Sleep science today knows a whole lot more of sleep disorders than it did only two decades ago. From the first recognition of nightmares, sleepwalking, sleep talking and the like, to the current detailed classification of over 81 listed disorders, the growth is evident. The landmark discoveries in technology are what made the most significant difference, allowing for more sophisticated scanning systems, accurate diagnosis, and far more precise understanding and distinction of sleep disorders. Fancy mechanisms and elaborate studies such as polysomnography advanced this area immensely, and it’s now easier than ever to detect barely-there symptoms that make all the difference.
However, as advanced as they are, these methods of diagnostics are often not the first or only steps in identifying sleep disorders. Reasons for this are a few: polysomnography can be expensive and requires a person to sleep over at a sleep clinic, which is not always necessary – for people whose symptoms are milder, this study won’t be cost-effective and might merely be an inconvenience. Besides that, this type of study isn’t able to identify all sleep disorders – people with insomnia often won’t find much use having polysomnography done. For these reasons, specialists at clinics leave such tests as a last resort, unless something changes their minds before. Polysomnography, in particular, is the one sure way to diagnose sleep apnea, and if a doctor suspects this disorder, or wants to eliminate something potentially as urgent, they will request polysomnography.
In most cases, doctors will start a patient with some sort of a questionnaire, physical examination, and above all, medical history. This step is crucial for any diagnosis and future treatment plan, as inaccurate history might result in serious complications. Here’s what it is.
One of the first steps in every possible appointment scenario in a sleep clinic will include you talking about your medical history. Pills you may or may not be taking, past medical events, allergies, psychiatric or other medical conditions need all be discussed with your doctor prior to any plan of action they may propose. This is not just to initially engage you in a conversation; all of the factors mentioned in this category have the potential to either make your diagnosis faster and easier. Not only do you risk leaving your condition untreated because of the potential lack of diagnosing, but the treatment for a wrong disorder may make matters even worse.
Medication and Substance Use
If your doctor manages to diagnose you correctly based on your symptoms even with the incomplete medical history, the prescribed treatment could still put you at risk. Let’s say you’ve just been appropriately diagnosed with a rather severe case of insomnia. You have been working at cognitive behavioral therapy (CBT) for a while now, and your symptoms still aren’t under control. After perhaps attempting another treatment route, your doctor decides it’s time you gave prescription sleep medication a shot. Only, they don’t know you stopped another medication just weeks ago. You may have forgotten to mention it, thinking that it wasn’t important, or that their effect would have passed by now. As a result, the combination of those leftovers and the new sleep drug you were just prescribed may wreak havoc on your entire organism.
To avoid such a scenario, currently used sleep and other meds, as well as those used in the past or recently stopped, need to enter the medical history. Medications like beta-blockers, sedatives, bronchodilators, and glucocorticoids can all be sleep-disruptive, too, and as such need to be considered when identifying a root cause of a sleep issue. It isn’t uncommon for high blood pressure drugs and medications for respiratory problems to have a side-effect on sleep.
Caffeine, nicotine, and alcohol are all linked to poor sleep quality. The first two stimulate you and prolong sleep latency, while alcohol is a depressant that may get you to fall asleep, but it disrupts it later. Antihistamines have a sedative effect, and some over-the-counter drugs that contain ephedrine can also cause sleep delay. These substances are relatively addictive, too, and abruptly stopping their consummation after a prolonged period of using them can cause problems, and even some withdrawal symptoms.
Another Medical Condition
Lack of treatment of another medical condition may also worsen sleep, which brings us to the next point. A sleep issue or disorder may be primary (unrelated to some other condition) or secondary (related to another, root condition present in an individual). This means that the sleep issue is directly caused by this other condition, which means it can’t be treated alone – the cause must be addressed first. For example, if your insomnia coexists with depression, treating just insomnia won’t be practical or attainable.
In some cases, treating both at the same time is possible, and sometimes even the treatment for one might accidentally help ease the other condition, too. Such a case may occur in patients who are diagnosed with asthma and obstructive sleep apnea – continuous positive airway pressure (CPAP) therapy, used to treat apnea, also aids nocturnal asthma symptoms. This picture goes downhill quickly for some other combinations, like GERD and obstructive sleep apnea (OSA). The same CPAP therapy that was just a one size fits all causes further damage for people dealing with acid reflux problems; the pressurized air meant to keep your airways open and treat OSA might send the air through your esophagus in a detour. This stomach-gateway muscle is already weakened if you have GERD and even worse with CPAP therapy, resulting in your stomach acid traveling the upwards to your mouth easier than ever.
