Nails
Nails support and protect the sensitive tips of fingers and toes. Fingernails also help us to pick up objects, scratch an itch or untie a knot. Common causes of nail problems include injury, infection and skin diseases such as psoriasis.
Fingernails grow about three times faster than toenails.
Nail anatomy
Nails are made from a protein called keratin. This is the same protein that makes up skin and hair. Nails grow from cells that multiply within the base of the nail, then layer on top of each other and harden. This is called keratinisation.
The structures of the nail include:
Nail matrix – where nail growth occurs, tucked under the skin behind the nail.
Nail plate – the visible part of the nail.
Nail bed – the nail plate sits on top of the nail bed. The nail plate looks pink because of the blood-rich capillaries in the nail bed.
Lunula – the ‘crescent moon’ shape that is sometimes visible at the base of the nail plate.
Nail folds – the slender skin grooves that hold the nail plate in place.
Cuticle – the flap of thin tissue over the base of the nail plate.
Nail conditions
Some conditions that affect the nail include:
Discolouration – causes typically include medications such as antibiotics or antimalarial drugs, nail varnish, certain infections, injury to the nail bed, staining from cigarette smoking and melanoma.
Thickened nails – toenails are more commonly affected than fingernails. Causes include neglect, injury, poor circulation, arthritis in the toes, altered gait (walking) patterns and ill-fitting shoes. The elderly are at increased risk.
Ridged nails – typically caused by medical conditions such as rheumatoid arthritis or peripheral vascular disease.
Infection – can be bacterial or fungal. Examples include onychomycosis and paronychia.
Skin diseases – such as psoriasis, lichen planus or lupus can affect the nail. Abnormalities may include pits, grooves or crumbling nails.
Ingrown toenail – the nail grows into the skin. Causes include ill-fitting shoes and cutting the nails incorrectly.
Unusual nail shape – such as the nails becoming concave. Causes include iron deficiency.
Nail tumours – including squamous cell carcinoma, usually caused by infection with the human papilloma virus (HPV). Melanoma can also affect the nail.
Splinter haemorrhages – thin lines of blood running along the nail bed. Causes include injury, severe anaemia, infective endocarditis (inflammation of the inner tissue of the heart) and certain diseases such as rheumatoid arthritis.
Congenital disorders – conditions that are present at birth such as nail-patella syndrome, where the nails are improperly formed or missing.
Nail problems
Nail problems affect people of all ages. Common causes of nail problems include trauma, infection and various skin diseases, such as eczema and psoriasis. Diet is generally not responsible for abnormal nail changes, unless the person is suffering from severe malnutrition. Some nail conditions need professional treatment from either a doctor or a dermatologist, while others respond to simple self-help techniques and minor lifestyle changes. When in doubt, seek medical advice.
The structure of the nail
Nails are made from a protein called keratin. The strength, thickness and growth rate of nails are inherited characteristics. The structures of the nail include:
Nail plate - the visible part of the nail.
Nail bed - the nail plate sits on top of the nail bed.
Nail folds - the nail plate rests inside slender skin grooves.
Cuticle - a thin flap of tissue that lies over the base of the nail.
Nail matrix - the site of nail growth, tucked under the skin.
Common conditions
Some of the more common conditions that affect nails include:
Discolouration
Thickened nails
Ridged nails
Splitting nails
Lifted nail plate
Bacterial infection
Fungal infection
Trauma
Skin diseases
Other diseases
Advancing age.
Nail discolouration
The healthy nail plate is pink, and the nail looks white as it grows off the nail bed. Nails can be discoloured by various factors including:
Nail polish
Some medications, including antibiotics and anti-malarial drugs, and some of the drugs used in chemotherapy
Nicotine from cigarette smoking
Hair colouring agents.
Thickened nails
This condition most commonly affects the toenails. Causes of thickened nails include:
Fungal infection
Psoriasis.
Ridged nails
Ridges running either the length or width of the nail plate can have a number of causes, including:
Age-related changes
Trauma to the nail matrix
Overzealous attention to the cuticles
Fever or illness
Eczema
Rheumatoid arthritis
Lichen planus infection.
Splitting nails
This condition is characterised by the splitting or layering of the nail plate as it grows off the nail bed. Common causes include:
Having constantly wet hands, especially while using soap and washing detergents.
Frequently using and removing nail polish.
Continuous mild trauma such as habitual finger-tapping or using the nails as tools (to pick between the teeth, for example).
Lifted nail plate
The healthy nail plate adheres to the underlying nail bed and appears pink. The nail looks white as it grows off the nail bed. If the nail plate lifts off the nail bed, it will appear white. Common causes include:
Overzealous cleaning under the fingernails
Nail polishes that contain hardening chemicals such as formalin
Rough removal of artificial nails
Psoriasis
Tinea (a fungal infection).
Bacterial infection
The Staphylococcus aureus bacterium is a common cause of bacterial infection of the nail. Typically, the infection first takes hold in the fold of skin at the base of the nail (proximal nail fold). Without treatment, the infection can worsen to include inflammation and pus. It is often associated with candida infection, particularly when it becomes chronic. Activities that predispose a person to a bacterial nail infection include:
Having constantly wet hands
Overzealous attention to the cuticles
Severe nail biting, which can expose underlying tissues to infection
Eczema around the fingernails.
Trauma
A blow to the nail or compulsive nail biting can cause a range of problems, including:
Bruising of the nail bed
Lifting of the nail plate
Loss of the nail plate
Nail ridges
Subsequent deformed growth of the nail plate, if the nail matrix is injured.
Feet - toenail problems
Toenail problems can affect people of all ages, but tend to be more common with advancing age. Causes of nail problems include trauma, ill-fitting shoes, poor circulation, poor nerve supply and infection. Problems with toenails can be successfully treated by a podiatrist.
Ingrown toenail
One of the most common problems treated by podiatrists are ingrown toenails. The big toe is particularly prone to this painful condition.
Causes may include:
Incorrect trimming technique
Trauma (such as stubbing your toe)
Nails that naturally curve sharply on the sides and dig into the skin
Wearing tight shoes.
Treatment from a podiatrist depends on the severity of the injury, but may include removing the ingrown nail section using a local anaesthetic.
Suggestions to prevent an ingrown toenail include:
Trim nails straight across rather than rounding off the edges.
Wear comfortable, well-fitting shoes that don’t press on the toes.
Fungal infections
Symptoms of a nail with fungal infection include discolouration and thickening of the nail, and the separation of the nail from the nail bed. There may also be a white, yellow or green, smelly discharge. Without treatment, the nail bed itself can become infected.
Treatment for fungal infection includes:
Use of antifungal preparations applied topically (directly to the nail) or taken orally (by mouth)
Professional trimming, shaping and care of the nail by your podiatrist.
Inflammation of the skin alongside the nail
The skin lying alongside the nail can become infected with bacteria, typically Staphylococcus aureus. This infection is called paronychia.
Symptoms may include pain, redness and swelling around the cuticle and yellow–green discharge.
Treatment for paronychia includes:
Keeping the feet as dry as possible
Use of barrier creams, antiseptic lotions and antifungal preparations
Antibiotic therapy (in acute cases).
Chronic paronychia (where the condition is present for a long time) is more difficult to treat. In chronic paronychia, the nail may distort and become discoloured, and the skin may lift at the site of infection. Sometimes, the inflammation spreads from one nail to another. A range of micro-organisms working together are responsible for chronic paronychia.
Deformed or brittle nails
A violent toe-stubbing, dropping a heavy object on the toe or some other trauma can injure the nail bed and cause the nail to grow in deformed ways. The nail may be thickened or ridged. It is a normal aging process for nails to thicken.
Certain skin conditions may also affect the nails, causing thickening (for example, psoriasis). Deformed or brittle nails can benefit from regular professional attention. Trimming, shaping and nail care from your podiatrist can improve the health of your nails and help diagnose and treat more serious nail concerns
Tinea
Tinea is a contagious fungal infection that can infect the skin. The most commonly affected areas include the feet, groin, scalp and beneath the breasts. Tinea can be spread by skin-to-skin contact or indirectly through towels, clothes or even floors. Tinea is also known as ringworm, which is a misleading name since no worm is involved.
All fungi need warm, moist environments and tinea is no exception. This is why the hottest, most sweat-prone areas of the body are the likely targets of a tinea infection. Communal showers and locker rooms are typical places where infection may be spread.
Treatment includes antifungal medication, antiperspirants and good hygiene.
Types of tinea
Tinea infections are known by specific names, depending on the part of the body that is affected. The most common types of tinea include:
Athlete’s foot – tinea of the foot, known as tinea pedis.
Jock itch – tinea of the groin, known as tinea cruris.
Ringworm of the scalp – tinea of the head, known as tinea capitis (mainly affects children).
Ringworm of the body – tinea of the body, known as tinea corporis.
Nail infection (onychomycosis) – tinea of the toe or finger nails, known as tinea unguium.
Symptoms
The symptoms can include:
Itching and stinging
Red scaly rash that is shaped like a ring (annular)
Cracking, splitting and peeling in the toe web spaces
Blisters
Yellow or white discoloration of the nails
Bald spots on the scalp.
How to avoid infection
Overheating and perspiration contribute to tinea infections. Suggestions to avoid tinea infection include:
After washing, dry the skin thoroughly, particularly between the toes and within skin folds.
Expose the skin to the air as much as possible.
Wear cotton socks instead of synthetics.
Use antiperspirants to control excessive perspiration (sweating).
Wear thongs to swimming pools, locker rooms, gyms and other communal areas.
Treating an infection
Tinea infections respond well to antifungal creams. Some infections are harder to shift and might also require an antifungal medication in the form of a tablet.
Preventing the spread of tinea
It is important to remember that tinea is contagious. Suggestions on how to prevent the spread of infection to others include:
Treat tinea infections with antifungal cream.
Wash your hands after touching infected areas.
Do not share towels.
Do not walk around barefoot if you have tinea pedis (tinea of the feet).
Clean the shower, bath and bathroom floor after use.
Self-help strategies
You can reduce the risk of nail problems in a variety of ways, including:
Practise good personal hygiene.
Wear protective gloves for wet jobs such as washing the dishes.
Avoid harsh chemicals such as strong soaps and detergents.
Avoid or limit the handling of chemicals such as hair dyes.
Take care with the use of nail polish.
Don’t clean under your nails too frequently or too aggressively.
When giving yourself a home manicure, do not push back the cuticles.
Resist the urge to bite or tear off hangnails - use nail clippers.
Don’t bite your nails.
Remove artificial nails carefully and according to the manufacturer’s instructions.
Don’t smoke.
Moisturise the hands frequently, particularly after washing them.
Remember to rub the moisturiser over your nails and cuticles too.
Treat any sign of eczema on your hands promptly.
To protect yourself from fungal infections, don’t share towels, always dry yourself thoroughly after bathing (particularly between the toes), and wear thongs in communal bathing areas such as the local gym or swimming pool.
