Sleep Related Problems

Sleep disorders are problems with sleeping, including trouble falling or staying asleep, falling asleep at the wrong times, too much sleep, or abnormal behaviors during sleep.

Primary Sleep disorders are divided into two subcategories: Dyssomnias are those disorders relating to the amount, quality, and timing of sleep. Parasomnias relate to abnormal behavior or physiological events that occur during the process of sleep or sleep-wake transitions. We use the perm primary to differentiate these sleep disorders from other sleep disorders that are caused by outside factors, such as another mental disorder, medical disorder, or substance use.

There are more than 100 different sleeping and waking disorders. They can be grouped into four main categories :

1. Problems falling and staying asleep (insomnia)
2. Problems staying awake (excessive daytime sleepiness)
3. Problems sticking to a regular sleep schedule (sleep rhythm problem)
4. Unusual behaviors during sleep (sleep-disruptive behaviors)


Insomnia includes trouble falling asleep or staying asleep. Episodes may come and go, last up to 3 weeks (be short-term), or be long-lasting (chronic).


People with excessive daytime sleepiness feel tired during the day. Symptoms that are not caused by a lack of sleep or interrupted sleep are called hypersomnia.

Causes of this problem include :
Medical conditions such as fibromyalgia and low thyroid function
Mononucleosis or other viral illnesses
Narcolepsy and other sleep disorders

When no cause for the sleepiness can be found, it is called idiopathic hypersomnia.


Problems may also occur when you do not stick to a regular sleep and wake schedule. This occurs when people travel between time zones and with shift workers who are on changing schedules, especially nighttime workers.

Disorders that involve a disrupted sleep schedule include :
Irregular sleep-wake syndrome
Jet lag syndrome
Paradoxical insomnia (the person sleeps a different amount than they think they do)
Shift work sleep disorder


Abnormal behaviors during sleep are called parasomnias. They are fairly common in children and include:

Sleep terrors
REM sleep-behavior disorder (a person moves during REM sleep and may act out dreams)

Worried you may be suffering from a sleeping disorder? Check here for the symptoms you should look for before consulting a mental health professional. Insomnia
Sleepwalking Disorder
Circadian Rhythm Sleep Disorder
Nightmare Disorder
Sleep Terror Disorder

Insomnia, Primary (can’t get to sleep)

The predominant complaint is difficulty initiating or maintaining sleep, or nonrestorative sleep, for at least 1 month.

The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The sleep disturbance does not occur exclusively during the course of Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia.

The disturbance does not occur exclusively during the course of another mental disorder (e.g., Major Depressive Disorder, Generalized Anxiety Disorder, a delirium).

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Hypersomnia, Primary (Sleeping too much)

The predominant complaint is excessive sleepiness for at least 1 month (or less if recurrent) as evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily.

The excessive sleepiness causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The excessive sleepiness is not better accounted for by insomnia and does not occur exclusively during the course of another Sleep Disorder (e.g., Narcolepsy, Breathing-Related Sleep Disorder, Circadian Rhythm Sleep Disorder, or a Parasomnia) and cannot be accounted for by an inadequate amount of sleep.

The disturbance does not occur exclusively during the course of another mental disorder.

The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

Sleepwalking Disorder

Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode.

While sleepwalking, the person has a blank, staring face, is relatively unresponsive to the efforts of others to communicate with him or her, and can be awakened only with great difficulty.

On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the episode

For those who suffer from the ill effects of sleep disorders, many diagnostic tests are available that may lead to a better understanding of what the problem may be. These may include the following:

Overnight Oximetry
Overnight oximetry is one of the simplest and, generally, earliest sleep studies that may be conducted. It involves the use of a probe similar to a clothespin worn on the finger or earlobe that continuously measures oxygen levels and heart rate. This is accomplished with a red light and sensor that detects changes in the color of blood that may suggest desaturations (or loss of oxygen) are occurring. This test will typically be done at home while sleeping. It may identify individuals at risk for nocturnal breathing disorders such as sleep apnea, and may be used to identify those who need additional evaluation such as with a polysomnogram.

Polysomnography (PSG)
This is largely regarded as the gold standard for the diagnosis of sleep disorders. It involves a visit to a sleep center, which may consist of specially designated rooms in a hospital, sleep laboratory, or even a specially equipped hotel room. These sleep studies involve an overnight stay that is monitored by a trained technician.

Various physiological parameters are monitored while the individual sleeps, including: an EEG, EKG, respirations, oxygen levels, muscle tone, and eye and extremity movements. There is also a video and audio recording that provides a record of the night’s sleep. These tests can diagnose many sleep disorders — from sleep apnea to restless legs syndrome to parasomnias — and may even be useful in ruling out other causes of insomnia.

