Insomnia

Overview

The struggle for a good night's sleep

Every year, 30% of the people in the United States have problems getting to sleep or staying asleep. Insomnia affects everyone. In at least 50%, insomnia stems from psychological factors, such as anxiety or depression. Medical conditions, your lifestyle, inappropriate diet, using alcohol or drugs, travel, shift work, bereavement, and aging may all contribute to sleeping struggles. Some people need less sleep than others, and insomnia can only be diagnosed in relation to the individual experience and needs of each person.

Because of the wide variety of factors that can develop into sleeping problems, the best way to treat insomnia is on an individual basis, looking at the underlying issues and adapting to develop regular sleeping patterns. The use of hypnotic drugs, while effective in the short term, can have long-term adverse effects and should be used only as a last resort for treating insomnia.

Detailed Description

Insomnia is not a condition unto itself. It is a symptom, a disturbance in sleep that could be due to many different causes. Most insomnia falls into four categories:

• Sleep-onset insomnia (difficulty falling asleep)
• Sleep-maintenance insomnia (frequent, sustained awakenings)
• Sleep-offset insomnia (early morning awakenings)
• Nonrestorative sleep (persistent sleepiness despite adequate duration of sleep)

Whatever its cause, insomnia is one of two types. Primary insomnia is a long-standing condition with little or no apparent relationship to any stress or life event. Secondary insomnia is connected directly to a condition or life event, and is due to physical pain, anxiety, medication, depression, or extreme stress.

Normal sleeping patterns

Brain-wave recordings have helped divide sleep into two broad states — non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM sleep has four distinct stages, starting with stage 1 (the lightest level when it is easy to wake) to stage 4 (the deepest level, during which waking is difficult). Stage 4 has several distinct physiological signs. Muscles are relaxed, blood pressure is at its lowest, and the heart and breathing slow down. REM sleep is the time when electrical activity in the brain is unusually high. When you dream, you are usually experiencing a REM sleep pattern. Sleep talking, sleep walking, and sleep terrors occur when you're in REM sleep and stages 3 or 4. Normally, REM sleep is cyclical, with several periods of NREM sleep following a period of REM sleep.

Sleeping patterns with insomnia

It is normal for older people to sleep less. As we age, stage 4 sleep becomes shorter and eventually disappears, and more awakenings occur during all stages. This shift in sleeping patterns can lead us to believe that we aren't getting enough sleep. There's no proof, however, that older people need as much sleep as younger people, or that sleep medications are needed to rectify a normal part of these age-related changes.

Disturbed patterns of sleep that are experienced with insomnia are not necessarily related to the aging process, however, and can occur at any age.

• Sleep-onset insomnia is difficulty in falling asleep. This can be due to anxiety or tension, environmental changes or disruptions such as high altitude or travel, emotions, pain or discomfort, and consumption of caffeine or alcohol. The fear of not being able to get to sleep (fear of insomnia) and a phobia of sleep can also make falling asleep very difficult.
• Sleep-maintenance insomnia is difficulty in staying asleep. It can be contributed to depression or emotional disturbance. Conditions such as hypoglycemia, sleep apnea, and restless leg syndrome can also lead to this pattern disruption. Environmental changes, pain or discomfort, and drugs and alcohol can also cause wakefulness after sleep has begun.
• Sleep-offset insomnia, or early morning awakening, is a pattern that is more commonly experienced in elderly people, but could also be an indication of depression.
• Nonrestorative sleep. Persistent sleepiness despite adequate duration of sleep.
• Sleep rhythm reversal. This is the experience that occurs when your sleeping pattern has been disturbed, and it results in falling asleep at inappropriate times and being unable to fall asleep during normal evening hours. This sleeping pattern abnormality could be due to jet lag (especially when traveling from east to west), irregular work shifts, frequent changes in work hours, or excessive alcohol use. Sleep patterns can also be effected by medication, or by any kind of condition that might damage the brain's built-in clock, such as a stroke or Alzheimer's disease.

How Common Is Insomnia?

Over a third of the adult population has insomnia at some point and it is one of the most common complaints heard by primary care physicians. It affects all age groups, but older people seem to be the most affected. Women sufferer from insomnia at a higher rate than men.

What You Can Expect

Insomnia will usually resolve when the underlying cause is removed from your life. In other cases, it may resolve with time. Some types of insomnia without a readily treatable cause may persist. Bear in mind that not everyone needs eight hours of sleep — for many, six to seven hours is adequate.

Conventional Treatment

Goals of Treatment

The goal of treating insomnia is to help you fall asleep easily, stay asleep throughout the night, and awaken refreshed.

