Management of sleep disorders

Dr Dharmendra Das
Dr Bulti Debnath,

“Each night, when I go to sleep, I die. And the next morning, when I wake up, I am reborn.” – Mahatma Gandhi

Sleep is a naturally recurring state of mind and body, Characterized by altered consciousness, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles, and reduced interactions with surroundings. Sleepiness is a serious, potentially life-threatening condition that affects not only the sleepy individual but also his or her family, co-workers, and society in general. International Statistical Classification of Diseases and Related Health Problems 10^th Revision: – G47.9.

Homoeopathy, with its scientific firm, time–tested principle of “Similia Similibus Curentur” has got a great potential to be useful in treating sleep disorders, as homoeopathy is equally effective, cheaper with no hazardous sign as compared to other system of medicine. It can prove itself to be the best in developing countries like India, where millions of poor people below poverty line can afford it.

Normal Sleep: – Sleep is one of the most significant of human behaviors, occupying roughly one third of human life. It is a universal behavior that has been demonstrated in every animal species studied, from insects to mammals. Sleep is a process the brain requires for proper functioning. Prolonged sleep deprivation leads to severe physical and cognitive impairment and, eventually, death. Sleep may appear to be a passive process but in fact can be associated with a high degree of brain activation. There are several distinct types of sleep that differ both qualitatively and quantitatively. Each type of sleep has unique characteristics, functional importance, and regulatory mechanisms. The ancient Greeks ascribed the need for sleep to the god Hypnos (sleep) and his son Morpheus, also a creature of the night, who brought dreams in human forms. Dreams have played an important role in psychoanalysis. Freud believed dreams to be the “royal road to the unconscious.” They have figured prominently in art and literature from ancient times to the present. Sleep is made up of two physiological states: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep.

Functions of sleep:- The functions of sleep have been examined in a variety of ways. Most investigators conclude that sleep serves a restorative, homeostatic function and appears to be crucial for normal thermoregulation and energy conservation.

Sleep Requirements: – Some persons are normally short sleepers who require fewer than 6 hours of sleep each night to function adequately. Long sleepers are those who sleep more than 9 hours each night to function adequately. Long sleepers have more REM periods and more rapid eye movements within each period (known as REM density) than short sleepers.

Sleep Disorders: – Sleep is regulated by several basic mechanisms, and when these systems go awry, sleep disorders occur. Sleep disorders are both dangerous and expensive to treat. Obstructive sleep apnea research verifies its contribution to hypertension, heart failure, and stroke. Investigations link many major industrial catastrophes to sleepiness. Sleepiness is a serious, potentially life-threatening condition that affects not only the sleepy individual but also his or her family, co-workers, and society in general. 

Icd-10: –

International Statistical Classification of Diseases and Related Health Problems 10^th Revision: –     G47.9

Sleep disorder, unspecified. G47.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

Pathobiology: –
Wakefulness is controlled by the reticular activating system of the rostral brain stem, which projects to the thalamus and cortex. Inhibition of these projections, which is modulated by neurons in the pons and midbrain, results in sleep. REM sleep, during which most dreaming occurs, is generated within the tegmentum of the pons with modulation from the norepinephrine- and serotonin-containing neurons of the locus ceruleus and the dorsal raphe nucleus. Electrical events generated in the pontine reticular formation (i.e., ponto-geniculo-occipital [PGO] waves) are propagated through the oculomotor and visual system during REM sleep simultaneously with rapid eye movements. PGO waves are suppressed by norepinephrine, and serotonin neuronal systems suppress PGO waves and REM; cholinergic neurons are stimulatory. PGO input can induce an action potential in neurons below their usual threshold. Such PGO-facilitated activity in the visual system may play a role in the random imagery of dreaming.

