Sleep Disorders: Teeth Grinding in Sleep (Sleep Bruxism)
Most people probably grind and clench their teeth during sleep from time to time. Occasional teeth grinding, medically called bruxism, does not usually cause harm, but when teeth grinding occurs on a regular basis, the teeth can be damaged and other complications can arise, such as jaw muscle discomfort.
Why Do People Grind Their Teeth?
Although the causes of bruxism are not really known, several factors may be involved. Stressful situations, an abnormal bite, and crooked or missing teeth appear to contribute.
Can Teeth Grinding Be Prevented?
Bruxism can be prevented with the use of a mouth guard. The mouth guard, supplied by a dentist, can fit over the teeth to prevent teeth from grinding against each other. Stress reduction and other lifestyle modifications, including the avoidance of alcohol and caffeine, may also be helpful.
Periodic Limb Movement Disorder
Periodic Limb Movement Disorder Overview
Periodic limb movement disorder (PLMD) is repetitive cramping or jerking of the legs during sleep. It is the only movement disorder that occurs only during sleep, and it is sometimes called periodic leg (or limb) movements during sleep. "Periodic" refers to the fact that the movements are repetitive and rhythmic, occurring about every 20-40 seconds. PLMD is also considered a sleep disorder, because the movements often disrupt sleep and lead to daytime sleepiness.
PLMD may occur with other sleep disorders. It is often linked with restless legs syndrome, but they are not the same thing. Restless legs syndrome is a condition involving strange sensations in the legs (and sometimes arms) while awake and an irresistible urge to move the limbs to relieve the sensations. At least 80% of people with restless legs syndrome have PLMD, but the reverse is not true.
When PLMD was first described in the 1950s, it was called nocturnal myoclonus. Nocturnal means night, and myoclonus is a rapid, rhythmic contraction of a group of muscles similar to that seen in seizures. PLMD movements are not myoclonus, however, and the original name is not used today.
PLMD can occur at any age. Like many sleep disorders, PLMD is more common in middle-aged and older people.
Periodic Limb Movement Disorder Causes
Persistent sleep disruption and daytime sleepiness are not part of normal aging.
Periodic limb movement disorder can be primary or secondary. Secondary PLMD is caused by an underlying medical problem. Primary PLMD, on the other hand, has no known cause. It has been linked to abnormalities in regulation of nerves traveling from the brain to the limbs, but the exact nature of these abnormalities is not known.
Secondary PLMD has many different causes, including the following. Many of these are also causes of restless legs syndrome.
* Diabetes mellitus
* Iron deficiency
* Spinal cord tumor
* Spinal cord injury
* Sleep apnea syndrome - Breathing difficulties that disrupt sleep, causing daytime sleepiness and a number of other problems
* Narcolepsy - A sleep disorder involving excessive sleepiness and overpowering urge to sleep during waking hours
* Uremia - Build-up of waste products in the blood because of poor kidney function
* Anemia - Low level of hemoglobin, the substance that carries oxygen in the blood
* Medication - Neuroleptics and other antidopaminergic agents such as Haldol, dopaminergic agents such as Sinemet (despite the fact that Sinemet is often a treatment for PLMD), or tricyclic antidepressants such as amitriptyline (Elavil)
* Withdrawal from sedative medications such as barbiturates or benzodiazepines (such as Valium)
Periodic Limb Movement Disorder Symptoms
The most common symptoms noted by people with PLMD are not leg movements but poor sleep and daytime sleepiness. Many people with PLMD are unaware of their leg movements unless their bed partner tells them.
Leg movements involve one or both limbs.
* Typically the knee, ankle, and big toe joints all bend as part of the movements.
* The movements vary from slight to strenuous and wild kicking and thrashing.
* The movements last about 2 seconds (and thus are much slower than the leg jerks of myoclonus).
* The movements are rhythmic and repetitive and occur every 20-40 seconds.
Exams and Tests
In most people with PLMD, poor sleep and daytime sleepiness are the most bothersome symptoms. Many people do not link their sleep problem with leg movements. Sleep disturbance has many, many different causes. Depending on how you describe your symptoms, your health care provider may ask you many very detailed questions. These questions concern your medical problems now and in the past, family medical problems, medications you take, your work and travel history, and your habits and lifestyle. A detailed physical examination will look for signs of an underlying cause for your sleep problem.
There is no lab test or imaging study that can prove that you have PLMD. However, certain tests can identify underlying medical causes such as anemia, other deficiencies, and metabolic disorders that could cause PLMD.
