Are you suffering from a sleeping disorder?

Here’s what you need to know!

Sleep and its importance:

Sleep is a complex physiological process in which the body goes into a reversible unconsciousness where the body and the mind go into a rest state for some time. Facts state that humans spend one-third of their time sleeping. On average, an adult spends about 8 hours a day sleeping, which means 121 days in a year is spent sleeping. The right quantity of sleep is necessary for the normal functioning of the body systems. There are two types of sleep, Rapid Eye Movement sleep and Non-Rapid Eye Movement sleep. The NREM sleep occurs first and transitions to REM sleep. The brain waves are recorded during different stages of sleep using an electroencephalogram (EEG). These waves are termed as, alpha (8-14cycles/s), beta (15-35 cycles/sec), Theta (4-7 cycles/sec) and delta (0.5-3 cycles/second).

The REM sleep stage is when there are marked irregular and darting eye movements, dreams and nightmares occur. Heart rate and BP fluctuate and are irregular, muscles are completely relaxed but irregular body movements occur occasionally. Sleep is controlled by various aspects of the brain such as the hypothalamus, brain stem, cerebral cortex, the pineal gland, and the amygdala. The sleep cycle follows the circadian rhythm or the light/dark cycle. In the morning, exposure to light makes the circadian clock promote waking but when the sunlight is absent or when darkness prevails, the pineal gland tends to secrete melatonin which induces sleep thus the circadian clock promotes sleeping. This is the reason why gloomy days make one feel excess sleepy. The sleep-wake homeostasis keeps a track of the “need for sleep”. This system reminds the body to take rest/ sleep after a certain time and also regulates sleep intensity. Hence the sleep drive gets stronger for every hour one is awake and the intensity of the sleep increases after a period of sleep deprivation.

Sleep tends to calm all the body systems effectively, which includes the heart, the lungs, the muscles, the brain, and the immune system. Four theories explain why sleep is necessary for normal functioning. The first is Restorative theory which states that sleep is necessary for revitalizing and rejuvenating the normal functioning of the body systems. Cellular repair, muscle repair, tissue growth, and protein synthesis, and the release of important growth hormones occur during sleep. One of the reasons why children tend to sleep more than 12 hours a day.
The second is the Cognitive Function Theory which states that sleep is important for maintaining memory functions and formations. Memory is consolidated and assimilated during sleep. Lack of sleep can cause impairment in maintaining attention, decision making, and difficulty in recalling long-term memories. The third and fourth are energy conservation and adaptive theory. It is during sleep when the brain fluid is cleaned of all the metabolic waste. The healthy functioning of the heart and the kidneys is associated with good sleep as both these organs slow down during sleep. Sleep deficiency also causes obesity, hormonal imbalance, insulin fluctuance, immune deficiency.

Sleeping disorders:

Sleeping disorders are a group of conditions that interfere with the normal sleeping pattern in an individual. They can be excessive sleep (hypersomnolence, excessive daytime sleeping), inadequate or poor-quality sleep (insomnia, dyssomnia), and abnormal behavior during sleep (parasomnias). These can be caused by external factors such as an underlying medical and psychiatric condition or due to endogenous disturbances. Medical conditions causing sleep disorders include heart failure, obstructive sleep apnea, headache, hyperthyroidism, diabetes, asthma, COPD, GERD, fibromyalgia, any chronic pain, and/or pain from arthritis. Psychiatric conditions include depression, anxiety, phobias and panic attacks, medications taken for psychiatric conditions like anti-depressants, and benzodiazepines which cause altered sleep patterns and produce rebound insomnia respectively. Other factors can include, environmental problems such as work shifts, jet lag, etc, aging, childhood trauma, other medications such s diuretics which causes increased urination, caffeine, opioids, etc.

Hypersomnia: person complains of excessive uncontrollable daytime sleepiness. Difficulty in maintaining alertness during the major awake hours during the day. Sleepiness is experienced during inappropriate hours which affects daily routine.