Hypocretins (orexins) are sleep modulatory neuropeptides made in the lateral hypothalamus with projections to the locus ceruleus and dorsal raphe, as well as to the thalamus, where they modulate the release of excitatory (glutamate) and inhibitory (γ-aminobutyric acid) neurotransmitters. Disruption of this system induces narcolepsy in animals, and hypocretin neurotransmission is deficient in most narcoleptic patients.

Classification of Sleep Disorders:- 

Sleep-wake disorders involve disruptions in sleep quality, timing, and amount that result in daytime impairment and distress. 

According to American Sleep Disorder Association’s International (ICSD), Diagnostic and coding manual, it divides sleep disorder into four categories:-

1. Dysomnias 
2. Parasomnias 
3. Sleep disorders associated with medical-psychiatric disorders
4. Proposed sleep disorder.

“James Sadock, Alcott Sadock, et al” have categorized sleep disorders in their book with DSM-5 and “Ravi Gupta in his book entitled,- Psychiatry for beginners” and “Michael J. Thorpy, Giuseppe Plazzi” mentioned in their book ‘the parasomnias and other sleep related movement disorders’ that Sleep disorders include the following disorders, – 

• Insomnia: – This is characterized by inability to fall asleep or multiple nocturnal awakenings or early morning awakening with difficulty in falling back asleep. Insomnia can be an independent condition, or it can be comorbid with another mental disorder, another sleep disorder, or another medical condition. They should be present on at least three nights in a weak for a period of at least 3 months. This is termed as “Insomnia disorder” or if the duration of symptom is less, then the diagnosis is “Situational or Acute Insomnia.” It is seen in 10-15% of the population.
• Hypersomnolence Disorder: – Hypersomnolence disorder, or hypersomnia, occurs when a person excessive sleepiness despite 7 hour of sleep during the main sleep period and feels excessively tired despite normal or because of prolonged quantity of sleep. However, the patient must not have any other disorders like sleep apnea or narcolepsy, etc. To be considered clinically significant, symptoms must be present at least thrice a week for at least 3 months. It is seen with a prevalence of 1% with equal frequency between both genders.
• Parasomnias: – Parasomnias are marked by unusual behavior, experiences, or physiological events during sleep. This category is divided into three subtypes: 

1. Non-REM movement sleep arousal disorders, which involve incomplete awakening from sleep accompanied by either sleepwalking or sleep terror disorder.

1. Sleepwalking Disorder or Somnambulism: – It consists walking during sleep usually with blank face and open eyes, difficulty in waking up, no recall of the episode. Patients sit up and sometimes perform preservative motor acts, such as walking, dressing, going to the bathroom, talking, screaming, and even driving.
2. Sleep Terrors Disorder or Pavour Nocturnus: – Sudden onset inconsolable crying during sleep, appears frightened, not able to appreciate the surroundings and not able to recall the episode, or dream after waking up. It is an arousal in the first third of the night during deep sleep.
3. Sleep talking or Somniloquy: – Talks during sleep, often coherent and able to communicate but not able to recall after waking up; no recall of the episode. The talking usually involves a few words that are difficult to distinguish.
4. Sexsomnia disorder: – Sexual activity during the sleep, often violent but not able to recall after being woken up, difficult to wake up.
5. Sleep-Related eating disorder: – Eating during sleep, often large amounts and not able to recall in the morning and when made to wake up.
6. Sleep-Related Bruxism or Tooth grinding: – It occurs throughout the night, most prominently in stage II sleep. The condition often goes unnoticed by the sleepers, except for an occasional jaw ache in the morning, but bed partners and roommates are consistently awakened by the sound. 

2. Nightmare disorder: – In which nightmares induce awakening repeatedly and cause distress and impairment. Frightening dreams that wake up the person having sympathetic arousal, but becomes oriented soon after waking up, able to recall the dream.
3. Rapid Eye Movement (REM) sleep behavior disorder: – Which is characterized by vocal or motor behavior during sleep. These patients often act in their dreams, often the dreams are violent and hence they injure themselves or their bed partner; they are able to recall the dream on waking up.

