Sleep is an absolute requirement for sustaining human life, and disorders that affect sleep are among the most common medical complaints in our society. The brain and nervous system are of paramount importance in regulating our sleep, so it is consequently appropriate that patients might want to consult with a neurologist when there are problems in this area.
For convenience, sleep disorders are basically classified into three major categories:insomnias (difficulty initiating sleep or staying asleep), hypersomnias (literally, "too much" sleep, meaning excessive sleepiness at inappropriate times), and the so-calledparasomnias (which include various sorts of disruptive phenomena and behaviors that occur during sleep or are exaggerated by sleep). Not all apparent "sleep disorders" are really disorders at all or related to disease. Individual sleep patterns evolve over time and with physical maturation or aging. Poor individual "sleep hygiene" is also a frequent cause of problems for many patients, including such bad habits as staying in bed too long, varying sleep-wake timing (especially on weekends, for example), frequent day-time napping, lack of adequate exercise or activity while awake, and inappropriate use or abuse of alcohol, caffeine, and tobacco. Further complicating the challenge of determining what is normal or abnormal sleep are the demands of what has been loosely called the "modern lifestyle" of our fast-paced, highly efficient and industrialized, "24 x 7" society.
Most people will from time to time experience a temporary poor night of sleep, often due to worry, excitement, or pain. This is not considered pathological insomnia. Chronic insomnia, however, is more difficult to diagnose and manage and usually points to some underlying physical or emotional problem that prevents the individual from obtaining adequate, restful sleep. Probably the most common cause of so-called adjustment or transient insomnia is poor sleep hygiene as mentioned earlier. A patient with an underlying emotional problem (including anxiety disorders, depression, bipolar disease) may have psychophysiological insomnia. Other causes for insomnia include idiopathic insomnia, restless legs syndrome,drug-dependent sleep disorders, periodic limb movements, environmental factors, so-called limit-setting or sleep-onset association disorders (usually related to childhood bed-time rituals), nocturnal eating (or drinking) syndrome, and food allergy syndrome.
There are numerous causes of excessive daytime sleepiness, or hypersomnia, including the various forms of obstructive and central (or non-obstructive) sleep apneas (the word apnea means "cessation of breathing"). Unfortunately, space limitations do not permit an adequate discussion of the topic of sleep apnea here. On the other hand, narcolepsy is probably one of the more interesting, and frightening, of the hypersomnias. Although of unknown origin, narcolepsy is most likely related to a genetic defect that leads to abnormal sleep patterns. While these patients do suffer from very disrupted nocturnal sleep, they more importantly experience frequent, excessive, and irresistible urges to fall asleep suddenly during the day. They can also manifest other symptoms commonly associated with narcolepsy, including cataplexy, sleep paralysis, and hypnogogic hallucinations.
Cataplexy consists of a brief, sudden loss of muscle or postural tone, often precipitated by some emotional stimulus such as laughter, anger, or excitement. Patients may literally collapse to the ground during a cataplectic attack, but there is no impairment of consciousness during these episodes (thus differentiating this problem from epilepsy). Sleep paralysis refers to a total inability to move the voluntary muscles during the sleep-wake transition periods of falling to sleep or waking up. Hypnogogic hallucinations are very vivid "dreamlike" visual or auditory experiences that may occur just at the point the subject is first falling to sleep.
The parasomnias include various disorders of arousal from sleep. Most of us have had the normal experience of a short period of confusion when awakened from a very deep sleep (also known medically as "slow-wave" sleep). Partially aroused, we are still "half asleep" yet frequently capable of purposeful and apparently normal behavior, like a trip to the bathroom, turning off the wake-up alarm clock, and even talking (usually nonsense), often without any recollection of these events the next day. In some patients with pathological parasomnias, however, arousal from slow-wave sleep is almost impossible. Rather than coming to more full wakefulness, they enter a prolonged state of confusion, during which time they may exhibitsomnambulism (sleep walking) or sleep terrors. Other types of parasomnias includedream anxiety attacks (more commonly known as nightmares), sleep paralysis (like narcoleptic patients), sleep bruxism (involuntary jaw clenching, which can damage the teeth or TMJs), and so-called REM behavior disorders (when patients dangerously or violently "act out" what they may be dreaming).
Much research has advanced our knowledge about the biological mechanisms underlying sleep disorders, and this activity has led to a great deal of progress with reference both to diagnosing these problems accurately and formulating highly effective medication regimens and treatment plans. Diagnosis always requires a thorough history and physical examination by the neurologist. The neurologist also will often refer the patient for a formal "sleep study," a so-called polysomnogramwhere the patient spends an entire night at a "sleep lab" while various brain wave activities and physiologic functions are accurately and painlessly monitored with advanced medical instrumentation. Once the true nature of the sleep disorder is diagnosed, the most effective medication or treatment plan can be prescribed.
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