Make sure your shoes are well-fitting and have plenty of room for air movement.
Professional diagnosis and treatment
Any abnormal changes to your nails should be medically investigated. See your doctor for treatment or possible referral to a dermatologist. If the cause of your nail problem is not immediately apparent, nail clippings and scrapings from beneath the nail may be taken for laboratory analysis. Fingernail infections usually respond faster to treatment than toenail infections. Depending on the cause, treatment options may include:
Antibiotics for bacterial infections.
Anti-fungal preparations, mainly oral tablets, for fungal infections in the nails.
Hair
Hair is actually a part of the skin that has its own specialised function. The human body is covered in hair, except on the palms of the hands, soles of the feet, genitals, eyelids and lips. Hair keeps us warm, and protects sensitive areas, such as the nose and eyes, from dust. The colour, curl, length, thickness and amount of hair depend on genetic factors.
Normal hair growth
Human hair grows from a root, which is the only living part of the hair. Hair gets longer by multiplying new cells in the root. As the hair grows, the cells die and harden to form the hair shaft. This is called keratinisation, because hair is made of a protein called keratin. This is the same protein that makes up skin and nails. The tough outer layer of the hair shaft is called the cuticle. Beneath the cuticle is the cortex, which makes up the bulk of the hair shaft. At the core is the soft medulla.
Hair follicles are pouch-like tubes of skin cells that contain the hair root. At the bottom of the follicle is the papilla, which supplies oxygen and nutrients to the root through a tiny artery. Typically, an individual hair grows about half a centimetre every month. Hair grows in phases, with around one in ten scalp hairs ‘resting’ at any given time.
Hair disorders
The broad categories of hair disorders include:
Hair loss (alopecia)
Excess hair (hirsutism)
Hair infections
Hair shaft disorders.
Excess hair (hirsutism)
In women, hirsutism is the growth of thick, dark hair in typically ‘male’ areas of the body such as the face, chest and back. A common cause is polycystic ovarian syndrome (PCOS). The causes of PCOS are unknown. In some cases, it seems to run in the family. For other women, the condition only occurs when they are overweight.
Hair infections
Hair infections are usually contagious, which means the infection can pass from one person to another. Hair loss is the typical result. Some examples of hair infections include:
Ringworm – this fungal infection of the scalp typically starts as a small circle of red, itchy and scaly skin. As this ring grows, the hairs within its circumference snap off close to the scalp.
Folliculitis – this bacterial infection of the hair follicles can cause temporary or permanent hair loss, depending on the severity and duration of the infection.
Demodex folliculorum infection – this parasite likes to live in the follicles of the scalp and face. A severe infection can cause irritation and inflammation.
Piedra – this fungal disease causes hard nodules to form along the hair shaft. The hair tends to snap off at the nodules.
Hair shaft disorders
Hair shaft disorders are caused by the inheritance of faulty genes, which result in either hair loss or unmanageable hair. Examples include:
Trichothiodystrophy – the hair shaft is brittle because of inadequate elements and proteins such as sulphur and cystine.
Pili torti – causes patches of hair loss and hair stubble.
Menkes syndrome – the inability to properly metabolise copper causes a range of problems including brittle and unpigmented hair.
Trichorrhexis nodosa – a split in the cortex frays and weakens the hair, causing it to split and break off.
Trichorrhexis invaginata – also known as ‘bamboo hair’. The hair shaft has abnormal nodules. Breakages occur at these weak points.
Monilethrix – nodules cause hair breakages. Usually, monilethrix only affects the scalp.
Woolly hair – frizzy, tightly curled hair on a person of non-African descent.
Uncombable hair syndrome – typically, the hair is silvery-blonde, slow to grow, dry and unusually stiff.
Marie Unna hypotrichosis – the child is born without scalp hair, then grows coarse hair until pre-puberty when the hair falls out.
Hair loss
Hair loss (also known as alopecia) can ‘just happen’ or it may be linked to some medical conditions or use of medicines. It can be patchy or widespread, and may range from mild to severe.
Male pattern baldness (androgenic alopecia) is the most common cause of hair loss and is the result of genetic and hormonal factors. Hereditary baldness is so common that many people think it is a normal part of the ageing process.
Many men and women will be affected by hair loss at some stage in their lives. For most people, hair loss is mild and occurs later in life. However, when hair loss is premature or severe, it can cause distress. A range of treatments is available to slow or reduce hair loss and stimulate partial regrowth.
How hair grows
The human body is completely covered with hair follicles, except on the palms of the hands, soles of the feet and lips. Hair follicles are pouch-like tubes of skin cells that contain the hair root. Most follicles are tiny, and many of the hairs they produce do not grow long enough to stick out from the pore.
Hair is made from a protein called keratin. The only living part of the hair is the root (sometimes known as the bulb), which is anchored to the base of the follicle. The follicle supplies oxygen and nutrients to the root, and lubricates the hair shaft with an oily substance called sebum.
Hair is in a constant cycle of growth, rest and renewal – it is natural to lose some hair each day. Hair grows in phases. The colour, curl, length, thickness and amount of hair depend on genetic factors.
Causes of hair loss
There are many possible causes of hair loss. Some result in temporary hair loss (known as telogen effluvium), while others may have longer-term effects. Breaking or damaging the hair shaft has no effect at all on the health of the hair root.
Some causes of hair loss include:
Severe illness, major surgery or high fever, which may lead to a period of excess hair shedding
Hormonal changes resulting from thyroid disease, childbirth or use of the birth control pill
Alopecia areata, an autoimmune disorder
Medications such as those used in cancer chemotherapy or oral retinoids (powerful drugs used to treat skin conditions)
Nervous habits such as continual hair pulling or scalp rubbing
Rough handling – brushing too vigorously, tight rolling of hair curlers
Overbleaching, or the use of harsh dyes and chemicals, which may cause split ends
Burns or injuries
Tinea capitis (ringworm of the scalp)
Certain skin diseases such as lichen planus or lupus.
Genetic factors in hair loss
Identical twins lose hair at the same age, at the same rate and in the same pattern. This indicates that genetic factors are more important than environmental factors in causing hair loss.
Stress, diet, wearing hats, frequent washing, cigarettes and alcohol use are exaggerated as causes of hair loss.
Male pattern baldness (androgenic alopecia)
While there are a number of treatments available for male pattern baldness, there is no cure. Treatments include minoxidil lotion and finasteride tablets, which are available on prescription. Cosmetic options include camouflage sprays, wigs and hair transplant surgery.
Hair loss in women (androgenetic alopecia)
Hair loss in women produces scattered thinning over the top of the scalp rather than a bald spot. Minor patterned hair loss occurs in over 55 per cent of women as they age, but only about 20 per cent of women develop moderate or severe hair loss.
A number of treatments are available for female pattern hair loss, including topical minoxidil lotion (not recommended for pregnant and breastfeeding women) and tablets such as spironolactone, which have antiandrogen properties (they lower the levels of male hormones). These are available on prescription and require medical supervision.
Treatment for hair loss
Treatment aims to slow or reduce hair loss, stimulate partial regrowth or replace damaged hair. Surgical treatment involving hair transplantation is available from hair transplant surgeons and can be helpful for some men with advanced balding.
Non-surgical treatments include lotions and tablets. These generally need to be used continuously to maintain regrowth. If treatment is stopped, regrowth ceases and hair loss will start again. Cosmetic options include wigs and hairpieces.
A number of other treatments have been suggested for hair loss including massage, vitamin supplements, herbal remedies (such as saw palmetto), zinc, amino acids, hair lotions and tonics. None of these has been shown to promote hair growth or prevent hair loss.
There is also no scientific evidence that the use of lasers is effective. If unsure, consult with your doctor before starting treatment.
Minoxidil
Minoxidil lotion has been available in Australia since the 1970s. A number of different brands are available from pharmacies without a prescription. Drops are applied to the scalp morning and night and rubbed in. There is also a new foam preparation that appears to be easier to use and just as effective. Hair regrowth generally takes six months to appear. Patients considering taking minoxidil should tell their pharmacist if they are taking any other medicines, especially high blood pressure medication.
Minoxidil is not recommended for pregnant and breastfeeding women.
Finasteride
Finasteride is the active ingredient in the hair loss treatment Propecia, which has been available in Australia since the late 1990s. One tablet a day will arrest further hair loss in over 90 per cent of men and stimulate partial hair regrowth in over two thirds. Regrowth may be visible at six months, but can take up to two years to be visible. Side effects are uncommon, although Propecia does require a prescription from your doctor.
Finasteride is not recommended for women.
Spironolactone
This medication has been widely used to treat high blood pressure and fluid retention in Australia since the 1960s. It blocks the effect of androgen hormones. In women, androgens can cause oily skin, acne, unwanted facial and body hair, and scalp hair loss. Spironolactone can be used to treat all of these conditions, but it requires a prescription from your doctor.
Spironolactone is not recommended for men. Pregnant and breastfeeding women should not take spironolactone.
Cyproterone acetate
This medication was also developed in the 1960s. It blocks the effect of androgen hormones. It is also a weak progestogen and is used as a component of some oral contraceptives (the pill). Cyproterone acetate can also be used to treat acne, unwanted facial and body hair, and hereditary hair loss in women. Cyproterone acetate requires a prescription from your doctor.
Cyproterone acetate is not recommended as a treatment for hair loss in men.
Hair transplantation surgery
Hair transplantation is a surgical procedure for the treatment of hair loss that first became popular in the 1950s. Originally, large plugs of hair were used, which sometimes led to unsatisfactory and unnatural results.
Currently, very small mini- and micro-plugs of skin, containing one to five hairs, are used. Unlike the original large plugs, this modern technique does not produce very thick or dense hair growth. It appears more natural and, in many cases, is undetectable as a transplant.
Types of hair loss that respond best to hair transplantation include:
Androgenetic hair loss in men – this is the most common type of baldness that can be helped by hair transplantation
Hair loss due to accidents and operations.
Hair plugs are taken from the back or sides of the scalp where the hair is less likely to fall out. These plugs are transferred to the bald areas and placed in such a way that they receive adequate blood flow during the healing process. The transplant session may take several hours.
One to three months later, more grafts can be added. Several treatments are required to give a progressive increase in the amount of hair. Hair will regrow in the area from which the hair plug was taken for transplantation.
A sedative is usually given prior to the procedure. Local anaesthetic is also used at the hair removal (donor) and recipient sites. As the anaesthetic wears off, you may notice some discomfort. This can be eased with simple pain-killing medications.
Complications of hair transplantation
Possible complications of hair transplant surgery include:
Infection – this can occur because the skin is broken to perform the procedure. It can be treated with antibiotics.
Bleeding – this is usually controlled through careful postoperative care.
Scarring – approximately 11 per cent of the population have a tendency to scar.
Temporary, operation-induced hair loss – known as telogen effluvium, can occur with hair transplantation as well as some other operations. It occurs in approximately five per cent of patients.
