Sleep Soundly Every Night, Feel Fantastic Every Day (12 page)

A.
 
What you are describing is, unfortunately, very common with the medication Sinemet, also known as carbidopalevodopa. The condition is
augmentation
and affects 70% of patients on this medication for RLS. The pain worsens
and occurs earlier in the evening and may spread to other parts of the body. I recommend that you see your health care provider. You need to switch to a different medication such as Requip, Mirapex, or gabapentin. Increasing the dose and frequency of Sinemet will only make matters worse.

Q.
 
My brother takes a medication called Ritalin for ADHD. He is 23 years old and can't sit still. Recently, I read that a disorder called RLS is related to ADHD. Can you explain this relationship?

A.
 
At a recent meeting of the American Academy of Neurology, a paper was presented pointing out this relationship. In 40 patients with RLS, 39% had ADHD, while in a controlled group without RLS, less than 15% had ADHD. The authors feel that this leg discomfort can cause people to be hyperactive and distractible. You may be on to something with your brother. Advise him to discuss this with his doctor. There are numerous new medications available to treat this disorder.

Q.
 
I have RLS. Recently, I was placed on a medication called Mirapex. Friends have told me that there have been reports of people falling asleep suddenly when on this medication. I drive to work every day. Should I be concerned?

A.
 
What you are referring to is “sleep attacks.” The truth is they are very rare. Moreover, they have been noted in people with Parkinson's disease who take doses many times higher than what is used for RLS. As of now, I am unaware of any reports of sleep attacks in patients with RLS.

Q.
 
I have RLS. Is there an exercise program that could help me prevent the discomfort I feel that keeps me from sleeping?

A.
 
Unfortunately, no exercise program cures RLS. However, stretching the legs before bedtime has proven helpful in some patients with RLS.

Q.
 
I have RLS and do not like taking medications. Is there anything I can do that does not include oral medications?

A.
 
Yes. Although not as successful as medication, nonpharmacological treatments are available. These include improving sleep hygiene with a regular sleep–wake time, avoiding caffeine, alcohol, and nicotine and, lastly, performing moderate daily exercise. Some patients report that acupuncture and massage are helpful. These modalities have not yet been scientifically studied.

Q.
 
I've had fibromyalgia for 10 years. My legs hurt at night, and I get some relief by rubbing and moving them. I heard at a support group that this was part of my fibromyalgia. However, I have seen on the Internet that this could be a sign of RLS. What do you think?

A.
 
I think you are correct. We know that RLS is very common in people with fibromyalgia. In fact, in a recent study published in the
Journal of Clinical Sleep Medicine,
RLS was 10 times more common in those with fibromyalgia. In addition, you state that the symptoms occur predominantly at night. That is a key characteristic of RLS.
I recommend that you discuss this with your primary care provider.

Q.
 
I have RLS. It keeps me from falling asleep, sometimes for hours. It also bothers me when I am in the car and my legs are not moving. I have varicose veins and my legs swell. I am thinking of seeing a vascular specialist. Will this give me relief?

A.
 
In sclerotherapy, a chemical irritant is injected through the skin to close unwanted varicose veins. Several studies have shown improvement in symptoms of RLS. In one study consisting of 113 patients with RLS and varicose veins, 72% of those treated who had relief were maintained at two years. There are some contraindications to the procedure such as active inflammation in the vein. However, if you have not been able to get relief with commonly used medications or have experienced unwanted side effects, it would appear to be a reasonable alternative.

Even though RLS is one of the most common neurological disorders in North America, there's no real test for diagnosis. However, there are four key points that doctors use to diagnose RLS. They can be described using the word URGE.

If you think you may have RLS, and this sounds like what you're experiencing, use this URGE acronym when you talk to your doctor.

 

 

Insomnia is a gross feeder. It will nourish itself on any kind of thinking, including thinking about not thinking.

—CLIFTON FADIMAN

Do you experience difficulty falling or staying asleep? Do you wake often during the night or have restless sleep? Insomnia is the most common sleep disorder in the United States, affecting approximately one of every three people. Insomnia in younger adults typically manifests itself as a difficulty to initiate sleep, whereas in older adults, insomnia tends to cause a difficulty in maintaining sleep. You may have had temporary bouts of insomnia, called transient or acute adjustment insomnia, going through a divorce, losing a job, or losing a family member in death. Fifteen percent of those one-in-three persons with bouts of acute adjustment insomnia eventually go on to suffer from chronic insomnia.

