Sleep Basics - 101 Questions About Sleep and Dreams

Chapter 7 - Things that Go Wrong in the Night (Part 1)

68. Just what can cause insomnia?
69. What are the best ways to treat these problems?
70. Can sleeping pills make matters worse?
71. How soon will it be before science develops a natural, non-addictive sleeping pill that acts like the natural sleep-producing chemicals in the brain?
72. Can behavior modification cure insomnia?
73. Is exercise helpful?
74. If one has trouble falling asleep, is it better to get up or stay in bed and 'count sheep'?
75. I wake up at about 3 AM every morning. Once I am awake, it is hard or impossible for me to go back to sleep. What causes this?
76. I have heard that someone can actually wake up to answer the phone, talk sensibly and yet not remember the call in the morning. Can this really happen?
77. My 82-year-old mother lives alone across town. She gets along pretty well during the day but says that she cannot sleep at night. We have been telling her that older people have trouble sleeping and to try and do something instead of worrying about it. Well, lately the neighbors have said that she is up and about all hours of the night. She is even out on the street at 3 AM! What can we tell her to do?
78. Aside from the many problems leading to the symptom of insomnia, what are some of the other major sleep disorders?
79. What are the signs of sleep apnea?
80. Can the sleep apnea be dangerous?
81. What causes apnea?

68. Q: Just what can cause insomnia?

Any one of some 40 different conditions have been identified. The most common is a psychological or psychiatric abnormality. That is true of about half the insomniacs who come to sleep disorders centers. The other half are people with more specific medical abnormalities. Here are some of the most common:
- breathing difficulty during sleep such as sleep apnea
- periodic twitching of the legs and arms that disturbs sleep
- overuse of sedatives or alcohol that disrupts sleep
- stomach problems such as reflux or indigestion
- physical pain such as with arthritis or rheumatism

69. Q: What are the best ways to treat these problems?

Once a specific diagnosis is made, proper treatment is aimed at the cause of the insomnia. For example, people with insomnia secondary to respiratory difficulty may take drugs to improve respiration during sleep. People who have insomnia associated with overuse or abuse of alcohol must stop drinking, and so on. Sleeping pills are best reserved for patients who have insomnia as a reaction to some crisis. Sleeping pills should be of the prescription variety, not the over-the-counter kind, because there are no good studies to show that non-prescription sleeping pills work as advertised. This is true, in part, because over-the-counter medications are not subject to the strict requirements that the U.S. Food and Drug Administration sets up for prescription drugs. Sleeping pills should be taken over not more than a three-week period -- and preferably not every night. Furthermore, the use of sleeping pills should be supplemented with other techniques to promote sleep, such as a regular wake-sleep schedule, regular activity after getting up in the morning and abstinence from caffeine-containing drink and food. The caffeine in coffee, tea or even several pieces of chocolate after dinner can be sufficient to keep a sensitive person awake for hours.

70. Q: Can sleeping pills make matters worse?

Absolutely. There is no question that abuse of sleeping pills leads to destruction of normal sleep and increased insomnia. For example, a barbiturate taken for too long can eventually make sleep much worse than it was during the period of insomnia that prompted taking the drug in the first place.

Furthermore, when the patient discontinues the medication or runs out of it, terrible insomnia follows. The person cannot sleep at all for days, and after finally falling asleep may have terrible nightmares. This predisposes the patient to return to the barbiturate and you have a vicious cycle of dependency and withdrawal. Still, if it is a matter of getting a good night's sleep before a difficult examination or during a brief family crisis, a good sleeping pill may be very useful.

71. Q: How soon will it be before science develops a natural, non-addictive sleeping pill that acts like the natural sleep-producing chemicals in the brain?

This is an area of intense investigation, but it is too early to tell what the results will be. Scientists are somewhat less optimistic about a super sleeping pill than they used to be. Sleep and wakefulness are complementary periods in a natural 24-hour cycle that cannot be manipulated on the spur of the moment. When we fly across the Atlantic from New York to Paris, our sleep structure as well as our work productivity adjust slowly, over several days, to this time shift. So, it is unlikely that taking a single pill could quickly reschedule all aspects of our natural body rhythms.

One disappointing 'natural' approach for insomnia and other problems related to jet-lag has been the specially timed use of melatonin, a natural chemical manufactured by certain brain cells. Melatonin is thought to be involved in regulating our body clock. Experiments giving melatonin to people at specific times each day for several days prior and after a long flight east or west have failed to show any improvement.

Another approach to sleep rescheduling is exposure to bright light at a particular time. The light should be in the form of regular sunlight or special artificial light with an intensity of about 2500 lux (the intensity of daylight just after dawn). Research indicates that people who need to sleep at a time later than their habitual time -- either because some disorder has shifted their schedule or because they must work on a new schedule -- can shift by sitting in bright light for several hours before they would normally go to bed. On the other hand, if one wants to shift their sleep to an earlier time, light exposure should occur just after awakening. The light is thought to reset the biological clock. Bright light's shifting effect requires at least 2 hours of properly scheduled exposure to a light source that is as least as bright as dawn sunlight for 2 or 3 consecutive days.