• Narcolepsy: – Narcolepsy is marked by sleep attacks, usually with loss of muscle tone (cataplexy). 
• Breathing- Related Sleep Disorders – It is characterized by sleep disruption leading to excessive sleepiness or insomnia caused by a sleep-related breathing disturbance.  There are three subtypes of breathing-related sleep disorders. 

1. A.Obstructive sleep apnea (OSA): – The most common of the three is obstructive sleep apnea hypopnea in which apneas (absence of airflow) and hypopneas (reduction in airflow) occur repeatedly during sleep, causing snoring, snorting, witnessed pauses during sleep, nocturia, sleep talking, daytime sleepiness and fatigue.
2. B.Central sleep apnea (CSA): – CSA is the presence of Cheyne-Stokes breathing in addition to apneas and hypopneas. Results from periodic failure of central nervous system mechanisms that stimulate breathing.
3. C.Sleep-related hypoventilation: – It causes elevated C0₂ levels from decreased respiration. In which no significant apneic episodes are present. 

• Restless Legs Syndrome: – Restless legs syndrome is the compulsive movement of legs during sleep. 
• Substance/Medication-Induced Sleep Disorder: – This category includes sleep disorders that are caused by a drug or medication (e.g., alcohol, caffeine). 
• Circadian Rhythm Sleep-Wake Disorders: – Underlying these disorders is a pattern of sleep disruption that alters or misaligns a person’s circadian system, resulting in insomnia or excessive sleepiness. There are six types: ( 1 ) delayed sleep phase type is characterized by sleep-wake times that are several hours later than desired or conventional times; (2) advanced sleep phase type is characterized by earlier than usual sleep-onset and wake-up times; (3) irregular sleep-wake type is characterized by fragmented sleep throughout the 24-hour day with no major sleep period and no discernible sleep-wake circadian rhythm; (4) non-24-hour sleep-wake type is a circadian period that is not aligned to the external 24-hour environment, most common among blind or visually impaired individuals; (5) shift work type is from working on a nightly schedule on a regular basis; and ( 6) unspecified type that does not meet any of the above criteria.

INVESTIGATIONS

1.	Clinical evaluation: A detailed sleep history is the most informative diagnostic tool. Abnormal sleepiness is suggested by the history of sleep before lunch or supper, even after adequate sleep at night, or falling asleep while eating, during short distance driving, talking to people or during sexual activities. It is important to supplement the patient’s history by information obtained from the spouse or bed partner, particularly regarding respiratory events (loud snoring, struggling respiration, or respiratory pauses). History regarding the use of drugs that could cause insomnia or sleepiness is important. Psychiatric or psycho-physiologic disorders or medical and neurological illnesses which result in secondary sleep disorders should be noted.
2.	Multiple sleep latency test (MSLT) is widely used to evaluate hypersomnolence. The test involves allowing the patient to nap and recording the EEG at intervals of two hours on a day following an adequate night’s sleep. Patients with pathological hypersomnolence fall asleep in five minutes or less compared to the normal’s who have mean sleep onset latency of over ten minutes. MSLT also provides a mechanism for detecting abnormal tendency to achieve REM sleep. Two or more sleep-onset REM periods (SOREMs), i.e., REM sleep emerging within 15 minutes of sleep onset, is considered diagnostic of narcolepsy/cataplexy syndrome.
3.	Polysomnography: Most patients require monitoring of various physiologic parameters during at least one night’s sleep. Episodes of sleep apnoea are usually more frequent and more severe during REM sleep which is usually missed in daytime naps. Polysomnography records 1) EEG to distinguish wakefulness from sleep and for sleep staging, 2) eye movements, 3) electrocardiogram, 4) electromyogram (EMG) of chin muscles, 5) EMG of tibialis anterior muscles, 6) oral and nasal airflow, 7) respiratory efforts of the chest and abdomen and 8) oxygen saturation.

