Myths & Facts: Sleep Disorders

SLEEP SCIENCE has rapidly advanced in the past 20 years, providing expanded insight about the importance of sleep, the biological mechanisms that control sleep and the ways it can be disrupted.¹ In fact, a lack of sleep can cause various concerns with mental and physical health in the long term.

According to estimates, 50 million to 70 million people have ongoing sleep disorders, with the most common among them being insomnia, sleep apnea (a common condition in which breathing stops and restarts many times while sleeping) and narcolepsy (feeling very drowsy during the day).² Indeed, nearly one-third of U.S. adults report getting less than the recommended amount of sleep. Lack of sleep is linked to many chronic diseases and conditions such as type 2 diabetes, heart disease, obesity and depression, and it can lead to motor vehicle crashes and mistakes at work, which cause a lot of injury and disability each year.³ 

Yet, despite this advanced knowledge, false information about sleep is commonly spread online or by word of mouth, according to experts at the Sleep Foundation, who say “some of this false information is repeated so often that it becomes a widely held belief, many of which can lead to poor sleep habits and insufficient sleep.”¹ So, not only can dispelling the myths surrounding sleep disorders help improve individuals’ health, understanding more about sleep duration and sleep insufficiency can help organizations develop programs to prioritize efforts to improve sleep health.

Separating Myth from Fact

Myth: Insomnia means having trouble falling asleep. 

Fact: Trouble falling asleep can be a sign of insomnia, but there are a lot more symptoms of insomnia, including waking up too early and not being able to get back to sleep, frequent awakenings and waking up feeling exhausted.⁴ According to the National Institutes of Health, short-term insomnia may be caused by stress or changes in one’s schedule or environment, and it can last for a few days or weeks. On the other hand, chronic (long-term) insomnia occurs three or more nights a week, lasts more than three months and cannot be fully explained by another health problem.⁵ 

Common causes of insomnia include medications that interfere with sleep; dietary choices such as caffeine later in the day that interfere with sleep; stress thoughts; depression; recent upheavals in one’s life such as divorce or the death of a loved one; hormone changes such as those accompanying menopause; bedtime habits that don’t lead to restful sleep; sleep disorders; chronic pain; medical conditions such as acid reflux, thyroid problems, stroke or asthma; substances like alcohol and nicotine; and travel, especially between time zones.⁶

Myth: Men and women have equal risk of insomnia. 

Fact: Actually, women are twice as likely to have insomnia than men, and older adults are more likely to experience insomnia.⁷ Insomnia is also more common among shift workers who don’t have consistent sleep schedules, people with low incomes, people who have a history of depression and those who don’t get much physical activity.⁶

Myth: A lack of sleep causes narcolepsy.

Fact: While a lack of restful sleep can be a cause of narcolepsy, there are many other causes as well. Narcolepsy is a sleep disorder that affects the brain’s ability to regulate sleep-wake cycles and causes persistent daytime sleepiness. Symptoms include severe and persistent drowsiness that can cause impairments in school, work and social settings, as well as a heightened risk of serious accidents and injuries. Even though narcolepsy is rare compared to other sleep disorders, it affects hundreds of thousands of Americans, including both children and adults.

According to the International Classification of Sleep Disorders, Third Edition (ICSD-3), there are two types of narcolepsy: narcolepsy type 1 (NT1) and type 2 (NT2). NT1 is identified by cataplexy (sudden loss of muscle tone) and the loss of neurons in the brain responsible for making hypocretin, also known as orexin, a chemical that helps regulate wakefulness and sleep. People with NT1 have a loss of 90 percent or more of the normal amount of hypocretin-making neurons. Researchers have also found that as many as 98 percent of people with NT1 carry a gene variation known as DQB1*0602, which could cause a genetic susceptibility to NT1, but it is not yet definitively proven. And, most individual cases of NT1 occur with no clear, direct cause. Some experts believe NT2 is a less pronounced loss of hypocretin-producing neurons, while others think NT2 may primarily be a precursor to NT1. However, cataplexy has only been observed to develop in about 10 percent of cases of people initially diagnosed with NT2, and once cataplexy develops, people can be rediagnosed with NT1. In some instances, NT2 has been reported following a viral infection, but most cases do not have an established cause. And, as with NT1, NT2 can arise because of other medical conditions such as head trauma, multiple sclerosis and other diseases affecting the brain.⁸

Myth: Individuals need a minimum of eight hours of sleep a night.

