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RLS sensations range from pain or an aching in the muscles, to "an itch you can't scratch", a "buzzing sensation", an unpleasant "tickle that won't stop", a "crawling" feeling, or limbs jerking while awake. The sensations typically begin or intensify during quiet wakefulness, such as when relaxing, reading, studying, or trying to sleep.
It is a "spectrum" disease with some people experiencing only a minor annoyance and others having major disruption of sleep and impairments in quality of life.
The sensations—and the need to move—may return immediately after ceasing movement or at a later time. RLS may start at any age, including childhood, and is a progressive disease for some, while the symptoms may remit in others. In a survey among members of the Restless Legs Syndrome Foundation, it was found that up to 45% of patients had their first symptoms before the age of 20 years.
- "An urge to move, usually due to uncomfortable sensations that occur primarily in the legs, but occasionally in the arms or elsewhere."
- "Motor restlessness, expressed as activity, which relieves the urge to move."
- "Worsening of symptoms by relaxation."
- "Variability over the course of the day-night cycle, with symptoms worse in the evening and early in the night."
- "Restless legs feel similar to the urge to yawn, situated in the legs or arms."
Individuals with RLS have higher rates of depression and anxiety disorders.
Other conditions that can produce similar symptoms include: akathisia and nocturnal leg cramps.
Peripheral artery disease and arthritis can also cause leg pain but this usually gets worse with movement.
Patients with PLMD will complain of excessive daytime sleepiness (EDS), falling asleep during the day, trouble falling asleep at night, and difficulty staying asleep throughout the night. Patients also display involuntary limb movements that occur at periodic intervals anywhere from 20–40 seconds apart. They often only last the first half of the night during non-REM sleep stages. Movements do not occur during REM because of muscle atonia.
The true primary hypersomnias include these: narcolepsy (with and without cataplexy); idiopathic hypersomnia; and recurrent hypersomnias (like Klein-Levin syndrome).
Periodic limb movement disorder (PLMD), previously known as nocturnal myoclonus, is a sleep disorder where the patient moves limbs involuntarily during sleep, and has symptoms or problems related to the movement.
PLMD should not be confused with restless legs syndrome (RLS). RLS occurs while awake as well as when asleep, and when awake, there is a voluntary response to an uncomfortable feeling in the legs. PLMD on the other hand is involuntary, and the patient is often unaware of these movements altogether.
Most RMD symptoms are relatively passive and do not cause any pain. Many patients are often unaware that an episode is occurring or has occurred. The rhythmic movements may produce some bodily injury via falls or muscle strains, but this is not reported in all patients
. In unique cases, RMD sufferers hum or moan while asleep during an episode. Some patients describe the repetitive movements as relaxing and are only occasionally awakened by an RMD episode. Often, it is the sufferer’s partner or parent who first notes the symptoms. Additionally, it is often the partner or parent who led patients to seek medical attention.
There are also several genetic disorders that may be associated with primary/central hypersomnia. These include the following: Prader-Willi syndrome; Norrie disease; Niemann–Pick disease, type C; and myotonic dystrophy. However, hypersomnia in these syndromes may also be associated with other secondary causes, so it is important to complete a full evaluation. Interestingly, myotonic dystrophy is often associated with SOREMPs (sleep onset REM periods, such as occur in narcolepsy).
There are many neurological disorders that may mimic the primary hypersomnias, narcolepsy and idiopathic hypersomnia: brain tumors; stroke-provoking lesions; and dysfunction in the thalamus, hypothalamus, or brainstem. Also, neurodegenerative conditions such as Alzheimer's disease, Parkinson's disease, or multiple system atrophy are frequently associated with primary hypersomnia. However, in these cases, one must still rule out other secondary causes.
Early hydrocephalus can also cause severe EDS. Additionally, head trauma can be associated with a primary/central hypersomnia, and symptoms similar to those of idiopathic hypersomnia can be seen within 6–18 months following the trauma. However, the associated symptoms of headaches, memory loss, and lack of concentration may be more frequent in head trauma than in idiopathic hypersomnia. "The possibility of secondary narcolepsy following head injury in previously asymptomatic individuals has also been reported."
