Sleep Disorders and Treatment

Below is a list of common sleep disorders. The initial assessment is intended to determine whether and what disorder may be impacting your sleep, as well as identifying the contributing factors. These contributing factors become part of a personalized treatment plan.

Insomnia

Insomnia is a common and frustrating problem defined by difficulty falling asleep or staying asleep, along with daytime symptoms such as sleepiness, irritability, and difficulty with concentration and memory.

Cognitive Behavioral Treatment for Insomnia (CBT-I) is the first-line treatment recommended for all adults by the American College of Physicians, American Academy of Sleep Medicine, and the National Institutes of Health. CBT-I includes rescheduling your sleep, changing what you do when you can’t sleep, and reducing the tension and worry that are preventing you from sleeping. Long term follow-up studies have shown that benefits from CBT-I continue 8 years or more.

Expected length of treatment: 3 to 8 sessions

Hypnotic Dependence

Many people want to stop taking sleeping pills but feel unable to do so. Either the pills stopped working, have too many side effects, or their doctors don’t want to prescribe them anymore. At the same time, the you may feel totally unable to sleep without the pills.

The first step is to improve your sleep using CBT-I. Then we will develop a systematic plan to get you off at a comfortable pace. This means that treatment usually takes as long as CBT-I, with one or more additional visits dedicated to making a tapering plan and subsequent follow-up visits as needed. Sometimes, people simply stop taking their sleeping pills on their own during CBT-I.

Expected length of treatment: incorporated into CBT-I with up to two additional sessions in most cases

Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is one of the most common sleep disorders. The physiological cause of OSA is that the upper airway partly or completely collapses during sleep. This happens repeatedly throughout the night leads to gasping and loud snoring. People with OSA often have difficulty staying awake during the day and are at increased risk of other health problems.

The gold standard treatment for sleep apnea is continuous positive airway pressure (CPAP). This treatment typically uses a small mask that covers only your nose to deliver pressurized regular room air into your airway, which acts like a splint to keep your airway open. This treatment is highly effective when used regularly. Unfortunately, many people have difficulty adapting to sleeping with CPAP.

We can help you become more comfortable with CPAP, so you can gain all the benefits of good sleep. If CPAP is truly not an option for you, we can refer you to someone who can help you find alternatives. You deserve a treatment that works for you. Length of treatment to improve adherence to CPAP varies depending on what the barriers are. Increasing knowledge about OSA and CPAP, problem-solving, moving from ambivalence to motivation, and increasing comfort wearing a CPAP mask are common goals as a part of CPAP adherence, and each takes a different amount of time.

Expected length of treatment: 4 to 8 sessions

Circadian Rhythm Disorders

Circadian rhythms control human physiology and behavior on a 24-hour clock, coordinating when we wake up in the morning, are active, eat, and digest during the day, and then become sleepy at night. The most common circadian rhythm disorder is Delayed Sleep Wake Phase Disorder (DSWPD). Often referred to as “night owls”, people with have circadian rhythms are set hours later than most people.

As a consequence, people with DSWPD tend to have trouble falling asleep at the beginning of the night, and then have a difficult time waking up in the morning in order to go to school, work, or other daytime activities. Basically, everything in life is scheduled too early for their brain. However, when they are able to choose their own sleep schedules, such as on the weekend, people with DSWPD are able to fall asleep and wake up much more easily. Since it is usually not possible to schedule your responsibilities around having a delayed circadian phase, it is helpful to shift the phase of your circadian rhythm earlier. Surprisingly, a recent study found that about half of people with DSWPD did not actually have biological signs of delayed circadian rhythm, suggesting that psychological and social factors may be involved.

The most effective ways to shift your circadian rhythm is by getting bright light and dim light at the exact right time. Getting bright light too early or too late can actually delay your rhythm even later. Meal timing can also help align clocks throughout your body. In some cases, melatonin can also be helpful, but just like light, the timing must be correct and consistent. Because of the findings that psychological and social factors may be important, these will also be addressed in treatment.

Other circadian rhythm disorders include Advanced Sleep Wake Phase Disorder, non-24 hour circadian rhythm disorder, shift work sleep disorder, and jet lag. The most effective interventions for these disorders are similar to those described above for DSWPD.

Expected length of treatment: 4 to 8 sessions

Shift Work Sleep Disorder

Shift work presents a unique challenge to sleep. Various types of shift work exist, such as permanent night shift, 24-hour shifts, and rotating shifts. While some people can adapt to shift work quite easily, many people cannot. They may find themselves unable to sleep while they are off duty and find themselves unable to stay awake while on duty. Others find themselves unable to sleep during both day and night, being in a constant state of elevated arousal.

Treatment is personalized according to the type of shift work and nature of the associated sleep problems. Interventions may include altering sleep schedules during the work week and days off, strategically timed napping, and light- and dark-based interventions. Family and social obligations are also given significant consideration in treatment.

Expected length of treatment: 4 to 8 sessions

Nightmare Disorder

Recurrent nightmares or unpleasant dreams from which you wake up very suddenly and are causing you distress or interfering with your day may be an actual disorder that can be effectively treated.

Depending on the type of nightmare, treatment may involve “rescripting” the nightmare in addition to reducing tension and stress before bed and treating symptoms of insomnia with components of CBT-I. Nightmares can be a symptom of PTSD, or can persist after PTSD has been successfully treated. Nightmares can also occur in people without PTSD. As such, trauma-focused treatment may or may not be indicated for people experiencing nightmares.

Expected length of treatment: 4 to 8 sessions

Sleep Walking, Sleep Eating, and Night Terrors

Sleep walking, sleep eating, and night terrors are categorized as NREM parasomnias. These are behaviors that occur while a person is asleep, usually in the early part of the night during NREM sleep. They are most common among young children, become less common when a child enters adolescence, and most cases resolve by early adulthood.

