01

Common Sleep Disorder Indicators

If your Sleep Baseline Assessment Session has advised you to learn about specific disorders, proceed to the disorder section below. Each disorder has a sleep center locator (as does the middle of this page).

02

We Educate on Follow-Up Pathways

Clinical confirmation of a disorder requires a physician. Educate yourself on the disorder screening criteria, diagnostic requirements and treatment modalities available. Discuss these with your physician.

03

We Address Overlapping Patterns

Common sleep disorders often overlap with poor sleep preparation patterns that invoke similar pathological mechanisms to the disorders. Visit educational sections on disorder mechanisms and sleep functions.

04

We'll Contextualize The Relevance

Poor sleep quality invokes physiological mechanisms that drive other common disorders such as obesity, diabetes and heart-disease even before sleep disorder states are reached. See OSA section for more.

Common Sleep Disorders

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The Impacts of Sleep Disorders Are Significant

Scroll down for a contextual overview of common sleep disorders including insomnia, OSA and other disorders or select from the set of specific disorders listed below

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Obstructive sleep apneadds a yearly burden of at least $150 billion to our annual budget. When you factor in transient episodes of insomnia and other patterns associated with poor sleep, the number rises to well over $400 billion dollars drained from the nation's economy. But it is actually the impact on the individual that is more alarming than that which applies economically to our collective society. Those impacts translate directly into the loss of basic health and mental wellbeing. Yet the impacts of poor sleep quality are still wildly underestimated, primarily because: (1) we tend to personally equate the impacts of poor sleep on our health and wellbeing only with the level of sleepiness that we feel and acclimate-to in modern life, and (2) the prevalence of clinical sleep disorders such as OSA and insomnia do not capture the much larger prevalence of sub-clinical varieties and poor sleep quality that nonetheless still invoke the same pathological mechanisms that are associated with those disorders, albeit (sometimes) to a lesser pathophysiological degree. In fact, it is precisely those mechanisms that we are largely unaware of that render the interpretation of our direct feelings about the impacts of sleepiness so very dangerous. It is a well-established fact that we overestimate our capacity to perform with sub-optimal sleep. Yet even the wider clinical sector has traditionally considered sleep problems (apart from primary sleep disorders) to be a mostly secondary effects from other primary medical and psychiatric conditions. This has radically changed, however. Sleep-disorder mechanisms are now known to drive cardiovascular and metabolic disorders such as heart-disease, obesity and diabetes (independent of obesity), and they have been implicated more and more in the onset and maintenance of nearly every known psychiatric disorder as well as dementia and Alzheimer's disease. At the very least, poor sleep mechanisms are a crucial component to a vicious cycle run amuck. That vicious cycle includes associations in the "metabolic syndrome" cluster as well as the links between poor sleep quality and mental/emotional disorders.
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The Characterization of Sleep Disorders

Sleep Specialists Characterize & Treat Sleep Disorders
Although clinical sleep specialists are the only specialists adequately trained and credentialed in the discipline of sleep medicine, poor sleep quality often presents serious impacts to health and wellbeing prior to the formal criteria that characterize a sleep disorder state. This suggests that large scale sleep optimization strategies should employ both the clinical sector and the preventative lifestyle sector, along with authentic measures to educate the public about the dangers of poor sleep quality. Nonetheless, when it comes to the individuals that do breach the sleep disorder threshold, it is clear that a clinical process is required to diagnose, treat and follow-up with sleep disorder candidates.
The formal classification of sleep disorders is beyond the scope and basic function of this learning platform. Still, it is useful to introduce the categorization schema utilized in clinical sleep diagnostics before we introduce a few common sleep disorders. The current diagnostic classification of sleep disorders is based on a classification system initiated in 1979. In 1990, a precursor organization to the current American Academy of Sleep Medicine (AASM) introduced the first edition of the International Classification of Sleep Disorders Diagnostic & Coding Manual (ICSD). In 2005, the ICSD was updated with a second edition that provided the structuring for AASM practice parameters and clinical guidelines for the diagnosis and treatment of sleep and arousal disorders. In 2014, the ICSD manual was updated to ICSD-3. In addition to ICSD, disorders are also coded in other general medical and psychiatric coding systems.