Symptoms of Rhythmic Movement Disorder vary, but most sufferers share common large muscle movement patterns. Many sufferers show consistent symptoms including:
- body rocking, where the whole body is moved while on the hands and knees.
- head banging, where the head is forcibly moved in a back and forth direction.
- head rolling, where the head is moved laterally while in a supine position.
Other less common muscle movements include:
- body rolling, where the whole body is moved laterally while in a supine position.
- leg rolling, where one or both legs are moved laterally.
- leg banging, where one or both legs are moved in a back and forth direction.
- a combination of the aforementioned symptoms
The majority of sufferers have symptoms that involve the head, and the most common symptom is head banging. Usually, the head strikes a pillow or mattress near the frontal-parietal region. There is little cause for alarm at the movements as injury or brain damage as a result of the movements is rare. Some infants with diagnosed Costello Syndrome have been observed to have unique RMD episodes affecting the tongue and other facial muscles, which is an uncommonly affected area. Episodes usually last less than fifteen minutes and produce movements that vary from 0.5 to 2 Hz. Muscle movements during REM sleep are often twitches and occur simultaneously with normal sleep. The position of the body during sleep may determine which motor symptom is displayed. For example, Anderson et al. reported that one individual showed entire body rolling movements while sleeping on his side while displaying head rolling movements when sleeping supine.
Dyssomnias are a broad classification of sleeping disorders involving difficulty getting to sleep, remaining asleep, or of excessive sleepiness.
Dyssomnias are primary disorders of initiating or maintaining sleep or of excessive sleepiness and are characterized by a disturbance in the amount, quality, or timing of sleep.
Patients may complain of difficulty getting to sleep or staying asleep, intermittent wakefulness during the night, early morning awakening, or combinations of any of these. Transient episodes are usually of little significance. Stress, caffeine, physical discomfort, daytime napping, and early bedtimes are common factors.
A degenerative disease of the autonomic nervous system, symptoms include dizziness and fainting (caused by orthostatic hypotension), visual disturbances and neck pain. Chest pain, fatigue and sexual dysfunction are less common symptoms that may also occur. Symptoms are worse when standing; sometimes one may relieve symptoms by lying down.
There are over 30 recognized kinds of dyssomnias. Major groups of dyssomnias include:
- Intrinsic sleep disorders – 12 disorders recognized, including
- idiopathic hypersomnia,
- narcolepsy,
- periodic limb movement disorder,
- restless legs syndrome,
- sleep apnea,
- sleep state misperception.
- Extrinsic sleep disorders – 13 disorders recognized, including
- alcohol-dependent sleep disorder,
- food allergy insomnia,
- inadequate sleep routine.
- Circadian rhythm sleep disorders, both intrinsic and extrinsic – 6 disorders recognized, including
- advanced sleep phase syndrome,
- delayed sleep phase syndrome,
- jetlag,
- shift work sleep disorder.
Excessive daytime sleepiness (EDS) is characterized by persistent sleepiness and often a general lack of energy, even during the day after apparently adequate or even prolonged nighttime sleep. EDS can be considered as a broad condition encompassing several sleep disorders where increased sleep is a symptom, or as a symptom of another underlying disorder like narcolepsy, sleep apnea or a circadian rhythm sleep disorder.
Some persons with EDS, including those with hypersomnias like narcolepsy and idiopathic hypersomnia, are compelled to nap repeatedly during the day; fighting off increasingly strong urges to sleep during inappropriate times such as while driving, while at work, during a meal, or in conversations. As the compulsion to sleep intensifies, the ability to complete tasks sharply diminishes, often mimicking the appearance of intoxication. During occasional unique and/or stimulating circumstances, a person with EDS can sometimes remain animated, awake and alert, for brief or extended periods of time. EDS can affect the ability to function in family, social, occupational, or other settings. A proper diagnosis of the underlying cause and ultimately treatment of symptoms and/or the underlying cause can help mitigate such complications.