Unacceptable cosmetic results – scarring and unacceptable cosmetic results are more common when hair transplants are carried out by inexperienced practitioners.
Seek advice from a specialist dermatologist
Many hair clinics offer hair transplantation. However, specialist dermatologists are best qualified to properly advise about this surgery, as they generally have the most knowledge about hair in health and disease.
Skin
The skin is the largest organ of the human body. It is soft, to allow movement, but still tough enough to resist breaking or tearing. It varies in texture and thickness from one part of the body to the next. For instance, the skin on the lips and eyelids is very thin and delicate, while skin on the soles of the feet is thicker and harder. The skin is a good indicator of general health. If someone is sick, it often shows in their skin.
A range of functions
Skin is one of our most versatile organs. Some of the different functions of skin include:
A waterproof wrapping for the entire body
The first line of defence against bacteria and other organisms
A cooling system via sweat
A sense organ that gives us information about pain, pleasure, temperature and pressure.
The epidermis
The skin you can see is called the epidermis. This protects the more delicate inner layers. The epidermis is made up of several ‘sheets’ of cells. The bottom sheet is where new epidermal cells are made. As old, dead skin cells are sloughed off the surface, new ones are pushed up to replace them. The epidermis also contains melanin, the pigment that gives skin its colour.
The dermis
Underneath the epidermis is the dermis. This is made up of elastic fibres (elastin) for suppleness and protein fibres (collagen) for strength. The dermis contains sweat glands, sebaceous glands, hair follicles, blood vessels and nerves.
Glands and blood vessels
The dermis is well supplied with blood vessels. In hot weather or after exercise, these blood vessels expand, bringing body heat to the skin surface. Perspiration floods out of sweat glands and evaporates from the skin, taking the heat along with it. If the temperature is cold, these blood vessels in the dermis contract, which helps to cut down on heat loss. Sebaceous glands in the dermis secrete sebum to lubricate the skin.
Hair and nails
Our lack of a complete cover of body hair makes human skin very different from the skin of any other animal. Hair is made up of a protein called keratin. The amount of hair on the body varies from place to place. Hairless sites include the lips, palms and soles of the feet. The hairiest sites include the scalp, pubis and underarms in both sexes, and the face and throat in men. Nails are made from skin cells but the only live parts are the nail bed and the nail matrix just behind the cuticle. The nail itself is made of dead cells.
Nerves
Both the dermis and epidermis have nerve endings. These transmit information on temperature, sensation (pleasure or pain) and pressure. Some areas have more of these nerves than others, like the fingertips for example.
Common problems
Some common skin problems include:
Acne - caused by hormones
Dermatitis - inflammation of the skin, with many different triggers
Fungal infections - like tinea (athlete’s foot)
Skin cancer - from long term exposure to the sun’s UV rays
Sunburn - a radiation burn from the sun’s UV rays
Warts - caused by a virus.
Healthy ageing - the skin
Skin is the first body part to show age. While age-related changes are inevitable, they are not universally embraced. A desire for younger looking skin can be satisfied with healthy lifestyle choices and good skin care.
There is a range of medical and surgical anti-ageing treatments available – however, these are not without risk. Before embarking on any surgical treatment you should consult with a dermatologist or plastic surgeon. Make sure you have realistic expectations of the potential benefits and understand all the potential risks, complications and side effects of the treatment.
Skin layers explained
The uppermost layer of the skin is called the epidermis. This layer contains pigment-producing cells (melanocytes) that give skin its colour. The epidermis renews itself constantly. New epidermal cells are born in the basal cell layer of the epidermis. These mature as they gradually rise to the surface where they ultimately die and are sloughed off.
Beneath the epidermis is the dermis, which contains blood and lymph vessels, nerves, sweat glands and oil glands. Hair follicles are extensions of the epidermis into the dermis. The dermis is made up of networks of elastic fibres (elastin) for suppleness and dense fibres (collagen) for strength. Finally, a layer of fatty tissue lies below the skin and gives it structure.
Signs of ageing
Some of the signs of ageing skin can include:
Thinning – the basal cell layer of the epidermis slows its rate of cell production and thins the epidermis. The dermis may become thinner. Together, these changes mean skin is more likely to crepe and wrinkle.
Sagging – older skin produces less elastin and collagen, which means it is more likely to sag and droop. Older skin is particularly vulnerable to the effects of gravity, for example, jowls along the jaw and bags under the eyes are simply skin that has yielded to gravity.
Wrinkles – reduced elastin and collagen, and the thinning of skin, mean those ‘high traffic’ areas of the face (like the eyes and mouth) are especially prone to lines and wrinkles.
Age spots – the remaining pigment cells (melanocytes) tend to increase in certain areas and cluster together, forming what’s known as age or liver spots. Areas that have been exposed to the sun, such as the backs of the hands, are particularly prone to age spots.
Dryness – older skin has fewer sweat glands and oil glands. This can make the skin more prone to dryness-related conditions, such as roughness and itching.
Broken blood vessels – blood vessels in older, thinner skin are more likely to break and bruise. They may also become permanently widened. This is commonly known as broken vessels.
Age-related skin conditions
Some skin conditions are more likely to develop as we get older. These can include:
Seborrhoeic keratosis – a type of benign skin tumour that looks like a brown wart.
Solar keratoses – spots of skin that are inflamed, scaly and dry. Common sites include the bridge of the nose, cheeks, upper lip and backs of the hands. Skin cancer (squamous cell) can develop in them, so examination by a doctor is advised.
Bowen’s disease – a type of slow-growing and scaly skin patch. It may be a pre-cancerous change. Sun exposure is thought to be a cause.
Skin cancer – including basal cell carcinoma, squamous cell carcinoma and melanoma.
Reducing your risk
Ways to reduce the signs of ageing include:
Limit sun exposure – sun exposure accelerates ageing of the skin. If you want proof, compare the skin on your hands with that on your buttocks. Wear a hat, loose fitting clothes, sunglasses and SPF15+ sunscreen when outdoors, and avoid sunbathing.
Don’t smoke – cigarette smoking promotes skin wrinkling and is thought to accelerate the damage caused by sun exposure. The action of puckering up for each drag on a cigarette increases the likelihood of wrinkles around the mouth.
Moisturise regularly – dry skin is more likely to show fine lines and wrinkles. Moisturise regularly if you have dry skin.
Care for skin gently – age-related dryness will be further exacerbated by skin irritants such as perfumed soaps, heavily chlorinated swimming pools and long hot showers. Use neutral pH balanced soaps, body washes or equivalents.
Anti-ageing treatments
There is a range of anti-ageing treatments available. However, these are not without risk and you should consult with a dermatologist or plastic surgeon to make sure you understand all the potential risks, complications and side effects of the treatment.
Some of the anti-ageing treatments offered include:
Sunscreen – daily application during the summer months is an effective way to reduce sun exposure.
Topical lotions – creams (such as tretinoin creams) are only available on prescription. These creams have been shown to visibly reduce fine lines and uneven skin colouration when used regularly. Niacinamide is available in a number of cosmetic creams and reduces uneven skin pigmentation.
Injections – for example, synthetic collagen or body fat harvested from other areas of the client’s body can be ‘piped’ along wrinkles via a small hypodermic needle.
Facial peels – chemicals are applied to the face to ‘burn off’ the top layer of skin. This removes the wrinkles and age spots and encourages faster regrowth of newer, younger-looking skin.
Botox – wrinkle-prone areas, such as around the eyes and between the eyebrows, are injected with the Botulinum toxin. The resulting paralysis prevents the muscles from wrinkling the skin.
Vascular laser – to remove broken blood vessels from the face or other areas of the skin.
Laser resurfacing – laser can be used to treat wrinkles, age spots, scars and skin growths.
Cosmetic surgery
Some cosmetic surgeries that are designed to reduce the signs of ageing include the eye lift (blepharoplasty) and face lift (meloplasty). Consult with an experienced plastic surgeon and make sure you understand all the potential risks, complications and side effects of surgery.
Moisturisers – be wary of outrageous claims
Moisturiser can keep the skin moist and reduce the appearance of fine lines. Many now contain sunscreen and some also contain skin-lightening agents. However, no product has so far been shown to ‘turn back the clock’. Consult with your doctor before buying an expensive moisturiser – you may be advised not to waste your money.
Bedbugs
Bedbugs are small, wingless insects found all over the world. They are nocturnal parasites, which means they rest during the day and are active at night. However, bedbugs are opportunistic and will bite in the day, especially if starved for some time. They feed on the blood of humans. Bedbugs prefer to hide in bedding and on mattresses where they have ready access to a source of food.
Bedbugs have highly developed mouth parts that can pierce skin. Their bite is painless. Some people do not react to the bites, but for others the bites can become itchy and swell into reddened weals.
Although bedbugs can harbour diseases in their bodies, transmission to humans is highly unlikely; they are not dangerous, unless a person is allergic to them. However, their presence can be distressing and their bites can be highly irritating.
Characteristics of the bedbug
The characteristics of a bedbug include:
Wingless
Half a centimetre long
Flat, oval-shaped body
Six legs
Light brown in colour, changing to rust-red after a meal of blood
Squat head
Large antennae
Large mouth parts (mandibles)
Complex life-cycle involving many stages of development
Ability to survive without feeding for months at a time
Susceptible to extremes of temperature.
Humans are the preferred host
Bedbugs live exclusively on blood. They prefer human blood, but will feed on other mammals if necessary.
Bedbugs are attracted to body heat and the carbon dioxide in expired air, which is how they find their host. Bedbugs commonly target the shoulders and arms.
During feeding, the bedbug’s proboscis (feeding organ) swings forward and downward to pierce the skin of the victim. Saliva (containing an anticoagulant) is then injected, which is the cause of an allergic reaction in some people. Bedbugs take around five to 10 minutes to feed. As the bedbug engorges with blood, its colouring changes from light brown to rust-red.
Common hiding spots
The living areas favoured by bedbugs include:
Mattresses, particularly along the seams
Bedding such as sheets and blankets
Beneath loosened edges of wallpaper
Between the cracks of wooden floors
In wall cracks or crevices
Carpet
Furniture, particularly in seams and cracks.
Causes of infestation
Bedbugs often hide in luggage, clothing, bedding and furniture. They are most often found in dwellings with a high rate of occupant turnover such as hotels, motels, hostels, shelters and apartment complexes.
Any household can be invaded by bedbugs, but a high standard of hygiene can discourage bedbugs from spreading widely throughout a home.
Recognising an infestation
The first indication of a bedbug infestation may be the presence of bites on family members. A thorough inspection of your premises, especially the common hiding spots, may also reveal:
The bedbugs themselves – however, due to their size, they are often hard to see
Small bloodstains from crushed bugs on sheets or mattresses
Rusty or dark spots of bug excrement on mattresses, bedding or walls
An offensive, sweet, musty odour from their scent glands, which may be detected when infestations are severe.
