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SLEEP WAKE DISORDERS
GROUP 4
BUENSALIDA, JESUFIDES R.
DELA CRUZ, KEVIN ANGELO
ELIZAN, JANN EARL HEINRICH S.
GENTOLIZO, MARIA ROMA BIANCA V.
GO, GENE LOROSE P.
GRAN, PAULA ANGELICA T.
LAYA, ANGELICA SHYR
NOJARA, DANNICA V.
OHARA, HEBER JUSTIN P.
RIVERA, CARMELA TERESA C.
SAN GABRIEL, BRYLLE ALLAN P.
VILLANUEVA, MA SOCCORRO G.
3BES1
ARREVILLAGA, MILAGROS C.
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INSOMNIA DISORDER
I. DESCRIPTION
It is the difficulty of falling asleep (onset) or staying asleep
(maintenance), even though the person had the opportunity to
get a full night of sleep. One or more things of the following are
experienced by people with Insomnia: fatigue, low energy,
difficulty concentrating, mood disturbances, and decreased
performance in work or at school.
Insomnia may be characterized depending on its duration.
Acute Insomnia and Chronic Insomnia.
Acute Insomnia: Often happens because of life circumstances,
many people may have experienced this passing sleep type of
disruption, and can be resolved without any treatment.
Chronic Insomnia: Changes in the environment, unhealthy
sleep habits, shift work, other clinical disorders, and certain
medications could lead to a long-term pattern of insufficient
sleep may cause this, as this is a disrupted sleep that occurs at
least three nights per week and lasts at least three months.
They may need treatment to be able to get back in their healthy
sleep pattern.
II. SYMPTOMS
Symptoms and causes of insomnia are different for every
patient. Insomnia symptoms may include:
Fatigue
Problems with attention, concentration or memory
(cognitive impairment)
Poor performance at school or work
Moodiness or irritability
Daytime sleepiness
Impulsiveness or aggression
Lack of energy or motivation
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Errors or accidents
Concern or frustration about your sleep
III. TREATMENT
A. SLEEP HYGIENE
In many chronic insomnia cases, by practicing good hygiene
and changing your sleep habits you can improve your sleep.
Sleep hygiene is a set of bedtime habits and rituals you can
do every night to improve how you sleep.
Sleep as much as you need to feel rested; do not
oversleep.
Exercise regularly at least 20 minutes daily, ideally 4-5
hours before your bedtime.
Avoid forcing yourself to sleep.
Keep a regular sleep and awakening schedule.
Do not drink caffeinated beverages later than the
afternoon (tea, coffee, soft drinks etc.) Avoid "night
caps," (alcoholic drinks prior to going to bed).
Do not smoke, especially in the evening.
Do not go to bed hungry.
Adjust the environment in the room (lights,
temperature, noise, etc.)
Do not go to bed with your worries; try to resolve them
before going to bed.
Go to bed when you feel sleepy.
Do not watch TV, read, eat, or worry in bed. Your bed
should be used only for sleep and sexual activity.
If you do not fall asleep 30 minutes after going to bed,
get up and go to another room and resume your
relaxation techniques.
Set your alarm clock to get up at a certain time each
morning, even on weekends. Do not oversleep.
Avoid taking long naps in the daytime.
B. MEDICAL TREATMENT
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A number of medication can possibly treat Insomnia, so this
should not be used as the only therapy to treat Insomnia.
Benzodiazepine sedatives: These include temazepam
(Restoril), flurazepam (Dalmane), triazolam (Halcion),
estazolam (ProSom, Eurodin), lorazepam (Ativan), and
clonazepam (Klonopin).
Nonbenzodiazepine sedatives: These include
eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem
(Ambien).
Antihistamines
C. COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA
Cognitive behavioral therapy for insomnia, or CBT-I,
addresses the thoughts and behaviors that keep you from
sleeping well. It also helps you learn new strategies to sleep
better. CBT-I can include techniques for stress reduction,
relaxation and sleep schedule management.
IV. FAMOUS PERSONALITIES
1. Jimi Hendrix
2. Michael Jackson
3. Madonna
4. Miley Cyrus
5. Bill Clinton
6. Sandra Bullock
7. George Clooney
8. Eminem
9. Jessica Simpson
10. Lady Gaga
V. FACTS / TRIVIAS
Pills might not help
Many people with sleeping problems might turn to sleeping
pills. However, these pills are not always the answer, especially
if the sleep problems are chronic. Instead, people should try to
make their bedrooms optimal for sleeping.
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Paying attention can worsen symptoms
Some people might put a lot of attention on their sleeping patterns and habits, preventing them from being able to relax
and actually fall asleep.
HYPERSOMNOLENCE DISORDER
I. HISTORY
In the year 1966, William Dement suggested that patients with
excessive daytime sleepiness, but without cataplexy, sleep
paralysis, or sleep-onset rapid eye movement (REM), should not
be considered narcoleptic. In 1972, Roth et al described a type
of hypersomnia with sleep drunkenness that consists of
difficulty coming to complete wakefulness, confusion,
disorientation, poor motor coordination, and slowness,
accompanied by deep and prolonged sleep. The abrupt sleep
attacks seen in classic narcolepsy are not present in this
disorder. (WEBMD, 2015)
II. DESCRIPTION
Also known as HYPERINSOMIA
Described as having excessive DAY-TIME NAPS despite the
night sleep.
Excessive INVOLOUNTARY DAY TIME SLEEPINESS.
Even if the person takes a nap for more than an hour, he or
she would still feel tired and unalert.
People diagnosed with hypersomnolence are compelled to nap
during inappropriate times of the day. (during a meal,
gatherings, comverstaions, etc)
Fully manifests in late adolescence to early adulthood.
III. SYMPTOMS
A. Self-reported excessive sleepiness (hypersomnolence)
DESPITE a main sleep period lasting at least 7 hours, with
at least one of the following symptoms:
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1. Recurrent periods of sleep or lapses into sleep within the
same day.
2. A prolonged main sleep episode of more than 9 hours per
day that is non-restorative (i.e., unrefreshing). 3. Difficulty being fully awake after abrupt awakening.
