Psychology Today Blogs - Sleepless in America

Sleep Apnea

John Cline, Ph.D. — Fri, 03 Oct 2008 09:14:10 -0700

Janet lay awake in bed. She had been unable to sleep, as usual, due to her husband's loud and incessant snoring. Recently she had become alarmed by the increasingly frequent pauses in his breathing. Earlier in the evening Charles had had several drinks while out at dinner with friends and his snoring was especially loud and disruptive on this night. Janet noticed that the snoring stopped. There was quiet and she realized that Charles was not breathing at all. As seemingly endless minutes went by, he appeared to be struggling to breathe. Finally she became so alarmed that he might die from being unable to breathe that she reached out to shake him. Before she could touch him, Charles suddenly gasped deeply. He seemed to briefly wake up- and then immediately fell back into a deep sleep. In just a moment the loud snoring started up again and in a few minutes there was another long, breathless pause. After another sleepless night for Janet, the alarm went off. Charles slowly awakened. He felt groggy and tired the rest of the day. Despite getting 8 hours of sleep, he could hardly keep his eyes open and nearly hit another car when driving to a nearby lunch spot.

This distressing story is a common experience for many couples. Charles later discussed his day time sleepiness and his wife's complaints about his snoring with his doctor. This led to a sleep study and a diagnosis of obstructive sleep apnea (OSA). Obstructive sleep apnea is an increasingly well known disorder and, depending on the parameters considered, affects 4% to 24% of men and 2% to 9% of women in the US. The difference in estimates mainly relates to whether or not the definition includes the criterion of excessive daytime sleepiness. Sleep apnea can occur at any age with increasing prevalence in middle and older age. Menopause is a risk factor for women. The major risk factor for sleep apnea is excess body weight with increasing risk accompanying increases in weight. Localized structural abnormalities such as enlarged adenoids and tonsils can cause sleep apnea even in normal weight individuals. Smokers appear to be at higher risk. Endocrine disorders such as hypothyroidism increase the risk for sleep apnea. Episodes of apnea are usually made worse by alcohol consumption and by nocturnal nasal congestion. Family background appears to make a difference either due to genetic or shared lifestyle factors. Sleep apnea is a significant disorder with both immediate and long range implications.

There are a number of different kinds of sleep apnea depending on what causes the sleeper to stop breathing, but the most common type is OSA. With OSA, during sleep either complete or partial obstruction of airflow occurs which may result in decreased blood oxygen levels and arousal or awakening from sleep. Typical features include snoring, breathing pauses, gasping, choking, and frequent movements. Daytime symptoms include fatigue and sleepiness. Daytime drowsiness may be so severe that car or industrial accidents occur.

OSA is the result of the upper air way becoming obstructed during sleep. Obstruction may occur anywhere in the upper airway as the muscles which keep the airway open relax with the onset of sleep. The further reduction in muscle tone that occurs during REM sleep may contribute to longer and more prominent airflow reductions during this stage of sleep. In children upper airway narrowing is most often due to enlarged tonsils and adenoids. The major cause in adults is excess weight as the increased fatty tissue contributes to the narrowing of the airway and increases obstruction.

As breathing is reduced or stopped, blood oxygen levels may decrease and carbon dioxide levels may increase. The heart needs to work harder to supply oxygen to the body at the very time that less oxygen is available to power the heart. As the brain notes the changing blood gas levels an alerting signal results in a brief arousal or awakening. This leads to an increase in muscle tone and re-establishment of airflow in the upper airway. The person is able to breathe again and falls back asleep. The process then repeats, perhaps many times during the night. Frequent arousal results in disrupted sleep and may contribute to daytime sleepiness. The cardiovascular system is stressed and does not get the rest that typically takes place during sleep.

OSA can cause disruption of the sleep of family members due to the loud snoring and frightening breathing pauses. In the individual with OSA there may be poor quality sleep, day time sleepiness, decreased cognitive functioning with poor attention, concentration and memory, and depressed mood. OSA is a significant risk factor for high blood pressure. It is associated with type II diabetes. OSA may worsen some forms of co-existing heart disease. OSA may have a causal relationship with heart attack, stroke, cardiac arrhythmia, pulmonary hypertension and depression. While weight gain is often a causative factor in sleep apnea, sleep apnea also appears to frequently result in increased weight gain that may contribute to the worsening of the sleep apnea and contribute to the increased risk of other diseases.