Treatment:-

The clinician should discuss any myths or misconceptions about sleep that the patient may hold. Lifestyle modifications and cognitive-behavioral treatments for sleep disorder may include: –

• Relaxation training
• Cognitive therapy
• Stimulus control (SC)
• Sleep restriction therapy (SRT)
• Sleep hygiene

• Relaxation Training for Sleep Disorders:-

Methods such as progressive muscle relaxation (PMR), deep breathing techniques, imagery, and self-hypnosis may help some people overcome a sleep disorder. PMR involves helping the individual to sequentially tense and relax the body’s major muscle groups while concentrating on contrasting sensations of tension and relaxation.

• Cognitive Therapy for Sleep Disorders:-

Cognitive therapy helps people with insomnia identify and correct inappropriate thoughts and beliefs that may contribute to insomnia. Cognitive therapy can give people the proper information about sleep norms, age-related sleep changes, reasonable sleep goals, and the influence of naps and exercise.

• Stimulus Control for Sleep Disorders:-

Stimulus control (SC) is a practice in which the bedroom is reserved for sleep and sex. SC derives from the idea that insomnia may be caused by bedroom associations unrelated to those uses, such as stressful situations, or TV watching. Therefore, the bedroom should be reserved for sleep, sex, and dressing only.

• Sleep Restriction Therapy for Sleep Disorders:-

Sleep restriction therapy (SRT) is based on the belief that excess time in bed makes sleep problems worse. SRT consists of limiting a person’s time in bed to only that time where they are sleeping.

• Sleep Hygiene for Sleep Disorders:-

Sleep hygiene refers to practices, habits, and environmental factors that are important for getting sound sleep. The four general areas important to sleep hygiene are the circadian rhythm (24-hour cycle), aging, psychological stressors that cause mini-awakenings (in which the brain wakes up for just a few seconds), and stimulant use.

• Circadian rhythms influence when, how much, and how well people sleep. These rhythms may be altered by the timing of various factors, including naps, bedtime, exercise, and exposure to light.
• Aging also plays a role in sleep. Sleep patterns change after people reach age 40. There are many more nocturnal awakenings as people age. The awakenings affect sleep quality and can interact with any other condition that may cause arousals or awakenings. The more awakenings people experience at night, the more likely they will awaken with a feeling of not being rested.
• Psychological stressors such as exams, deadlines, or job stress may interfere with sleep. It is beneficial for people to develop some kind of pre-sleep ritual to break the connection between stress and bedtime. Some people find it helpful to make a list of all the stressors of the day, along with a plan to deal with them. In addition, periods of relaxation (meditating or taking a hot bath) can help a person relax and get to sleep.
• Stimulants can stay in the body as long as 14 hours and can increase the number of times you awaken at night, decreasing your total amount of sleep time. Avoid caffeine, nicotine, and alcohol. The effects of nicotine, when consumed in high doses, are similar to those of caffeine. Alcohol may initially sedate you, making it easier to fall asleep. However, you may be awakened after the alcohol is cleared from your system. Recent sleep research shows that alcohol consumption before bedtime may result in inadequate REM sleep, which the body needs to restore itself.

• Sleep Diaries: – General practitioners can make use of sleep dairies in which patients record their sleep pattern for 1-2 weeks. Several diary templates are available on various websites (e.g., www.sleepeducation.com/pdf/sleepdairy.pdf). Sleep diaries can provide patients with insight into their actual sleep habits. They often reflect sleep trends, such as erratic schedules or identify predominant sleep patterns, such as taking a long time to fall asleep, frequent awakenings, early morning awakenings or a mixture. They can provide a starting point for the management of sleep problems in a personalized manner and can be used to monitor progress of certain treatments.