B. Occurs at least THREE TIMES PER WEEK, for at least
THREE MONTHS.
C. The hypersomnolence is accompanied by significant distress
or impairment in cognitive, social, occupational, and or other
important areas of functioning.
D. The hypersomnolence is not better explained by and does
not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder,
circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately
explain the predominant complaint of hypersomnolence.
Other Symptoms:
Anxiety
Increased Irritability
Decreased energy despite the excessive amount of
sleep
Slow thinking or response
Slow speech
Loss of appetite
Hallucinations
Memory difficulty
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Diagnosis:
By Duration:
Acute: Duration of less than 1 month.
Subacute: Duration of 1-3 months.
Persistent: Duration of more than 3 months.
By Severity:
Mild: Difficulty maintaining daytime alertness 1-2
days/week.
Moderate: Difficulty maintaining daytime alertness 3-4
days/week.
Severe: Difficulty maintaining daytime alertness 5-7
days/week.
IV. TREATMENT
The treatment for this disorder is based on the patients
environment. An example could be a change in behavior,
avoiding late night work.
Medication is also prescribed to some patients
Stimulants such as the following may be prescribed:
amphetamine,methylphenidate (Concerta, Metadate CD,
Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin LA,
Ritalin-SR), and modafinil (Provigil).
Other drugs used to treat hypersomnia include:
clonidine (Catapres),
levodopa (Larodopa),
bromocriptine (Parlodel),
antidepressants, and
monoamine oxidase inhibitors
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NARCOLEPSY
I. HISTORY
Narcolepsy, a neurological disorder that causes overwhelming
daytime drowsiness and sleep attacks was first recognized as a
clinical disorder in 1880.
Narcolepsy is the English form of the French word narcolepsie,
and was first used in 1880 by the French physician Jean-
Baptiste-Edouard Glineau (1828-1906). The origin is from the
Greek, narke (numbness, stupor) and lepsis (attack, to seize).
Early descriptions of narcolepsy were in case reports from the
German physicians Westphal (1877) and Fisher (1878). Both
authors noted the associations between sleep episodes and
attacks of muscle weakness triggered by emotion.
Thomas Willis (1621-1675) described patients with a sleepy
disposition who suddenly fall fast asleep, which may represent
the earliest account of narcolepsy.
Vogel in 1960 first recorded REM sleep at the onset of an attack
in a patient with narcolepsy
II. DESCRIPTION
Narcolepsy is a neurological disorder that affects the control of
sleep and wakefulness. People with narcolepsy experience
excessive daytime sleepiness and intermittent, uncontrollable
episodes of falling asleep during the daytime. These sudden
sleep attacks may occur during any type of activity at any time
of the day.
In a typical sleep cycle, we initially enter the early stages of
sleep followed by deeper sleep stages and ultimately (after about
90 minutes) rapid eye movement (REM) sleep. For people
suffering from narcolepsy, REM sleep occurs almost
immediately in the sleep cycle, as well as periodically during the
waking hours. It is in REM sleep that we can experience dreams
and muscle paralysis -- which explains some of the symptoms
of narcolepsy.
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Narcolepsy usually begins between the ages of 15 and 25, but it
can become apparent at any age. In many cases, narcolepsy is
undiagnosed and, therefore, untreated.
III. SYMPTOMS
Narcolepsy is typically characterized by the following symptoms
with varying degrees of frequencies, include:
Excessive daytime sleepiness
Cataplexy
Hypnagogic hallucinations
Sleep paralysis
Disturbed nocturnal sleep
Automatic behavior
Other complaints such as blurred vision, double vision,
or droopy eyelids
IV. TREATMENT
Currently, narcolepsy cannot be cured, and intensive research
to find a cure continues. The loss of hypocretin is believed to be
irreversible and lifelong. But the condition can be controlled in
most individuals with drug treatment. The leading medications
are Xyrem, Provigil and Nuvigil.
Drug therapy should accompany various behavioral strategies
according to the needs of the affected individual, such as:
Take short, regularly scheduled naps at times when
sufferers tend to feel sleepiest.
Maintain a regular sleep schedule.
Avoid alcohol and caffeine-containing beverages for
several hours before bedtime.
Avoid smoking, especially at night.
Maintain a comfortable, adequately warmed bedroom.
Engage in relaxing activities such as a warm bath before
bedtime.
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Exercising for at least 20 minutes per day no closer than
four to five hours before bedtime.
V. FAMOUS PERSONALITIES
1. Kurt Cobain (Musician)
2. Arthur Lowe (Actor)
3. Franck Bouyer (French Cyclist)
4. Jimmy Kimmel (Talk Show Host)
5. Thomas Edison (Inventor of the Light Bulb)
6. Winston Churchill (Former British Prime Minister)
7. Nastassja Kinski (Actress)
8. Harriet Tubman (Abolitionist who helped many slaves to
freedom)
VI. FACTS/TRIVIAS
Humans spend approximately 1/3 of their lives asleep.
Narcolepsy is a lifelong disorder that affects approximately
1 in every 2000 people in the US.
Many people with narcolepsy go through their lives
undiagnosed.
Symptoms of narcolepsy are usually first seen during the
adolescent years.
Narcolepsy has been observed in humans and a few other
species of animals, including dogs.
Narcolepsy has both genetic and sporadic forms.
The severity of the disorder varies from person to person.
Narcoleptics have 10 times the rate of automobile accidents
as non-narcoleptics.
A description of narcolepsy in a mother and a son dates
back to 1887.
BREATHING RELATED SLEEP DISORDERS
1. OBSTRUCTIVE SLEEP APNEA
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I. DESCRIPTION
OSA occurs when there are repeated episodes of partial or total
blockage in the upper airway during sleep. These blockages
cause the diaphragm and the chest muscles to work harder so
when breathing resumes, it is often accompanied with a loud
snort, jerk, or gasp.
It is more common to men more than women. For women it
usually occurs after the menopausal stage. Other risk factors
include: being overweight, having a large or thick neck.