Insomnia has no specific cure because it is due to numerous factors. Treatment, once the underlying cause of insomnia is identified, is individualized, allowing most individuals to reestablish normal sleeping patterns. Medications are sometimes used temporarily, but may produce adverse side effects in the long run. Sleep hygiene is important. Generally, insomnia should improve when its cause is identified and treated, although the most common cause, depression, is usually recurrent.

Treatment Overview

The goals of treatment vary according to the type of insomnia you are experiencing. A thorough review of your daily habits, drug intake, diet, and exercise pattern may uncover correctable causes of insomnia. For primary insomnia (a long-standing, chronic condition with no apparent relationship to any stress or life event), the treatment needs to address any medical or psychological issues that relate to the sleep disturbance.

Secondary insomnia is connected to a clear stress or life event, such as bereavement, medication, or depression. If the insomnia is transient (lasting less than four weeks), reassurance and supportive counseling are appropriate treatment options.

One of the most important measures in managing insomnia is attending to sleep hygiene. This includes:

• Optimizing your bedroom for sleep
• Keeping a regular sleeping schedule
• Avoiding daytime napping
• Avoiding heavy or spicy meals before bedtime
• Avoiding caffeine, alcohol, and exercise in the evening
• Seeking supportive counseling to help address the underlying causes of insomnia

Though hypnotic drugs are effective in inducing sleep, they can lose their effectiveness once your body becomes accustomed to them, and may produce withdrawal when discontinued. Furthermore, after only a few days of use, discontinuing the drug can make the original sleep problem worse (rebound insomnia) and increase anxiety.

The habit-forming potential of the benzodiazepine class of drugs is a long-term concern. These hypnotics work by suppressing brain functions. It can be particularly dangerous to get up — say, to answer the phone or go to the bathroom — in the hour after taking a hypnotic. They are also dangerous when taken with alcohol, other hypnotics, narcotics, antihistamines, and antidepressants. Overdose is possible with hypnotics. For these reasons, hypnotic drugs are not recommended for first-time treatment of insomnia.

Drug Therapy

Drugs Most Commonly Used
Ambien
Ativan
Desyrel
Elavil http://www.nmihi.com/a/amitriptyline.html
Klonopin
Neurontin http://www.nmihi.com/f/gabapentin.html
Remeron
Seroquel
Zyprexa

Healthcare Professionals Who May Be Involved in Treatment

• Internists
• Pediatricians
• Family physicians
• Psychologists
• Psychiatrists
• Sleep medicine specialists
• Pulmonologists
• Otolaryngologists

Activity and Diet Recommendations

Restricting daily activities does not treat insomnia. A daily exercise routine, especially aerobic, helps as long as you don't exercise close to bedtime.

To help avoid insomnia you should avoid consuming:

• Caffeine and related compounds. These are known to cause wakefulness. Caffeine isn't just found in coffee, but also in chocolate, soft drinks, tea, coffee-flavored ice cream, hot cocoa, and other foods. Even decaffeinated coffee contains some caffeine, and depending on your body's sensitivity to caffeine, this may be enough to cause insomnia.
• Alcohol. Even though alcohol is a depressant, it produces a number of sleep-impairing effects. Alcohol can cause your body to release adrenaline, and it disrupts serotonin levels that help initiate sleep. If you do not eliminate alcohol from your diet completely, it should be avoided for at least three hours before retiring.

Quality of Life

Adequate sleep is restorative. It may be more difficult to recover from other medical conditions when you don't get sufficient sleep.

Considerations for Children and Adolescents

Insomnia affects children and adolescent less often than adults, but when it does, the problem must be addressed and treated to avoid further complications. Sleep-inducing drugs may be addictive and may result in adverse side effects. When a sleep-inducing drug is prescribed short-term by a physician, monitor your child's intake of the drug. Children are especially sensitive to stimulants. Children with insomnia should not take cough suppressants and use nasal decongestants that are known to cause excitability in children. Consider switching brands or to versions formulated for children. Adolescents typically need more sleep than adults.

Considerations for Older People

A shift in sleeping patterns as we age is normal, and the amount of sleep decreases as we get older. It is important to recognize this in addressing insomnia for the older people, and not to assume that less sleep is a problem unless it is causing distress in your daily activities.

Medication for insomnia in older people is started at lower doses. If increases in dosage are needed, they are done slowly.

Current Therapies Available

Generally, appropriate self care and removing or treating the cause of insomnia are most effective, but some sleep-inducing drugs are available for short-term use:

• Benadryl (diphenhydramine)
• Benzodiazepines such as Restoril (temazepam) and Ativan (lorazepam)
• Ambien (zolpidem)
• Desyrel (trazodone)
• Tricyclic antidepressants such as Pamelor (nortriptyline).