Do’s  and  Don’ts  for  good  sleep  Hygiene: –

Tip’s	Do’s	Don’ts
Maintain regular hours of bedtime and arising.
If you are hungry, have a light snack before bedtime.
Maintain a regular exercise schedule.
Give yourself approximately an hour to wind down before going to bed.
If you are preoccupied or worried about something at bedtime, write it down and deal with it in the morning.
Keep the bedroom cool.
Keep the bedroom dark.
Keep the bedroom quiet.
Take naps.
Watch the clock so you know how bad your insomnia actually is.
Exercise right before going to bed in order wear yourself out.
Watch television in bed when you cannot sleep.
Eat a heavy meal before bedtime to help you sleep.
Drink coffee in the afternoon and evening.
If you cannot sleep, smoke a cigarette.
Use alcohol to help in going to sleep.
Read in bed when you cannot sleep.
Eat in bed Exercise in bed.
Exercise in bed.
Talk on the phone in bed.

HOMOEOPATHIC MANAGEMENT: –

Homoeopathy offers a much better treatment option for people suffering from sleep disorder. That is because homoeopathy does not aim at providing short term relief. On the contrary homoeopathy aimed at completely curing and eradication of the disease. Of course this requires sometime as the immune system has to get back into original shape, where it recognizes one’s own body as a friend and not as an enemy. It is purely a natural treatment for sleep disorder and no steroid or hypnotic drugs (Benzodiazepines or “Z-drugs”) are used. Following are the commonly indicated homoeopathic medicines in the management of sleep disorders,-

• Chammomila:- Irritable baby who refuses to be calmed. Sleeplessness caused by teething, anger or colic. Moaning when asleep, eyes are half open when asleep. For the person who exhibits irritability, peevishness and restlessness. It is an antidote for over use of coffee. Exhibits sleeplessness and restlessness during the first part of the night. They have frightening dreams.
• Arnica:- Good for physical over work and when the bed feels too hard and uncomfortable. This remedy is also useful for jet lag.
• Aconite:- Used for acute insomnia caused by shock, fright, bad news, or grief. Also for fear, anxiety and restlessness. May be waken by nightmares.
• Coffea:- Coffea , the homoeopathic remedy made from the coffee bean, is very useful in cases of sleeplessness when the mind is awake and working. Shows inability to relax due to the overexcitement caused by good news or ideas. Vivid dreams, overactive mind, over excitement. The thoughts are not fixed on a disappointment, but never the less the nervous system seems to be overexcited as if from drinking too much coffee. Take 3X to 200X for insomnia following too much coffee drinking.
• Arsenic alb:- When you feel sleepy during the day but anxious at night. Restlessness in bed with anxious dreams and nightmares. Also for warmth, warm drink, moving about and sleeping propped up in bed.
• Calcarea phosporicum:- Difficulty waking and getting up in the morning, waking up before midnight. Painful teething in restless babies. Anxious, irritable, sluggish and restless. Dislikes routine. Babies who scream in their step and needs lots of attention.
• Causticum:- Bedwetting in the early part of night. Oversensitive child easily upset and tearful. Afraid of dark. Strong sense of justice.
• Cocculus:-   If exhaustion is related to changing work shifts or too many nights of staying awake, as when caring for a sick person. For over tiredness and exhaustion, use 12X.
• Ignatia:- Sleeplessness caused by shock, emotional stress or grief, where the person has become over wrought and moody, with frequent yawning or sighing. Jerks limbs when falling asleep. Mood swings, no thirst, dreams with bottled up anger and tension.
• Kali phos:- Right terrors, or waking with a sinking feeling in the stomach. Caused by excitement or mental strain. Also for anxiety, irritability, and muscle fatigue. Exhausted by stress or over work.
• Equisetum:- Wetting the bed during dreams. Nervous-system immaturity.
• Lachesis:- sleep problems during the menopause. Sensations of suffocation at the throat or bed swaying as u go to sleep. Dread of going to bed because of sudden awakenings and the sensation of swaying. Tendency to hold breadth while feeling asleep. Night sweats. Waking anxious and feeling unwell.
• Muriaticum acidum:- Generally used for emotional problems.
• Nux vomica:- Excellent for the person who is irritable and sleepless from stopping sedatives or from too much mental stress , alcohol or food. For alcohol, over eating especially spicy, foods, noise, lack of sleep. The sleeplessness typically occurs after waking up very early in the morning. The person cannot get back to sleep until just before the alarm goes off, and then gets up irritable and angry from lack of sleep. For wakefulness in the middle of the night, use 6X to 12X.
• Opium:- If the person is feeling sleepy but unable to get to sleep, if the bed is to hot or else sleep comes but it is so heavy that the person snores and cannot be roused.
• Pulsatilla:- Early waking with an overactive mind and /or recurrent thoughts. For anxious or vivid dream, night sweats. Person is restless in first sleep feels to hot and throws covers off, then feels to cold and lies with arms above head, not thirsty or if the insomnia is worse after rich food.
• Sepia:- Difficulty falling asleep. Waking early feeling unrefreshed. Exhausted and depressed by over work and mental stress. Feels irritable and sleepy during the day. Suffers headaches, nausea and dizziness due to tiredness. Night sweats may be also present.
• Sulphur:- Awakened by the slightest noise and find it difficult to get back to sleep. Feels hot and throws limbs out from under the covers. Kept awake by a continuous flow of ideas. Vivid nightmares, disturbed and unrefreshing sleep, waking in the early hours then sleeping late.
• Thuja:- Wakes up early and unrefreshed just before time to get up. Pain where you have been lying, feeling cold, sleep–talking, anxious dreams, stress headaches. 