Pure autonomic failure (PAF), also known as Bradbury-Eggleston syndrome or idiopathic orthostatic hypotension, is a form of dysautonomia that first occurs in middle age or later in life; men are affected more often than women.
Over the past thirty years, several studies have found that those afflicted with NSRED all have different symptoms and behaviors specific to them, yet they also all have similar characteristics that doctors and psychologists have identified to distinguish NSRED from other combinations of sleep and eating disorders such as night eating syndrome. Winkelman says that typical behaviors for patients with NSRED include: "Partial arousals from sleep, usually within 2 to 3 hours of sleep onset, and subsequent ingestion of food in a rapid or 'out of control' manner." They also will attempt to eat bizarre amalgamations of foods and even potentially harmful substances such as glue, wood, or other toxic materials. In addition, Schenck and Mahowald noted that their patients mainly ate sweets, pastas, both hot and cold meals, improper substances such as "raw, frozen, or spoiled foods; salt or sugar sandwiches; buttered cigarettes; and odd mixtures prepared in a blender."
During the handling of this food, patients with NSRED distinguish themselves, as they are usually messy or harmful to themselves. Some eat their food with their bare hands while others attempt to eat it with utensils. This occasionally results in injuries to the person as well as other injuries. After completing their studies, Schenck and Mahowald said, "Injuries resulted from the careless cutting of food or opening of cans; consumption of scalding fluids (coffee) or solids (hot oatmeal); and frenzied running into walls, kitchen counters, and furniture." A few of the more notable symptoms of this disorder include large amounts of weight gain over short periods of time, particularly in women; irritability during the day, due to lack of restful sleep; and vivid dreams at night. It is easily distinguished from regular sleepwalking by the typical behavioral sequence consisting of "rapid, 'automatic' arising from bed, and immediate entry into the kitchen." In addition, throughout all of the studies done, doctors and psychiatrists discovered that these symptoms are invariant across weekdays, weekends, and vacations as well as the eating excursions being erratically spread throughout a sleep cycle. Most people that suffer from this disease retain no control over when they arise and consume food in their sleep. Although some have been able to restrain themselves from indulging in their unconscious appetites, some have not and must turn to alternative methods of stopping this disorder. It is important for trained physicians to recognize these symptoms in their patients as quickly as possible, so those with NSRED may be treated before they injure themselves.
The most common sleep disorders include:
- Bruxism, involuntarily grinding or clenching of the teeth while sleeping.
- Catathrenia, nocturnal groaning during prolonged exhalation.
- Delayed sleep phase disorder (DSPD), inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. Other such disorders are advanced sleep phase disorder (ASPD), non-24-hour sleep–wake disorder (non-24) in the sighted or in the blind, and irregular sleep wake rhythm, all much less common than DSPD, as well as the situational shift work sleep disorder.
- Hypopnea syndrome, abnormally shallow breathing or slow respiratory rate while sleeping.
- Idiopathic hypersomnia, a primary, neurologic cause of long-sleeping, sharing many similarities with narcolepsy.
- Insomnia disorder (primary insomnia), chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms. Insomnia can also be comorbid with or secondary to other disorders.
- Kleine–Levin syndrome, a rare disorder characterized by persistent episodic hypersomnia and cognitive or mood changes.
- Narcolepsy, including excessive daytime sleepiness (EDS), often culminating in falling asleep spontaneously but unwillingly at inappropriate times. About 70% of those who have narcolepsy also have cataplexy, a sudden weakness in the motor muscles that can result in collapse to the floor while retaining full conscious awareness.
- Night terror, "Pavor nocturnus", sleep terror disorder, an abrupt awakening from sleep with behavior consistent with terror.
- Nocturia, a frequent need to get up and urinate at night. It differs from enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties.
- Parasomnias, disruptive sleep-related events involving inappropriate actions during sleep, for example sleep walking, night-terrors and catathrenia.
- Periodic limb movement disorder (PLMD), sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. See also Hypnic jerk, which is not a disorder.
- Rapid eye movement sleep behavior disorder (RBD), acting out violent or dramatic dreams while in REM sleep, sometimes injuring bed partner or self (REM sleep disorder or RSD).