It may also be caused by other diseases especially those that
affect the lungs and those which may cause blockage in the
nose or throat.
II. SYMPTOMS
Signs and symptoms of obstructive sleep apnea include:
Excessive daytime sleepiness
Loud snoring
Observed episodes of breathing cessation during sleep
Abrupt
Awakenings accompanied by shortness of breath
Awakening with a dry mouth or sore throat
Awakening with chest pain
Morning headache
Difficulty concentrating during the day
Experiencing mood changes, such as depression or
irritability
Difficulty staying asleep (insomnia)
Having high blood pressure
Consult a medical professional if you experience, or if your
partner observes, the following:
Snoring loud enough to disturb your sleep or that of
others
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Shortness of breath that awakens you from sleep
Intermittent pauses in your breathing during sleep
Excessive daytime drowsiness, which may cause you to
fall asleep while you're working, watching television or
even driving a vehicle
III. TREATMENT
The treatment for obstructive sleep apnea will depend on the
factors causing the obstruction. There are several possible
treatments for obstructive sleep apnea
Conservative treatments -- In mild cases of sleep apnea,
conservative therapy may be all that is needed. These
treatments include the following:
Overweight individuals can benefit from losing weight.
Even a 10% weight loss can reduce the number of sleep
apnea events for most patients.
Individuals with sleep apnea should avoid the use of
alcohol and sleeping pills, which make the airway more
likely to collapse during sleep and prolong the apneic
periods.
In some patients who have mild sleep apnea, breathing
pauses occur only when they sleep on their backs. In
such cases, using pillows and other devices that help
them sleep in a side position may be helpful.
People with sinus problems or nasal congestion, who are
more likely to experience sleep apnea, can try nasal
sprays to reduce snoring and improve airflow for more
comfortable nighttime breathing.
Avoiding sleep deprivation is important for all patients
with sleep disorders.
1. Mechanical therapy -- Continuous positive airway
pressure (CPAP) is the preferred initial treatment for
most people with obstructive sleep apnea. With CPAP,
patients wear a mask over their nose and/or mouth.
An air blower forces constant and continuous air
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through the nose and/or mouth. The air pressure is
adjusted so that it is just enough to prevent the upper
airway tissues from collapsing during sleep. Other
types of positive airway pressure devices are also
available, including the BPAP, which has two levels of
air flow that vary with breathing in and out.
2. Mandibular advancement devices -- For patients with
mild sleep apnea, dental appliances or oral mandibular
advancement devices that prevent the tongue from
blocking the throat and/or advance the lower jaw
forward can be made. These devices help keep the
airway open during sleep. A sleep specialist and
prosthodontist -- a person with expertise in these types
of oral appliances -- should jointly determine if this
treatment is best for you.
3. Surgery -- Surgical procedures may help people with
sleep apnea. There are many types of surgical
procedures, often performed on an outpatient basis.
Surgery is reserved for people who have excessive or
malformed tissue that is obstructing airflow through
the nose or throat. For example, a person with a
deviated nasal septum, markedly enlarged tonsils, or
small lower jaw and a large tongue that causes the
throat to be abnormally narrow might benefit from
surgery. These procedures are typically performed after
sleep apnea has failed to respond to conservative
measures and a trial of CPAP.
Types of Surgery include:
1. Upper airway stimulator -- This device, called Inspire,
consists of a small pulse generator placed under the skin
in the upper chest. A wire leading to the lung detects the
person's natural breathing pattern. Another wire, leading
up to the neck, delivers mild stimulation to nerves that
control airway muscles, keeping them open. A doctor can
program the device from an external remote. Also, those
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who have Inspire use a remote to turn it on before bed and
turn off upon waking in the morning.
2. Somnoplasty -- a minimally invasive procedure that uses
radiofrequency energy to tighten the soft palate at the back
of the throat.
3. UPPP, or UP3, (which stands for
uvulopalatopharyngoplasty) -- a procedure that removes
soft tissue in the back of the throat and palate, increasing
the width of the airway at the throat opening.
4. Mandibular/maxillary advancement surgery -- surgically
moving the jaw bone and face bones forward to make more
room in the back of the throat -- an intricate procedure
that is reserved for patients with severe sleep apnea and
head-face abnormalities.
5. Nasal surgery-- correction of nasal obstructions, such as a
deviated septum.
IV. FAMOUS PERSONALITIES
1. Shaquille ONeal
2. Quincy Jones
3. Randy Jackson
4. Rosie oDonnell
2. CENTRAL SLEEP APNEA
I. HISTORY
(most historical background of central sleep apnea involves sleep-
apnea in general)
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II. DESCRIPTION
Central sleep apnea is when you repeatedly stop breathing
during sleep because the brain temporarily stops sending
signals to the muscles that control breathing.
Central sleep apnea often occurs in people who have certain
medical conditions. For example, it can develop in persons who
have life-threatening problems with the brainstem. The
brainstem controls breathing. As a result, any disease or injury
affecting this area may result in problems with normal
breathing during sleep or when awake.
III. SYMPTOMS
Common signs and symptoms of central sleep apnea include:
Observed episodes of stopped breathing or abnormal
breathing patterns during sleep
Abrupt awakenings accompanied by shortness of breath
Shortness of breath that's relieved by sitting up
Difficulty staying asleep (insomnia)
Excessive daytime sleepiness (hypersomnia)
Difficulty concentrating
Mood changes
Morning headaches
Snoring
Although snoring indicates some degree of increased
obstruction to airflow, snoring also may be heard in the
presence of central sleep apnea. However, snoring may not be
as prominent with central sleep apnea as it is with obstructive
sleep apnea.
IV. TREATMENT
Oxygen supplementation and the regulation of air pressure
during sleep are effective treatments for many people with
central sleep apnea. These include:
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CPAP, or continuous positive air pressure, provides a
steady source of pressure in your airways as you sleep.
You wear a mask over your nose and mouth that delivers
pressurized air throughout the night. CPAP is used to
treat obstructive sleep apnea, but can also be beneficial
for people with central sleep apnea.