Symptoms of a bedbug bite
The bite of a bedbug has certain features, including:
Large weals that reduce to a red mark then gradually fade over a few days
Itchiness
Reddening of the skin
Localised swelling
Formation of blisters
Small loss of skin tissue in some cases.
Treatment of bedbug bites
Bedbugs are not known to transmit any blood-borne diseases. However, the bites can be itchy and distressing.
Suggestions to treat bedbug bites include:
Resist the urge to scratch.
Use calamine lotion or anaesthetic creams to treat the itching.
Wash the bites with antiseptic soap to reduce the risk of infection.
Apply an icepack frequently to help relieve swelling.
Take pain-killing medication if symptoms are severe.
See your doctor if the bite develops an infection.
Avoiding an infestation
In general, bedbugs enter your home in luggage or on secondhand items such as bedding and furniture. Taking care with these items, in addition to high standards of hygiene and housekeeping, should help to minimise the chance of an infestation in your home.
Controlling a bedbug infestation
High standards of hygiene and housekeeping alone are unlikely to control an infestation. However, keeping a house clean will reveal the presence of bedbugs at an early stage, making control easier and reducing the chance of widespread infestation.
Some general suggestions to eliminate bedbugs include:
Thoroughly wash, vacuum or clean all surfaces and bedding.
Wash bedding and affected clothing where possible, using hot water. Dry in a clothes drier on a hot setting.
Vacuum mattresses, seal in dark plastic and leave outside in the hot sun for as long as possible.
Steam clean carpets.
Spray common hiding spots with a surface insecticide registered to control bedbugs. Follow the label directions carefully. Do not treat bedding with insecticide.
Your local council can offer information and advice on dealing with a bedbug infestation.
Hiring a professional pest control operator
A qualified pest control operator can determine the extent of the infestation, then use registered insecticides to kill the bedbugs. Repeat visits may be necessary to ensure all bedbugs at various stages of the lifecycle have been eradicated.
Good hygiene practices, such as frequent house cleaning, should help to prevent any further infestations. However, vacuuming immediately after treatment should be avoided to ensure that the residual insecticide is not removed. For further information, consult your pest control operator
Dandruff and itching scalp
Dandruff (pityriasis capitis) is the term used to describe simple scaling of the skin on the scalp. About 50 per cent of the population suffers from dandruff. Applying simple oils (for example, bath oil) to the scalp can be useful in the treatment of dandruff.
Why dandruff occurs
The top layer of the skin is constantly being shed and renewed. Although this usually goes unnoticed when it occurs on most areas of the body, it may become more visible on the scalp as the hair traps the scaling skin.
Itching scalp
Itching scalp, with or without scaling, is a very common problem. It commonly occurs in middle-aged people, for no obvious reason. The usual response is to scratch, and this will often cause scratch marks and little crusty sores throughout the scalp. Dandruff can cause itching scalp. There are also a number of less common skin conditions that can present as itching in the scalp.
Seborrhoeic dermatitis can cause itching scalp
Seborrhoeic dermatitis is the name given to a red, itchy, scaly reaction in the scalp. It can be considered a more severe form of dandruff, except the scale is more marked and the scalp is often inflamed. It can be very itchy and can affect other parts of the body, including the face, eyebrows, beard and central chest area.
Symptoms of seborrhoeic dermatitis
Symptoms of seborrhoeic dermatitis develop gradually and may include:
Dry or greasy diffuse scaling of the scalp. This is the most usual presentation.
Yellow-red scaling on those areas of the body that are generally affected in severe disease – along the hairline, behind the hair, on the eyebrows, on the bridge of the nose, in the creases between the nose and the lips inside the ears, over the sternum (middle of the chest), on the underarms and groin hairy areas.
Why it occurs
Seborrhoeic dermatitis affects areas with high densities of large oil glands. The inflammation is caused by the body’s reaction to a yeast on the scalp and to products that break down oil produced by the oil gland.
Cradle cap
Cradle cap is a form of seborrhoeic dermatitis that occurs in newborns. It may not be the same disease as in adults. It results in a thick, yellow-crusted scalp lesion. Other symptoms can include:
Splits in the skin and behind the ears
Red facial pustules
Stubborn nappy rash.
Older children can develop thick, stubborn plaques on the scalp, measuring one to two centimetres across.
Factors that can make seborrhoeic dermatitis worse
The incidence and severity of seborrhoeic dermatitis seems to be affected by:
Other illnesses – for example, patients with neurologic disease (especially Parkinson’s disease, stroke and paralysis) or HIV may have severe seborrhoeic dermatitis
Emotional or physical stress
Genetic factors
Seasonal – seborrhoeic dermatitis is usually worse in winter.
Psoriasis can cause itching scalp
Psoriasis is a relatively common skin condition that affects about three per cent of the population. It is often confined to the scalp, elbows and knees. While seborrhoeic dermatitis tends to involve almost all the scalp, psoriasis often occurs in small, localised patches of redness with quite prominent thick scaling. Because psoriasis may only occur on the scalp, it can be mistaken for a severe case of dandruff or seborrhoeic dermatitis. Psoriasis has a genetic link – there is often a family history of the condition. It may be triggered by some form of stress.
Medicated shampoos can help dandruff and itching scalp
Regular washing of the scalp with medicated soaps may be all that is required to relieve itching scalp. The most common anti-dandruff shampoos contain one or more of the following ingredients:
Tar – shampoos containing tar have been used for years, usually for more severe scalp conditions. In the past, the scent of the tar-based shampoos made them less acceptable. However, newer preparations are well tolerated and simple to use
Selenium sulphide
Zinc pyrithione or zinc omadine
Piroctone olamine – this is the most recent addition to the medicated shampoos. It is known as a 'second generation' anti-dandruff agent. It is less toxic than zinc pyrithione and is therefore safer for family use
Antifungal agents.
How often to use medicated shampoos
How often you need to use medicated shampoos will depend on how severe your dandruff is and what treatment you are using. Always read the directions on the shampoo pack before using it. Some products are mild enough to be used every day, while others should only be used once a week. Over time, you will work out how often to use the shampoo to keep your dandruff under control.
Typically, those with a scaly scalp should be shampooing everyday. Infrequent shampooing may result in scale build-up and thus make symptoms worse. A medicated shampoo should be used about twice a week, leaving the lather in the scalp for several minutes to allow the active ingredient to work. On the other days, a mild, non-medicated shampoo can be used to prevent scale accumulation. A conditioner should always be used to prevent excessive drying from frequent washing
Wrinkles
Wrinkles and sagging are age-related skin changes. Lifestyle has a major effect on the skin’s tendency to wrinkle. Sun exposure and smoking are the most common causes of premature skin wrinkling. If you limit sun exposure and avoid smoking, you can reduce the amount of wrinkles you develop.
Why skin wrinkles
Wrinkles and sagging are age-related skin changes. Elastin and collagen fibres give the skin suppleness and strength. The numbers of these fibres in the skin are reduced as we age, causing wrinkles. Our skin has a layer of fat just below the surface (subcutaneous layer), which gives form and structure. This layer of fat thins out as we age, causing the skin to sag.
Wrinkles and sun exposure
Sun exposure is the most common cause of skin damage and wrinkling. Exposure to the ultraviolet (UV) radiation in sunlight causes changes to the skin. UV rays prompt the formation of free radicals, among other things, which contribute to wrinkling and skin cancer. People with fair skin tend to experience more age-related skin changes, such as wrinkling, than people with dark skin. The best way to prevent wrinkling caused by sun exposure is to:
Wear protective clothing
Avoid the sun around the middle of the day
Use sunscreen for the parts of skin that can’t be protected by clothing.
Smoking and wrinkles
As well as all the other health risks associated with smoking, smokers will have more wrinkles. These changes may not show up till you are in your 30s or 40s but they will happen. Research has shown that people who have never smoked have less wrinkles than smokers
Acne
Acne is a medical skin problem that usually begins in the early teenage years and can last until the 30s and even 40s. It consists of mild to severe outbreaks of pimples and cysts – mainly on the face, back, arms and chest.
Cysts are lumps under the skin that have pus and other tissue in them, but do not come to a head like pimples do. They can cause scarring, blotchy, uneven skin colour and pitting.
Unfortunately, acne hits people at a time when they most want to look their best. Acne can make teenagers feel embarrassed and bad about themselves. There are treatments that can help if acne is causing distress. If you are concerned about skin problems or skin care, you should talk to your doctor or pharmacist for information about possible treatments.
Hormones and genetics
At the start of puberty, a lot of hormones are released into the body. One of these hormones is testosterone. Both boys and girls have testosterone and other related hormones called androgens, but boys have more of them. Androgens affect oil glands in the skin of the face, neck, back, shoulders and chest. They make the glands grow bigger and produce more oil (sebum).
Bacteria on the skin and blocked pores result in blackheads, pimples and cysts. A teenager is more likely to get acne if one of their parents had it during adolescence, but even in the same family, some people may get worse acne than others.
Girls tend to get it at a younger age than boys and it can become worse or ‘break out’ at certain times of a girl’s menstrual cycle, such as just before a period and they also tend to have ongoing acne, even into their 30s or 40s. Boys often have more outbreaks than girls, and they often seem to get more severe acne – worse pimples and more cysts.
Self-help strategies
Suggestions to manage acne include:
Cleansing – cleansers specifically developed for acne-prone skin can help. Try washing the affected areas twice per day. Don’t overdo it. Too much cleansing can cause other skin problems, such as dryness or skin irritations. Try to keep hair clean and off the face and neck, as oil from the hair can make acne worse.
Make-up – choose water-based, oil-free products where possible to avoid worsening acne by clogging the pores with oils or powder. Make-up should be thoroughly removed before going to bed.
Don’t squeeze – picking and squeezing pimples can make it worse and lead to scarring.
Stress – this can trigger an outbreak of pimples as it causes the release of hormones that can make oil glands release more oil onto the skin. This is why pimples seem to magically appear on stressful days, such as at the time of an exam or special date. While stress may be difficult to control, at least you know that the outbreak is due to stress, not a sign that the treatments do not work.
Diet – there is now more evidence that a low-GI diet may help some people with acne. Many people think that lollies or chocolate cause pimples. Research has not shown any strong link with these foods, but if you notice that eating certain foods causes pimples for you, try avoiding them.
Treatment for acne – non prescription
Some acne treatments can be bought over the counter at chemists or supermarkets. These work by cleaning the skin and drying up excess oil. Mild irritation can occur with such treatments. If this happens, take a short break from treatment and restart after a few days. If the irritation is excessive, stop the medication and speak to your doctor about an alternative.
It is a good idea to talk to the pharmacist before you buy a product to find out which treatment might be the most useful for you. A cleanser for acne-prone skin may be all that is needed for mild acne. Don’t rely on advertisements or the advice of friends.
