I’m a sleep doctor. These are the signs you have a real sleep problem

For many people, poor sleep has become so normalised that they no longer recognise it as a potential medical issue. Feeling tired all the time gets blamed on stress. Freight train snoring becomes a family joke at the dinner table. Trying not to doze off during that weekly meeting means your job is boring.

These signs all point to a possible sleep disorder. Yet, most people push through and ignore them.

As a sleep specialist who primarily treats people with chronic insomnia, I can say with confidence that even common sleep disorders remain underrecognised, underdiagnosed and undertreated.

Sleep disorders deserve medical attention – and often are highly treatable. Here are the most common (there are more than 80 clinical sleep disorders, by the way), and the signs you might have one.

Insomnia

Insomnia disorder is defined as difficulty falling asleep, staying asleep or waking up too early at least three nights per week for at least three months. It causes real impairment in daily life.

Sleep onset insomnia is the inability to fall asleep within a reasonable time frame (30 minutes) after getting into bed, while sleep maintenance insomnia involves waking up during the night and having trouble returning to sleep (for 30 minutes or more) or waking up much earlier than desired.

Insomnia can be acute, lasting days to weeks, usually triggered by an identifiable stressor and often resolving on its own, or chronic, persisting three months or longer and typically requiring intervention.

Decades of epidemiological research suggests that 10 to 15 per cent of the general population meets the criteria for chronic insomnia disorder, with higher rates among women, older adults and people with co-occurring mental health conditions.

Additional signs of insomnia disorder:

• Feeling exhausted, even after a full night of sleep
• Regularly experiencing irritability, low mood, mood changes, difficulty concentrating or paying attention, or memory problems
• Dread or anxiety as bedtime approaches
• Feeling exhausted getting into bed, but the moment your head hits the pillow, you’re wide awake (“tired but wired”)

The gold standard treatment is cognitive behaviour therapy for insomnia, also known as CBT-I, though other forms of sleep therapy as well as certain medications may also be appropriate.

Obstructive sleep apnoea

Obstructive sleep apnoea is a medical condition in which the muscles in the throat relax during sleep, causing the airway to narrow or close entirely – which often manifests as snoring, though you don’t have to snore to have OSA. As the airway collapses, breathing stops – sometimes for a few seconds, sometimes longer – until the brain partially wakes the body to restore airflow. This cycle can repeat hundreds of times a night, fragmenting sleep so often that most people wake up exhausted.

Women are overwhelmingly underdiagnosed because their symptoms often present differently – fatigue, mood changes, insomnia, morning headaches – compared with men, who are more likely to snore loudly or gasp/choke.

I hear this all the time from women in my practice. They didn’t fit the typical OSA stereotype, and instead their symptoms were attributed to depression, thyroid problems, stress or another sleep disorder.

Additional signs of OSA:

• Waking up with a dry mouth, sore throat or headaches
• Excessive daytime sleepiness
• Waking frequently to use the bathroom during the night (known as nocturia; this happens when apnoeas strain the heart and the body releases more of a hormone that increases urination)
• Difficulty concentrating, memory problems or cognitive slowing
• Increased irritability, mood changes, anxiety or depression that don’t fully resolve with treatment
• A history of chronic insomnia, particularly difficulty staying asleep
• High blood pressure or cardiac issues that are difficult to control

Sleep apnoea is often treated with continuous positive airway pressure therapy, which involves wearing a breathing machine that keeps airways open while sleeping, though other therapies and even surgery may be helpful for some. Lifestyle changes, such as weight loss and avoiding alcohol use, could also help.

Restless legs syndrome

Restless legs syndrome, also known as Willis-Ekbom disease, is characterised by an irresistible urge to move the legs (and/or arms), usually accompanied by uncomfortable sensations: crawling, tingling, pulling, aching, burning, itching or an indescribable inner restlessness.

Symptoms emerge or worsen at rest, and moving around, stretching or walking usually brings temporary relief. It is deeply uncomfortable in a way that makes staying still feel impossible and falling asleep extraordinarily challenging.

Because RLS cannot be visually detected on standard tests, and the sensation is difficult to explain, it was long dismissed as psychological or simply as “growing pains”.

Additional signs of RLS:

• Your bed partner complains that you kick or jerk your legs (and/or arms) repeatedly during sleep
• Excessive daytime sleepiness, mood changes, cognitive slowing and increased anxiety or depression

Anti-seizure medications and prescription-strength iron supplements may help, as can treating other health conditions and lifestyle interventions such as regular exercise, eating well, avoiding stimulants, massage, compression wear, hot/cold packs and magnesium supplementation.

Circadian rhythm sleep-wake disorders

Circadian rhythm sleep-wake disorders, or CRSWDs, occur when a person’s internal biological clock – which governs the timing of sleep, hormone release, body temperature and dozens of other physiological functions – is misaligned with the external environment or the person’s desired sleep schedule. These are not disorders of sleep quality per se but of sleep timing.

This can result in a sleep-wake schedule that’s much different from typical social norms, whether that means you can’t fall asleep until extremely late at night no matter how early you try, or you get sleepy in the early evening and wake up very early in the morning.

Additional signs of circadian rhythm disorders:

• You identify as an “extreme night owl” or “extreme early bird”
• When allowed to sleep freely on holiday or non-work days, you shift to a dramatically different schedule
• You work rotating shifts and struggle to sleep when you have the opportunity, despite feeling exhausted
• You have been told you have insomnia, but sleep medications or standard sleep hygiene advice have not helped
• Your “insomnia” or “fatigue” has never fully responded to treatment

The best “treatment” is to adapt your lifestyle so you can sleep in your natural, biological sleep-wake window. When that’s not possible, circadian rhythm management (e.g., microdosing melatonin, bright light therapy) or behavioral strategies, such as CBT-I, may be appropriate.

What to do if you suspect a sleep disorder

If any of the signs described above sound familiar, and especially if they’ve been going on for more than a few weeks, the first step is to talk to your doctor and specifically ask about sleep disorders.

Don’t just say you’re tired or can’t sleep. Be specific: describe when the problems occur, how long they’ve lasted, how they affect your daytime functioning and whether your bed partner has noticed anything unusual.

From there, your doctor may refer you to a sleep specialist (or you may need to ask directly for a referral), who can conduct a thorough sleep evaluation and, when appropriate, a sleep study. The list above is not exhaustive; other sleep disorders, such as narcolepsy and idiopathic hypersomnia, are less common but can also cause excessive daytime sleepiness despite your having logged plenty of hours in bed, and require proper diagnosis and treatment.

If you’ve been exhausted for months or years, and standard sleep hygiene advice hasn’t helped improve your sleep, you are not failing at sleep. Your sleep problems are probably not “just stress” or “just how you are,” and your exhaustion is not a badge of honour. Your sleep struggles deserve more attention.

Sarah Silverman, PsyD, is a sleep psychologist and behavioral sleep medicine specialist in private practice specialising in women’s sleep health and insomnia.

Washington Post

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