If you (or a loved one, adult or child), have symptoms of sleep apnea including loud and disruptive snoring, breathing pauses, nocturnal gasping or choking, and daytime sleepiness, this should be fully discussed with your physician. A sleep study may be ordered and treatment recommended. Fortunately, a number of effective treatments are now available for sleep apnea and have been shown to have a positive impact on symptoms such as daytime sleepiness and hypertension. If you have sleep apnea, getting it treated will go a long way towards preventing you, and your long-suffering bed partner, from being sleepless in America.

Incubus Attack

John Cline, Ph.D. — Mon, 08 Sep 2008 17:32:58 -0700

Jason struggled to open his eyes as the oppressive pressure on his chest became more severe. He sensed a presence in the room and felt her weight pushing down on him as he struggled to breath. As his eyes opened slightly he saw the shadowy figure above in the dimly lit bedroom. Her presence and a vague sense of dread filled him as he realized that he could not move. No matter how hard he willed his body to come to life and take protective action, nothing happened. What was happening and why? Time stretched on and his fear grew. Finally his arms and legs responded and he sat up, finding himself alone in the room and shaken by this frightening visitation. He found it difficult to fall back to sleep and wondered what had happened. Had he somehow been violated? Off and on during the next day he shuddered as he thought back on the unearthly presence he had encountered in his bed room.

Jason's experience, surprisingly, is not that uncommon and is certainly not the most dramatic report of what is sometimes referred to as an incubus attack. In this case it may be more appropriate to call it a succubus attack as that is the term used to denote the demonic female presence. This kind of experience is commonly reported around the world but with differing mythological explanations. For example, in Japan they have been referred to as kanashibari, in China as ghost oppression, and in England and America as the Old Hag. Frightening and overwhelmingly realistic, these experiences are another example of a parasomnia, specifically, sleep paralysis. They can be hypnopompic (occurring while awakening) or hypnagogic (occurring while falling asleep) and are associated with frightening imagery or hallucinations.

The idea of the incubus attack is based in the medieval lore of the nocturnal demonic visitation. In one version of this lore, the demon is able to take on both male and female human shape and potentially impregnate a woman, causing her to give birth to a demonic child. The demon would initially take on the form of a female, known as a succubus, which would mate with an unsuspecting male victim. Capturing his "seed" the demon could then take on the male form, known as the incubus. The incubus would then mate with a female victim who could be impregnated with "demon seed." This frightening explanation for these nocturnal experiences is still embraced by some today, and many people who have had this experience find the demonic explanation convincing, at least initially, because the experience is so intense and apparently real.

Other explanations have, of course, been offered. For example, an embarrassing nocturnal emission might have resulted from an uninvited demonic visitor. An unexplained pregnancy may have been explained as the result of a visit by an incubus.

The scientific explanation for the incubus attack is that the person experiences a state dissociation in which part of the mental apparatus comes to conscious awareness even as the rest of the brain is in the REM stage of sleep. The body remains paralyzed so as to prevent acting out the dream. The realization that it is not possible to move contributes significantly to the unpleasant and frightening quality of this event. In addition, a potential sexual aspect to the experience is provided by the physiology of REM sleep which causes erection in men and lubrication in women. Awakening from a frightening experience and subconsciously recognizing an erotic bodily feeling lends itself to seeing a connection between the experience, and the working of dark and evil forces. The conscious experience is a combination of dream mentation superimposed on the sensory background of the room in which the person is sleeping. Long before Hollywood perfected the green screen technique or computer graphics allowed for the easy integration of the fantastic with the realistic, the brain was able to seamlessly blend together the inner world of the dream with the outer world of sense perception during these state dissociations.

It must be emphasized that for the person who has experienced an incubus or succubus attack, the rational, scientific explanation may lack the powerful emotional force of the demonic explanation. Even for trained scientists who have had these experiences, shaking the belief of having been visited by a malignant force is very difficult. An interesting account of this may found in Ronald Siegel's book, "Fire In the Brain." Many patients seeking reassurance will agree that the state dissociation explanation makes good sense but .....