Titration Study
Titration with Continuous Positive Airway Pressure (CPAP) is commonly done during the same night as a diagnostic polysomnogram (PSG) to save waiting time, minimize cost to the patient, and treat sleep apnea as soon as possible. Early treatment may reduce cardiovascular complications of sleep apnea. In brief, the technician will gradually increase CPAP pressure (pressurized room air, not oxygen), delivered through the soft mask, to the level that eliminates most or all episodes of cessation of breathing. This level of CPAP pressure will be prescribed for home therapy.

The patient often begins the night on a low pressure of his CPAP or bilevel. As the person goes to sleep, he will be monitored for disruptions in his breathing. Any hypopneas, apneic events, or snoring will prompt the sleep technician to adjust the pressure of their CPAP machine remotely. Again, the person will be monitored at this higher pressure. The goal is to minimize apnea and hypopnea events and eliminate snoring.

It is also ideal for the patient to be titrated to an effective pressure supine (on their back) and during periods of rapid eye movement (REM) sleep. These two conditions will often lead to worsened sleep apnea, so an effective pressure in these conditions would be most favorable. Often towards the end of this study, the pressures may be increased even farther. This will allow the reviewing physician to make comparisons among the various pressures and may reveal changes that need to be made in the pressures for the most effective management of the person’s sleep apnea.

Multiple Sleep Latency Testing (MSLT)
Multiple Sleep Latency Testing (MSLT) is also often called a nap study. It is similar in set-up to the polysomnogram (PSG) described above. These studies will typically be done after an initial overnight PSG study. After waking up, the individual will have scheduled nap times throughout the day. These typically occur every two hours. Generally, the patient is put to bed and allowed to lie there for 20 minutes with the goal of falling asleep. The technician will monitor for the onset of sleep and, in particular, REM sleep. After 20 minutes, the person will be awakened or told that his time for a nap has ended. Then, in 2-hour intervals, this process is repeated. Typically these will occur over a 10-hour period. These tests are useful for identifying excessive daytime sleepiness. This may be present in numerous disorders, such as sleep apnea, idiopathic hypersomnia (excessive sleepiness without a cause), and narcolepsy. In particular, the early onset of REM in these sleep periods may suggest narcolepsy.

Actigraphy is the measurement of activity with the use of a small, wristwatch-sized device. This device monitors movement and can be used to assess sleep-wake cycles, or circadian rhythms, over an extended period of time. They may be worn for weeks or even months. They help determine whether disruptions in the sleep-wake cycle exist, as may occur in circadian rhythm disorders such as advanced sleep phase syndrome, delayed sleep phase syndrome, or even with insomnia. These results are often correlated with a sleep diary.

Sleep Diary
The sleep diary, or sleep log, is sometimes useful for assessing circadian rhythm disorders or insomnia, especially in adjunct to actigraphic data. These may also be used to assess sleep problems among children. In general, they are a paper record and document sleep and wakefulness over a period of weeks and months. The bedtimes and wake-times are noted. Any periods of wakefulness during the night or naps during the day are also documented. Sometimes the use of caffeine, alcohol, or medications may also be recorded.

Home Study
Finally, most individuals recognize that they sleep far better at home than they might in a sleep center. This is certainly true, and many are pushing to develop technologies that may allow home assessment of sleep disorders. These may include limited studies that monitor basic parameters of sleep, such as oxygen levels, heart rates, and the movement of the chest and abdomen with special belts. Some titration studies can be conducted at home through the use of the CPAP machine, such as auto-titration studies.

In addition, new technologies are being researched that may lead to other monitoring. In general, these new technologies are in their infancy and the data may not be reliable as the current gold standard of diagnosis which is the overnight polysomnogram performed in an accredited sleep center

Treatments for sleep disorders generally can be grouped into three categories :

Behavioral/ psychotherapeutic treatments
Somatic treatments

None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a specific treatment depends on the patient’s diagnosis, medical and psychiatric history, and preferences, as well as the expertise of the treating clinician. In general, medications and somatic treatments provide more rapid symptomatic relief from sleep disturbances. On the other hand, some emerging evidence suggests that treatment gains with behavioral treatment of insomnia may be more durable than those obtained with medications.

Some sleep disorders, such as narcolepsy, are best treated pharmacologically, whereas others, such as chronic and primary insomnia, are more amenable to behavioral interventions. The management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.

For most sleep disorders, behavioral/psychotherapeutic and pharmacological approaches are not incompatible and can be effectively combined to maximize therapeutic benefits.

When to call a doctor about sleep disorders ?
If you’ve tried a variety of self-help sleep remedies without success, schedule an appointment with us, especially if :

1. Your main sleep problem is daytime sleepiness and self-help hasn’t improved your symptoms.
2. You or your bed partner gasps, chokes, or stops breathing during sleep.
3. You sometimes fall asleep at inappropriate times, such as while talking, walking, or eating.

At your appointment, be prepared with information about your sleep patterns and provide as much supporting information as possible