In addition to my role as an independent sector GP I have a special interest in problems of sleep.

The importance of good sleep has become clearer in recent years.

The benefit of a GP managing sleep complaints is that they are assessed from a broad perspective. Many sleep problems are connected, or even caused by, other health issues, for example depression.

I aim to diagnose the problem and either help the patient resolve the problem or, if necessary, refer directly to specialists/ therapists with whom I have built up professional connections.

Typical sleep problems are insomnia (difficulty getting sleep), sleep apnoea (sleep breathing problems), parasomnias (such as sleep walking), circadian rhythm disorders (timing of sleep), movement disorders and excessive sleep (the hypersomnias).

Sleep problems include:

• Insomnia
• breathing disorders- typically, sleep apnoea
• Parasomnias, such as sleep walking, REM sleep disorders
• Sleep movement disorders- periodic limb movement and restless leg syndrome
• Circadian rhythm disorders- such as delayed sleep phase syndrome, shift work and jet-lag
• Excessive sleep- eg narcolepsy and idiopathic hypersomnia

Insomnia

Difficulty getting to sleep, frequent, prolonged awakenings and early morning waking are typical presentations

Sufferers are often fearful of their beds and there may be misconceptions as to their sleep and the sleep requirements. A careful evaluation, with sleep diaries, is necessary.

A useful triad, from Spielman, of ‘predisposing, precipitating and perpetuating’ is used in sleep medicine in examining the background.

Approaches to insomnia are broadly CBT insomnia (different to general CBT though with clear overlap); pharmacological management; and, more in depth psychological, often in conjunction with co-morbid illness, management.

Sleep related breathing disorders

An important, frequently underdiagnosed, problem is the reduced oxygenation of the brain and poor, unfulfilling sleep in sleep apnoea (episodes of no breathing) and hypopnoea (reduced breathing). More pronounced in the latter hours of the night during dream (REM) sleep where the body is largely paralysed (hence not ‘acting out’ dreams) there may be many episodes of inadequate breathing usually associated with snoring, the overweight and excess alcohol consumption- though this is by no means always the case.

These episodes lead to stress on the body potentiating high blood pressure, diabetes, depression and other illnesses. It leads to daytime sleepiness and symptoms of unfulfilling sleep. It may happen in younger, slim patients where oxygenation not is significantly reduced but enough to cause night time disturbance.

It is thus important to diagnose and treat. Current methods include CPAP (or similar) with a small machine and mask- that are becoming more comfortable and less obtrusive; mandibular advancement devices are sometimes appropriate; and, there are newer treatments in development phase.

Parasomnias; sometimes called ‘Things that go bump in the night’

Sleep walking and talking often happen in children. These phenomena usually take place at the beginning of the night. They can start to occur in adulthood. These are NREM disorders ie sleep problems arising in non dream sleep (‘not in REM sleep’)

REM sleep disorders typically occur later in the night and may lead to disruptive actions and even harm bed partners or the individuals themselves.

Sleep movement disorders

These include restless leg syndrome- comprising the irresistible urge to move the legs, usually worse in the evening. Periodic limb movements during sleep are often disruptive to the bed partner.

NFLE (nocturnal frontal lobe epileptic )- often repetitively patterned movement phenomena need careful evaluation by neurologists and overnight studies (polysomnography).

Circadian Rhythm Disorders

The body’s own body clock may be disturbed by external factors such as jet lag, shift work or internal such as delayed sleep phase syndrome. There are methods of at least ameliorating the effects of jet lag. Melatonin may be recommended but is generally used for large time zone changes where the individual is staying in the new zone for a time long enough to warrant the use. Shift work is associated with increased health risk and it is important that individuals manage their disrupted clocks in the most supportive manner. This may well mean increased screening for health problems. Adolescents may create their own sleep rhythm not entirely conducive to adequate sleep, though there are genetic factors often involved. Hence some schools consider changing the day routine to benefit students with a later start. Nevertheless there are ways of addressing the issue that help a sleep pattern more attuned to society at large if is beneficial to the individual.

Excessive sleep

An uncommon disorder related to lack of the hormone involved in the waking state (orexin) is called narcolepsy. It presents with individuals complaining of the inability to stay awake, where a nap may give temporary relief. This can be associated with a condition known as cateplexy when ‘surprises’ can evoke loss of muscle tone leading to collapse.

There is a relatively rare condition called idiopathic hypersomnolence is essentially diagnosed by exclusion, as the cause is to date unknown.