Narcolepsy: Caused due to the inability of the brain to control sleep and wake state. The key symptom is sudden, irresistible ‘sleep attacks’, often in inappropriate circumstances such as while eating or talking. Characteristic symptoms include sleep attacks, cataplexy or sudden loss of muscle tone triggered by surprise, laughter, etc, hypnagogic (while falling asleep) or hypnopompic (while waking up) hallucinations, sleep paralysis- brief paralysis on waking up.

Insomnia: difficulty in falling asleep and/or staying asleep. The person tends to take more than 30 minutes to fall asleep and also complains of fatigue, daytime sleepiness, attention deficit, increased incidence of accidents, aggressive behavior patterns, decreased energy during the day, and low motivation.

Parasomnias are further divided as Non-REM parasomnia, REM sleep behavior disorder (RBD), Restless Leg Syndrome (RLS), Periodic Limb Movements in Sleep (PLMS).
Non-REM parasomnia occurs when one is incompletely awakened from non-REM sleep. Presents with sleepwalking, night terrors, confused arousals (sleep drunkenness). Typically occur within an hour or two after sleep onset. Sometimes, manifestations are complex such as dressing up, eating, moving objects, or even acts of violence. The person has little or no recollection of the episode whatsoever. It can be familial.
In RBD, they ‘act out’ their dreams during sleep due to the failure of complete muscle relations during sleep (atonia). Sleep partners, give histories of obvious ‘fighting’ or ‘struggling’ during the sleep, also causing injuries to themselves or partners occasionally. The person is easily aroused from this state and has complete recollection.
RLS is very common with about 10% of the people presenting it. Characterized by the unpleasant leg and arm sensations which is eased by movements. The unpleasant sensation is known as motor restlessness. It is present only while resting or lying down, it’s worse in evenings or nights, and the sensations are relieved when activity such as walking or stretching is done. Sometimes associated with other disorders such as Parkinson’s disease.
PLMS occurs only during sleep and causes repetitive flexion movements of the limbs, usually in the elderly.

What are sleeping pills and how do they work?

Sleeping pills are a general term which is used to describe the drugs which help in improving the induction, quality, and quantity of sleep. In medical terminology, they are known as ‘sedatives’ or ‘hypnotics’. Any drug which reduces the level of excitement thus producing a calming feeling also producing some amount of drowsiness is known as a sedative. While, a hypnotic induces or maintains sleep, similar to normal arousable sleep. Sedatives have slower onset while hypnotics have a steeper duration of onset. High doses of either of these drugs are dangerous and have high addiction potential. These are used in sleeping disorders which occur due to poor quality sleep or lack of sleep.
Disorders with excessive daytime sleeping need to be treated with psychostimulants or wakefulness-promoting agents, sodium oxybate, etc.
Sleeping pills are available as over-the-counter drugs and also as prescription drugs. However, in the UK and US most of the sleeping drugs are available only with a prescription. These have known to cause high abuse and addiction potential.

Benzodiazepines belong to the group which acts as a sedative and a hypnotic.
Drugs such as diazepam, lorazepam, temazepam, zolpidem, zopiclone are used to treat lack of sleep. They can be bought online in the UK, US, and Canada.

These benzodiazepines act by fastening the onset of sleep, reducing intermittent awakening, and increased total sleep time. It also reduces night terrors and body movements during sleep. People taking diazepam, usually wake up with a feeling of refreshing sleep. The effects of diazepam are biphasic, the initial phase lasts for 30 mins and the redistribution phase lasts for about 12-24 hours thus making it long-acting. It does not cause extrapyramidal effects and shows very low dependence and abuse potential compared to other drugs. The withdrawal symptoms are milder and delayed owing to its longer duration of action. Bensen, galena are trade names of the same drug. The sleep-inducing dosage is 5-10mg taken once or twice a day in divided dosage as prescribed by your physician.
Lorazepam is often used for short durations and presents high addiction potential. It is a prescription-only drug and is available as tablets and liquid. They take about 20-30 mins to start acting and last for about 6-8 hours. Because of its high addiction potential, the drug is not advised to be taken beyond 4 weeks.
Zolpidem, zopiclone belong to the group of non-benzodiazepines hypnotics.
Zopiclone is used to treat insomnia for a short duration of time, less than 2 weeks. It improves the sleep but doesn’t structurally alter the sleep architecture. It is used in patients who have rebound insomnia due to benzodiazepine addiction. Imovane is the drug name for zopiclone, which are available as 7.5mg and 5mg tablets. They are round, white tablets with “IMOVANE 5” or oval, scored blue tablet marked “IMOVANE” on one side, and the logo “rPr” on the other side.
Zolpidem improves the sleep duration in hypnotics, has less residual daytime sleepiness, little no or no rebound insomnia, and very low abuse potential. Ambien is the drug name for the same. Ambien is available as oblong tablets in white or pink with “AMB” embossed on the drug. The dosages available are 10mg and 5 mg.