The second edition of ICSD listed 85 sleep disorders in 8 major categories that were largely unchanged in ICSD-3. The major categories include: (1) insomnias, (2) sleep-related breathing disorders, (3) hypersomnias of central origin, (4) circadian rhythm sleep disorders, (5) parasomnias, (6) sleep-related movement disorders, (7) isolated and unresolved variants, and (8) other sleep disorders. The number of sub variants in certain categories has since grown, however we discuss only a few of the most common disorders here.

INSOMNIA

Insomnia classification underwent a significant change in the transition from ICSD-2 to ICSD-3.  The change reflects the emphasis that sleep disorders should be regarded as primary disorders treated independently, as opposed to secondary effects that are resolved only with the resolution of other primary disorders.


Insomnia is largely defined as persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs in the context of adequate opportunity for sleep, and results in some form of daytime impairment. The three components of insomnia— (1) persistent sleep difficulty, (2) adequate sleep opportunity, and (3) daytime dysfunction associated with sleep difficulty—are all implied with formal references to the term insomnia. The subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep and results in some form of daytime impairment is required. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and ICSD-3 have similar criteria. Criteria specify that symptoms must cause clinically significant functional distress or impairment, be present for at least 3 nights/week for at least 3 months, and not be linked to other sleep, medical, or mental disorders.

Various studies have shown the prevalence of insomnia to be 10%–30% of the population, but some even estimate a prevalence as high as 50%–60%. The discrepancy often has to do with the fact that the public largely utilizes the term insomnia for any sleep-related problem, which can often be far more prevalent than the strict medical criteria suggest. The differentiating factors for clinicians are (apart from the absence of another primary disorder) the frequency and the fact that functional impairment is involved.

Insomnia is common in older adults, females, and people with medical and mental illness. The consequences of insomnia include depression, impaired work performance/quality of life, and increased risk for motor vehicle accidents. Apart from increased safety risks and cognitive/emotional impacts, the data also increasingly link short sleep varieties to cardiovascular, metabolic and immune dysfunctions.


I. Insomnia

Insomnia is thought to emerge from a combination of factors that may make it more likely in some individuals. These factors have been summarized in the sleep literature as the “3 P’sof insomnia, including: Predisposing factors such as a general hyperarousal tendency that lowers one’s threshold for waking. Sleep clinicians consider predisposing tendencies to be difficult to modify relative to other factors because they often include a genetic predisposition, including mood/affective disorders that amplify anxiety and the tendency toward hyperarousal and other psychiatric disorders, including depression, bi-polar disorder and others. In addition to hyperarousal states, hyper-rumination or "excess worry" may be a tendency for a subset of this general class of predisposing dispositions. Precipitating factors of insomnia are events and episodes that have become triggers for the onset or worsening of sleep difficulties. They are often related to stressful life changes and intense emotional experiences (both positive and negative) that, in turn, precipitate sleep difficulties. Cognitive and behavioral interventions can diminish the intensity of these reflexive triggers. Perpetuating factors of insomnia are repeating behaviors or conditions that contribute to insomnia. Examples of perpetuating factors include inadequate sleep hygiene, negative forethought about the effects of insomnia, and environmental factors such as stimuli that impact the circadian rhythm entrainment system at the wrong time. Perpetuating factors are the most responsive to interventions, but perpetuating interventions do not treat insomnia on their own.

If patients or practitioners need to find a sleep specialist associated with a sleep center in their area, the American Academy of Sleep Medicine (AASM) has a sleep center: locator.

Are Pills The Answer?

As suggested, the so-called "insomnia with short sleep" sub category is associated with hypertension, diabetes, neurobehavioral performance impairments and safety risks. The principle emphasis point and main learning sections of this education platform provide us opportunity to understand how that link between short sleep and medical diseases and dysfunctions is not a simple association of "bad lifestyles". Instead, if we look under the hood we discover that there is an engine driving the adverse connections associated with poor sleep. That engine is comprised of the physiological mechanisms that poor sleep sets in motion within our cardiovascular system, metabolic functions, immune system and sleep-dependent cognitive/emotional processes. In a subsequent section below, we will discover that the engine is turbocharged when sleep related breathing disorders are added to the mix.