72. Q: Can behavior modification cure insomnia?

It is important to remember that there are many causes for the symptom of insomnia. Behavioral approaches are unlikely to work if the cause of insomnia is, for example, sleep apnea or respiratory irregularity associated with altitude. Behavioral techniques, particularly of the self-help variety, can be dangerous when they delay proper diagnosis and treatment. Do not be too quick to 'psychologize' your sleep problem -- it could be a treatable physical condition.

However, if medical problems are ruled out and the sleep problem is chronic and psychophysiological, behavior modification often is the best choice. There are many approaches: relaxation therapy, biofeedback, meditation, improvement of sleep habits. A patient who does not respond to one approach may respond to another one, so sleep experts advise patients to continue trying until they find the technique that works best for them, rather than to rely on exclusively pills.

73. Q: Is exercise helpful?

Yes, if it is done consistently. One day a week of exercise is likely to disturb rather than promote sleep during the following night. But consistent, daily exercise, preferably in the morning or at least well before dinner, helps promote a regular wake-sleep cycle and improves chances for a good night's sleep.

74. Q: If one has trouble falling asleep, is it better to get up or stay in bed and 'count sheep'?

That depends on the individual, which is why the decision as to what to do should be guided by a professional. One approach is to behave exactly as you would normally behave during sleeping hours -- lie in bed and try to relax. Do not get up and do push-ups. But, if by remaining in bed you only create a great deal of anxiety and misery for yourself, then you should get up and try to engage in some activity to reduce anxiety and tension. However, there is always the risk that in getting up you may further disturb the natural 24-hour cycle of activity and rest that is necessary for good sleep.

75. Q: I wake up at about 3 AM every morning. Once I am awake, it is hard or impossible for me to go back to sleep. What causes this?

The most common reason for this symptom is drinking too much alcohol too late in the evening. While alcohol near bedtime may help with getting to sleep, its effects wear off quickly leaving one awake, dehydrated and uncomfortable 2 - 4 hours later.

The next most common reason for early morning awakening is depression. There are data from almost every sleep laboratory in the country indicating that early morning awakening without being able to return to sleep is one of the hallmarks of depression. Sleep laboratories have found that another sign of depression is the premature onset of REM sleep. The normal interval between falling asleep and the first period of REM sleep is 80 - 100 minutes. Doctors think that a premature REM sleep period -- say, 15 - 30 minutes after sleep begins, is a sign of depression. When depression underlies the symptom of insomnia, treatment is focused on the depression rather than the insomnia. Once such depression is adequately treated, problems with insomnia improve greatly.

The third most common reason is a time shift in the natural sleep period so that one feels ready for bed at about 8 PM, rather than the normal 10 to 11 PM. Then, an early morning awakening marks the normal end of the sleep period. Such time shifting is especially common in people over the age of 50 and is thought to be related to the effects of aging on biological timing systems. If this is the cause of early morning awakening, then establishing a consistent schedule of going to bed no earlier than 11 PM or so, should help.

76. Q: I have heard that someone can actually wake up to answer the phone, talk sensibly and yet not remember the call in the morning. Can this really happen?

Yes, this kind of occurrence is really rather common. Sleep research and clinical experiences point out four key factors which influence the type of behavior that follows such a nighttime arousal: (1) the phase of sleep during which the arousal occurs, (2) the level of alertness that results from the arousal, (3) the duration of the arousal and (4) the psychological make-up of the sleeper. A number of possibilities result from these four factors. Most common is that a sleeper awakens completely, the subsequent behavior is quite typical of the sleeper's personality, and the incident is remembered the next day. If, however, the activity during an arousal is brief and the person goes back to sleep quickly, there may be no recall of the event.

There are several other, more exotic possibilities. Suppose the sleeper is in slow-wave sleep and does not awaken completely when aroused. Under these circumstances people essentially can sleepwalk and sleeptalk. The general term for these phenomena is 'nocturnal confusional arousal'. Under circumstances of nocturnal confusional arousal, people may do things that make sense or do things that make no sense. For example, many doctors, most particularly young, sleep-deprived doctors, have been awakened by phone, given proper instructions and then been unable to recall the telephone conversation.

People with histories of severe psychological stress, such as war veterans, have been known to partially wake up and then act out past battle activities, sometimes wrecking the room and even hurting the bedpartner, with no recall of the incident in the morning.

This is the stuff that mystery novels are made of -- the wealthy man signing a new will and never remembering, etc. Do not get any ideas, though. While it is possible for someone to make another person do something that is not in their best interests during a confusional arousal, chances are great that the victim will fully awaken, protest vigorously and remember everything in the morning.