Fact: Everyone has different sleep needs based on factors such as age, activity levels and sleep patterns. Therefore, the eight-hour rule is not necessarily the “perfect amount” of sleep. In fact, trying to follow a set rule for an exact number of hours of sleep can cause sleep anxiety, leading to lower-quality sleep.⁹ What’s more important is the number of times a person goes through a sleep cycle and experiences the different stages of sleep: non-REM sleep and REM sleep. (REM is the acronym for rapid eye movement, named for the way the eyes erratically move behind the eyelids during this sleep stage.)

Non-REM happens first and includes three stages. Non-REM stage N1 is the typical transition from wakefulness to sleep and generally lasts only a few minutes. It is the lightest stage of sleep. During this stage, eye movements are typically slow and rolling, heartbeat and breathing slow down, muscles begin to relax and low amplitude mixed frequency waves in the theta range (4 to 7 Hz) are produced. NREM stage N2 is the next stage of non-REM sleep, which comprises the largest percentage of total sleep time and is considered a lighter stage of sleep from which a person can be easily awakened. This is the stage before a person enters deep sleep. During this stage, heartbeat and breathing slow down further, there are no eye movements, body temperature drops, and sleep spindles and K-complexes are two distinct brain wave features that appear for the first time. NREM stage N3, the final stage of non-REM sleep, is the deepest sleep stage. During this stage, arousal from sleep is difficult, heartbeat and breathing are at their slowest rate, there is no eye movement, the body is fully relaxed, delta brain waves are present, tissue repairs and grows, cell regeneration occurs and the immune system strengthens.

There are two phases of REM sleep: phasic and tonic. Phasic REM sleep contains bursts of rapid eye movements, while tonic REM sleep does not. REM sleep occurs about 90 minutes after falling asleep and is the primary “dreaming” stage of sleep. It lasts roughly 10 minutes the first time, increasing with each REM cycle. The final cycle of REM sleep may last roughly between 30 to 60 minutes. During this stage, eye movements become rapid, breathing and heart rate increase and become more variable, muscles become paralyzed (but twitches may occur) and brain activity is markedly increased.¹⁰

Myth: The brain rests during sleep. 

Fact: The body rests during sleep, but the brain remains active, gets recharged and still controls many body functions, including breathing.¹¹ As previously stated, the brain typically drifts between two sleep states, REM sleep and non-REM sleep, making the brain active during sleep.⁴

REM sleep is the stage of sleep when people usually have vivid dreams. While it isn’t the only stage of sleep when people can dream, it tends to be the stage in which people have the most intense dreams. During the REM stage of sleep, brain activity is similar to when people are awake, which may explain why vivid dreams occur.⁹

Myth: Older adults need less sleep. 

Fact: Older adult sleep patterns change, but the amount of sleep they need doesn’t. As people age, certain changes happen in their hormones and circadian rhythm, both of which affect sleep patterns. This may cause older adults to experience sleeplessness at night and wake up more often, which means they may spend more time awake.⁹

According to the Sleep Foundation, changes in the quality and duration of sleep in older adults occur due to changes in the body’s internal clock, which is located in a part of the brain called the hypothalamus and is made up of approximately 20,000 cells that form the suprachiasmatic nucleus (SCN). The SCN controls 24-hour daily cycles, called circadian rhythms, that influence when people get hungry, when the body releases certain hormones and when a person feels sleepy or alert. Deterioration in the function of the SCN can disrupt circadian rhythms, directly influencing when people feel tired and alert. The SCN receives information from the eyes, and light is one of the most powerful cues for maintaining circadian rhythms. Unfortunately, research shows that many older people have insufficient exposure to daylight, averaging around one hour each day. In addition, changes in production of hormones such as melatonin and cortisol may also play a role in disrupted sleep in older adults. As people age, the body secretes less melatonin, which is normally produced in response to darkness and helps promote sleep by coordinating circadian rhythms.¹²

Myth: The body gets used to a lack of sleep.