Treatment for acne – professional
If your acne is not improving with over-the-counter treatments or if you have more severe forms of acne, you will need to see your doctor. They can prescribe medication after assessing your acne. The may also refer you to a dermatologist. Medications can lead to huge improvements in how the skin looks and can reduce the number of new pimples.
Medical treatments are topical or oral and can include:
Retinoids, which unblock pores of existing acne and prevent new blockages from developing
Antibiotics to kill bacteria and reduce inflammation
Hormonal agents, such as the contraceptive pill, to reduce the amount of androgen in the body and therefore oil secretion.
Doctors may also recommend more than one acne treatment, as different treatments work differently to fight acne. Fixed-combination products are also available, which blend together two treatments into one product.
Sweat
Sweat is produced by glands in the deeper layer of the skin, the dermis. Sweat glands occur all over the body, but are most numerous on the forehead, the armpits, the palms and the soles of the feet. Sweat is mainly water, but it also contains some salts. Its main function is to control body temperature. As the water in the sweat evaporates, the surface of the skin cools. An additional function of sweat is to help with gripping, by slightly moistening the palms.
Normal sweating
Normal, healthy sweating is caused by:
Hot temperatures, such as in summer
Physical exercise
Emotional stress
Eating hot or spicy foods
Fever associated with illness.
Increased sweating (hyperhidrosis)
Abnormal increased sweating is known as hyperhidrosis. Idiopathic hyperhidrosis is the most common form of excessive sweating. It is called idiopathic because no cause can be found for it. It can develop during childhood or later in life and can affect any part of the body, but the palms and soles or the armpits are the most commonly affected areas. The excessive sweating may occur even during cool weather, but it is worse during warm weather and when a person is under emotional stress.
Some known causes include:
Obesity
Hormonal changes associated with menopause (hot flushes)
Illnesses associated with fever, such as infection or malaria
An overactive thyroid gland (hyperthyroidism)
Diabetes
Certain medications.
In the majority of cases, no investigations are required to diagnose hyperhidrosis. Occasionally, a blood test for thyroid disease is recommended.
Treatment for excessive sweating
Treatment for excessive sweating depends on the cause. This may include:
Reducing weight – if obese
Medical management – to reduce the hot flushes of menopause
Antiperspirant applications – sprays, powders and roll-ons
Iontophoresis – the activity of sweat glands is temporarily reduced by passing a low-level electric current through the skin
Botox injections – to paralyse sweat glands. The effect from a single injection lasts six to nine months
Surgery – to the nerves that control sweat glands may be considered in severe cases where all other treatments have been unsuccessful.
Self-help strategies for hyperhidrosis
Some strategies for managing hyperhidrosis at home include:
Wear loose clothing.
Use antiperspirants that contain aluminium chloride and are designed for hyperhidrosis – follow the instructions carefully. While advertised mainly for use in the armpits, these agents can also be used on the palms, soles and forehead or wherever the hyperhidrosis occurs.
Reduced sweating (hypohydrosis)
Reduced sweating is called hypohidrosis, if there is partial loss of sweating, or anhidrosis if there is complete lack of sweating. This can occur for a number of reasons, which include:
Some skin disorders
Burns to skin that damage the sweat glands
Underactive thyroid (hypothyroidism)
Dehydration
Prolonged excessive heat or exercise during hot weather.
Lack of sweating may create problems of temperature control and lead to steep rises in body temperature during hot weather. Occasionally, this can be life threatening.
Heat stroke and heat exhaustion
Heat stroke (or sun stroke) can occur in hot weather when not enough sweat is produced to keep the body cool. Symptoms can include:
Muscle cramps
Headache
Nausea
Vomiting.
Excessive loss of body salts and water can lead to a life-threatening complication known as heat exhaustion. Heat stroke can be managed, and heat exhaustion prevented, by seeking a cool, shaded place, drinking plenty of fluids and sponging the body with water, if necessary
Mental illness
Mental illness is a general term for a group of illnesses. A mental illness can be mild or severe, temporary or prolonged. Most mental illnesses can be treated.
Mental illness can come and go throughout a person’s life. Some people experience their illness only once and fully recover. For others, it is prolonged and recurs over time. Mental illness can make it difficult for someone to cope with work, relationships and other aspects of their life.
The symptoms of mental illness
A person with a mental illness can experience problems with their thinking, emotions and/or behaviour. These changes may happen quickly, or they may be gradual and subtle. It may take time to understand and identify what is happening.
Psychotic symptoms
These symptoms can include:
Thoughts and feelings that are out of the ordinary or difficult to understand, such as thought of being persecuted or under surveillance for which there is no proof
Experiencing sensations (seeing, hearing, smelling, tasting something when there is nothing there that others can identify)
Odd behaviour.
Schizophrenia is a psychotic illness
Mood symptoms
Some of the symptoms of a changed mood may include:
Persistent and pervasive feelings of sadness, elation, anxiety, fear or irritability
Changes in sleep patterns
Changes in appetite
Loss of interest in things that were previously enjoyable
Periods of increased or decreased activity, where things may be started and not finished
Difficulty thinking and concentrating
Excessive worries
Changes in use of alcohol and other drugs
Exact causes are unknown
Many mental illnesses are thought to have a biological cause. What triggers a mental illness is not known.
The relationship between stress and mental illness is complex, but it is known that stress can worsen an episode of mental illness.
Compassion and understanding helps recovery
Many people may not know how to respond to a person who is mentally ill. People may react with embarrassment, rejection and abuse if they do not understand unusual behaviour. Such reactions can be a big hurdle for people with a mental illness who are trying to get well.
A person with a mental illness often faces isolation and discrimination from family, friends, employers and neighbours. These attitudes can make people hide their illness and feel ashamed. Family, friends, colleagues and other people can make a huge difference to a person’s recovery with understanding and compassion.
Mental illness and violence
Research has shown that people receiving treatment for a mental illness are no more violent or dangerous than the rest of the population. People with a mental illness are more likely to harm themselves – or to be harmed – than they are to hurt other people. A person with schizophrenia is around 2,000 times more likely to commit suicide than they are to harm someone else.
A weak association between mental illness and violence
Violence is not a symptom of psychotic illnesses such as schizophrenia. There is a slightly increased possibility someone with a psychotic illness may be violent if they:
Are not receiving treatment
Have a previous history of violence
Misuse alcohol or drugs.
Symptoms of psychotic illnesses may include frightening hallucinations and delusions as well as paranoia. This means there is a small chance someone who is experiencing these symptoms may become violent when they are scared and misinterpret what is happening around them. This is especially true when someone experiences these symptoms for the first time. However, if a person is being effectively treated for psychotic illness and is not misusing alcohol or drugs, there is no more risk they will be violent than anyone else.
Putting violence and mental illness into perspective
Research by the Australian Institute of Criminology shows that the vast majority of violence is committed by males aged 18–30 years. This is more likely when someone has been violent in the past and misuses alcohol or drugs. People in this group are far more likely to be violent than someone with a mental illness.
Schizophrenia and violence
People with schizophrenia who are receiving treatment are no more dangerous than the rest of the population. Research has shown that people with schizophrenia are about 2,000 times more likely to harm themselves than others.
Violence is generally not a problem, as long as the person is receiving appropriate treatment and support. However, it is true that a minority of people with schizophrenia can become aggressive when unwell. One reason for such a response could be a fear of symptoms, such as hallucinations. Aggression is usually expressed towards themselves, or family and friends – rarely to strangers.
Self-harm or abuse from others is more common
A Federal Government study found that a sizeable group of Australians with a psychotic illness (for example, schizophrenia) reported physical abuse within the previous year. For instance:
18 per cent had been a victim of violence
17 per cent attempted suicide or deliberate self-harm
15 per cent did not feel safe in the area where they were living. This highlights that people with a psychotic illness have the added burden of feeling vulnerable to harm.
Early treatment is the key to preventing violence
Mental health workers, people with a mental illness and their families all agree that the most important step in preventing violence is to make sure people receive effective treatment. Mental health workers need to know who is most at risk of being violent or a victim of violence and make sure they receive the right treatment – as quickly as possible and for as long as they need it. This is especially important in the first episode of illness.
It is important for everyone in the community to understand that mental illness is not a choice and could happen to anybody. It is equally important to understand that violence is always unacceptable.
How families can cope with aggressive or violent behaviour
If a family member with a mental illness becomes aggressive or violent:
Avoid a confrontation – sometimes it can be best just to leave the person until they calm down and become reasonable again.
Speak firmly – a very firm ‘please stop’ can sometimes help the person to regain control.
Have a plan – know who you are going to call if the aggressive behaviour persists. This may be a mental health crisis team, police or a neighbour.
Bipolar disorder
Bipolar disorder, or bipolar mood disorder, used to be called ‘manic depression’. It is a psychiatric illness characterised by extreme mood swings. A person may feel euphoric and extremely energetic, only to drop into a period of paralysing depression, in a cycle of elation followed by sadness. The exact cause is unknown and a number of factors may be involved, although a genetic predisposition has been clearly established.
It is estimated that around one in 50 Australians develops this illness, which affects men and women equally. Most of those affected are aged in their 20s when first diagnosed.
Bipolar disorder typically involves extreme moods of mania and depression – each lasting days, weeks or even months. Some people experience more highs than lows, others report more lows than highs. The severity of the mood swings and the symptoms will also vary from person to person. The person may be affected so much that they experience the symptoms of psychosis and are unable to distinguish reality from fantasy.
Bipolar disorder and mania
Common symptoms include:
Feeling extremely euphoric (‘high’) or energetic
Going without sleep
Thinking and speaking quickly
Delusions of importance
Reckless behaviour, such as overspending
Unsafe sexual activity
Aggression
Irritability
Grandiose, unrealistic plans.
Bipolar disorder and depression
Common symptoms include:
Withdrawal from people and activities
Overpowering feelings of sadness and hopelessness
Lack of appetite and weight loss
Feeling anxious or guilty without reason
Difficulty concentrating
Suicidal thoughts and behaviour.
Contributing factors to bipolar disorder
The underlying mechanisms of bipolar disorder are not fully understood, although a strong genetic predisposition has been established. One theory is that the illness might be linked to particular brain chemicals (neurotransmitters) called serotonin and norepinephrine that help regulate mood. In a person with bipolar disorder, it is thought that these chemicals are easily thrown out of balance.
Other contributing factors may include stressors in life that can trigger episodes of illness.
Treatment for acute episodes of bipolar disorder
When people experience an acute episode of mania or depression, they often require immediate care and treatment. These episodes can often be prevented by regular medication such as lithium.
Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a set of mental health reactions that can develop in people who have experienced or witnessed an event that threatens their life or safety (or others around them) and leads to feelings of intense fear, helplessness or horror. This could be a car or other serious accident, physical or sexual assault, war-related events or torture, or a natural disaster such as bushfire or flood.
Other life-changing situations such as being retrenched, getting divorced or the expected death of an ill family member are very distressing, and may cause mental health problems, but are not considered events that can cause PTSD.