“The important thing is not to stop questioning. Curiosity has its own reason for existing.”  Albert Einstein.

References: –

1. https://en.wikipedia.org/wiki/sleep. 
2. Benjamin James Sadock, Virginia Alcott Sadock, Pedro Ruiz, KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY : Behavioral Sciences/Clinical Psychiatry, 11^th edition 2015 by Wolters kluwer.
3. https://www.icd10data.com/ICD10CM/Codes/G00-G99/G40-G47/G47-/G47.9.
4. Lee Goldman, Dennis Ausiello, Cecil Medicine, 23rd ed., Chapter 429 – Disorders of Sleep, Mark W. Mahowald © 2008 by Saunders, An Imprint of Elsevier Inc
5. American Academy of Sleep Medicine, INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS, REVISED: DIAGNOSTIC AND CODING MANUAL 2001, Chicago, Illinois, American Academy of Sleep Medicine.
6. Ravi Gupta, Psychiatry for beginners, Elsevier © 2016, RELX India Private Limited.
7. Michael J. Thorpy, Giuseppe Plazzi: THE PARASOMNIAS AND OTHER SLEEP RELATED MOVEMENT DISORDERS, 2010.
8. A.P.I. Textbook of Medicine, SECTION XII, NEUROLOGY, SLEEP AND ITS DISORDERS, OMKAR N MARKAND, SHRIDHAR SHARMA, 6^th edition 1999.
9. http://www.webmed.com/sleep-disorders/behavioral-treatments.
10. Jagdish N Vyas et al, Concise Textbook of Psychiatry, Paras Medical Publisher, 2017.
11.     Allen, H.C.,” Key Notes and characteristics with comparisons of the Leading Remedies of the Materia Medica”, reprinted of 8^th edition, New Delhi, B. Jain publishers Pvt. Ltd., 2000.

Dr. Dharmendra Das,BHMS, MD Scholar,
Dept. of Homoeopathic Philosophy,Sonajirao Kshirsagar Homoeopathic Medical College, Beed, Maharashtra – 431 122                                             

Dr. Bulti Debnath,BHMS, MD Scholar,
Dept. of Paediatrics,
Sonajirao Kshirsagar Homoeopathic Medical College, Beed, Maharashtra – 431 122