* You may have blood drawn to check your blood cell counts and hemoglobin, basic organ functions, chemistry, and thyroid hormone levels. You also may be checked for certain infections that could cause secondary PLMD.
* A urine sample may be collected to check for traces of drugs that can cause sleep problems.
Polysomnography (sleep lab testing) is the only way to confirm that you have PLMD. As you sleep in the lab, your leg movements can be documented.
At any time during your evaluation, your health care provider may refer you to a neurologist (a specialist in disorders of the nervous system). This specialist can help rule out other neurological problems and confirm the diagnosis of PLMD.
Periodic Limb Movement Disorder Treatment
Treatment does not cure the disorder but usually relieves symptoms.
Treatment involves medication that either reduces the movements or helps the person sleep through the movements.
Therapy does not cure PLMD but relieves symptoms. Note that many of the medications used to treat PLMD are the same as those used to treat restless legs syndrome.
* Benzodiazepines: These drugs suppress muscle contractions. They are also sedatives and help you sleep through the movements. Clonazepam (Klonopin), in particular, has been shown to reduce the total number of periodic limb movements per hour. It is probably the most widely used drug to treat PLMD.
* Dopaminergic agents: These drugs increased the levels of an important neurotransmitter (brain chemical) called dopamine, which is important in regulating muscle movements. These medications seem to improve the condition in some people but not in others. Widely used examples are a levodopa/carbidopa combination (Sinemet) and pergolide (Permax).
* Anticonvulsant agents: These medications reduce muscle contractions in some people. The most widely used anticonvulsant in PLMD is gabapentin (Neurontin).
* GABA agonists: These agents inhibit release of certain neurotransmitters that stimulate muscle contractions. The result is relaxation of contractions. The most widely used of these agents in PLMD is baclofen (Lioresal).
Next Steps - Follow-up
Your health care provider will ask you to return for one or more follow-up visits after trying his or her recommendations.
It is very important that your bed partner understand the nature of PLMD and that you are not intending to injure him or her with your movements.
See your health care provider regularly for proper care of any medical or mental problems.
Primary PLMD may be chronic (permanent). Many people with primary PLMD have improved nighttime sleep (remission) but experience one or more relapses over time.
Secondary PLMD may cease with treatment of the underlying cause.
Sleep-Related Eating Disorders
Sleep-related eating disorders are characterized by abnormal eating patterns during the night.
Although it is not as common as sleepwalking, nocturnal sleep-related eating disorder (NS-RED) can occur during sleepwalking. People with this disorder eat while they are asleep. They often walk into the kitchen and prepare food without a recollection for having done so. If NS-RED occurs often enough, a person can experience weight gain and increase their risk of developing type 2 diabetes.
A closely related disorder, known as night eating syndrome (NES), is diagnosed when a person eats during the night with full awareness and may be unable to fall asleep again unless he/she eats.
Symptoms of NES include the following and often persist for at least two months:
* Little or no appetite for breakfast.
* Eating more food after dinner than during the meal.
* Eating more than half of daily food intake after dinner hour.
* Recurrent awakenings from sleep requiring eating to fall back asleep.
NS-RED and NES differ in that people with NES eat when they are conscious. However, the disorders are similar in that they both are hybrids of sleep and eating disorders. Both of these conditions can interfere with an individuals nutrition, cause shame, and result in depression and weight gain.
Who Gets Sleep-Related Eating Disorders?
Both men and women are vulnerable to these disorders, but they are more common among women. About one to three percent of the general population is affected and 10% to 15% of people with eating disorders are affected by sleep-related eating disorders. Many of these individuals diet during the day, which may leave them hungry and vulnerable to binge eating at night when their control is weakened by sleep. In some cases, people with sleep-related eating disorders have histories of alcoholism, drug abuse and other sleep disorders.
How Are Sleep-Related Eating Disorders Treated?
Treatment of nocturnal eating behaviors begins with a clinical interview and may include an overnight stay in a sleep laboratory, where brain activity is monitored during the night. Medication sometimes can be helpful for these disorders; however, sleeping pills should be avoided as they can increase confusion and clumsiness that can lead to injury. Additional treatments may include methods to release stress and anxiety. Examples of these methods include stress management classes, assertiveness training, counseling, and limiting intake of alcohol and caffeine.
Sleep Disorders: What Is Hypersomnia?
Hypersomnia is a condition marked by excessive daytime sleepiness. People who have hypersomnia can fall asleep at any time; for instance, at work or while driving. They may also have a lack of energy and trouble thinking clearly.
According to the National Sleep Foundation, up to 40% of people have some symptoms of hypersomnia from time to time.
What Causes Hypersomnia?