The incubus attack is just one example of what can occur during state dissociations in sleep. There is also a great deal of sleep related sexual mentation and potentially many sleep related sexual behaviors. In future posts these interesting and potentially disturbing experiences will be discussed.

Cognitive Behavioral Therapy of Insomnia

John Cline, Ph.D. — Sun, 17 Aug 2008 20:43:15 -0700

When Representative Patrick Kennedy crashed into a security barricade while driving near the capital in Washington, D.C., on May 4, 1996, he explained that he had been using Ambien, a well known sleeping medication. He said that he had taken the sleeping medication as well as another prescription for gastroenteritis. He later falsely believed that he had to be present for a vote in congress and began driving when the accident occurred.

Sleeping medication, under the right conditions, can be helpful for insomnia but there are potential problems. When you are dependant on sleeping medication, episodes of rebound insomnia occur when you stop taking it. Side effects such as feeling "hung over" in the morning are common and alarming effects such as sleep walking and even sleep driving, as claimed by Representative Kennedy, are well known.

While sleeping medication is big business, research has shown that the most effective treatment for insomnia is actually cognitive behavioral therapy. This approach to psychotherapy was originally pioneered by such leading researchers as Albert Ellis and Aaron Beck. Beck's outstanding research, theoretical formulation and clinical techniques were first published in a series of significant books and articles in the 1960's and 1970's. Further research since the publication of the breakthrough "Cognitive Therapy of Depression" in 1979 has shown the utility and effectiveness of this treatment approach with numerous psychological and physical disorders including anxiety, chronic pain and insomnia.

The most important aspect of cognitive behavior therapy (CBT) for insomnia is that it actually treats the cause of the insomnia itself - and not just the symptoms as medication does. Furthermore, CBT can be combined with medication management for patients who need rapid relief or to help initially break a pattern of insomnia.

CBT works because the primary cause of insomnia is over-arousal or a "too active" awake system in the brain. By helping reduce the arousal associated with the stressors that cause and maintain insomnia, normal sleep can be restored.

CBT helps reduce worry, anxiety, and fear that one won't sleep by providing accurate information about sleep. For example, recognizing that you may be getting more sleep than you think (due to misperceiving lighter stages of sleep as wakefulness) and understanding that you may need less sleep than you thought, can reduce anxiety about not getting enough sleep and paradoxically lead to being able to relax and sleep better. For example, the minimum amount of sleep necessary to maintain alertness in most people is 5.5 hours. This is known as "core sleep" and is less than what most people need to feel fully refreshed but may be adequate for normal functioning. Cognitive techniques help people identify, challenge and replace negative, inaccurate sleep thoughts with accurate, positive sleep thoughts. Negative sleep thoughts can occur during the night ("I won't be able to function tomorrow if I don't get to sleep soon") as well as during the day ("I got an awful night of sleep last night so I will have a terrible day at work today"). Positive sleep thoughts are used to counteract the negative thoughts with more accurate information ("I am not sleeping well tonight but I have had many other nights like this and have been able to function reasonably well at work anyway"). Cognitive techniques help reduce stress and allow better sleep.

Many behavioral techniques are used as part of this therapy. With sleep restriction and sleep scheduling the amount of time in bed is reduced to be closer to the amount of actual sleep the person is getting and regular sleep and wake times are maintained. If someone is usually sleeping an average of 6 hours a night but is spending 8 hours in bed, the recommendation will be to reduce time in bed to about 6.5 hours. This decreases the unpleasant sense of being awake in bed at night. By increasing the amount of time out of bed (and therefore not in light sleep that is misperceived as wakefulness), sleep drive is increased thus helping the person more rapidly enter into a deeper sleep. Other techniques include avoiding daytime naps (which decrease night time drive to sleep), stimulus control, sleep hygiene, and stress management. Stimulus control is based on classical conditioning effects in which long periods of being awake in bed result in association learning such that getting into bed results in the expected response of being alert and awake. To extinguish this response the following instructions are given: after subjectively being awake for 20 to 30 minutes, get out of bed and go to a quiet, comfortable place and relax until drowsiness occurs. At that time go back to bed. If another 20 to 30 minutes go by without falling asleep, repeat the process, doing so as many times as necessary. In time the automatic alertness is extinguished and the conditioned arousal associated with the bed is eliminated. Sleep hygiene involves the use of guidelines to create the best conditions and environment for sleep. An example would be avoiding caffeine later in the day. Stress management might include setting up a "buffer zone" of about an hour for winding down and relaxing before going to bed.