- Restless legs syndrome (RLS), an irresistible urge to move legs. RLS sufferers often also have PLMD.
- Shift work sleep disorder (SWSD), a situational circadian rhythm sleep disorder. (Jet lag was previously included as a situational circadian rhythm sleep disorder, but it doesn't appear in DSM-5 (see Diagnostic and Statistical Manual of Mental Disorders)).
- Sleep apnea, obstructive sleep apnea, obstruction of the airway during sleep, causing lack of sufficient deep sleep, often accompanied by snoring. Other forms of sleep apnea are less common. When air is blocked from entering into the lungs, the individual unconsciously gasps for air and sleep is disturbed. Stops of breathing of at least ten seconds, 30 times within seven hours of sleep, classifies as apnea. Other forms of sleep apnea include central sleep apnea and sleep-related hypoventilation.
- Sleep paralysis, characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of narcolepsy.
- Sleepwalking or "somnambulism", engaging in activities normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject.
- Somniphobia, one cause of sleep deprivation, a dread/ fear of falling asleep or going to bed. Signs of the illness include anxiety and panic attacks before and during attempts to sleep.
REM sleep behavior disorder or RBD is the most common REM sleep parasomnia in which muscle atonia is absent. This allows the individual to act out their dreams and may result in repeated injury—bruises, lacerations, and fractures—to themselves or others. Patients may take self-protection measures by tethering themselves to bed, using pillow barricades, or sleeping in an empty room on a mattress.
Demographically, 90% of RBD patients are males, and most are older than 50 years of age.
Typical clinical features of REM sleep behavior disorder are:
- Male gender predilection
- Mean age of onset 50–65 years (range 20–80 years)
- Vocalisation, screaming, swearing that may be associated with dreams
- Motor activity, simple or complex, that may result in injury to patient or bed-partner
- Occurrence usually in latter half of sleep period (REM sleep)
- May be associated with neurodegenerative disease
Acute RBD, occurs mostly as a result of a side-effect in prescribed medication—usually antidepressants. But if not then 55% of the time the cause is unknown the other 45% the cause is associated with alcohol.
Chronic RBD is idiopathic, meaning of unknown origin, or associated with neurological disorders. There is a growing association of chronic RBD with neurodegenerative disorders—Parkinson's disease, multiple system atrophy (MSA), or dementia—as an early indicator of these conditions by as much as 10 years.
Patients with narcolepsy also are more likely to develop RBD.
Both of these conditions (RLS and PLM) are classified as dyssomnias according to the DSM-IV.
Akathisia may range in intensity from a sense of disquiet or anxiety, to excruciating discomfort, particularly in the knees. Patients typically pace for hours because the pressure on the knees reduces the discomfort somewhat; once their knees and legs become fatigued and they are unable to continue pacing, they sit or lie down, although this does not relieve the akathisia. When misdiagnosis occurs in antipsychotic neuroleptic-induced akathisia, more antipsychotic may be prescribed, potentially worsening the symptoms. Neuro-psychologist Dennis Staker had drug-induced akathisia for two days. His description of his experience was this: "It was the worst feeling I have ever had in my entire life. I wouldn't wish it on my worst enemy." Many patients describe symptoms of neuropathic pain akin to fibromyalgia and restless legs syndrome. In Han et al. (2013), the authors describe restless legs syndrome's relation to akathisia, "Some researchers regard RLS as a 'focal akathisia' [in the legs]." Although these side effects disappear quickly and remarkably when the medication is stopped, tardive, or late-persisting akathisia may go on long after the offending drug is discontinued, sometimes for a period of years.
Healy, et al. (2006), described the following regarding akathisia: tension, insomnia, a sense of discomfort, motor restlessness, and marked anxiety and panic. Increased labile affect can result, such as weepiness.
Jack Henry Abbott (1981) describes the sensation:
In addition, not all observable restless motion is akathisia. For example, mania, agitated depression, and Attention Deficit Hyperactivity Disorder may look like akathisia, but the movements feel voluntary and not due to restlessness.