There are several potential causes of hypersomnia, including:
* The sleep disorders narcolepsy (daytime sleepiness) and sleep apnea (interruptions of breathing during sleep)
* Not getting enough sleep at night
* Being overweight
* Drug or alcohol abuse
* A head injury or a neurological disease, such as multiple sclerosis
* Prescription drugs, such as tranquilizers
* Genetics (having a relative with hypersomnia
REM Sleep Behavior Disorder
REM Sleep Disorder Overview
Normal sleep has 2 distinct states: non–rapid eye movement (NREM) and rapid eye movement (REM) sleep (see Sleep: Understanding the Basics for details of various stages of sleep). NREM sleep is divided into 4 stages. During REM sleep, rapid eye movements occur, breathing becomes irregular, blood pressure rises, and there is loss of muscle tone (paralysis). However, the brain is highly active, and the electrical activity recorded in the brain by EEG during REM sleep is similar to that recorded during wakefulness. REM sleep is usually associated with dreaming. REM sleep accounts for 20-25% of the sleep period.
In a person with REM sleep behavior disorder (RBD), the paralysis that normally occurs during REM sleep is incomplete or absent, allowing the person to "act out" his or her dreams. RBD is characterized by the acting out of dreams that are vivid, intense, and violent. Dream-enacting behaviors include talking, yelling, punching, kicking, sitting, jumping from bed, arm flailing, and grabbing. An acute form may occur during withdrawal from alcohol or sedative-hypnotic drugs.
RBD is usually seen in middle-aged to elderly people (more often in men).
REM Sleep Disorder Causes
The exact cause of REM sleep behavior disorder (RBD) is unknown, although the disorder may occur in association with various degenerative neurological conditions such as Parkinson disease, multisystem atrophy, diffuse Lewy body dementia, and Shy-Drager syndrome. In 55% of persons the cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine, sertraline, or paroxetine) or other types of antidepressants (mirtazapine).
RBD often precedes the development of these neurodegenerative diseases by several years. In one study, 38% of patients diagnosed with RBD subsequently developed Parkinson disease within an average time of 12-13 years from the onset of RBD symptoms. The prevalence of RBD is increased in persons with Parkinson disease and in multisystem atrophy where it is observed in 69% of these patients. The relationship between RBD and Parkinson disease is complex; however, not all persons with RBD develop Parkinson disease.
Drug- and Alcohol-Related Sleep Problems
Sleep problems have been associated with drug use, drug abuse and withdrawal from drug abuse. Sleep disturbances also have been linked to the use of alcohol and to chronic alcoholism.
Drugs and Sleep
Many prescription and nonprescription medications can cause sleep problems. The severity of sleep problems caused by a medication will vary from person to person.
Prescription drugs that may cause sleep problems include:
* High blood pressure medications
* Hormones such as oral contraceptives
* Steroids including prednisone
* Respiratory inhaled medications
* Diet pills
* Attention deficit/hyperactivity disorder medications
* Some antidepressants
Nonprescription medicines that can cause sleep problems include:
* Pseudoephedrine, including the brand Sudafed
* Medications with caffeine. These include the brands Anacin, Excedrin, and No-Doz as well as some cough and cold medications.
* Illegal drugs such as cocaine, amphetamines, and methamphetamines.
* Nicotine, which can disrupt sleep and reduce total sleep time. (Smokers report more daytime sleepiness than do nonsmokers, especially in younger age groups.)
Alcohol and Sleep
Alcohol often is thought of as a sedative or calming drug. While alcohol may induce sleep, the quality of sleep is often fragmented during the second half of the sleep period when the alcohol's relaxing effect wears off. As a result, alcohol induced sleep prevents you from getting the deep sleep you need since alcohol keeps you in the lighter stages of sleep.
Sleep Disorders: Parasomnias
Parasomnias are disruptive sleep-related disorders that can occur during arousals from REM sleep or partial arousals from Non-REM sleep. Parasomnias include nightmares, night terrors, sleepwalking, confusional arousals and many others.
Types of Parasomnias
Nightmares are vivid nocturnal events that can cause feelings of fear, terror, and/or anxiety. Usually, the person having a nightmare is abruptly awakened from REM sleep and is able to describe detailed dream content. Usually, the person having a nightmare has difficulty returning to sleep. Nightmares can be caused by many factors including illness, anxiety, the loss of a loved one, or negative reactions to a medication. Call your doctor if nightmares occur more often than once a week or if nightmares prevent you from getting a good night's sleep for a prolonged period of time.