CBT has been tested in a number of well controlled research studies and has been found to be an effective treatment for insomnia. Of significance, a course of CBT may not only continue to have positive outcomes 12 months after completion of the program but also the effect can continue to improve long after treatment. This is because patients continue to practice the techniques and so experience further improvement with time. With consistent use of these methods it is possible to get a good, natural night of sleep. No pills, no dependency, no side effects- just wonderful, refreshing sleep! Zzzzzzzzzz...

Medication Management of Insomnia

John Cline, Ph.D. — Mon, 28 Jul 2008 19:13:03 -0700

Soft, drifting on air, light and beautiful...The Luna moth is now associated in everyone's mind with the sleeping medication Lunesta - the result of a brilliant marketing campaign. Who wouldn't be able to sleep, adrift on a blanket of calm, serene night air?

Sleeping medication is frequently prescribed and is big business. Anyone watching TV or reading magazines sees plenty of perfectly coifed, rested-looking individuals smiling as they gently awaken and greet the sunlit morning. In other words, these medicines are being advertised aggressively by the pharmaceutical industry. Properly used they can be very helpful - but there are associated risks and costs.

Medication management is one of the two major approaches to the treatment of insomnia, the other being cognitive behavior therapy, which will be discussed next time. The focus of this post is prescription medications that are used by health care providers to treat insomnia. The use of regulated (over-the-counter) medications and unregulated (herbal, homeopathic, hormonal and dietary) supplements as sleep aids will be discussed in the future.

How do these seemingly magical potions help us to sink into sleep? Current sleeping medications work in a number of different ways, by affecting various brain systems involved with the sleep and wake systems. Each has benefits and potential risks which need to be understood and weighed in any given clinical situation. First, there are medications which are not FDA approved as sleep medications but that physicians may use "off-label" to treat sleep problems. Second, there are FDA-approved insomnia treatment medications.

Indeed, some of the most frequently prescribed medications for insomnia are actually antidepressants used off-label for this purpose. The major ones are trazodone, amitriptyline and mirtazapine. These drugs have complex effects on many neurotransmitters including serotonin, norepinephrine and histamine. These are know as sedating antidepressants and may well help sleep in depressed people but there are few data that show they're effective or safe in non-psychiatric patients. A few of the problems that may occur with these medications include morning "hangover," cardiac arrhythmias, and orthostatic hypotension.

The FDA has approved two types of medication specifically for the treatment of insomnia. These are the benzodiazepine receptor agonists and the melatonin receptor agonists (of which only one drug has been approved to date). The benzodiazepine receptor agonists include the benzodiazepines and the nonbenzodiazepine hypnotics (drugs that promote sleep by affecting the benzodiazepine receptor complex but are structurally unrelated to the benzodiazepines). These drugs work by affecting the GABA receptor complex. GABA (gamma-aminobutyric acid) is the major inhibitory neurotransmitter in the central nervous system. Benzodiazepine receptor agonists may have a general cortical sedating effect but most importantly affect the ventrolateral preoptic nucleus which is involved in the regulation of sleep and wakefulness. Melatonin receptor agonists have an entirely different mode of action and selectively affect melatonin receptors in the suprachiasmatic nucleus which is involved in the regulation of the sleep-wake cycle (circadian or 24 hour rhythms).

The benzodiazepines include such well know drugs such as Valium and Xanax that may be used to promote sleep but also have other medical uses such as the management of anxiety. These medications were introduced in the 1960's and were first recommended for insomnia in the 1970's.