Parasomnia disorders are classified into the following categories:
- arousal disorders
- sleep-wake transition disorders
- parasomnias associated with REM sleep
Nocturnal sleep-related eating disorder (NSRED), also known as sleep-related eating disorder (SRED), sleep eating, or somnambulistic eating, is a combination of a parasomnia and an eating disorder. It is described as being in a specific category within somnambulism or a state of sleepwalking that includes behaviors connected to a person's conscious wishes or wants. Thus many times NSRED is a person's fulfilling of their conscious wants that they suppress; however, this disorder is difficult to distinguish from other similar types of disorders.
NSRED is closely related to night eating syndrome (NES) except for the fact that those suffering from NES are completely awake and aware of their eating and bingeing at night while those suffering from NSRED are sleeping and unaware of what they are doing. NES is primarily considered an eating disorder while NSRED is primarily considered a parasomnia; however, both are a combination of parasomnia and eating disorders since those suffering from NES usually have insomnia or difficulty sleeping and those suffering from NSRED experience symptoms similar to binge eating. Some even argue over whether NES and NSRED are the same or distinct disorders. Even though there have been debates over these two disorders, specialists have examined them to try to determine the differences. Dr. J. Winkelman noted several features of the two disorders that were similar, but he gave one important factor that make these disorders different. In his article "Sleep-Related Eating Disorder and Night Eating Syndrome: Sleep Disorders, Eating Disorders, Or both", Winkelman said, "Both [disorders] involve nearly nightly binging at multiple nocturnal awakenings, defined as excess calorie intake or loss of control over consumption." He also reported that both disorders have a common occurrence of approximately one to five percent of adults, have been predominantly found in women, with a young adult onset, have a chronic course, have a primary morbidity of weight gain, sleep disruption, and shame over loss of control over food intake, have familial bases, and have been observed to have comorbid depression and daytime eating disorders. However, Winkelman said, "The most prominent cited distinction between NES and SRED is the level of consciousness during nighttime eating episodes." Therefore, these two disorders are extremely similar with only one distinction between them. Doctors and psychologists have difficulty differentiating between NES and NSRED, but the distinction of a person's level of consciousness is what doctors chiefly rely on to make a diagnosis. One mistake that is often made is the misdiagnosis of NSRED for NES. However, even though NSRED is not a commonly known and diagnosed disease, many people suffer from it in differing ways while doctors work to find a treatment that works for everyone; several studies have been done on NSRED, such as the one conducted by Schenck and Mahowald. These studies, in turn, provide the basic information on this disorder including the symptoms, behaviors, and possible treatments that doctors are using today.
Under DSM-5 criteria, there are 11 diagnostic groups that comprise sleep-wake disorders. These include, Insomnia disorder, Hypersomnolence disorder, Narcolepsy, Obstructive sleep apnea hypopnea, Central sleep apnea, Sleep-related hypoventilation, Circadian rhythm sleep-wake disorders, Non–rapid eye movement (NREM) sleep arousal disorders, Nightmare disorder, Rapid eye movement (REM) sleep behavior disorder, Restless legs syndrome, and substance-medication-induced sleep disorder. Sexsomnia is classified under NREM arousal parasomnia.
A sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for some sleep disorders.
Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a person suffers from difficulty falling asleep and/or staying asleep with no obvious cause, it is referred to as insomnia.
Sleep disorders are broadly classified into dyssomnias, parasomnias, circadian rhythm sleep disorders involving the timing of sleep, and other disorders including ones caused by medical or psychological conditions and sleeping sickness.
Some common sleep disorders include sleep apnea (stops in breathing during sleep), narcolepsy and hypersomnia (excessive sleepiness at inappropriate times), cataplexy (sudden and transient loss of muscle tone while awake), and sleeping sickness (disruption of sleep cycle due to infection). Other disorders include sleepwalking, night terrors and bed wetting. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.
Symptoms vary according to the kind of dystonia involved. In most cases, dystonia tends to lead to abnormal posturing, in particular on movement. Many sufferers have continuous pain, cramping, and relentless muscle spasms due to involuntary muscle movements. Other motor symptoms are possible including lip smacking.