Sleep terrors/night terrors
A person experiencing a night terror or sleep terror abruptly awakes from sleep in a terrified state. The person may appear to be awake, but is confused and unable to communicate. They do not respond to voices and are difficult to fully awaken. Night terrors last about 15 minutes, after which time the person usually lies down and appears to fall back asleep. People who have sleep terrors usually don't remember the events the next morning. Night terrors are similar to nightmares, but night terrors usually occur during deep sleep.
People experiencing sleep terrors may pose dangers to themselves or others because of limb movements. Night terrors are fairly common in children occurring in approximately 5% of them mostly between the ages of three to five. Children with sleep terrors will often also talk in their sleep or sleepwalk. This sleep disorder, which may run in families, also can occur in adults. Strong emotional tension and/or the use of alcohol can increase the incidence of night terrors among adults.
Sleepwalking occurs when a person appears to be awake and moving around but is actually asleep. They have no memory of their actions. Sleepwalking most often occurs during deep non-REM sleep (stages 3 and 4 sleep) early in the night and it can occur during REM sleep in the early morning. This disorder is most commonly seen in children aged eight to twelve; however, sleepwalking can occur among younger children, the elderly and adults.
Sleepwalking appears to run in families. Contrary to what many people believe, it is not dangerous to wake a person who is sleepwalking. The sleepwalker simply may be confused or disoriented for a short time upon awakening. Although waking a sleepwalker is not dangerous, sleepwalking itself can be dangerous because the person is unaware of his or her surroundings and can bump into objects or fall down. In most children, it tends to stop as they enter the teen years.
Confusional arousals usually occur when a person is awakened from a deep sleep during the first part of the night. This disorder, which also is known as excessive sleep inertia or sleep drunkenness, involves an exaggerated slowness upon awakening. People experiencing confusional arousals react slowly to commands and may have trouble understanding questions that they are asked. In addition, people with confusional arousal often have problems with short-term memory and have no memory of doing these things the following day.
Rhythmic movement disorders
Rhythmic movement disorder occurs mostly in children who are one year old or younger. A child may lie flat, lift the head or upper body, and then forcefully hit his or her head on the pillow. Rhythmic movement disorder, which also has been called "head banging," also can involve movements such as rocking on hands and knees. The disorder usually occurs just before a person falls asleep.
Sleep talking is a sleep-wake transition disorder. Although it usually is harmless, sleep talking can be disturbing to sleep partners or family members who witness it. Talk that occurs during sleep can be brief and involve simple sounds, or it can involve long speeches by the sleeper. A person who talks during sleep typically has no recollection of the actions. Sleep talking can be caused by external factors including fever, emotional stress or other sleep disorders.
Nocturnal leg cramps
Nocturnal leg cramps are sudden, involuntary contractions most commonly of the calf muscles during the night or periods of rest. The cramping sensation may last from a few seconds to 10 minutes, but the pain from the cramps may linger for a longer period. Nocturnal leg camps tend to be found in middle-aged or older populations, but people of any age can have them. Nocturnal leg cramps differ from restless legs syndrome as the latter usually does not involve cramping or pain. The cause of nocturnal leg cramps is not known. Some cases of the disorder can occur without a triggering event, while other causes of leg cramps may be linked to prolonged sitting, dehydration, an overexertion of the muscles, or structural disorders (such as flat feet). Muscle-stretching, exercise and adequate water intake may help prevent leg cramps.
People with sleep paralysis are not able to move their body or limbs either when falling asleep or waking up. Brief episodes of partial or complete skeletal muscle paralysis can occur during sleep paralysis. Sometimes sleep paralysis runs in families, but the cause of sleep paralysis is not known. This disorder is not harmful, but people experiencing sleep paralysis often are fearful because they do not know what is happening. An episode of sleep paralysis often is terminated by sound or touch. Within minutes, the person with sleep paralysis is able to move again. It may occur only once in your lifetime or can be a recurrent phenomenon.
Impaired sleep-related penile erections
This disorder occurs among men who are unable to sustain a penile erection during sleep that would be sufficiently rigid enough to engage in sexual intercourse. Men usually experience erections as a part of REM sleep, and impaired sleep-related erections may indicate erectile dysfunction.
Sleep-related painful erections
Erections are a normal component of REM sleep for men. In rare cases, however, erections become painful and cause a man to wake up. The treatment of sleep-related painful erections may involve drugs that suppress REM sleep (some antidepressants, for example).
REM sleep cardiac arrhythmias
A cardiac arrhythmia is a change from the normal rate or control of the hearts contractions. People who have coronary artery disease and whose blood oxygen is lowered by sleep-disordered breathing may be at risk for arrhythmias, which take place during REM sleep. Continuous positive airway pressure (CPAP) treatment may reduce this risk.