There are five immediate release benzodiazepines approved specifically for treatment of insomnia: ProSom, Dalmane, Dorale, Restoril and Halcion. All of these medications speed sleep onset and increase sleep time and are moderately effective for the treatment of insomnia. There are three immediate release nonbenzodiaepines indicated for the treatment of insomnia: Lunesta, Sonata, and Ambien. There is also a time release version which is designed to help maintain sleep later in the night: Ambien CR. These medications are effective for treatment of insomnia. Based on recent research Lunesta and Ambien CR have been found effective for long term use (more than 6 months). In the past, they were recommended only for short term use, as are the other benzodiazepine receptor agonists.

These medications work rapidly and should be taken only when going to bed. Except for Sonata, which is very rapidly eliminated from the body, all should be taken only if the patient has 7 to 8 hours to spend in bed. They are generally well tolerated, although adverse effects can include day time sleepiness, amnesia for events prior to taking the medication, headache, diarrhea, nausea, and dizziness. A rare effect with potentially significant impact is sleep walking or confused behavior in the hours after taking the medication. All can result in rebound insomnia if suddenly stopped. Medically supervised slow tapering is necessary when discontinuing these medications.

The first FDA approved sleeping medication in several decades that has an entirely new mode of action is Rozerem, a melatonin receptor agonist. This drug affects the melatonin receptors without significant interaction with other neurotransmitter systems. It promotes sleep without causing a sedating effect and because of its targeted activity it has few potential adverse effects. It appears to work by decreasing the arousal generated in the evening by the circadian clock which is located in the suprachiasmatic nucleus . It is most effective for sleep onset insomnia and can be used for long term treatment. To date it has no shown no abuse potential, unlike other sleep medications which may be habit forming.

If you are having difficulty with insomnia, a good place to start is to discuss your concerns with your primary care physician. Different treatments can be considered. Sleeping medications can be helpful in preventing sleeplessness in America but do not yet rival the quality of natural sleep. They treat the symptoms of insomnia but not the insomnia itself. Next time we will explore effective cognitive behavioral techniques to promote natural sleep. These techniques have the benefit of directly treating the causes of insomnia. So-no moths, just a good night's sleep- coming up!

Insomnia

John Cline, Ph.D. — Sun, 06 Jul 2008 14:59:04 -0700

Lying awake, late at night, reliving the negative events of the day and dreading the morning but wishing the night was over is one of the more difficult and yet fairly common experiences of life. This is the experience of insomnia.

Insomnia is the most commonly diagnosed sleep disorder. Approximately one out of three Americans reports having disturbed sleep and chronic insomnia affects 10% - 15% of the population. Insomnia can be acute or chronic and is variable in its presentation and effects. Although rarely the main reason for seeing a doctor, more than half the patients consulting a primary care physician have a complaint of insomnia of some kind. It is more frequent among women, people with chronic medical problems, people with psychiatric disorders and in older people. In 9 out of 10 cases, it occurs along with some other disorder, although it can be a primary condition without co-morbid conditions.

While being awake at night is a very unpleasant and difficult experience, it is the daytime symptoms which most impact on the lives of those suffering with insomnia. Common problems include fatigue, negative mood, problems with work, decreased quality of life, increased irritability, mood disturbance, decreased functioning and increased risk of depression. The impact of insomnia on the health and well being of insomniacs results in lost productivity and increased cost to society.

Insomnia is a disorder of arousal. Increased arousal, often related to fear of not sleeping or being unable to function effectively during the day, prevents the usual functioning of brain systems which initiate and maintain sleep. One way of thinking about insomnia is to consider whether the insomnia is a symptom associated with other problems or is a disorder that stands on its own. Primary insomnia is a disorder of arousal that lasts for one month or longer and results in significant distress or impairment. Co-morbid insomnia is insomnia associated with, but not necessarily caused by, other difficulties such as poor sleep habits, medications, medical problems or psychiatric conditions.

In the case of primary insomnia there is a state of hyperarousal and increased metabolic rate and elevated high-frequency EEG activity. It is often long standing, perhaps starting in childhood. Successful treatment consists of decreasing arousal and strengthening the sleep system so as to allow more natural sleep to occur. In the case of co-morbid insomnia, it may be sufficient to treat the co-morbid condition to relieve the arousal and restore normal sleep. An example of this would be improved sleep following the successful treatment of a pain problem which resulted in difficulty sleeping. It may also be necessary to treat both the insomnia and the co-morbid condition. In this example, even after successful treatment of the pain problem the insomnia may persist.

