Sleep disorders

Insomnia is one of the most common health problems brought to the attention of family doctors. Not being able to sleep is, however, not just a single complaint, it is several subtly interwoven problems. In many cases insomnia is no more than persistent dissatisfaction with the quality of sleep; in a few cases, however, it is a symptom of some underlying illness which may need medical investigation. Insomnia has been extensively investigated by researchers, not so much through scientific curiosity about a condition that is familiar to a greater or lesser extent to nearly all of us, but rather as part of the pharmacological hunt to find better hypnotic drugs to help people sleep. Curiously, at a time when one might have expected people to complain much more than usual about not being able to sleep – that is, during wartime – there is evidence that the complaints appeared to decrease rather than rise. This, certainly, was the case in Britain during World War II, when the incidence of cases of insomnia treated reduced remarkably. There was also a marked drop at that time in the frequency of suicides and mental illness of all kinds. This surprised the health planners of the day because, at the outset of the war, they had made extensive plans for dealing with the expected rise in numbers of psychological casualties among the civilian population. On the other hand, there is little doubt that the people who lived in the cities bombed night after night for months would have suffered from disturbed sleep. One is forced to conclude that lack of sleep did not appear to have any serious effects on health or at least, no effects that seemed serious enough to report in those dangerous and troubled times.

How common are sleeping problems?

In the 1980s the picture is very different. In Britain, for example, it is estimated that 25 per cent of the population experience sleeping difficulties at some time in their lives, and that 10 per cent take some kind of sleeping tablet. Over 18 million prescriptions are written for these drugs annually. Could it be that we have lost the ability to sleep soundly in a generation or two, or are there simpler explanations? Let us first look more closely at what people really mean when they say ‘I suffer from insomnia… I just can’t sleep a wink’.

Some people who believe they are suffering from insomnia are in fact experiencing only variable durations of sleeping time. They may feel tired, and think they are not sleeping long enough, and although this may be disturbing, it is not a pathological condition. Others may have difficulty in falling asleep, and once asleep may have difficulty in maintaining it. Some have restless sleep, in which the sleeper wakes in the middle of the night and has difficulty in getting back to sleep.

Yet others wake very early and cannot drop off again. It is important to determine into which of these categories any particular individual’s sleeping difficulty falls, in order to decide how the problem can best be resolved.

Who suffers from insomnia?

Generally, the older you are the more likely you are to have difficulty in sleeping. Most hypnotic drugs are prescribed for elderly patients. But insomnia is not a disease of aging, it is a natural part of the aging process. You cannot expect to enjoy the same depth and duration of sleep in old age as you did when you were a young adult.

Statistically, women are more likely to suffer from insomnia than men. In studies carried out on two groups of women, one of good sleepers and one of insomniacs, little differences could be found between the two groups in the amount of REM and non-REM sleep. Many similar studies have shown that ‘insom-niacs’ do in fact get enough of the vital REM sleep, even though they report being poorly refreshed after a night’s sleep.

What causes insomnia?

We know little about what actually makes us sleep so this question is a difficult one to answer. However, we do know that one of the earliest signs of impending sleep is a reduction of muscular tension followed by a sensation of drowsiness. It follows that something which prevents muscle relaxation, or prolongs or induces muscular tension, will stop sleep. One obvious cause is pain, but a much more common cause of muscular tension is simply anxiety. Any degree of emotional distress may cause anxiety, and some people are naturally more susceptible than others. Stimulants such as tea, coffee or nicotine (through cigarettes) will also negate the body’s mechanisms for inducing muscular relaxation. If you are already a light sleeper, these factors will make matters worse. Eating certain foods that cause indigestion or simply eating a large meal not long before bedtime is likely to keep you awake for obvious reasons. Even though it can seem to make you feel drowsy, alcohol can have much the same effect as indigestible food. It can also cause added complications and problems in sleeping soundly because it usually becomes necessary to get up in the night to empty the bladder.

When pre-school children have difficulty in falling asleep, it is usually because of a fear of separation, a normal phenomenon with children between eight months and two years old. The child is afraid that his parents will ‘leave’ him as soon as he’s asleep. This is especially likely if a child has experienced that his parents sometimes do go out when he’s in bed, and in such cases this fear can be very strong – the more so if they had promised beforehand to stay at home. Later on, jealousy of elder brothers or sisters who are allowed to stay up longer may play a part.

Solutions to insomnia

People’s desire for a good night’s sleep has been an enormous incentive to pharmatologists in their search for reliable hypnotic drugs. In the 1950s barbiturates were widely prescribed as sleeping pills. These drugs were extremely effective in getting people to sleep, but the quality of sleep they induce is poor and users would wake up in the morning feeling ‘hung-over’. Worse still, barbiturates taken in even a moderate overdose will kill, and these drugs gained notoriety as a popular choice of suicide victims. Today doctors prefer to prescribe sleep-inducing drugs which belong to a group known as the benzodiazepines. These drugs have a wide range of actions, all of which can help people to fall asleep. Diazepam, for instance, is a renowned antianxiety or ‘anxiolytic’ drug. Such a tranquillizer has the effect of helping people to relax.

Other benzodiazepines, such as flurazepam, have a more direct and specific influence on the induction of sleep.