BPAP, or bi-level positive air pressure, adjusts the air
pressure to a higher level when you inhale and a lower
level when you exhale. BPAP is also delivered through a
facemask.
ASV, or adaptive servo-ventilation, monitors your
breathing as you sleep. The computerized system
remembers your breathing pattern. The pressurized
system regulates the breathing pattern to prevent apnea
episodes.
V. FACTS / TRIVIAS
In general, the main risk factors for sleep apnea are male
gender, being overweight, and being over 40 years of age.
However, anyone can have any of the types of sleep apnea.
Central sleep apnea is often associated with other conditions.
One form of central sleep apnea, however, has no known cause
and is not associated with any other disease. In addition,
central sleep apnea can occur with obstructive sleep apnea, or
it can occur alone.
Conditions that may be associated with central sleep apnea
include the following:
Congestive heart failure
Hypothyroid Disease
Kidney failure
Neurological diseases, such as Parkinson's
disease, Alzheimer'sdisease, and amyotrophic lateral
sclerosis (ALS or Lou Gehrig's disease)
Damage to the brainstem caused by encephalitis, stroke,
injury, or other factors
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3. SLEEP RELATED HYPOVENTILATION
I. DESCRIPTION
Trait of abnormal gas exchange that significantly worsens or
may only be present during sleep. Such abnormalities are
usually caused by hypoventilation and result in hypercapnea
and hypoxemia Even during normal sleep mild
hypoventilation occurs, as documented by a rise in PaCO2
of about ~5 mm Hg.1,2 But in people with respiratory,
neurologic or neuromuscular disease, such hypoventilation
can compound existing deficiencies and have clinical
consequences, such as headaches, insomnia, and
pulmonary hemodynamic complications.
Can present with sleep-related complaints of insomnia or
sleepiness
Caused By:
Ventilatory insufficiency
Pulmonary hypertension
Right heart failure
Polycythemia
Neuorocognitive Dysfunction
TYPES:
1. IDIOPATHIC SLEEP-RELATED HYPOVENTILATION
Very uncommon
Slowly progressive disorder of respiratory
impairments
Can manifest during infancy, childhood and
adulthood because of variable penetrance of
PHOX2B
Associated with reduced ventilator drive due to a
blunted chemoresponsivess to CO2
Complications:
Pulmonary hypertension
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Cor pulmonale
Cardiac dysrhythmias
Polycythemia
Neurocognitive dysfunction
Worsening respiratory failure can develop with
increasing severity of blood gas abnormalities
2. COMORBID SLEEP-RELATED HYPOVENTILATION
Chronic obstructive pulmonary disease
Nueormuscular disorders
Obesity
II. SYMPTOMS
Excessive daytime sleepiness
Frequent arousals and awakening during sleep
Morning headaches
Insomnia complaints
Episodes of shallow breathing may be observed
Obstrusive sleep apnea hypopnea
4. CIRCADIAN RHYTHM SLEEP DISORDER
I. HISTORY
The earliest recorded account of circadian process is during
the 4th century when a ship captain serving under Alexander
the Great described the diurnal movements of a tamarind
tree leaves.
In 1896, it was observed that during prolonged period of
sleep deprivations, sleepiness decreases and increases with
approximately 24 hour period.
The term circadian was termed by Franz Halberg during
1950s
Circadian comes from the Latin words circa, meaning
around, and diem, meaning day.
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II. DESCRIPTION
Circadian rhythm disorder is a disruption in a persons
circadian rhythm or bodys internal body clock.
The key feature of CRD is the continuous or occasional
disruption of sleep patterns.
There is a malfunction of the internal body clock or there is a
mismatch between the internal body clock and d the external
environment regarding the timing and duration of sleep.
III. SYMPTOMS
Difficulty initiating sleep
Difficulty maintaining sleep
Nonrestorative sleep
Daytime sleepiness
Poor concentration
Impaired performance, including decrease in cognitive skills
Poor psychomotor coordination
Headaches
Gastrointestinal distress
When poor sleep for more than one month is accompanied by
one or more of the ff:
Poor concentration
Forgetfulness
Decreased motivation
Excessive daytime sleepiness
Difficulty falling asleep
Nonrefreshing sleep
Habitual snoring
TYPES OF CIRCADIAN RHYTHM SLEEP DISORDER
1. Delayed Sleep Phase Disorder
Occurs when a person regularly goes to sleep and
wakes up more than two hours later than is
considered normal.
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People tend to be evening types and stays up until
1am or later and wake up in the late morning or
afternoon.
More common among adolescents and young adults
2. Advance Sleep Phase Disorder
Occurs when a person regularly goes to sleep and
wakes up several hours earlier than most people.
People tend to be morning types who typically
wake up at 2am to 5am and go to sleep between
6pm and 9pm.
Affects approximately 1% of middle-aged and older
adults and increases with age.
3. Jetlag Disorder
Occurs when long travel by airplane quickly puts a
person in another time zone.
In this new location the person must sleep and
wake at times that are misaligned with his or her
body clock.
The severity of the problem increases with the
number of time zones that are crossed. The body
tends to have more trouble adjusting to eastward
travel than to westward travel.
Jet lag affects all age groups. However, in the
elderly, symptoms may be more pronounced and
the rate of recovery may be more prolonged than in
younger adults.
Sleep deprivation, prolonged uncomfortable sitting
positions, air quality and pressure, stress and
excessive caffeine and alcohol use may increase the
severity of insomnia and impaired alertness and
function associated with transmeridian travel.
Jet lag is a temporary condition with symptoms
that begin approximately one to two days after air
travel across at least two time zones. Exposure to
light at inappropriate times may prolong the time of
adjustment by shifting the circadian rhythms in
the opposite direction.
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4. Shift Work Disorder
Occurs when a persons work hours are scheduled
during the normal sleep period.
Sleepiness during the work shift is common, and
trying to sleep during the time of day when most
others are awake can be a struggle.
Depending on the type of shift, diurnal or circadian
preferences may influence the ability to adjust to
shift work.
Persons with comorbid medical, psychiatric and
other sleep disorders such as sleep apnea and
individuals with a strong need for stable hours of
sleep may be at particular risk.