We discuss immediately below that cognitive behavioral therapy for insomnia (CBT-I) and related techniques are useful not just for insomnia, but also for comorbid psychiatric conditions such as depression, bipolar disorder, PTSD, and schizophrenia. The momentum toward CBT-I is not simply because of its apparent effectiveness to assist sleep quality, however. It is also because studies have disclosed sleep aids and sleeping pills to be problematic over the long-term relative to the capacity to re-engage our natural patterns.
One of the basic premises of CBT-I is that psychological patterns of thought become reflexive and thereby perpetuate and exacerbate sleep onset and sleep maintenance issues. Those issues, however, may not always begin as a primary insomnia subtype. In the circadian rhythm learning section we discover how easy it is to have our circadian rhythm 'drift' later and later, thereby causing sleep onset difficulties that may be exacerbated and "locked in" through our cognitive associations. Sleep disordered breathing (SDB) subtypes such as obstructive sleep apnea (OSA), primary snoring, partial airway restriction, and now increasingly: central sleep apnea (CSA) due to opioid use, all contribute to the 'triggers' that turn our attempts to sleep into a wary battle. To make matters worse, our culture has turned to both over-the-counter (OTC) sleep aids and prescribed sleeping pills with a voracious appetite. These substances, in many cases, have added to our cognitive dependence and lack of confidence in our natural capacity to slide into restorative sleep. Moreover, although there is a place for the disciplined use of some aids to temporarily assist, for example, circadian rhythm shifts for rotating shift workers, the long-term use of both categories (OTC & prescribed pills) is increasingly disclosed by large meta studies to be robustly associated with adverse outcomes. These associations may or may not be mechanistic and causal, nonetheless the pattern is real.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

AASM clinical guidelines for the evaluation and management of chronic insomnia consider behavioral treatment options, such as CBT-I, to be a recommended "first-line treatment option". Common pharmacological interventions such as benzodiazepine receptor agonist medications (i.e., 'sleeping pills') are increasingly revealed to be associated with adverse outcomes with long-term use. CBT-I is a combination of component behavioral therapy interventions, including therapeutic protocols derived from: (1) Stimulus Control Therapy; (2) Sleep Restriction Therapy; (3) Relaxation-Based Interventions; (4) Cognitive Strategies/Mindfullness Techniques; and (5) Sleep Hygiene Education.

A very telling fact about the efficacy of CBT-I is to note its effectiveness for the treatment of insomnia in the context of other disorders. CBT-I is effective for the treatment of insomnia related to: depression, anxiety, PTSD, and substance-abuse issues. It is well-established that insomnia is closely associated with mental illnesses, both as a symptom and as a trigger. Its co-occurrance with major depression is 80%. In some studies, CBT-I is considered more effective than cognitive therapies addressed specifically to those psychiatric disorders. In addition to psychiatric disorders, CBT-I has also been shown to be effective for insomnia due to medical disorders, including chronic pain, fibromyalgia, cancer and various medical conditions in the elderly population. Insomnia in older individuals is more likely to be comorbid with other medical conditions, medications, or substances. If insomnia is comorbid with OSA or any other condition, CBT-I and insomnia treatment in general are no longer considered secondary treatment priorities but can be applied in tandem with other treatment modalities because contraindications do not arise with CBT-I, except for some advanced illnesses.

To learn more about the multiple components of CBT-I Protocols, select the link.
CBT-I

Stimulus Control

The goal is to turn your negative reflexives about the challenges you have with sleep onset into positive, confident associations with your bedroom and your sleep environment.

CBT-I

Sleep Restriction

It is completely counter-intuitive at first but one of the best ways to "reset" your association with sleep is to make you physiologically sleepy enough to overcome your intruding concerns.

CBT-I

Relaxation & Feedback

You will learn in the circadian rhythm education section that sleep onset follows a natural dip that prepares the way for sleep. Relaxation techniques can assist this natural process.

CBT-I

Cognitive Control & Therapy

Therapy, guided imagery and mindfulness can help control intrusive thoughts. After all, one of sleep's basic functions is to "finish" processing your emotions if you are ready to let it.