Rather than waiting years for this naturally dissipate, improvement can be seen within weeks or months by using behavioral interventions to regularize sleep and reduce stress and tension, along with carefully timed awakenings. In some cases, certain medications can help, and we can coordinate with your physician to discuss this.

Expected length of treatment: 4 to 8 sessions

Narcolepsy and Idiopathic Hypersomnia

Hypersomnolence is a symptom of excessive sleepiness. This can include difficulty maintaining wakefulness and alertness during the day, irresistible need for sleep, and unintended lapses into sleep. In children, hypersomnolence can manifest as inattentiveness, emotional lability, or hyperactivity. Hypersomnolence has several potential causes, including inadequate sleep, circadian misalignment, untreated OSA, medical or psychiatric condition, medication or substance, or it may be of central origin. Hypersomnia of central origin can be caused by Kleine-Levin Syndrome, Narcolepsy, or Idiopathic Hypersomnia.

Kleine-Levin Syndrome is characterized by episodes of very long sleep intermixed with periods of normal sleep. We do not have relevant training or experience to treat KLS. Instead, we refer patients for neurological evaluation and treatment.

Narcolepsy can be thought of as the intrusion of REM sleep phenomena into wakefulness. In addition to excessive daytime sleepiness, people with narcolepsy experience sleep paralysis (being unable to move when waking from sleep), and hypnagogic or hypnapompic hallucinations (hallucinations that occur only during the sleep-wake transition). People with Type 1 Narcolepsy may also experience cataplexy: sudden loss of muscle tone in response to surprise or strong emotion. This can be as dramatic as collapsing, or as subtle as slurring words or knee buckling. Diagnosis typically requires an overnight sleep study (polysomnogram, PSG) followed by Multiple Sleep Latency Test (MSLT), in which patients are given 4 to 5 opportunities, two hours apart, to nap during the day. The PSG will usually show short sleep latency, short REM latency, and generally disrupted sleep throughout the night. The MSLT will show a short average sleep onset latency and quick transition into REM sleep.

Idiopathic Hypersomnia is characterized by excessive daytime sleepiness that cannot be accounted for by Narcolepsy or any other medical disorder. Nocturnal sleep time may be quite long, followed by significant difficulty waking and subsequent “sleep drunkenness”, and naps are typically long and unrefreshing.

The standard treatments for Narcolepsy are medications such as stimulants (e.g., modafinil, methylphenidate), sodium oxybate, and REM-suppressing medications. The standard treatments for Idiopathic Hypersomnia are stimulant medications. Narcolepsy and hypersomnia are frequently comorbid with anxiety and depression, which is not surprising due to the significant impairment in one’s ability to live their life while excessively sleepy. Sleep physicians are experts in medication treatments for hypersomnia, but seldom have the time or expertise to address the psychosocial consequences. of these disorders. Similarly, most mental health professionals have expertise in treating problems like anxiety and depression, but are completely unfamiliar with sleep disorders such as hypersomnia. As such, treatments are being developed to be delivered by Behavioral Sleep Medicine professionals, who have expertise in both sleep and psychological disorders. Dr. Dawson was co-investigator on a treatment development study at Northwestern University and have worked with people with Narcolepsy Type 1 and Type 2 as well as people with Idiopathic Hypersomnia. The initial treatment model was 6 sessions, but most participants felt that a longer treatment would be more beneficial.

Expected length of treatment: 6 to 12 sessions

Isolated Sleep Paralysis

Some people frequently experience total or near-total muscle paralysis upon awakening from sleep. While it is not unusual for a person to have this sort of experience from time to time, if it happens frequently and causes distress, it may warrant a clinical diagnosis of Isolated Sleep Paralysis (ISP). People with ISP tend to also have significant anxiety. Unfortunately, anxiety and fear can exacerbate sleep paralysis, creating a vicious cycle.

Treatment may include education, general anxiety reduction, and reducing catastrophic thoughts that happen during episodes of sleep paralysis. We are in the early days of treatment development for ISP. The only existing treatment protocol recommends 5 visits.

Expected length of treatment: 5 sessions

Nocturnal Panic Attacks

Panic attacks that begin while a person is asleep tend to be a sign of severe Panic Disorder.

Treatment for Panic Disorder usually includes a systematic approach to reduce the distress and anxiety caused by certain bodily symptoms, carefully resuming activities one has given up out of fear of panic attacks, as well as addressing catastrophic thoughts that occur during panic attacks and unhelpful beliefs about panic attacks.

Expected length of treatment: 8 to 12 visits

Comorbid Psychological Disorders

Problems such as depression, anxiety, and PTSD are common in people with sleep disorders, and can be improved by treating your sleep disorder. However, mood and anxiety problems can also make it difficult to engage in or benefit from sleep-focused treatments.

Treatment may need to be adjusted, may take longer, or the focus of treatment may need to shift to those problems before taking on your sleep difficulties. In addition, some degree of mood and anxiety problems may persist after sleep treatment. If we have the therapeutic competence to provide you with effective treatment for non-sleep problems, we will offer to do so. Otherwise, we will provide you with a list of other providers who are better equipped to help.

Expected length of treatment: may increase time of any of the treatments above, may require an additional 8 to 16 visits, possibly more, or may require transferring care.

Long Term Follow Ups

After completing treatment, many patients feel more comfortable knowing they have an opportunity to touch base with their clinician several months later. This can be helpful in terms of maintaining progress and trouble-shooting setbacks or new problems. In some cases, appointments are set in advance, but most of the time, patients are advised that long term follow ups are available. Most of our patients find that they do not require long term follow ups.