77. Q: My 82-year-old mother lives alone across town. She gets along pretty well during the day but says that she cannot sleep at night. We have been telling her that older people have trouble sleeping and to try and do something instead of worrying about it. Well, lately the neighbors have said that she is up and about all hours of the night. She is even out on the street at 3 AM! What can we tell her to do?

Nighttime sleeplessness, wandering and confusion are very frightening and dangerous symptoms. These symptoms are increasingly common in our population's elderly and a leading reason for admission to nursing homes. There are several possible reasons why older persons develop sleeplessness and wandering at night. These symptoms can be a sign of Alzheimer's Disease or other forms of dementia. Such symptoms can also develop with conditions of severely disrupted sleep, such as sleep apnea and periodic limb movements during sleep, in which the patient reports little or no sleep but actually alternates between sleep and confused wakefulness hundreds of times per night. Certain medications taken for chronic medical conditions may also contribute to the problem. The symptoms described in this question are serious and termed 'nocturnal wandering'. Consult a physician.

78. Q: Aside from the many problems leading to the symptom of insomnia, what are some of the other major sleep disorders?

Insomnia or poor sleep is the most common complaint concerning sleep. However, the most common reason people go to sleep specialists is not for insomnia but for difficulty staying awake. The two most common problems causing difficulty staying awake are sleep apnea and narcolepsy. Sleep apnea (stoppage of breath or difficulty in breathing during sleep) is quite common. Sleep laboratory studies on a random sample of middle-aged adults in Wisconsin showed that the prevalence of clinically significant sleep apnea at night with the symptom of sleepiness during the day was 2 percent for women and 4 percent for men. Randomized studies in California indicate that as many as 1 out of every 4 people over the age of 65 is affected with sleep apnea. Narcolepsy involves sudden 'sleep attacks' during the day and brief periods of muscle weakness brought on by laughter. Some 250,000 Americans, about equally divided between men and women, suffer from narcolepsy. While the sleepiness in sleep apnea stems from disrupted sleep and in narcolepsy, from a chronic neurological disorder; if either condition goes untreated, the symptoms can be disabling.

79. Q: What are the signs of sleep apnea?

The most common signs are loud, irregular snoring and daytime sleepiness. In the apnea patient, breathing during wakefulness may seem entirely normal. However, during sleep the brain's control of breathing and of muscles changes and apneas occur as the walls of the airway close-in during the act of breathing in (i.e. during inspiration). The patient struggles for air, the airway opens somewhat and air rushes in, causing loud snoring. The patient tosses about and goes back to sleep. This cycle is repeated hundreds of times throughout the night, each time disrupting sleep and contributing to the patient's excessive sleepiness during the daytime.

80. Q: Can the sleep apnea be dangerous?

Very. The condition can be particularly dangerous if it is combined with any significant heart or lung abnormality. In all major metropolitan areas there are medical facilities that evaluate sleep problems, and most have had the experience of an apnea patient dying at home in bed before treatment was given -- most commonly while the center's evaluation had yet to be completed or after the patient had refused treatment for sleep apnea.

If, as a result of apnea, a patient falls asleep inappropriately during the daytime, this symptom also can be life-threatening or cause serious injury and property damage. Consider the potential harm, for example, of a pilot or a school bus driver who falls asleep on the job.

81. Q: What causes apnea?

The most important single factor is narrowing at one or more points in the anatomy (shape) of the airway. The narrowing may be no problem at all during waking hours. During sleep however, because of changes in the way breathing is regulated and because we are usually lying horizontally, the narrowing leads to sleep apnea. Narrowing can be anywhere along the airway from the back of the nose and throat (nasopharyngeal airway) to the point where the wind pipe (trachea) divides into the two tubes (bronchi) leading to the lungs. Narrowing could stem from hereditary influences in the way the body's bones and muscles grow. Narrowing can also result from fat deposits or other types of extra flesh around the walls of the airway. The important thing is that the anatomical problem acts to partially reduce the size of the airway. Most sleep specialists now use an x-ray procedure, or some other imaging technique, to locate all places where the airway is too narrow.

Probably the most common reason for sleep apnea is extra tissue in the oropharyngeal airway -- the spot between the base of the tongue and the Adam's apple. Such extra tissue is common in overweight men with short muscular necks. The extra tissue reduces the opening in the airway available for breathing. The typical apnea patient is a man who is in his 40's or 50's, overweight, with a short, muscular neck, and history of snoring and progressively worsening sleepiness. Another common type of patient is someone with a jaw abnormality -- like someone with a large overbite due to a receding chin. Such problems with facial structure can have the same effect on the airway during sleep as problems with extra tissue in the oropharyngeal airway.

Sleep apnea tends to run in families. This is because the shape of the face tends to be passed on from parents to children. The positioning of facial tissue and certain bones in the head and jaw greatly affect the size of the upper airway and thereby the likelihood of sleep apnea.

Alcohol and sedatives, by depressing the central nervous system and relaxing the airway muscles, can also contribute to sleep apnea. So can age -- older people snore more, presumably because the airway tissues are more limp and therefore more likely to close in during intake of air.

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