Fact: This myth can be especially harmful because sleep deprivation can wreak havoc on diverse aspects of health, including metabolism, the cardiovascular system, the immune system, hormone production and mental health.¹

Indeed, in a literature search conducted to provide a nonsystematic review of the health consequences of sleep deprivation, researchers found there are both short- and long-term consequences. Specifically, they found that “in otherwise healthy adults, short-term consequences of sleep disruption include increased stress responsivity, somatic pain, reduced quality of life, emotional distress, mood disorders and cognitive, memory and performance deficits. For adolescents, psychosocial health, school performance and risk-taking behaviors are impacted by sleep disruption. Long-term consequences of sleep disruption in otherwise healthy individuals include hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, type 2 diabetes mellitus and colorectal cancer. All-cause mortality is also increased in men with sleep disturbances. For those with underlying medical conditions, sleep disruption may diminish the health-related quality of life of children and adolescents and may worsen the severity of common gastrointestinal disorders.”¹³

Myth: Lack of sleep can be made up over the weekend.

Fact: Yes, it can feel good to sleep in on the weekend, but this change in sleep patterns can disrupt a person’s sleep schedule. It’s always better to go to bed and wake up at the same time every day, even on the weekends.⁹

Myth: Napping makes up for a lack of nighttime sleep. 

Fact: Sleeping only a few hours at night and taking multiple naps during the day is known as biphasic or polyphasic sleep, which can work for some people, but it’s not healthy for extended periods of time.⁴

Biphasic sleepers sleep twice per day, whereas polyphasic sleepers sleep in multiple segments (three of more periods) per day. According to the Sleep Foundation, unintentional polyphasic sleep can be a sign of a sleep disorder or a neurodegenerative disease such as Alzheimer’s. For those who do sleep this way intentionally, it is associated with negative physical and mental health outcomes.

Still, for some, biphasic sleep schedules come naturally. And, it is unknown whether biphasic sleep is better, worse or about the same as monophasic sleep (sleeping only one time per day). For instance, research has found that midday napping has consistently been linked to improved cognitive performance, shorter naps have been shown to reduce sleepiness and cause cognitive improvements that are felt almost immediately, and longer naps lasting more than 30 minutes produce cognitive benefits for a longer time period, but the person tends to experience a period of grogginess after waking up.¹⁴

Myth: The only thing that matters is the duration of sleep. 

Fact: While getting enough sleep is important, even more important is sleep quality. Awakening numerous times during the night interferes with the sleep cycle, decreasing time spent in the most restorative stages of sleep.¹

Myth: Alcohol before bed improves sleep. 

Fact: Alcohol may make it easier to fall asleep at night, but can disrupt sleep later in the night and may cause periods of awakening that would otherwise not have been experienced. According to an article in the Handbook of Clinical Neurology, “Alcohol acts as a sedative that interacts with several neurotransmitter systems important in the regulation of sleep. Acute administration of large amounts of alcohol prior to sleep leads to decreased sleep onset latency and changes in sleep architecture early in the night, when blood alcohol levels are high, with subsequent disrupted, poor quality sleep later in the night. Alcohol abuse and dependence are associated with chronic sleep disturbance, lower slow wave sleep and more rapid eye movement sleep than normal, that last long into periods of abstinence and may play a role in relapse.¹⁵

Myth: Snoring while sleeping is harmless. 

Fact: Snoring can actually be a sign of sleep apnea, a sleep disorder that is associated with other medical problems such as heart disease and diabetes. While it is a common condition that causes breathing to stop and restart many times while sleeping, it can prevent the body from getting enough oxygen. 