The most effective way we have of understanding insomnia is the three factor model proposed by Spielman. In this model there are predisposing factors (such as an easily aroused nervous system) which form the foundation for insomnia, precipitating factors (such as life stresses like the loss of a job) which cause the initial over arousal and insomnia, and perpetuating factors (such as maladaptive coping strategies and poor sleep habits) that maintain chronic insomnia. Treatment involves targeting the perpetuating factors which keep the insomnia going even if the initial stress has resolved.

Several aspects of insomnia are important to mention. People with insomnia tend to unknowingly over estimate the time it takes to fall asleep and underestimate the time they are asleep. In addition, state misperception can occur wherein the person is actually in a very light state of sleep but misperceives this as being awake. Addressing these issues is an important component of treating insomnia.

Treatment falls into two broad types, medication and cognitive behavior therapy. These may be used alone or in combination. The next two posts will discuss the treatment of insomnia with medication and with the use of cognitive behavior therapy. Some milder forms of insomnia may be successfully managed with a self help approach and two good books to consult are "No More Sleepless Nights" by Peter Hauri and Shirley Linde and "Say Good Night to Insomnia" by Gregg Jacobs.

Can Insomnia be Fatal?

John Cline, Ph.D. — Tue, 17 Jun 2008 16:56:16 -0700

"I just don't understand it. According to the history given by her friend, she hasn't slept in 8 days and there have been no behavioral indications that she has slept since being admitted. We'll need to get an EEG as part of the work up. "

"Hard to believe, how long can this go on?"

"Well, 10 days without sleep and death ensues..."

If you are familiar with the hit TV show "House, M.D." you will recognize that in the dialogue above I borrowed heavily from an episode about a patient with potentially fatal insomnia. (For some interesting reviews of the show from a medical stand point see House Medical Reviews.) The impact of this program is so great that I have had exhausted patients express concern that their death is imminent because they were nearing the fatal 10th day without sleep! Is this possible? Are there documented cases of this happening? And is this really insomnia we are talking about?

First of all, insomnia and sleep deprivation are two different things. Insomnia, according to the International Classification of Sleep Disorders, is "a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment." This means that despite having enough time and opportunity to sleep, there is difficulty falling or staying asleep or sleep is non-restorative. Day time problems associated with insomnia are well known and include irritable or depressed mood, fatigue and cognitive difficulties. In contrast, sleep deprivation involves getting less than a sufficient amount of sleep, either acutely or chronically, and results in difficulty with attention and concentration, decreased motivation, depressed mood, and daytime sleepiness. The cognitive effects of sleep deprivation are greater than for insomnia. It can be hard to think straight when you have missed a night of sleep. In any case, there are no recorded human fatalities directly attributable to either insomnia or to lack of sleep. There is, however, a rare disease with associated insomnia which does result in death that is described below.

Second, insomnia is a problem of over arousal or an overly active awake system while sleep deprivation results simply from not getting enough sleep. Insomnia affects millions of people, is the most common sleep disorder diagnosis and is highly treatable. Sleep deprivation can result from a number of causes. For example, from a life style that chronically fails to allow sufficient time for sleep, or from an acute situation such as combat, or from being in a crisis situation such as being lost at sea and being unable to sleep while treading water.

Despite the wretched feelings that accompany insufficient sleep, it is clear that sleep is, at least at first, relatively easy to do without. In fact people today are often sacrificing sleep to have more time for other activities. Indeed people seem to be able to function with very little sleep for prolonged periods of time, albeit not happily. Randy Gardner in 1964 showed that even after 264 hours (eleven days!) of total sleep deprivation he was able to continue to function. With a relatively short period of recovery sleep (about 14 hours) he showed no lasting negative effects. Even longer periods of sleep deprivation have been reported. Results of experiments using completely sleep deprived rats indicate that very prolonged sleep deprivation could result in death but this has never been observed in humans. Estimates indicate that humans may be able to survive 2 to 10 years of total sleep deprivation before dying. Of course, indirect death caused by errors related to impaired cognitive functioning, say while driving, are another story.