Anyone can develop PTSD following a traumatic event but people are at greater risk if:
The event involved physical or sexual assault
They have had repeated traumatic experiences such as sexual abuse or living in a war zone
They have suffered from PTSD in the past.
Signs and symptoms
People with PTSD often experience feelings of panic or extreme fear, which may resemble what was felt during the traumatic event. A person with PTSD has three main types of difficulties:
Reliving the traumatic event – through unwanted and recurring memories and vivid nightmares. There may be intense emotional or physical reactions when reminded of the event. These can include sweating, heart palpitations or panic.
Being overly alert or ‘wound up’ – sleeping difficulties, irritability, lack of concentration, becoming easily startled and constantly being on the lookout for signs of danger.
Avoiding reminders of the event and feeling emotionally numb – deliberately avoiding activities, places, people, thoughts or feelings associated with the event. People may lose interest in day-to-day activities, feel cut off and detached from friends and family, or feel flat and numb.
People with PTSD can also have what are termed ‘dissociative experiences’, which are frequently described as follows:
‘It was as though I wasn’t even there.’
‘Time was standing still.’
‘I felt like I was watching things happen from above.’
‘I can’t remember most of what happened.’
A health practitioner may diagnose PTSD if a person has a number of symptoms in each of the three areas for a month or more, which:
Lead to significant distress, or
Impact on their ability to work and study, their relationships and day-to-day life.
It is not unusual for people with PTSD to experience other mental health problems at the same time. Up to 80 per cent of people who have long-standing PTSD develop additional problems, most commonly depression, anxiety and alcohol or other substance misuse. These may have developed directly in response to the traumatic event or have developed sometime later after the onset of PTSD.
Impact of PTSD on relationships and day-to-day life
PTSD can affect a person’s ability to work, perform day-to-day activities or relate to their family and friends. A person with PTSD can often seem disinterested or distant as they try not to think or feel in order to block out painful memories. They may stop participating in family life, ignore offers of help or become irritable. This can lead to loved ones feeling shut out.
It is important to remember that these behaviours are part of the problem. People with PTSD need the support of family and friends but may not know that they need help. There are many ways you can help someone with PTSD. See ‘Where to get help’ for further information and resources.
Risky alcohol and drug use
People commonly use alcohol or other drugs to blunt the emotional pain that they are experiencing. Alcohol and drugs may help block out painful memories in the short term, but they can get in the way of a successful recovery.
When to get help
A person who has experienced a traumatic event should seek professional help if they:
Don’t feel any better after two weeks
Feel highly anxious or distressed
Have reactions to the traumatic event that are interfering with home, work and relationships
Are thinking of harming themselves or someone else.
Some of the signs that a problem may be developing are:
Being constantly on edge or irritable
Having difficulty performing tasks at home or at work
Being unable to respond emotionally to others
Being unusually busy to avoid issues
Using alcohol, drugs or gambling to cope
Having severe sleeping difficulties.
Support is important for recovery
Many people experience some of the symptoms of PTSD in the first couple of weeks after a traumatic event, but most recover on their own or with the help of family and friends. For this reason, formal treatment for PTSD does not usually start for at least two weeks following a traumatic experience.
It is important during those first few days and weeks after a traumatic event to get whatever help is needed. This might include information and access to people and resources that can assist you to recover. Support from family and friends may be all that is needed. Otherwise, a doctor is the best place to start, to get further help.
A range of treatments
If problems persist after two weeks, a doctor or a mental health professional may discuss starting treatment. Effective treatments are available. Most involve psychological treatment but medication can also be prescribed. Generally, it’s best to start with psychological treatment rather than use medication as the first and only solution to the problem.
The cornerstone of treatment for PTSD involves confronting the traumatic memory and working through thoughts and beliefs associated with the experience. Trauma-focussed treatments can:
Reduce PTSD symptoms
Lessen anxiety and depression
Improve a person’s quality of life
Be effective for people who have experienced prolonged or repeated traumatic events, but treatment may be required for a longer period.
Mental health - care plans
Mental health care plans are for people with a mental illness who have several healthcare professionals working with them. A care plan explains the support provided by each of those professionals and when treatment should be provided. Your care plan might also include what to do in a crisis or to prevent relapse.
Your doctor will use a care plan to help you work out what services you need, set goals and decide on the best treatment options for you. At other times, your doctor may contribute to a care plan that someone else has organised – for example, when you are returning home from spending time in hospital.
Reasons for a mental health care plan
Providing ongoing care and support for someone who is living with a mental illness can involve many different support organisations. These may include psychologists, GPs, psychiatrists, psychiatric nurses or other community care providers. They are all part of the healthcare team, which works together to provide you with the best level of care possible.
Everyone’s treatment needs are different. A care plan puts down in writing the support you can expect from each of the people in your mental healthcare team and makes sure that everyone knows who is responsible for what and when. You are an important part of this team and should be fully involved in preparing your mental health care plan.
Preparing your mental health care plan
Your doctor will work with you to decide:
What your mental health needs are
What help you require – your medical, physical, psychological and social needs are all considered
What result you would like
What treatment would be best for you.
Once you and your doctor have agreed on your goals and what support you need to achieve them, your doctor will write out a mental health care plan. They will then discuss this with the other members of your healthcare team. Preparing the plan might take one visit or it might take a number of visits.
Your doctor will offer you a copy of the plan and will also keep a copy on your medical record. If you give permission, a copy can also be given to other people, such as psychologists or your carer. You should tell your doctor if there is any information you don’t want other people in your healthcare team to know.
Benefits of a mental health care plan
Having a care plan will help you become more involved in your healthcare. A care plan can:
Help you to set and achieve goals
Make sure everyone involved in your mental healthcare team is working towards the same goals
Help you and your doctor manage your long-term care in a way that is clear and easy to understand
Give you a way to monitor your progress and check that you continue to receive the care you need
Lead to better treatment by focusing on improving and maintaining your health rather than just dealing with problems as they arise
Provide life-saving information in emergencies.
Issues to consider with care plans
Most care plans are done in your doctor’s office. However, you may also have a care plan prepared for you when you leave hospital. The time it takes to draw up the care plan depends on your healthcare professional and the complexity of your situation.
Some things to think about include:
You will need to request a long consultation with your doctor to allow enough time to prepare your care plan and discuss your treatment options.
If you would like a carer, family member or someone else to accompany you to the care plan appointments, you may wish to let your doctor know beforehand.
Your doctor must get your consent before a care plan is developed, and you should be given a written statement of your rights and responsibilities.
Discuss with your doctor any aspects of your assessment that you do not want discussed with the other members of your healthcare team.
Regular reviews are important
Once you have a mental health care plan, you should continue to see the same doctor for review and management. Significant changes in your health may mean you need to make a new care plan. Even if there are no big changes to your situation, your care plan should be reviewed regularly to make sure it continues to meet your needs.
How often a new plan is prepared may vary depending on which health professionals are involved. Care plans may be prepared every 12 months and should be reviewed after three or six months, or sooner if needed. A date for review should be written into your care plan.
Costs of a mental health care plan
If you have a Medicare card, Medicare will cover some or all of the cost of care planning by a doctor. It may also rebate some of the costs of certain specialists or other health professionals, which will be charged separately. Your doctor should tell you what costs (if any) are involved when you agree to make a mental health care plan. If you are unsure, ask your doctor what fees will be involved.
Mental illness services - residential care
A wide range of public mental health services is available for people of all ages. Residential care services can provide short-term or long-term beds, and offer treatment and support to people who are experiencing a serious mental illness. These services can be offered in hospitals or other residential care facilities.
Short-term residential care for people experiencing mental illness
Sometimes, people with a mental illness need short-term care in a hospital or residential care facility. These ‘acute inpatient units’ provide a bed with short-term treatment for people who have been referred by a community mental health service.
Secure and extended residential care for people experiencing mental illness
Secure treatment in a residential care facility can be provided for people with serious, enduring mental illness and associated behavioural disturbance. Sometimes people in this situation need an extended period of treatment and rehabilitation in a contained environment.
Community care units for people experiencing mental illnes
Community care units provide clinical treatment for people with a serious mental illness and major psychosocial disabilities. The services help people learn and reinforce everyday skills that are needed to live in the community.
Residential rehabilitation services for people experiencing mental illness
Residential rehabilitation services help people with a serious mental illness and associated disabilities learn and reinforce everyday skills that are needed to live successfully in the community.
Services for older people experiencing mental illness
Aged persons mental health residential services care for older people with a mental illness. The facilities are designed to have a home-like atmosphere and residents can participate in a range of activities.
Sleep
Sleep is as essential for good health as oxygen, food and water. Yet we still don’t know exactly what it is or how it works. Most scientists agree that sleep is important for restoring physical and mental health. It refreshes the mind and repairs the body. Lack of sleep, or sleep deprivation, can cause fatigue, poor concentration and memory, mood disturbances, impaired judgement and reaction time, and poor physical coordination.
The body’s internal clock regulates when and how we sleep depending on the amount of light around us. When the sun sets, your brain releases hormones to make you sleepy. In the morning, exposure to daylight suppresses these hormones and releases brain chemicals to keep you awake
Getting enough sleep
Before electricity, people used to sleep between sunset and sunrise. The typical person’s sleep averaged a generous ten hours – the same amount enjoyed by other primates like chimpanzees and baboons. Today, sleep deprivation is common in developed nations, with the average adult sleeping for only six or seven hours each night.
Most of us feel fatigued at least some of the time. It is thought that fatigue causes about one road accident in six. Studies show that a common distraction from sleep is the Internet and more recently, texting. Parenthood, shift work, travel across time zones, illness, poor sleeping habits and some medications are other common sleep-stealers. New parents lose, on average, between 450 and 700 hours of sleep during their child’s first 12 months of life
Sleep stages
Sleep isn’t a static state of consciousness. The brain moves through distinct stages of sleep, over and over, every night. The two broad categories of sleep include:
Rapid eye movement (REM) sleep
Non-rapid eye movement (NREM) sleep.
Rapid eye movement (REM) sleep
Rapid eye movement sleep occurs regularly, about once every 90 to 120 minutes. It makes up about one-quarter of your night’s sleep. The brain in REM sleep shows significant electrical activity. The sleeper’s eyes tend to dart about under closed lids, hence the name.
The bulk of dreams are thought to occur during REM sleep. Sleep researchers have established that at least some eye movements correspond with dream content, which suggests that we watch our dreams like we watch movies on a screen. REM sleep makes up a larger proportion of the total sleep period in babies (especially premature babies), which suggests that dreams help to mature a developing brain.
Non-rapid eye movement (NREM) sleep
Non-rapid eye movement sleep is what you experience for the remaining three-quarters of your sleep time. The amount and type of NREM sleep vary with age and the degree of sleep deprivation.
The four broad stages of NREM sleep include:
Stage 1 – Dozing or drowsiness. You hover between being asleep and awake.