Benzodiapines are relatively safe drugs in that it is difficult to take a fatal overdose. Unfortunately they do not induce a completely normal sleep pattern. The depth of the sleep is greater, but the intensity of the REM sleep is reduced. We know the brain needs REM sleep to organize itself, so it would be fair to assume that benzodiapine-induced sleep is poorer in quality than natural sleep. This is one of the causes of morning hangovers. Another problem with these drugs is that it takes a long time for the body to get rid of them after they have been swallowed. Twelve hours after taking them, half of the total amount may still be present in the blood. This means that, especially in the morning after having taken benzodiazepines the night before, driving a car should be avoided. After having taken sleeping pills for more than a few weeks, it is impossible to stop using them without having some kind of withdrawal symptoms. This is partly the effect of catching up the suppressed REM sleep. For a couple of days or even one or two weeks you will not be able to fall asleep easily and your dreams will be very vivid. This phenomenon is called rebound insomnia.

After a time, however, the sleeping pattern will be-come normal again. Unfortunately, such withdrawal symptoms tend to lead to a renewed use of sleeping pills and it can be difficult to break this vicious circle. Doctors now try to avoid prescribing sleeping pills, and review any prescriptions critically and often. Many people – doctors included – now recognize that ‘hi-tech’ and drug-based solutions to insomnia are not the best answers. As alternatives, the insomniac should consider first whether the sleeping problem is a symptom of something, such as emotional stress, pain or itching disorders. If it is, then the underlying problem must be resolved and this should in turn remove the cause of the insomnia.

Next the insomniac should seriously consider age-old, practical remedies to the problem of getting a good night’s sleep: . is the bed too hard or soft? . are the covers too heavy, or of the wrong thickness so that you are too hot or too cold? . Is the bedroom too hot or cold, or too noisy? (For most people an ideal temperature is 16°C to 18°C). . do you relax before turning in, instead of going straight from a business problem or an exciting film to bed, when you lie awake thinking or worrying? . An emotional upset just before trying to fall asleep is likely to have a retarding effect. On the other hand, satisfactory sexual intercourse will have a relaxing effect. . have you tried a warm, relaxing bath and/or hot, milky drink before getting into bed? . Do you work in bed, with the possible result that turning in has become associated with work worries and frustrations? . Some people are able to relax themselves by various relaxation exercises, like yoga or meditation, although for others this can have the opposite effect. . If all else fails – get up and do something construc-tive.

For some insomniacs the bed becomes linked with a new behaviour pattern of lying awake worrying about sleep, as opposed to actually sleeping. Get up and do not go back to bed until you feel tired and ready to sleep; repeat this if necessary, so that you retrain yourself in the correct behaviour pattern.

Early wakening

Early wakening may be a sign of good health, but it is one of the characteristic signs of depression. A doctor would take this into account when examining someone who complained of poor sleep. But early wakening can also be part of the natural decline in the number of hours’ sleep needed as we get older. Be-cause REM (dream) sleep is the state in which we are most likely to be aroused, we wake remembering dreams. This, coupled with the stimulus of light coming through the windows, plus noise and activity, is often sufficient to wake us early in the mornings. Unless one is suffering with symptoms of depression, therefore, early wakening is quite harmless and is no cause for concern. Get up and enjoy the day!

Too much sleep

Much rarer than complaints about not getting enough sleep are sleeping disorders characterized by too much sleep. A well-known example is the African tropical disease called sleeping sickness, one of the most obvious symptoms of which is extreme lethargy and apparent drowsiness. In another disorder, Kleine-Levin syndrome, the victim may sleep for excessive periods over cycles of about two to four weeks and then wake with a ravenous appetite. In narcolepsy, another very rare condition, there are sudden unpreventable lapses into a deep sleep, with no warning whatsoever. The condition is sometimes caused by encephalitis (brain inflammation) or a brain tumour in the hypothalamic area, where it is believed the sleep centre is located. Usually the narcoleptic wakes quite refreshed from a short sleep.

Other minor sleep problems

Most sleep-related problems begin and end in childhood. Bed-wetting (enuresis) is perhaps the commo-nest; it is usually caused by an inability to wake even when the brain is receiving signals from a full bladder.

Sometimes, however, enuresis is a child’s attempt to attract attention or annoy parents. Rarely in childhood is the condition a pathological one. Sleep-walking (somnambulism) is also seen in children and is a result of a neurological immaturity in the brain which disappears as the child develops. The human nervous system can be divided into two parts, one over which we have conscious control and a second which maintains the vital systems such as breathing and heartbeat. In somnambulists, it is believed that some of the messages intended for vital systems get misrouted and cause normally conscious actions to occur unconsciously: the result is sleep-walking. If you find your child sleep-walking, gently guide the child to bed again. To prevent a serious fall during a future episode it is wise to fix a gate across the top of the stairs.

Although nightmares are a common experience to all, some children suffer a particularly unpleasant kind known as night terrors. This is caused by sudden cessation of slow-wave sleep. The child awakes, usually with a scream, and is often inconsolable. Fortunately this sleep disturbance nearly always disappears as the child gets older. One disturbing problem for sleeping partners is snoring. It is caused by turbulence in the airways between the nose and the lungs; the whole of the respiratory system acts as a resonator to create the characteristic sound.

Adopting a different sleeping position, or changing the pillow for a smaller one, may be helpful. Occasionally snoring can be serious enough to stop the person breathing while asleep (sleep apnoea). In the most severe cases of snoring it is possible to treat the problem with surgery.

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