5. Irregular Sleep-Wake Rhythm
Occurs when a person has a sleep-wake cycle that
is undefined.
The persons sleep is fragmented into a series of
naps that occur throughout a 24-hour period.
Sufferers complain of chronic insomnia, excessive
sleepiness or both.
A low-amplitude or irregular circadian rhythm of
sleep-wake pattern may be seen in association with
neurological disorders such as dementia and in
children with mental retardation.
6. Free-running
Occurs when a person has a variable sleep-wake
cycle that shifts later every day.
It results most often when the brain receives no
lighting cues from the surrounding environment.
Occasionally, the disorder is associated with mental
retardation or dementia. It has also been suggested
that there may be an overlap between circadian
rhythm sleep disorder, delayed sleep phase type,
and circadian rhythm sleep disorder, free-running
type.
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IV. TREATMENT
1. Lifestyle changes - People may cope better with certain
circadian rhythm sleep disorders by doing such things as
adjusting their exposure to daylight, making changes in the
timing of their daily routines, and strategically scheduling
naps.
2. Sleep hygiene - These instructions help patients develop
healthy sleep habits and teach them to avoid making the
problem worse by attempting to self-medicate with drugs or
alcohol.
3. Bright light therapy - This therapy synchronizes the body
clock by exposing the eyes to safe levels of intense, bright
light for brief durations at strategic times of day.
4. Medications - A hypnotic may be prescribed to promote
sleep or a stimulant may be used to promote wakefulness.
5. Melatonin - This hormone is produced by the brain at night
and seems to play a role in maintaining the sleep-wake cycle.
Taking melatonin at precise times and doses may alleviate
the symptoms of some circadian rhythm sleep disorders.
PARASOMNIAS
NON RAPID EYE MOVEMENT SLEEP AROUSAL
DISORDER
A. SLEEPWALKING
I. DESCRIPTION
Repeated occurrence of incomplete arousals, usually
beginning during the first third of the major sleep episode
(Criterion A) that typically are brief, lasting 1 10 minutes,
but may be protracted, lasting up to 1 hour.
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Slow-wave sleep
The eyes of the individual are typically open during these
events.
Varying degrees of simultaneous occurrence of wakefulness
Complex behaviors arising from sleep with varying degrees of
conscious awareness, motor activity and autonomic
activation
II. SYMPTOMS
Recurrent episodes of incomplete awakening from sleep,
usually occurring during the first third of the major sleep
episode, accompanied by either one of the following:
1. Sleepwalking: Repeated episodes of rising from the
bed during sleep and walking about. While
sleepwalking, the individual 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.
2. Sleep terrors: Recurrent episodes of abrupt terror
arousals from sleep, usually beginning with a panicky
scream. The individual has intense fear and show
signs of autonomic arousal (mydriasis, tachycardia,
rapid breathing and sweating) during each episode.
There is also relative unresponsiveness to efforts of
others to comfort the individual during the episodes.
No or little (e.g., only a single visual scene) dream imagery is
recalled.
Amnesia for the episodes present.
The episodes cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
The disturbance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication)
Coexisting mental and medical disorders do not explain the
episodes of sleepwalking or sleep terrors.
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III. TREATMENT
1. Improving sleep conditions
setting a regular bedtime
practicing relaxation
limiting food and drink before sleeping
establishing a bedtime routine
2. Medication
Levodopa/carbidopa, gabapentin and clonidine are
sometimes used but there is little systematic evidence of
benefit.
Benzodiazepines anti-anxiety drugs such as
diazepam (Valium) or alprazolam (Xanax) can be used to
help relax muscles, although these may not result in
fewer episodes of sleepwalking.
3. Stress management
4. Biofeedback training
5. Relaxation techniques
6. Hypnosis - Has been used help sleepwalkers awaken once
their feet touch the floor.
7. Psychotherapy - May help individuals who have underlying
psychological issues that could be contributing to sleep
problems.
IV. FAMOUS PERSONAITIES
Sleepwalking
1. Jennifer Aniston
2. Bobby Brown
3. Park Ha Sun
Sleep Terrors
1. Florence Welch
2. Gerard Way
3. H.R. Giger
4. H.P. Lovecraft
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5. Travis Pastrana
V. FACTS AND TRIVIAS
30% of children will experience at least once sleepwalking
episode.
40% of children will experience at least once sleep terror
episode.
Only 2-3% of children and adults sleepwalk often.
Only about 2% of adults experience sleep terror.
More than half of adults who sleep walk also experience
sleep terror and nearly three quarters of adults who
experience sleep terrors also sleepwalk (Reite, Weissberg &
Ruddy, 2008).
80% of individuals who experience a sleep walking or sleep
terror episode have a family history of similar occurrences.
Use of medications or sedatives is a common cause in adults.
In children and adults, episodes often occur during a period
of stress or sleep deprivation.
Boys are more likely to sleepwalk than girls.
The highest prevelance of sleepwalking was 16.7% at age 11
to 12 years of age.
Sleepwalking can have a genetic tendency. If a child begins
to sleepwalk at the age of 9, it often lasts into adulthood.
Night terrors are most common in boys ages 5 to 7
(Kaneshiro, 2011).
There is some evidence that night terrors run in families.
It is rare for night terrors to persist beyond the age of 12.
Sleep terrors differ from nightmares. The dreamer of a
nightmare wakes up from the dream and may remember
details, but a person who has a sleep terror episode remains
asleep.