Early symptoms may include loss of precision muscle coordination (sometimes first manifested in declining penmanship, frequent small injuries to the hands, and dropped items), cramping pain with sustained use, and trembling. Significant muscle pain and cramping may result from very minor exertions like holding a book and turning pages. It may become difficult to find a comfortable position for arms and legs with even the minor exertions associated with holding arms crossed causing significant pain similar to restless leg syndrome. Affected persons may notice trembling in the diaphragm while breathing, or the need to place hands in pockets, under legs while sitting or under pillows while sleeping to keep them still and to reduce pain. Trembling in the jaw may be felt and heard while lying down, and the constant movement to avoid pain may result in the grinding and wearing down of teeth, or symptoms similar to temporomandibular joint disorder. The voice may crack frequently or become harsh, triggering frequent throat clearing. Swallowing can become difficult and accompanied by painful cramping.
Electrical sensors (EMG) inserted into affected muscle groups, while painful, can provide a definitive diagnosis by showing pulsating nerve signals being transmitted to the muscles even when they are at rest. The brain appears to signal portions of fibers within the affected muscle groups at a firing speed of about 10 Hz causing them to pulsate, tremble and contort. When called upon to perform an intentional activity, the muscles fatigue very quickly and some portions of the muscle groups do not respond (causing weakness) while other portions over-respond or become rigid (causing micro-tears under load). The symptoms worsen significantly with use, especially in the case of focal dystonia, and a "mirror effect" is often observed in other body parts: Use of the right hand may cause pain and cramping in that hand as well as in the other hand and legs that were not being used. Stress, anxiety, lack of sleep, sustained use and cold temperatures can worsen symptoms.
Direct symptoms may be accompanied by secondary effects of the continuous muscle and brain activity, including disturbed sleep patterns, exhaustion, mood swings, mental stress, difficulty concentrating, blurred vision, digestive problems, and short temper. People with dystonia may also become depressed and find great difficulty adapting their activities and livelihood to a progressing disability. Side-effects from treatment and medications can also present challenges in normal activities.
In some cases, symptoms may progress and then plateau for years, or stop progressing entirely. The progression may be delayed by treatment or adaptive lifestyle changes, while forced continued use may make symptoms progress more rapidly. In others, the symptoms may progress to total disability, making some of the more risky forms of treatment worth considering. In some cases with patients who already have dystonia, a subsequent tramatic injury or the effects of general anethesia during an unrelated surgery can cause the symptoms to progress rapidly.
An accurate diagnosis may be difficult because of the way the disorder manifests itself. Sufferers may be diagnosed as having similar and perhaps related disorders including Parkinson's disease, essential tremor, carpal tunnel syndrome, TMD, Tourette's syndrome, conversion disorder or other neuromuscular movement disorders. It has been found that the prevalence of dystonia is high in individuals with Huntington's disease, where the most common clinical presentations are internal shoulder rotation, sustained fist clenching, knee flexion, and foot inversion. Risk factors for increased dystonia in patients with Huntington's disease include long disease duration and use of antidopaminergic medication.
Symptoms of insomnia:
- difficulty falling asleep, including difficulty finding a comfortable sleeping position
- waking during the night and being unable to return to sleep
- feeling unrefreshed upon waking
- daytime sleepiness, irritability or anxiety
Sleep-onset insomnia is difficulty falling asleep at the beginning of the night, often a symptom of anxiety disorders. Delayed sleep phase disorder can be misdiagnosed as insomnia, as sleep onset is delayed to much later than normal while awakening spills over into daylight hours.
It is common for patients who have difficulty falling asleep to also have nocturnal awakenings with difficulty returning to sleep. Two-thirds of these patients wake up in the middle of the night, with more than half having trouble falling back to sleep after a middle-of-the-night awakening.
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of depression.
Poor sleep quality can occur as a result of, for example, restless legs, sleep apnea or major depression. Poor sleep quality is caused by the individual not reaching stage 3 or delta sleep which has restorative properties.
Major depression leads to alterations in the function of the hypothalamic-pituitary-adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.