There are very rare conditions associated with genetic abnormalities that can result in a relentlessly progressive illness involving insomnia that ends in death. For example, Fatal Familial Insomnia is an illness in which the victim initially has difficulty falling and staying asleep, lapses from quiet wakefulness into sleep with enactment of dreams, and has loss of deep sleep. The illness relentlessly progresses with symptoms such as excessive salivation, rapid heart rate, rapid breathing, tremor and eventually coma and death. Death occurs 8 to 72 months following onset of the illness.

In the end, it must be noted that we can often go a long time with little or even no sleep and continue to function. Surgeons, medical interns, military personnel, and truck drivers often function on very little sleep. However, they are not typically happy about it and accidents due to cognitive errors tend to increase in frequency with decreasing sleep. Many of us have had the experience of forgetting to make that left turn when driving after a night of too little sleep. Being sleepless in America, or anywhere else, feels bad. But- there is good news! If you suffer from insufficient sleep, some life style changes may be all that are needed to restore healthy functioning. And if you suffer from insomnia, you can rest assured that your life is not on the line and that treatment is available. For optimal functioning, health and quality of life, nothing beats a good night's sleep! ZZZzzzzzzzzzzzz...

Things that Go Bump in the Night

John Cline, Ph.D. — Sun, 01 Jun 2008 16:38:47 -0700

Cornelia Collins awoke to an incessant rain of blows. As she fully awakened she saw that her husband was distressed, frightened, and lashing out. Several of the blows had landed with sufficient force to leave bruises on her face. As she shielded herself she forcefully called out his name several times. He stopped and seemed to awaken, wide-eyed with alarm. Shaken, he told her that he was being attacked and fighting off a group of hoodlums trying to mug them - but it must have been a dream. About a week later a similar series of events again unfolded and after several episodes, Cornelia needed to move to another bedroom. Her husband recognized that he needed to see his doctor to find out what was happening to him.

When Jim Collins was referred by his physician to a sleep specialist he had never heard of Rapid Eye Movement Sleep Behavior Disorder (RBD). After describing the recent nighttime episodes to the specialist, he learned that he may be suffering from a relatively rare condition, RBD. This is one of a class of sleep disorders known as parasomnias. Parasomnias are undesirable physical events or experiences associated with sleep. They can occur as people fall asleep, are asleep or when arousing from sleep. RBD is associated with Rapid Eye Movement (REM) sleep. During this stage of sleep the body is paralyzed and vivid dreams with clear story lines occur. The phenomenon of a coherent dream sequence corresponding with observable sleep behaviors is termed isomorphism and is characteristic of this disorder.

Parasomnias are often described as the "things that go bump in the night." The old Scottish prayer,

"From ghoulies and ghosties
And long-leggedy beasties
And things that go bump in the night
Good Lord, deliver us"

aptly addresses the fear and sense of danger that can accompany these sleep disorders. They include dramatic episodes such as night terrors and less obvious but potentially harmful behaviors such as grinding teeth. Treatment for parasomnias may involve prevention, taking measures to ensure safety, and medication.

Jim will need further evaluation to determine the exact nature of his problem and any treatment it will require. RBD is most commonly seen in men over 50 years of age, although women and people of any age can be affected. A number of sleep disorders may manifest in ways similar to it. For example, Jim's symptoms could be due to the disruption of REM sleep which may occur in sleep apnea. Correct diagnosis is important as RBD may be associated with neurological disorders such as Parkinson's disease or with the use of certain psychotropic medications. The prevalence of RBD is currently unknown but is estimated to be about 0.38% in the general population and 0.5% in the elderly population.

Parasomnias, insomnia, sleep apnea and a host of other sleep disorders are the problems which plague our sleep. But why do we need sleep? What could be so important that it takes up one third of our lives? What constitutes good sleep? And how much sleep do we really need?

These are vital questions facing people living in an increasingly stressful and demanding social and economic environment. Never before has good sleep been so important for maintaining mental alertness and good physical health as it is in today's world. At the same time it seems that getting good sleep is more difficult than ever given our time pressured schedules and relentless"24/7" life styles. This blog will focus on sleep and its disorders and will provide useful information about sleep, health and what can be done to avoid being "Sleepless in America."