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SLEEP TERRORS
I. DESCRIPTION
Also known as: Night Terrors, or Pavor Nocturnus
The sudden arousal of the individual usually begins with a
horrified scream or cry
A typical sleep terror episode involves a sense of intense anxiety
or apprehension and a pressing urge to escape
During the episode, the individual is not completely awake and
returns to sleep after the episode
The episode lasts for 1-10 minutes, but it may last longer and
may go on for an hour, especially in children
Generally, only 1 episode occurs on any night, but there are
instances wherein several episodes occur at intervals
throughout the night
Sleep terrors during daytime naps are rare
Causes:
Sleep deprivation
Fatigue
Fever
Physical and/or emotional stress
Hereditary Factors
Complications include:
Regular disruption of sleep, which may lead to excessive
sleepiness during
Daytime and difficulty to accomplish daily tasks
Embarrassment over sleep terrors
Possibility to injure self and others
II. SYMPTOMS
During an episode:
1. The individual abruptly sits up in bed screaming or
crying
2. Abnormal increase in heart rate
3. Rapid breathing
4. Sweating
5. Dilation of the pupils
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6. The individual is difficult to awaken, therefore
inconsolable and unresponsive to
7. Others attempt to comfort him/her
After an episode:
1. The individual returns to sleep
2. If not none, only fragmentary vivid images are recalled
from dreams
3. The individual has amnesia for the episode on
awakening the next morning
III. TREATMENT
Treating an underlying condition such as a medical or mental
condition, or another sleep disorder
Improving sleeping habits
Counseling or simply comforting (for children)
Relaxation techniques (for adults)
Talk therapy or psychotherapy to help the individual cope with
the stress causing the sleep terrors (for adults)
Hypnotics such as Diazepam (a sleep-inducing medication),
which can prevent sleep terror episodes by calming the nerves
(for adults)
IV. FAMOUSE PERSONALITIES
1. Florence Welch (Florence and the Machine)
2. Gerard Way (My Chemical Romance)
3. H.R. Giger (Sci-fi Surrealist who creates alien visions)
4. H.P. Lovecraft (Author - Horror Fiction)
5. Travis Pastrana (Motorsports Competitor and Stunt
Performer)
V. FACTS / TRIVIAS
Sleep Terrors are more common in children, than in adults
Sleep Terrors are more common in young boys, than young girls
For adults, males and females have an equal tendency to suffer
from sleep terrors
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Children are more likely to have complete amnesia and provide
vague reports regarding episodes
Individuals (children or adults) who experience sleep terrors are
likely to have elevated scores for depression and anxiety on
personality inventories
NIGHTMARE DISORDER
I. DESCRIPTION
Nightmare disorder, also known as 'dream anxiety disorder'
and is referred to by doctors as parasomnia, is a sleep disorder
characterized by unwanted experiences that take place while
you're falling asleep, during sleep or when you're waking up.
The nightmares, which often depict the individual in a situation
that jeopardizes their life or personal safety, usually occur
during the second half of the sleeping process, called the rapid
eye movement (REM) stage. Though such nightmares occur
within many people, those with nightmare disorder experience
them with a greater frequency.
Nightmares can be caused by extreme pressure or irritation if
no other mental disorder is discovered. The death of a loved one
or a stressful life event can be enough to cause a nightmare but
mental conditions like post-traumatic stress disorder and other
psychiatric disorders have been known to cause nightmares as
well.
If the individual is on medication, the nightmares may be
attributed to some side effects of the drug. Amphetamines,
antidepressants, and stimulants like cocaine can cause
nightmares. Blood pressure medication, levodopa and
medications for Parkinson's disease have also been known to
cause nightmares
Diagnosis according to its duration:
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Acute: Duration of period of nightmares is 1 month or
less.
Subacute: Duration of period of nightmares is greater
than 1 month but less than 6 months.
Persistent: Duration of period of nightmares is 6 months
or greater.
Severity is rated by the frequency with which the nightmares
occur:
Mild: Less than one episode per week on average.
Moderate: One or more episodes per week but less than
nightly.
Severe: Episodes nightly.
II. SYMPTOMS
The sleeper may scream and yell out things during the
nightmare
Victim is often awakened by these threatening and frightening
dreams and can often vividly remember their experience
Upon awakening, the sleeper is unusually alert and oriented
within their surroundings
Increased heart rate and symptoms of anxiety, like sweating.
Have trouble falling back to sleep for fear they will experience
another nightmare
Have trouble going through everyday tasks; the anxiety and
lack of sleep caused by the fearful dreams would hinder the
individual from completing everyday jobs efficiently and
correctly
III. TREATMENT
Medical condition treatment - If the nightmares are
associated with an underlying medical or mental health
condition, treatment is aimed at the underlying problem.
Stress or anxiety treatment - If stress or anxiety seems to be
contributing to the nightmares, your doctor may suggest
stress-reduction techniques, counseling or therapy.
30
Medication - Medication is rarely used to treat nightmares.
However, medications that reduce REM sleep or reduce
awakenings during sleep may be recommended if you have
severe sleep disturbance.
Imagery rehearsal therapy - Often used with people who have
nightmares as a result of PTSD, imagery rehearsal therapy
involves changing the ending to your remembered nightmare
while awake so that it's no longer threatening. You then
rehearse the new ending in your mind. This approach may
decrease the frequency of nightmares.
IV. FACTS AND TRIVIAS
Fear is not the main emotion in nightmares. Research
published in the journal Sleep has found that fear is not the
prominent emotion in nightmares. Rather, researchers found
that it's more often feelings of sadness, confusion and guilt.
They said these are the nightmares more likely to stick with a
person after they wake up.
Bad dreams and nightmares are different. Researchers asked
572 volunteers to record their dreams over a period of two to
five weeks and then analyzed the 9,796 dreams that were
reported. Death, health concerns and threats are common to
nightmares. But, bad dreams, according to the researchers, are
more about interpersonal conflicts.
RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER
I. HISTORY
Mark Mahowald, MD and Carlos Schenck, MD from the
University of Minnesota were the first to describe the first cases
of REM Behavior disorder in 1985.
In Principles and Practice of Sleep Medicine (W.B. Saunders
Company, 2000), they outlined several case histories of people
with RBD:
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A 77-year old minister had been behaving violently in his
sleep for 20 years, sometimes even injuring his wife.
A 60-year old surgeon would jump out of bed during
nightmares of being attacked by "criminals, terrorists and
monsters."
A 62-year old industrial plant manager who was a war
veteran dreamt of being attacked by enemy soldiers
and fights back in his sleep, sometimes injuring himself.