Modafinil is a psychostimulant or promotes wakefulness. They do not make one jittery or excessively energetic. Modafinil is eugeroic or helps in making a person feel awake. The doses usually taken are 100mg or 200mg based on the severity of the disease. They are available in the names of Modalert or Provigil. Modalert is round tablets that are white in color.

Uses and disadvantages of sleeping pills

The group of drugs, benzodiazepines are used to bring in a sense of calming effect and induce sleep. They do not cause change n the REM sleep which means, that the depth of the sleep is not affected but the quality of the sleep is affected. People on these drugs can be aroused from sleep like any normal person.
Diazepam, zolpidem, zopiclone are also used to treat anxiety and its associated disorders. They produce centrally acting muscle relaxation which is an absolute necessity for good sleep especially in sleeping disorders such as restless leg syndrome.
Another drug that is commonly used is Kirkland sleep aid, which contains doxylamine succinate and is available in 25mg dosage forms. They are available as capsules and tablets of white and blue colors. The disadvantages of these drugs are many. Primarily they have abuse and addiction potential and hence shouldn’t be taken beyond a duration of 4 weeks. They have to be monitored in patients who are pregnant as they can cross the human-fetus barrier. These drugs are mainly excreted through the urine and hence, patients with kidney trouble or elderly patients have to be given reduced dosages of the drug.

Long-term consumption of these drugs causes rebound insomnia, which means, the lack of sleep is present despite the consumption of the drug.
They also cause carryover of sleepiness over to the next day morning known as residual daytime sedation. Repeated dosages can cause a decrease in hypnotic effects.
The most common side effects include nausea vomiting, flatulence, excessive drowsiness, agitated behavior, or other behavioral changes, etc.
Paradoxical stimulation, sweating, and irritability occur occasionally. Withdrawal symptoms to these drugs especially diazepam is are restlessness, anxiety, insomnia, malaise, loss of appetite, bad dreams, agitation, panic reaction, tremors, and delirium and in very rare cases seizures also occur.
The sleeping pills have to be taken during bed-time except those which are being used to treat narcolepsy. If a dose is missed, the next dose should be taken, and replacement of the previous missed dose shouldn’t be consumed.

Summary

Sleep is a physiologic process that is done subconsciously and is an important element of life. An average adult sleeps about 7-9 hours a day. While children below 12 years of sleep 10-12 hours a day. Babies sleep about 16-18 hours a day which helps in maximal growth and mental development of the baby. Sleep maintains the health of all body systems including the heart, kidneys, lungs, immune system, and also the brain. Cognitive functions and memory consolidation are mostly affected by lack of sleep or excess sleep.
Sleeping disorders usually have no definite causal but life-style and social relations and environment play an important role. They cause, reduce performance at work and personal levels, in turn affecting the other health systems. Heart problems and immune-related problems are most commonly seen in individuals having sleep disorders. Familial predisposition to these disorders has been scientifically proven.

Medical management of sleeping disorders is best when prescribed by the general physician. Self-medication for sleep is dangerous and sometimes can be fatal too. Non-medical management of the condition can be done with the help of yoga, physical activities, tai-chi, meditation, and other allied health fields.