Ally was 21 years old, and a recent education graduate of the state university. Her soft-spoken voice gave way to more enthusiasm and ease as she discussed why she came to the Sleep Disorders Center, “My mom encouraged me to come see you. What she tells me, now that I've been home most of the summer applying for teaching jobs, is that I seem snappy and irritable. Sometimes I talk faster, like I'm brushing off her questions. I will say that this is true because I feel tired. Her house is hot, and I don't sleep well at night as it is. I am trying to adjust living with her again. Then we get into an argument. Sometimes I cry. She says I cry a lot.”

Searching for sleep disorder clues, I asked, “Ally, I appreciate that your mom sent you to the Center, as she must feel you don't sleep well. What's your take on how you sleep?”

“Hmmm, I don't think I really sleep but for a few hours here and there. At night it seems I worry a lot, and so I try and keep myself busy. I watch a little television, fill out job applications, or keep up with college friends on Facebook. Mom doesn't like it, but now and then I might have a glass of wine that she reserves for us only at dinner.”

“So a few hours here and there means …”

“Well, if I go to bed and lie there, sometimes I see a couple of hours have passed when I check the clock in between trying to read a few pages of a book or texting a few friends. You know, that just gets old, so I get up and then find something to do to take my mind off not being able to sleep.”

“Good, next are your nighttime rituals new? Or, did you do these night activities before you went to college? And how about when you lived in the dorm?”

“Mom had a cancer scare when I was 12. Yes, in high school, I worried all the time. I heard her squeaky bed every time she turned over, and listened intently to make sure she
turned again. Man, I was hyper back then … maybe I still am. Then when I was dating, I always made curfew, and still worried about her. The house is so small, and I've never seen Mom smile much at all.”

“Ally, let me summarize this for a moment. In high school, your mom had a cancer scare, and that triggered in you this worrying at night, listening for her bed noise to make sure she was okay, or perhaps still alive?”

“Yeah, it's true. I used to shake in bed at night I was so afraid she would die. That was when I was 12, and sometimes I'd stay awake in my room and color, read, do homework, or talk to my girlfriends late at night because I didn't want to cry in bed.”

“Ally,” I said, “you are very clear in your descriptions, but there is one point that I want you to be certain about. I realize you associate your worrying at night with the trauma you and your mom went through around your early teen years. Yet, people adapt, and you would have let go of the cancer moment in your teen years.

“The fact that the sleep patterns are still going on had to shift into a habit of not being able to fall asleep whether or not you thought about your mom. Can you remember when you realized that you just couldn't fall asleep, and the longer you stayed in bed, the more you worried about falling asleep and all the repercussions that would have on you the next day?”

“Like, how do you mean?”

“I mean that from age 12 forward, what started as worry and fear around your mom and cancer has grown into an anxiety about going to sleep. The bedtime rituals you started and continued through your teen years have become a perpetuating habit that keeps you from sleeping, as hard as you try. Can you remember a shift in your worry patterns from the subject of mom to the subject of going to bed?”

Ally felt her anxiety turned from her mom into not being able to fall asleep or wanting to go to bed somewhere between her junior and senior years. She shared that she would take a book to bed, and read … waiting to be sleepy. Rather, she tended to be more awake. She would watch the clock, turn over, read some more, and finally get up.

In college, Ally learned to drink alcohol with friends, and she felt this helped her sleep better, but she still woke up within one to two hours after going to bed, and rarely returned to sleep. During all-night study sessions, her friends took amphetamines, but she drank caffeine–colas or coffee all night. In college, she scheduled her courses so she was always in her dorm room in the afternoon to “study and sleep.” However, she never slept.

Now that she is living with her mom again, she does drink wine, but has reverted to the same bedtime rituals, and subsequent anxiety about sleep.

Ally's story reveals how a smart teen developed insomnia over time as fears and worrisome thoughts took hold within her brain and body. She developed sleep-preventing behaviors and associations that made falling asleep almost impossible without the use of alcohol or medications for sleep. Any symptoms her mom may have noticed were masked in comments like “teens always sleep in, drinking alcohol is just part of college life, the hot bath relaxes me, I am handling
it …”

When a mental health screening ruled out anxiety as a primary disorder, Ally learned her diagnosis was
psychophysiological insomnia,
one of five types of the most common primary insomnias that affect 15% of the population in the Unites States. Primary insomnia patients are moody and anxious, especially around sleep and bedtime. Ally had developed severe anxiety and muscle tension associated around her inability to fall asleep and the bedroom
environment. Over her teen and college years, she developed hyperarousal, a state of being constantly alert at night, and developed rituals at night that served:

1.
 
To delude Ally into thinking she was taking care of herself.

2.
 
As sleep-preventing behaviors, which created poor sleep habits.

Another way to understand the development and continuance of primary insomnia is through the three-Ps, which are predispositions, precipitating factors, and then perpetuating variables or conditions.