A 57-year old retired school principal was inadvertently
punching and kicking his wife for two years during vivid
nightmares of protecting himself and family from aggressive
people and snakes.
"Past history and current neurological and psychiatric
evaluations were unremarkable, apart from the findings
reported," the authors noted. "All four men were known by day
to be calm and friendly individuals."
Mahowald and Schenck also found out that males compromise
90% of RBD patients and age ranges from 50 to older.
Furthermore, the doctors noted that most RBD patients are
placid and good-natured when awake; however, many of them
display rhythmic movements in their legs during non-REM and
slow-wave sleep.
II. DESCRIPTION
REM sleep begins with signals from an area at the base of the
brain called the pons. These signals travel to a brain region
called the thalamus, which relays them to the cerebral cortex
the outer layer of the brain that is responsible for learning,
thinking, and organizing information.
The pons also sends signals that shut off neurons in the spinal
cord, causing temporary paralysis of the limb muscles. If
something interferes with this paralysis, people will begin to
32
physically act out their dreams a rare, dangerous problem
called REM sleep behavior disorder.
REM sleep behavior disorder associated with neurodegenerative
disorders
May improve as the underlying neurodegenerative disorder
progresses most notably one of the synucleinopathies
(Parkinson's disease, multiple system atrophy, or major or mild
neurocognitive disorder with Lewy bodies), the neurological
status of individuals with REM sleep behavior disorder should
be closely monitored.
III. SYMPTOMS
1. Repeated episodes of arousal during sleep, associated with
vocalization and/or complex motor behaviors.
2. These behaviors arise during rapid eye movement (REM) sleep
and therefore usually occur more than 90 minutes after sleep
onset. They are more frequent during the later portions of
the sleep period. While they may occur during daytime
naps, it is uncommon.
3. Upon awakening from these episodes, the individual is
completely awake, alert and not confused or disoriented.
4. Either of the following:
REM sleep without atonia on polysomnographic
recording.
A history suggestive of REM sleep behavior disorder and
an established synucleinopathy diagnosis (e.g.,
Parkinsons disease, multiple system atrophy).
The behaviors cause clinically significant distress or
impairment in social, occupational or other
important areas of functioning (which may include injury
to self or the bed partner).
5. The disturbance is not attributable to the physiological effects
of a substance or another medical condition.
6. Co-existing mental and medical disorders do not explain the
episodes.
IV. TREATMENT
33
1. MEDICATION
Clonazepam has proven to be a highly successful
treatment for RBD. It is effective in nearly 90% of
patients (complete benefit in 79% of patients and partial
benefit in another 11% of patients), with little evidence of
tolerance or abuse. The response usually begins within
the first week, often on the first night. 0.5 mg initial dose.
Melatonin restores RBD-related desynchronization of the
circadian rhythms.[35]Polysomnographic studies showed
possible direct restoration of the mechanisms producing
REM sleep muscle atonia. 3-6mg initial dose.
Levodopa may be very effective in patients in whom RBD
is the harbinger of Parkinson disease. In addition,
anecdotal reports exist of responses to carbamazepine,
clonidine, and L-tryptophan in patients with RBD.
2. LONG-TERM MONITORING
Since RBD has strong relationships with many
neurodegenerative disorders, such as Parkinson disease,
multiple system atrophy, and dementia, the neurologist
always should explore the possibility of RBD in these
conditions. RBD symptoms may be the first
manifestations of these disorders and may precede the
onset of other typical symptoms and signs by several
years. Therefore, careful follow-up is needed to assess the
risk of neurodegenerative disorder development, for
patient counseling, and to plan for potential
neuroprotective trials.
V. FAMOUS PERSONALITY
Mike Birbiglia - His sleep disorder has been the basis for a
book and one-man show. Now the comedians REM sleep
behavior disorder is featured in film. Sleepwalk with Me made
its premiere at the 2012 Sundance Film Festival in Park City,
Utah.
34
VI. FACTS/TRIVIAS
REM sleep stimulates the brain regions used in learning. This
may be important for normal brain development during
infancy, which would explain why infants spend much more
time in REM sleep than adults.
Like deep sleep, REM sleep is associated with increased
production of proteins. One study found that REM sleep affects
learning of certain mental skills. People taught a skill and then
deprived of non-REM sleep could recall what they had learned
after sleeping, while people deprived of REM sleep could not.
RESTLESS LEGS SYNDROME (RLS)
I. HISTORY
The term Restless Leg Syndrome was coined by Professor Karl-
Axel Ekbom in 1944 and is therefore also known as "Ekbom's
disease". Ekbom studied medicine at the Karolinska Institute
and later became the first Professor and head of the
department of neurology at Uppsala university hospital. In his
1945 publication entitled "Restless Legs", Ekbom described the
disease and presented eight cases.
Ekbom was not the first to describe the disease. The earliest
documentation was appears to be by Thomas Willis, a 17th
century English physician of Charles II. Willis studied at the
private school of Edward Sylvester in Oxford and is probably
most famous for his publication Cerebri anatome, published in
1664, a foundational text on the anatomy of the cerebral
system. This book was the first to describe the term reflex
action and the Circle of Willis was outlined and understood.
In 1672 described what may have been RLS. Willis wrote in a
chapter entitled "Instructions for curing the Watching evil":
.......Wherefore to some, when being in bed they betake
themselves to sleep, presently in the arms and legs. Leaping and
contractions of the tendons and so great a restlessness and
tossing of the members ensure, that the diseased are no more
35
able to sleep, than if they were in the place of the greatest
torture!....
Willis went on to think that the diseases originated in the
spinal cord and was a product of spinal irritation and used
opiates as his therapy of choice.
Sometimes since I was advised with for a lady of quality, who in
the night was hindered from sleep by reason of these spasmodic
effects which came upon her only twice a week; she took
afterward daily for almost three months, receiving no injury
thereby, either on the brain or about any other function, and
when while by the use of other remedies; the dyscrasia of the
blood and nervous juice being corrected, the animal spirits
became more benign and mild. She afterward leaving wholly the
opium was able to sleep indifferently well!!