Circadian Rhythm Shifts & Insomnia

The actual diagnoses of a circadian rhythm shift disorder may not be very common in comparison to the diagnosis of other sleep disorders, but even subclinical circadian shifts impair the sleep onset timing of a significant number of individuals— enough even to apparently drive the frequent misdiagnoses of insomnia by primary care physicians who do not consider circadian rhythm shifts when prescribing sleeping pills. One of the differentiating features of a circadian rhythm delay relative to insomnia is that sleep onset difficulties do not arise during typical weekends or days off, but they are persistent during the week for individuals with delayed rhythms. More generally, apart from the potential impacts from sleep-related breathing disorders (below) and other medical disorders, circadian rhythm shifts may impact sleep quality more than nearly any other factor. Subtle shifts, drifting rhythms, and misaligned circadian rhythms are a great concern for much of risk management, and on the other side of the coin, when optimized, circadian rhythms create an organizing framework for increased athletic performance. More commonly, however, a shifted rhythm may create an environment that elicits problematic cognitive cycles that are conducive to the development of chronic insomnia. Circadian rhythm optimization is therefore a crucial component of good sleep hygiene practices that prepare the body for consistently timed sleep onset patterns. By virtue of this critical role for the timing of sleep onset and all of the intervening sleep stage functions within sleep, we present an entire learning section on circadian rhythm. We believe that it is important to take the time to understand circadian rhythms.

II. Sleep Related Breathing Disorders (SRBD)

SDB

Sleep-Disordered Breathing

As a disorder class, SDB's (SRBD's) include not only OSA, but central sleep apnea (CSA) due to opioids (from reduced respiratory drive) and Cheyne-Stokes respiration (CSR) from the reduced blood flow of conditions such as congestive heart failure (CHF) and stroke.

OSA

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is what is often referred to by the public as simply "sleep apnea". OSA is more prevalent in obese individuals, the male gender and advanced age (male and female). The economic and individual health impacts from OSA are substantial.

CSR

Cheyne Stokes Respiration

Cheyne-Stoke respiration (CSR) is an alternating crescendo-decrescendo breathing pattern that cycles between periods of hyper breathing and under breathing which is common in congestive heart failure (CHF) patients. It is a different pattern than CSA due to opioids.

CSA

Central Sleep Apnea

CSA types can vary, including CSR subtypes from stroke or CHF, and an under and over breathing cycle due to the overall reduced respiratory drive that opioids induce. When present with OSA, CSA creates 'complex' apnea types that are more difficult to treat than OSA alone.

OSA Under The Radar

The adverse mechanisms that ensue from OSA are key to appreciating its insidious effects on our health. The effects from OSA are often completely "under the radar" for both the individuals that have OSA yet do not know it, and individuals with other clinical conditions such as hypertension, diabetes and obesity where OSA may contribute to the condition unbeknownst to patients & physicians. Yet OSA is only one SDB and even primary snoring can induce a number of pathophysiological mechanisms. Despite these concerns, OSA is easy to screen through validated screening questionnaires inquiring into well-established symptoms . To learn more about OSA visit the following links: OSA Intro, Screening, Treatment & Impact.

OSA

Existing Medical Conditions

Individuals with diabetes, hypertension, cardiac arhythmmia, heart disease, obesity, heart-failure, stroke; and women with PCOS are significantly more likely to have OSA or some other form of SDB.

OSA

Older Versus Younger

Due to a number of factors that include the penchant for weight-gain and reductions in the stiffness of the upper-airway musculature, individuals over 50 (and post-menopausal women) are at increased risk.

OSA

Men Versus Women

Males are significantly more likely to have OSA, however post-menopausal women approach the rate of men overall and women with PCOS are at significantly higher risk for OSA than women in general.

OSA

Signs & Symptoms

Aggressive snoring is a major indicator for upper-airway resistance and OSA. Body mass index (BMI) is also a good indicator but for some populations neck circumference is a better indicator that abdominal fat.

Click To Review Additional Common Sleep Disorders

Sleep Is Not Rest

Although Nourish Sleep is a non-clinical entity, we do not operate outside of a responsible care pathway. Nourish Sleep screening does not constitute confirmation of a sleep disorder or lack thereof. Only a face-to-face clinical evaluation with a clinician or board certified sleep physician can affirm the necessity for further diagnostics or treatment. Our role is to educate you and provide you a rigorous, but highly tailored and comprehensive understanding of your specific sleep quality. Although we work collaboratively with a diverse array of clinical and educational resources to fulfill that mission, Tri-Nourish Inc and Nourish Sleep constitute non-clinical entities offering non-clinical services. Our goal is to assist your sleep quality in a pre-pathological (preventative) approach that takes into consideration domains that impact health and wellbeing before they transition into common sleep, mental or physiological disorders. Poor sleep quality radically impacts productivity, performance, health, emotional resilience, and safety— well before the sleep disorder threshold has been breached.