Stage 2 –You lose awareness of your surroundings. Body temperature starts to drop. Breathing and heart rate slow down.
Stages 3 and 4 – Deep sleep, also known as ‘delta sleep’. Your blood pressure, heart rate and breathing become very slow and your muscles relax. Growth and repair processes occur during this stage.
Sleep disorders
Some of the sleep disorders that may contribute to or cause excessive daytime sleepiness include:
Sleep apnoea – the person’s breathing stops or is reduced regularly during sleep, sometimes every minute. The brain registers the breathing problem and sends a ‘wake-up’ call. The person rouses slightly, gasps and then goes back to sleep. Sleep is fragmented.
Insomnia – this is very common, but does not necessarily cause hypersomnia. A person may have difficulty getting to sleep or staying asleep. Insomnia is a symptom, not a disease.
Restless legs syndrome – sensations of cramps or irritation are felt under the skin in the legs, particularly the calves. The person feels compelled to move their legs or get out of bed and walk around.
Sleep walking – this is a common abnormal behaviour during sleep. The person may walk around the house while still asleep. Sleep walking tends to affect children more than adults.
Narcolepsy – this is a relatively rare sleep disorder characterised by sleepiness to the degree of involuntary napping, paralysis of the muscles (sleep paralysis), vivid, dream-like hallucinations just prior to falling asleep (hypnagogic hallucinations), and muscle weakness during periods of strong emotion (cataplexy).
Idiopathic hypersomnia – this sleep disorder is characterised by excessive night-time sleeping and the need for naps during the day. Unlike narcolepsy, it doesn’t include cataplexy or sleep paralysis
Sleep apnoea
Sleep apnoea occurs when the walls of the throat come together during sleep, blocking off the upper airway. Breathing stops for a period of time (generally between a few seconds and up to one minute) until the brain registers the lack of breathing or a drop in oxygen levels and sends a small wake-up call. The sleeper rouses slightly, opens the upper airway, typically snorts and gasps, then drifts back to sleep almost immediately.
In most cases, the person suffering from sleep apnoea doesn’t even realise they are waking up. This pattern can repeat itself hundreds of times every night, causing fragmented sleep. This leaves the person feeling unrefreshed in the morning, with excessive daytime sleepiness, poor daytime concentration and work performance, and fatigue. It’s estimated that about five per cent of Australians suffer from this sleep disorder, with around one in four men over the age of 30 years affected.
Degrees of severity
The full name for this condition is obstructive sleep apnoea. Another rare form of breathing disturbance during sleep is called central sleep apnoea. It is caused by a disruption to the nerve messages sent between the brain and the body. The severity of sleep apnoea depends on how often the breathing is interrupted. As a guide:
Normal – less than five interruptions an hour
Mild sleep apnoea – between 5 and 15 interruptions an hour
Moderate sleep apnoea – between 15 and 30 interruptions an hour
Severe sleep apnoea – over 30 interruptions an hour.
Symptoms of sleep apnoea
People with significant sleep apnoea have an increased risk of motor vehicle accidents and high blood pressure, and may have an increased risk of heart attack and stroke. In the over-30 year age group, the disorder is about three times more common in men than women. Some of the associated symptoms include:
Daytime sleepiness, fatigue and tiredness
Poor concentration
Irritability and mood changes
Impotence and reduced sex drive
Need to get up to toilet frequently at night
Causes of sleep apnoea
Obesity is one of the most common causes of sleep apnoea. A loss of around 5kg to 10kg may be enough to dramatically reduce the severity of the disorder. Other contributing factors include:
Alcohol, especially in the evening – this relaxes the throat muscles and hampers the brain’s reaction to sleep disordered breathing
Certain illnesses, like reduced thyroid production or the presence of a very large goitre
Large tonsils, especially in children
Medications, such as sleeping tablets and sedatives
Nasal congestion and obstruction
Facial bone shape and the size of muscles, such as an undershot jaw.
Treatment for sleep apnoea
Treatment for sleep apnoea relies on changes to lifestyle, including losing weight and cutting down on alcohol. Any contributing medical condition, such as low production of thyroid hormone, also needs to be corrected. Any surgical conditions such as large tonsils should be corrected.
The most effective treatment available is a mask worn at night that keeps the back of the throat open by forcing air through the nose. This is called ‘nasal continuous positive airway pressure’ (CPAP). However, some people with sleep apnoea find the mask difficult to tolerate.
Another treatment is the use of a mouthguard (or oral appliance or mandibular advancement splint). They work by holding the jaw forward during sleep. When properly made, they can be effective for mild to moderate sleep apnoea.
Although not always effective, surgery to the palate and base of tongue may be useful when other therapies fail. These types of surgeries are best undertaken by otolaryngologists (ENT surgeons) who take a special interest and have had training in sleep-related surgery.
Insomnia
Insomnia is a symptom, not a disease. It means being concerned with how much you sleep or how well you sleep. This may be caused by difficulties in either falling or staying asleep. Self-reported sleeping problems, dissatisfaction with sleep quality and daytime tiredness are the only defining characteristics of insomnia. It is an individual perception of sleep. Long-term chronic insomnia needs professional support from a sleep disorder clinic.
The concept of ‘a good sleep’ differs widely from person to person. While the average night’s sleep for an adult is around eight hours, some people only need five, while others like up to 10 hours or more. What seems like insomnia to one person might be considered a good sleep by another.
Insomnia is a common complaint
Over one third of people experience insomnia from time to time, but only around five per cent need treatment for the condition. Transient or short-term insomnia is typically caused by such things as stressful life events, jet lag, changes in sleeping environments, some acute medical illnesses and stimulant medications. Normal sleeping habits return once the acute event is over.
If a person has experienced sleeping difficulties for a month or more, this is called persistent or chronic insomnia. There are many causes of persistent insomnia. These include:
Secondary insomnia – due to a range of medical and psychiatric problems and the chronic use of drugs and alcohol.
Primary sleep disorders – include circadian rhythm disorders, central sleep apnoea-insomnia syndrome, inadequate sleep syndromes and periodic limb movement or restless legs syndromes.
Idiopathic insomnia – sleeplessness without a known cause, formerly called childhood onset insomnia.
Keep sleep in perspective
People who suffer from insomnia are normally frustrated or annoyed by it. Paradoxically, this emotional state contributes to keeping them awake, starting a vicious cycle. It helps to stop expecting a set amount of sleep every night. Having less sleep than you’d like doesn’t cause any harm. Allow yourself to fall short of the ideal without getting anxious about it.
Home remedies for short-term insomnia
Reducing anxiety and sticking to a day–night routine can improve sleep quality. Suggestions include:
Don’t nap during the day.
Cut down on smoking and drinking.
Avoid tea, coffee and other caffeinated drinks before bed.
Don’t exercise strenuously before bedtime.
Do something to relax, such as meditate or have a warm bath.
Only go to bed if you feel sleepy.
Go to bed later.
Stop reading, worrying or watching television in bed and limit your activities in the bedroom to sleeping and sex.
If you can’t sleep, get up, go to another room and do something else until you feel sleepy again.
Get up at the same time every morning regardless of how much sleep you have had.
Avoid ‘judging’ your sleep on a day-to-day basis
Treatment for long-term insomnia
Insomnia that has persisted for years needs professional support and a lot of patience. It might take some time to re-establish normal sleeping patterns.
Some of the techniques used by a sleep disorder clinic might include:
A sleep diary, to help pinpoint the pattern of insomnia
A program of mild sleep deprivation
Medication to help set up a new sleeping routine
Exposure to bright light in the morning
Behavioural therapy.
Restless legs syndrome (RLS)
Restless legs syndrome (RLS) is an unusual condition of the nervous system characterised by the compelling need to move the legs. It is usually worse in the evening and can be a problem when trying to sleep.
The strange sensation in the calves has been described as a type of cramp, soreness or a creeping, crawling feeling. Some liken the sensation to shooting darts of electricity or even squirming insects inside the legs. The same symptoms can also be caused by other conditions including diabetes, iron deficiency anaemia, alcoholism and some forms of arthritis. It is relatively common in pregnancy.
Around five out of every 100 people will experience RLS at some time. Usually both legs are affected, but it is not uncommon to experience the unpleasant sensations in only one leg. The symptoms can be mild, moderate or severe. In severe cases, the person may be unable to sleep.
No one knows what causes RLS. It can begin at any age, including childhood (although this is thought to be underreported). There is a strong genetic link. Iron deficiency is the most important risk factor.
Restless legs syndrome can affect anyone
Restless legs syndrome can affect people of any age, but certain groups of people tend to be more susceptible, including:
Middle-aged and elderly people
Pregnant women
Those with a parent who experiences RLS (which suggests a genetic link)
Those who have another sleep disorder called periodic limb movement disorder
People on antidepressant medication.
Periodic limb movement disorder (PLMD)
Periodic limb movement disorder involves uncontrollable jerking of the legs or, occasionally, the arms. It is also known as ‘sleep myoclonus’. During sleep, these recurring movements can be severe enough to wake the sleeper.
In other cases, the person sleeps, but only lightly, since the jerks rouse them from deep slumber without waking them. The result may be poor sleep quality and daytime fatigue. The jerking can increase or decrease in severity from one night to the next, for no apparent reason.
The cause of PLMD is unknown, but factors that are recognised as being associated with this condition include:
Being middle-aged or elderly
Pregnancy
Iron deficiency
Renal failure
The regular use of antidepressants
A family history of the disorder
Restless legs syndrome – most people with RLS have PLMD
Sleep deprivation and restless legs syndrome
Standing up, walking or any other exercise that involves the legs can usually relieve the unpleasant physical sensations of RLS. Sleep deprivation is one of the more common side effects of RLS, since sufferers may need to get out of bed and walk around many times every night in order to alleviate the cramps.
The nervous system and RLS
Restless legs syndrome is thought to be caused by some type of malfunction of the motor system and, more specifically, of the dopamine pathway. However, research so far has failed to find any abnormalities in the brains, nerves or muscles of any RLS sufferer.
Treatment of restless legs syndrome
Diagnosing RLS or PLMD is based on symptoms. Since the cause of RLS is unknown, the treatments that are available relieve the symptoms rather than curing the condition.
Some people find that symptoms improve if they cut back or avoid caffeine, alcohol and nicotine. Successfully managing an underlying condition, such as anaemia or diabetes, can sometimes alleviate RLS. As with many sleep disorders, inadequate sleep or sleep deprivation will make RLS worse.
It is very important to correct iron deficiency, after investigation of the cause of the iron deficiency. In some cases, an intravenous infusion (IV drip into your vein) of iron is needed.
In severe cases, medications such as anti-Parkinson disease medications, benzodiazepines or morphine can offer symptom control. Other medications used for RLS include some anti-epileptic medications.