Psychological history plays the next role in the story. This should include your overall state, mood, stressful events in home and work environment, etc. If you have a bad spell of insomnia right after getting divorced, this is no surprise, and mentioning it will save everyone the unnecessary tests and evaluations. You will probably still be required to fill out some questionnaire or otherwise be briefly checked just in case, depending on your symptoms, their duration, severity, and so on. Other than psychiatric illnesses, some health conditions that regularly disrupt sleep include heart disease, endocrine diseases, respiratory conditions, menopause, gastrointestinal issues, etc.
Subjective Overview and Steps to Take
After this, your doctor will want to know about your sleep habits, the position you predominantly sleep in, your exact issues (like whether you can’t fall asleep or keep waking up, etc.) and your basic, subjective grasp of what’s happening. To make things much more comfortable, the doctor may ask you to keep a sleep journal.
Here, you are to write and describe everything you experience within at least two or three weeks:
- how fast you fall asleep
- how many times you wake up and at what times of night/morning
- how you feel upon waking
- whether you are tired during the day
- what else you feel
- what issues you face
- how you go about your bedtime routine etc.
Anything you can remember counts – your doctor knows this will be subjective and possibly not precise, but you will still write down much more than you would be able to remember cumulatively while being interrogated at the clinic.
This is something you can do even before you schedule your first appointment, especially if you are hesitant about it. If it’s written, you are sure not to miss mentioning it. To make the journal even more useful, it is recommended that you ask your sleeping partner, parent or other household members to write a parallel one as well. This will provide a significant angle outside of your own, as you might not remember some things that happened during your sleep – your spouse may notice sleeptalking, walking, snoring, choking, etc.
Sleep hygiene is something else you can work on before scheduling a doctor’s appointment. Some of its elements you’ve undoubtedly heard of many times:
- Set a bedtime at the same time each day, and get up at the same time in the morning, too. This will train your mind to expect sleep at a certain moment and over time, improve your sleep latency. Waking up at the same time every morning benefits you the same way; as your body gets used to the schedule, you might not even need an alarm after a while, as your body will automatically be alert in set time.
- Set up a calming evening ritual. You may have attempted this before but got overly excited, wrote an endless to-do list instead of a few steps worth routine and then threw it away altogether after a week. What you should do is set up such habits that you won’t want to procrastinate and delay sleep as a result. Only do what needs be done but is attainable – maybe not an hour-long bath, but a shower and a 15-minute meditation. Perhaps just getting into your pajamas, brushing teeth and reading a calming book. You know yourself best.
- Adhere to the treatment of another existing condition. If it wasn’t clear enough before, you can’t expect to have optimal sleep, if you don’t take all of the present issues seriously.
Diagnostic steps that follow the medical history
Doctors will often give sleepiness tests and questionnaires for patients to fill out as a personal outlook on the matter. The Stanford and Epworth sleepiness scales are just some of the most common tests of the sort. A sleep log serves that purpose, too, but it takes some weeks before its information gains significance. If you haven’t started it before reaching out to a specialist, they might still advise you write it, if only to keep track of progress.
Multiple sleep latency test (MSLT) is the golden standard of sleepiness measuring tests. A patient is given opportunities to nap throughout the day, but for no longer than an hour. How fast they fall asleep, and whether or not they reach the REM-stage can tell us how sleepy they are and what type of disorder may be present.
Next, you may be prescribed a sleep monitoring device like an actigraph. Worn around your wrist or ankle, this machine records your movement during sleep to provide a more complete picture of what your body goes through at that time. It is usually prescribed if polysomnography isn’t available, affordable or necessary.
Finally, polysomnography is as advanced as sleep monitoring gets. A patient is required to sleep over at a laboratory for the night while this machine records their brain activity, heart rate, blood oxygen flow, respiratory airflow, and more. A licensed sleep specialist looks after the procedure and reviews the results.
Co-founder of Counting Sheep and Sleepaholic