II. DESCRIPTION
Restless legs syndrome (RLS) is a neurological disorder with
unpleasant sensations in the legs and an uncontrollable urge
to move when at rest to try to relieve these feelings. RLS
sensations are often described by people as burning, creeping,
tugging, or like insects crawling inside the legs, and a wide
variety of descriptions is included in diagnostic criteria. Often
called paresthesias (abnormal sensations) or dysesthesias
(unpleasant abnormal sensations), the sensations range in
severity from uncomfortable to irritating to painful. Lying down
and trying to relax activates the symptoms or makes them
worse.
III. SYMPTOMS
People with RLS feel uncomfortable sensations in their legs,
especially when sitting or lying down, often more in the evening
than the day, with an irresistible urge to move about. Although
the sensations can occur on just one side of the body, most
often they affect both sides. Many people with RLS find it
difficult to describe the feeling that they get in their legs. It may
36
be like a crawling sensation, or like an electric feeling, or like
toothache, or like water running down your leg, or like itchy
bones or just fidgety, jumpy or twitchy legs, or just
uncomfortable. Some people describe a deep painful feeling in
their legs. The unpleasant feelings make you have an urge to
move. Typically, when the unpleasant feelings occur they occur
every 10-60 seconds and so you become quite restless.
Typically, the symptoms:
1. Develop when you are resting - particularly when you are
sitting down or lying in bed. They tend to be worse if you are
in a confined space such as in a cinema seat.
2. Are usually worse in the evening. In many people they only
occur in the evening, especially when trying to get to sleep.
The symptoms can make it difficult to get to sleep. This can
have a knock-on effect of causing poor sleep, and tiredness
the next day.
3. Are usually eased briefly by moving, walking, massaging or
stretching the legs. However, the symptoms tend to return
shortly after resting again.
4. Usually affect both legs. Occasionally, the arms are affected
too.
5. About 3 in 4 people with RLS also have sudden jerks
(involuntary movements) of their legs when they are asleep.
This is called periodic limb movements of sleep (PLMS).
These movements can wake you up (and/or your partner).
Some jerks may also occur when you are awake but resting.
6. About 3 in 4 people with RLS also have sudden jerks
(involuntary movements) of their legs when they are asleep.
A more common condition known as periodic limb
movement disorder (PLMD). PLMD is involuntary leg
twitching or jerking movements during sleep that typically
occur every 10 to 60 seconds, in periods or throughout the
night. Unlike RLS, the movements caused by PLMD are
involuntary-people have no control over them. Although
many patients with RLS also develop PLMD, most people
with PLMD do not experience RLS. Like RLS, the cause of
PLMD is unknown.
37
The cause is not known in most cases.
This is called primary or idiopathic RLS. (Idiopathic means of
unknown cause.) This most commonly first develops in younger
adults (under 45 years old). Symptoms tend to become slowly
worse over the years. It is thought that the cause may be a slight
lack of, or imbalance of, some brain chemicals
(neurotransmitters), especially one called dopamine. It is not
known why this should occur. There may be some genetic factor,
as primary RLS runs in some families.
Secondary causes
Symptoms of RLS can develop as a complication of certain other
conditions. For example:
Pregnancy. About 1 in 5 pregnant women develop RLS
during pregnancy (especially in the later part of
pregnancy). Symptoms often go after giving birth.
Lack of iron (iron deficiency) - which can cause anaemia.
If this is the cause, then the symptoms of RLS usually go
if you take iron tablets.
As a side-effect of some medicines. For example, it occurs
in some people who take: antidepressants, antipsychotics,
dopamine antagonists, antihistamines, calcium-channel
blockers, phenytoin, or steroids.
As a symptom of some other conditions - for example, kidney
failure, Parkinson's disease, diabetes, and underactive thyroid.
IV. TREATMENT
Relief on movement is generally only temporary. However, RLS
can be controlled by finding any possible underlying disorder.
Often, treating the associated medical condition, like anaemia,
peripheral neuropathy or diabetes, will alleviate many
symptoms. For patients with idiopathic RLS, treatment is
directed toward relieving symptoms.
For those with mild to moderate symptoms, prevention is key,
and many physicians suggest certain lifestyle changes and
38
activities to reduce or eliminate symptoms. Decreased use of
caffeine, alcohol, and tobacco may provide some relief. Doctors
may suggest the use of supplements to correct deficiencies in
iron, folate, and magnesium. Studies also have shown that
maintaining a regular sleep pattern can reduce symptoms.
Some individuals, finding that RLS symptoms are lower in the
early morning, change their sleep patterns. Others have found
that a program of regular moderate exercise helps them sleep
better. Taking a hot bath, massaging the legs, or using a
heating pad or ice pack can help relieve symptoms in some
patients. Although many patients find some relief with such
measures, rarely do these efforts completely eliminate
symptoms, and for many of these measures there is only
anecdotal evidence that they work.
V. FAMOUS PERSONALITIES
Keith Olbermann: Restless Legs Syndrome - Former MSNBC
talk-show host and outspoken pundit Keith Olbermann has
been diagnosed with restless legs syndrome, a condition that
causes people to feel such discomfort in their legs that they
have an urge to move or stretch even when they are trying to
settle down for sleep. His sleep problem was mentioned in a
New Yorker profile that also detailed Olbermann's intense work
schedule. Staying active may reduce symptoms.
VI. FACTS / TRIVIAS
RLS occurs in women and men, probably slightly more often in
women. Although the syndrome may begin at any age, even as
early as infancy, most patients who are severely affected are
middle-aged or older. In addition, severity appears to increase
with age. Older patients experience symptoms more frequently
and for longer.
Other triggering situations are periods of inactivity such as
long car trips, sitting in a movie theater, long-distance
flights, immobilization in a cast, or relaxation exercises.
39
Studies have also linked RLS to high blood pressure and
erectile dysfunction, possibly due to chronically interrupted
sleep or factors involving dopamine in the brain.
That RLS often runs in families and appears to be most
prevalent among people of Western European descent has
long hinted at a genetic component of the condition.
40
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