There are two types of sleep apnea: obstructive and central. Obstructive sleep apnea, the most common type, occurs when the upper airway becomes blocked many times while sleeping, reducing or completely stopping airflow. This can be caused by anything that could narrow the airway such as obesity, large tonsils or changes in hormone levels. Central sleep apnea occurs when the brain fails to send the signals needed to breathe.¹⁶

There are many factors that raise the risks of both obstructive and central sleep apnea. Risks of obstructive sleep apnea include older age; endocrine disorders; family history and genetics; heart or kidney failure; large tonsils and a thick neck; lifestyle habits such as drinking alcohol and smoking; obesity; and sex (it is more common in men than women). Risks of central sleep apnea include older age; family history and genetics; lifestyle habits (again, alcohol and smoking); opioid use; health conditions that affect how the brain controls the airway and chest muscles such as heart failure, stroke, amyotrophic lateral sclerosis and myasthenia gravis; and premature birth.¹⁷

Myth: There is no treatment for sleep disorders other than lifestyle modifications. 

Fact: While lifestyle modifications can certainly help to treat sleep disorders, there are many other treatments available:¹⁸

Light therapy. Sitting in front of a light box that produces bright light similar to sunlight can help to adjust the amount of melatonin the body needs to reset the sleep-wake cycle. A  light box can be used in the morning to help reduce daytime sleepiness or in the afternoon or early evening to help treat advanced sleep-wake phase disorder, shift work disorder and jet lag. In place of a light box, light visors and light glasses can also be effective.

Orofacial therapy. Exercising the mouth and facial muscles can help treat sleep apnea in children and adults.

Cognitive behavioral therapy for insomnia (CBT-I). CBT-I is a six- to eight-week treatment plan to help individuals learn how to fall asleep faster and stay asleep longer. It is recommended as a first-line therapy with a healthcare provider, nurse or therapist. CBT-I involves five parts: 1) cognitive therapy, 2) relaxation or meditation therapy, 3) sleep education, 4) sleep restriction therapy and 5) stimulus control therapy.

Prescription medicines. These include benzodiazepine receptor agonists such as zolpidem, zaleplon and eszopiclone; melatonin receptor agonists such as ramelteon; orexin receptor antagonists such as suvorexant; and benzodiazepines if other treatments and medicines haven’t worked. In addition, stimulants and depressants such as sodium oxybate can be prescribed.

Off-label medicines. In some cases, medications often used for other health conditions but not approved by the U.S. Food and Drug Administration to treat insomnia can be prescribed. These include antidepressants, antipsychotics and anticonvulsants.

Over-the-counter (OTC) medicines. Many OTC products can help with sleep disorders, including antihistamines, melatonin supplements and dietary supplements.

Devices. Both over-the-mouth and in-the-mouth devices can help treat sleep disorders. A continuous positive airway pressure (CPAC) device works by using mild air pressure to keep airways open while sleeping. The CPAP machine includes a mask the fits over the nose and mouth and a tube that connects the mask to the machine’s motor. 

Oral devices that are worn in the mouth are often custom-made by a dentist or orthodontist. There are two types that open the upper airway while sleeping: 1) mandibular advancement devices that cover the upper and lower teeth and hold the jaw and 2) tongue retaining devices that hold the tongue in a forward position.

Surgical procedures. When CPAP machines or oral devices don’t work, one of four types of surgery may be needed: 1) adenotonsillectomy surgery removes the tonsils and adenoids, 2) an implant to help monitor breathing patterns and control certain muscles, or a nerve stimulant to control the tongue muscles, can prevent the airway from becoming blocked, 3) removing the soft tissue from the mouth can make the upper airway larger and 4) maxillary or jaw advancement surgery moves the upper jaw and lower jaw forward to make the upper airway larger.

Dispelling the Myths Now

Getting enough sleep is not a luxury — it is something people need for good health. Lack of sleep can have short- and long-term consequences, and it has detrimental effects on mental health, metabolism, the immune system and more. On the other hand, getting enough sleep makes people feel healthier and rested during the day.

Fortunately, sleep is receiving increasing attention in public health. In a recent viewpoint article published in The Lancet, the authors proclaim that “despite the strength of evidence showing that sleep has a critical influence on all aspects of human health, the importance of sleep health remains under-recognized globally.” They recommend that sleep health “be promoted as an essential pillar of health, equivalent to nutrition and physical activity … with a focus on education and awareness, research and targeted public health policies.” In addition, they recommend developing sleep health educational programs and awareness campaigns; increasing, standardizing and centralizing data on sleep quantity and quality; and developing and implementing sleep health policies across sectors of society.¹⁹