one or more breaths are missed, and occurs repeatedly throughout sleep. Clinically significant levels of sleep apnea are defined as five or more episodes per hour. Individuals suffering from this sleep disorder are rarely aware of having difficulty breathing, even upon awakening. It is usually recognized as a problem by others witnessing the individual during episodes or is suspected because of its effects on the body. Symptoms may be present for years, even decades without identification, during which time the sufferer may become conditioned to the daytime sleepiness and fatigue associated with significant levels of sleep disturbance. The most common treatment for sleep apnea is the use of a positive airway pressure (PAP) device. The PAP ‘splints’ the patient’s airway open during sleep by means of a flow of pressurized air into the throat. Other treatments such as surgery and medication also exist.

Sleep Talking / Somniloquy – is a condition in which a person talks aloud in their sleep. It can be quite loud, ranging from simple sounds to long speeches, and can occur many times during sleep. Listeners may or may not be able to understand what the person is saying. Sleep-talking usually occurs when the body does not move smoothly from one stage in non-REM sleep to another, and they become partially aroused from sleep. Further it can also occur during REM sleep at which time it represents a motor breakthrough of dream speech, when words spoken in a dream are spoken out loud.  There are no medical treatments for this, but in order to prevent sleep-talking a mouth guard may be worn.

Sleep Walking / Somnambulism – is a condition in which a person does actions typical of being awake such as walking around, eating or dressing, without conscious knowledge or awareness.  This usually occurs during stage 4 sleep (the deepest stage) and lasts between 5 and 15 minutes. Sleepwalking usually begins between ages 6 and 12.  It runs in families and affect boys more often than girls. Those who sleepwalk may appear to be awake as they move around, but are actually asleep and in danger of hurting themselves.

What is the Difference Between a Nightmare and Night / Sleep Terror?

Nightmares are relatively common during childhood, begin at a variety of ages, and occur throughout life.  Nightmares affect girls more often than boys. Children often remember nightmares, which usually involve major threats to their well being.  For some children nightmares are serious, frequent, and interfere with restful sleep.

Night / Sleep Terrors are different from nightmares. Children with sleep terrors will scream uncontrollably and appear to be awake, but are often confused and can’t communicate. Night / Sleep Terrors usually begin between ages 4 and 12.  Sleep terrors run in families and affect boys more often than girls.

Most often, children with these sleep disorders have single or occasional episodes of the disorder. However, when episodes occur several times a night, or nightly for weeks at a time, or interfere with the child’s daytime behavior, treatment by a child and adolescent psychiatrist may be necessary. A range of treatments is available for sleep disorders.

What are the symptoms of Sleep Terrors?

The symptoms include frequent recurrent episodes of intense crying, fear during sleep, and difficulty arousing the child.  They may also include an increased heart rate, an increased breathing rate and sweating during the episodes.  Unlike nightmares, most children do not recall a dream after a night terror episode, and they usually do not remember the episode the next morning. The typical night terror episode usually begins approximately 90 minutes after falling asleep. The child sits up in bed and screams, appearing awake but is confused, disoriented, and unresponsive to stimuli. Although the child seems to be awake, the child does not seem to be aware of the parents’ presence and usually does not talk. The child may thrash around in bed and does not respond to comforting by the parents. Most episodes last 1-2 minutes, but they may last up to 30 minutes before the child relaxes and returns to normal sleep. If the child does awake during a night terror, only small pieces of the episode may be recalled.

When do you need to seek Medical Care?

Sleep disruption is parents’ most frequent concern during the first years of a child’s life. Half of all children develop a disrupted sleep pattern serious enough to warrant physician assistance.  In children younger than 3 years, the peak frequency of night terrors is at least one episode per week.  In older children, the peak frequency of night terrors drops to one to two episodes per month.

If your child seems to be experiencing night terrors, an evaluation by the child’s pediatrician may be useful. During this evaluation, the pediatrician may also be able to exclude other possible disorders that might cause night terrors. Usually, a complete history and a physical exam are sufficient to diagnose night terrors. If other disorders are suspected, additional tests may be useful to exclude them:

  • An electroencephalogram (EEG), which is a test to measure brain activity, may be performed if a seizure disorder is suspected.
  • A sleep study, known as a Polysomnography (a combination of tests used to check for adequate breathing while asleep) may be done if a breathing disorder is suspected.
  • CT scans and MRIs are usually not necessary.

What is Narcolepsy?

Narcolepsy is a neurological disorder that affects the control of sleep and wakefulness. People with narcolepsy experience excessive daytime sleepiness and intermittent, uncontrollable episodes of falling asleep during the daytime. These sudden sleep attacks may occur during any type of activity at any time of the day.

In a typical sleep cycle, we initially enter the early stages of sleep followed by deeper sleep stages and ultimately (after about 90 minutes) rapid eye movement (REM) sleep. For people suffering from narcolepsy, REM sleep occurs almost immediately in the sleep cycle as well as periodically during the waking hours. It is in REM sleep that we can experience dreams and muscle paralysis, which explains some of the symptoms of narcolepsy.

What Are the Symptoms of Narcolepsy?

Symptoms of narcolepsy include:

Excessive daytime sleepiness (EDS): In general, EDS interferes with normal activities on a daily basis, whether or not a person with narcolepsy has sufficient sleep at night. People with EDS report mental cloudiness, a lack of energy and concentration, memory lapses, a depressed mood, and/or extreme exhaustion.

Hallucinations: Usually, these delusional experiences are vivid and frequently they are frightening. The content is primarily visual, but any of the other senses can be involved. These are called hypnagogic hallucinations when they occur while falling asleep and hypnopompic hallucinations when they occur while waking up.

Cataplexy: This symptom consists of a sudden loss of muscle tone that leads to feelings of weakness and a loss of voluntary muscle control. It can cause symptoms ranging from slurred speech to total body collapse depending on the muscles involved and is often triggered by intense emotion, for example surprise, laughter, or anger.

Sleep paralysis: This symptom involves the temporary inability to move or speak while falling asleep or waking up. These episodes are generally brief lasting a few seconds to several minutes. After episodes end, people rapidly recover their full capacity to move and speak.

What Causes Narcolepsy?

The cause of narcolepsy is not known, but very likely involves multiple factors that interact to cause neurological dysfunction and REM sleep disturbances. However, scientists have made progress toward identifying genes strongly associated with the disorder. These genes control the production of chemicals in the brain that may signal sleep and wake cycles. One such chemical is called hypocretin.   Experts believe a deficiency in the production of this chemical by the brain is responsible for Narcolepsy.  In addition, researchers have discovered abnormalities in various parts of the brain that contribute to symptom development.  These areas are involved in regulating REM sleep.

How Is Narcolepsy Treated?

There is no cure for narcolepsy, but the most disabling symptoms of the disorder can be controlled in most people with medication treatment.  These include excessive daytime sleepiness and symptoms of abnormal REM sleep, such as cataplexy. Sleepiness is treated with stimulants, such as amphetamine (that have wake-promoting properties) and other medications, such as antidepressants, can help treat the symptoms of abnormal REM.

In addition to this, lifestyle changes can be helpful.  These include avoiding caffeine, alcohol, nicotine, and heavy meals.  Regular exercise, regular sleep schedules, small naps (15 min or so) and regular meal schedules may also reduce the symptoms.