REM sleep behavior disorder (RBD)
People with rapid eye movement (REM) sleep behavior disorder act out dramatic and/or violent dreams during REM sleep. REM sleep usually involves a state of sleep paralysis (atonia), but people with this condition move the body or limbs while dreaming. Usually, RBD occurs in men aged 50 and older, but the disorder also can occur in women and in younger people. It differs from sleep walking and sleep terrors in that the sleeper can be easily awakened and can recall vivid details of the dream. In the diagnosis and treatment of RBD, potentially serious neurological disorders must be ruled out. Polysomnography (sleep tests) and drug treatments also can be involved in the diagnosis and treatment of this disorder.
Sleep bruxism involves the involuntary, unconscious, excessive grinding or clenching of teeth during sleep. It may occur along with other sleep disorders. Sleep bruxism may lead to problems including abnormal wear of the teeth and jaw muscle discomfort. The severity of bruxism can range from mild cases to severe cases that involve evidence of dental injury. In some cases, bruxism can be prevented with the use of a mouth guard. The mouth guard, supplied by a dentist, can fit over the teeth to prevent teeth from grinding against each other.
Sleep enuresis (bedwetting)
In this condition, the affected person is unable to maintain urinary control when asleep. There are two kinds of enuresis -- primary and secondary. In primary enuresis, a person has been unable to have urinary control from infancy onward. Primary bedwetting appears to run in families. Children are more likely to have it if their parents or siblings had it as children. In secondary enuresis, a person has a relapse after previously having been able to have urinary control. Enuresis can be caused by medical conditions (including diabetes, urinary tract infection, or sleep apnea) or by psychiatric disorders. Some treatments for bedwetting include behavior modification, alarm devices, and medications.
Nocturnal Paroxysmal Dystonia (NPD)
This disorder is sometimes marked by seizure-like episodes during non-REM sleep. Most evidence points to NPD being a form of epilepsy. Episodes of NPD typically recur several times per night.
Sleep Disorders: What Causes Bedwetting?
While bedwetting can be a symptom of an underlying disease, a large majority of children who wet the bed have no underlying disease that explains their bedwetting. In fact, an underlying condition is identified in only about 1% of children who routinely wet the bed.
That does not mean that the child who wets the bed can control it or is doing it on purpose. Children who wet are not lazy, willful, or disobedient. Bedwetting is most often a developmental issue.
Types of Bedwetting
There are 2 types of bedwetting: primary and secondary. Primary means bedwetting that has been ongoing since early childhood without a break. A child with primary bedwetting has never been dry at night for any significant length of time. Secondary bedwetting is bedwetting that starts up after the child has been dry at night for a significant period of time, at least 6 months.
What Causes Primary Bedwetting?
The cause is likely due to one or a combination of the following:
* The child cannot yet hold urine for the entire night.
* The child does not waken when his or her bladder is full.
* The child produces a large amount of urine during the evening and night hours.
* The child has poor daytime toilet habits. Many children habitually ignore the urge to urinate and put off urinating as long as they possibly can. Parents usually are familiar with the leg crossing, face straining, squirming, squatting, and groin holding that children use to hold back urine.
What Causes Secondary Bedwetting?
Secondary bedwetting can be a sign of an underlying medical or emotional problem. The child with secondary bedwetting is much more likely to have other symptoms, such as daytime wetting. Common causes of secondary bedwetting include the following:
* Urinary tract infection: The resulting bladder irritation can cause pain or irritation with urination, a stronger urge to urinate (urgency), and frequent urination (frequency). Urinary tract infections in children may indicate another problem, such as an anatomical abnormality.
* Diabetes: People with diabetes have a high level of sugar in their blood. The body increases urine output to try to get rid of the sugar. Having to urinate frequently is a common symptom of diabetes.
* Structural or anatomical abnormality: An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence or other urinary problems that could show up as bedwetting.
* Neurological problems: Abnormalities in the nervous system, or injury or disease of the nervous system, can upset the delicate neurological balance that controls urination.
* Emotional problems: A stressful home life, as in a home where the parents are in conflict, sometimes causes children to wet the bed. Major changes, such as starting school, a new baby, or moving to a new home, are other stresses that can also cause bedwetting. Children who are being physically or sexually abused sometimes begin bedwetting.
Is Bedwetting Inherited?
Bedwetting does tend to run in families. Many children who wet the bed have a parent who did too. Most of these children stop bedwetting on their own at about the same age their parent did.