Narcolepsy
Excessive daytime sleepiness that is not due to a mood disorder or medication is a common health problem that has three broad causes:
Inadequate quantity of sleep from sleep restriction, sleep deprivation or timing disorders such as jet lag and shift work
Inadequate quality of sleep due to a problem that fragments sleep such as sleep-disordered breathing, excessive limb movement, chronic pain or chronic illness
A primary problem with keeping awake and vigilant during the daytime. The term narcolepsy is generally used for this group of disorders
Diagnosis of narcolepsy
Narcolepsy is a rare sleep disorder. A person with narcolepsy has excessive daytime sleepiness, with repeated episodes of sleep attacks, falling asleep involuntarily at inappropriate times, often several times every day. Narcolepsy can develop at any age, but it commonly starts either during the teenage years or in middle age. A person with narcolepsy usually has the condition for life.
All people with narcolepsy have extreme levels of sleepiness during the day, but how this shows itself can differ. For instance, some people with narcolepsy might fall asleep for 10 to 20 minutes several times every day, whether they want to or not. Others with this condition have more control over their naps and can choose when and where they will sleep, such as during lunch breaks.
Since symptoms vary so much between people, a laboratory test called the Multiple Sleep Latency Test can be used to measure daytime sleepiness during four to five naps of 20 minutes. This test may also show if there is very early interruption of REM (rapid eye movement or dreaming) sleep.
Symptoms of narcolepsy
As well as extreme sleepiness and a tendency to fall asleep during the day, other symptoms of narcolepsy all reflect the intrusion of REM sleep outside of established sleep, including:
Cataplexy – a sudden, brief reversible episode of muscle weakness brought on by a powerful emotional trigger such as laughing or anger. This can cause a collapse without loss of consciousness and can last from a few seconds to minutes. It is thought to be related to the muscle paralysis that occurs to everyone during REM sleep.
Hypnagogic hallucinations – vivid, dream-like perceptions that happen when the person isn’t quite asleep and may involve hallucinations of sight, sound or feeling (seeing or hearing things).
Sleep paralysis – at the point of falling asleep, or more often on waking, the person cannot speak or even breathe. This immobilisation can last for a few seconds
Cause of narcolepsy
The hypothalamus is a small structure that sits deep inside the brain. Some of its vital roles include controlling body temperature, appetite and thirst. The hypothalamus is also connected to the reticular activating pathways, which are the brain structures that govern our sleep and wake cycles.
It is thought that narcolepsy is caused by a malfunctioning of the hypothalamus that prevents pathways in the brain from working properly. Instead of introducing sleepy feelings towards the end of each day, narcolepsy prompts random sleepiness.
Some people with narcolepsy have a deficiency of a wake-promoting chemical called orexin or hypocretin. This deficiency is usually present in patients who have narcolepsy-cataplexy.
Treatment for narcolepsy
Treatment depends on the severity of the condition. If the symptoms are mild, simple management and coping techniques, such as making time for naps during the day, are helpful. In more severe cases, medications that stimulate the nervous system are used, such as amphetamine, methylphenidate or modafinil.
Hypersomnia
Hypersomnia means excessive sleepiness. There are many different causes, the most common in our society being inadequate sleep. This may be due to shiftwork, family demands (such as a new baby), study or social life. Other causes include sleep disorders, medication, and medical and psychiatric illnesses.
Hypersomnia can be helped or cured with a few adjustments to lifestyle habits. Seek advice from your doctor or sleep disorder clinic if you still feel excessively sleepy.
Characteristics of hypersomnia
The characteristics of hypersomnia vary from one person to the next, depending on their age, lifestyle and any underlying causes. Under the International Classification of Sleep Disorders, daytime sleepiness is defined as ‘the inability to stay awake and alert during the major waking episodes of the day, resulting in unintended lapses into drowsiness or sleep’.
In extreme cases, a person with hypersomnia might sleep soundly at night for 12 hours or more, but still feel the need to nap during the day. Sleeping and napping may not help, and the mind may remain foggy with drowsiness. It is possible that a person with hypersomnia may have very disturbed sleep but not be aware of it.
Symptoms of hypersomnia
Depending on the cause, the symptoms of hypersomnia may include:
Feeling unusually tired all the time
The need for daytime naps
Feeling drowsy, despite sleeping and napping – not refreshed on waking up
Difficulty thinking and making decisions – the mind feels ‘foggy’
Apathy
Memory or concentration difficulties
An increased risk of accidents, especially motor vehicle accidents.
Causes of hypersomnia
Excessive daytime sleepiness can be caused by a wide range of events and conditions, including:
Insufficient or inadequate sleep – long working hours and overtime can be tolerated for months or years before the symptoms of sleepiness take effect. Teenagers who stay out until the early hours of the morning on weekends may be tired during the week.
Environmental factors – broken sleep can be caused by a variety of things such as a snoring partner, a baby that wakes, noisy neighbours, heat and cold, or sleeping on an uncomfortable mattress.
Shiftwork – it is very difficult to get good sleep while working shiftwork, especially night shift. As well as the problem of trying to sleep, there is also the effect of being out of synchronisation with the body’s internal clock (the circadian rhythm).
Mental states – anxiety can keep a person awake at night, which makes them prone to sleepiness during the day. Depression saps energy.
Medications – such as alcohol, caffeinated drinks, tranquillisers, sleeping pills and antihistamines can disrupt sleeping patterns.
Medical conditions – like hypothyroidism (underactive thyroid gland), oesophageal reflux, nocturnal asthma and chronic painful conditions can disrupt sleep.
Changes to time zone – such as jet lag can affect the internal biological clock, which regulates sleep. This clock responds to light.
Sleep disorders – such as sleep apnoea, restless legs syndrome, sleep walking, narcolepsy, idiopathic hypersomnia and insomnia may all cause sleep disruption or fragmented sleep.
Self-help strategies
Hypersomnia can be helped in many cases with lifestyle adjustments to improve sleep quality, so called good sleep hygiene. Suggestions include:
Avoid cigarettes, alcohol and caffeinated drinks near bedtime.
Follow a relaxation routine to prevent night-time anxiety.
Exercise regularly and maintain a normal weight for your height.
Eat a well-balanced diet to prevent nutritional deficiencies.
If possible, change your environment to reduce disturbances – for example, don’t watch television in the bedroom.
Be comfortable; make sure you don’t overheat or feel too cold in bed.
Have a regular sleeping routine so that your body ‘knows’ it is time to sleep.
Only go to bed when you feel sleepy.
If necessary, take brief ‘power’ naps during the day to help you stay alert and vigilant. Daytime napping is generally not recommended when improved sleep is possible, as it can reduce the drive to sleep at night. However, brief naps can be very valuable in occupational settings and on other occasions where concentration is required, such as preparation for driving or in regular breaks on a long trip
Other sleepiness conditions
Sleep restriction – from not getting enough sleep due to late nights from social activities, TV or computer use
Jet lag, shift work – the brain’s internal ‘clock’ sets our sleep and wake cycles to coincide with day and night, and this rhythm is disrupted by moving to a different time zone or sleeping routine
Depression – lethargy to the point of sleepiness is a symptom of this emotional disorder
Snoring with or without sleep apnoea – broken sleep over a period of time leads to a sleep debt, which causes daytime sleepiness
Fatigue, lethargy and lack of energy – common problems that often need to be investigated to exclude sleepiness
Chronic fatigue syndrome – thought to be triggered by a viral infection. Other symptoms include weakness, aching muscles, sore throat and headaches
Sleep hygiene
Sleep hygiene’ means habits that help you to have a good night’s sleep. Common sleeping problems (such as insomnia) are often caused by bad habits reinforced over years or even decades. You can dramatically improve your sleep quality by making a few minor adjustments to lifestyle and attitude.
Obey your body clock
The body’s alternating sleep-wake cycle is controlled by an internal ‘clock’ within the brain. Most bodily processes (such as temperature and brain states) are synchronised to this 24-hour physiological clock. Getting a good sleep means working with your body clock, not against it. Suggestions include:
Get up at the same time every day. Soon this strict routine will help to ‘set’ your body clock and you’ll find yourself getting sleepy at about the same time every night.
Don’t ignore tiredness. Go to bed when your body tells you it’s ready.
Don’t go to bed if you don’t feel tired. You will only reinforce bad habits such as lying awake.
Get enough early morning sunshine. Exposure to light during early waking hours helps to set your body clock.
Improve your sleeping environment
Good sleep is more likely if your bedroom feels restful and comfortable. Suggestions include:
Invest in a mattress that is neither too hard nor too soft.
Make sure the room is at the right temperature.
Ensure the room is dark enough.
If you can’t control noise (such as barking dogs or loud neighbours), buy a pair of earplugs.
Use your bedroom only for sleeping and intimacy. If you treat your bed like a second lounge room – for watching television or talking to friends on the phone, for example – your mind will associate your bedroom with activity.
Avoid drugs
Some people resort to medications or ‘social drugs’ in the mistaken belief that sleep will be more likely. Common pitfalls include:
Cigarettes – many smokers claim that cigarettes help them relax, yet nicotine is a stimulant. The side effects, including accelerated heart rate and increased blood pressure, are likely to keep you awake for longer.
Alcohol – alcohol is a depressant drug, which means it slows the workings of the nervous system. Drinking before bed may help you doze off but, since alcohol disturbs the rhythm of sleep patterns, you won’t feel refreshed in the morning. Other drawbacks include waking frequently to go to the toilet and hangovers.
Sleeping pills – drawbacks include daytime sleepiness, failure to address the causes of sleeping problems, and the ‘rebound’ effect – after a stint of using sleeping pills, falling asleep without them tends to be even harder. These drugs should only be used as a temporary last resort and under strict medical advice.
Relax your mind
Insomnia is often caused by worrying. Suggestions include:
If you are a chronic bedtime worrier, try scheduling a half hour of ‘worry time’ well before bed. Once you retire, remind yourself that you’ve already done your worrying for the day.
Try relaxation exercises. You could consciously relax every part of your body, starting with your toes and working up to your scalp. Or you could think of a restful scene, concentrate on the rhythmic rise and fall of your breathing, or focus on a mantra (repeating a word or phrase constantly)
General suggestions
Other lifestyle adjustments that may help improve your sleep include:
Exercise every day, but not close to bedtime and try not to overheat yourself – your body needs time to wind down.
Try not to engage in mentally stimulating activities close to bedtime. Use the last hour or so before sleep to relax your mind.
Don’t take afternoon naps.
Avoid caffeinated drinks (like tea, coffee, cola or chocolate) close to bedtime. Instead, have a warm, milky drink, since milk contains a sleep-enhancing amino acid.
Take a warm bath.
Turn your alarm clock to the wall. Watching the minutes tick by is a sure way to keep yourself awake.
If you can’t fall asleep within a reasonable amount of time, get out of bed and do something else for half an hour or so, such as reading a book.
If you have tried and failed to improve your sleep, you may like to consider professional help. See your doctor for information and referral.
