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Sleep Disorders

Several Different Sleep Problems

10/13/2009

Question:

Hello. I have been working with a sleep specialist. The doctor said I have PLMD, as well as a mild version of sleep apnea. I also have some symptoms of narcolepsy.

I have tried Neurontin for the PLMD, and a CPAP machine for the sleep apnea. Neither of these are helping me. I still sleep very poorly at night (only about 4 hours a night), and feel very fatigued and exhausted during the day. I still have extremely vivid dreams, both when I am sleeping at night, and when I take naps (longer then 30 minutes) during the day. A lot of times when I am sleeping, I wake up about every 1 1/2 hours and remember a vivid dream in very clear detail.

The only other medication I am currently taking (and have been taking for years) is Luvox. I used to be a very good sleeper, even when I was taking Luvox. I do not drink alcohol, and try to be aware of my caffeine intake.

I am totally frustrated and do not know where to go from here. Do you have any suggestions? Are the sleep disorders (PLMD, sleep apnea, narcolepsy) causing me to sleep poorly and remember the vivid dreams or is it the other way around - where the vivid dreams are causing me to have poor, restless sleep? If it is the vivid dreams that are causing the problems, do you have any advice as to how to treat them?

Thank you for reading my e-mail, and I look forward to seeing what you suggest.

Answer:

Your case is very complicated and certainly more information will be required to be able to make suggestions. You report you have been diagnosed with periodic limb movement disorder (PLMD as well as mild obstructive sleep apnea (OSA), presumably both diagnosed on a sleep study. While the diagnosis of narcolepsy can be straight forward in many cases, it can be difficult to diagnose in the setting of other sleep disorders that can interrupt sleep and cause associated symptoms. I’ll talk about that first.

Narcolepsy is characterized by excessive sleepiness and abnormal intrusions of rapid eye movement (REM) sleep phenomena into awake time. Typically, during REM sleep, our muscles are inactive (except for our breathing muscles and eye muscles) and unable to move. In individuals with narcolepsy, this "paralysis" of muscles may occur during wakefulness (known as cataplexy, usually brought on by strong emotions) or during transitions between sleep and wakefulness (sleep paralysis). In addition, dreams may intrude up in these times as well (known as hypnagogic or hypnopompic hallucinations). Other symptoms of narcolepsy may include poor nighttime sleep and automatic behaviors (performing tasks without being aware of what you are doing or having recall of having done it).

While true cataplexy (brief, sudden, bilateral loss of muscle tone brought on by strong emotions) is considered very strong evidence of narcolepsy, the other symptoms listed may be seen in individuals without narcolepsy. I have noticed that many physicians inappropriately use the term narcolepsy to describe excessive daytime sleepiness from any reason. The diagnosis of this condition is usually determined by a Sleep Specialist after taking a thorough history, performing an examination, and obtaining objective testing - a sleep study and a daytime nap study (known as a Multiple Sleep Latency Study or MSLT). However, the other sleep disorders need to well-controlled before this testing can be done. In your case, you may not have narcolepsy. Rather, OSA, PLMD, and depression are all likely causes of sleepiness. Medication side effects also need to be considered.

The first thing is to make sure your sleep apnea is being adequately treated. You did not mention whether you are actually using CPAP and if not, then alternative therapies should be considered. It is also possible that your OSA is very mild and is not contributing to the sleep disturbance or the sleepiness, though I would make sure this is addressed first and foremost.

The PLMD is also a confounding issue that may need to be addressed. Periodic limb movements in sleep can occur as a primary disorder, though they can also be part of the arousal phenomena seen with respiratory disturbances in OSA. It is very important, once again, to make sure the OSA is treated to determine if the periodic limb movements are persisting and not related to the OSA. If the PLMD is real, Neurontin is usually not the first line medication for this condition. Another group of medications (including medications such as levo dopa, ropinirole, and pramipexole) are considered more effective.

Now as far as the dreaming goes, depression can manifest in early morning awakenings and vivid dreaming due to increased rapid eye movement sleep. Rapid eye movement sleep is the stage during which most of our dreaming occurs. Generally, patients experience more sleep apnea in this stage, resulting sometimes in more awakening in this stage of sleep. Therefore, it is possible that you have more awakening from this stage and subsequently you have more dream recollection. Normally, we all experience dreams; we remember these dreams mostly if we woke up from the dreaming stage of sleep.

Given the complex nature of your case, I suggest that you follow up with your sleep doctor. If you are unable to work thru your issues to your satisfaction, you may wish to consider a second opinion

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University