Insomnia

Insomnia

Introduction

When we have difficulty falling asleep, staying asleep or problems waking up during the nights sleep we are suffering from insomnia. A 1991 Gallup poll found that 36% of American adults have some type of insomnia and 9% have chronic sleep difficulty. For the 36% with insomnia, 72% complain of waking up in the morning feeling drowsy or tired. In addition to this 36%, almost everyone experiences difficulties with poor sleep from time to time when facing problems such as a family crisis, death of a loved one or loss of a job. These are situations in which it is quite common -- maybe even normal -- to have difficulty with sleep. We try and break insomnia into certain categories:

Short term or transient insomnia - as stated, the type usually brought on by some life event and lasting a few days to a few weeks.
Chronic insomnia - insomnia lasting weeks and then sometimes months or years. This may start with a psychological factor but become an engrained pattern and be very challenging to change. There may also be a genetic component to chronic insomnia.
Medical causes for insomnia - in some patients a medical problem other than sleep may lead to insomnia. For example, arthritis with nighttime pain is a common problem. The first step in evaluating insomnia is to exclude a medical cause.

It is only recently that physicians and other health care workers have begun to take the complaint of insomnia seriously. This change in attitude has come about because of the vast numbers of people with sleep problems and the fact that people with chronic insomnia report significantly more problems meeting their work and family responsibilities and have over twice as many auto accidents as people without sleep problems.

Short Term Insomnia

Most of us experience this at least occasionally. The important thing is to try and break the pattern before we become severely sleep deprived and before the pattern becomes a chronic one. You can try several things to help yourself in this situation

Try not to become anxious about the very fact of not falling asleep as this tends to only make the problem worse. You should never TRY to fall asleep, learn to ALLOW yourself to sleep. Trying to sleep is almost always counterproductive and actually increases anxiety about sleep.
Follow the guidelines for good sleep habits called sleep hygiene.
For those who have occasional difficulty falling asleep, the best advice is to do whatever helps and avoid whatever makes matters worse. There are many reasons why someone may have trouble falling asleep ranging from 'nerves', to trying to sleep at the wrong time in the body's daily wakefulness-sleep cycle. So, sleep aids that work for one person may do nothing at all for someone else.
This may be an excellent indication for trying a sleep aid such as a sleeping pill. When used appropriately it may break the pattern quickly.

Chronic Insomnia

Some people seem born with a tendency to be poor or light sleepers. They fall into a pattern of interrupted sleep, awakening several times, often getting out of bed, and then having difficulty falling back asleep. Others develop the problem after some life event but cannot break it on their own or become so anxious that they anticipate not sleeping, which of course then becomes a reality. While more challenging to treat, there are answers :

As with short term insomnia, the first things to consider trying is to develop good sleep hygiene starting with a regular schedule of sleep and wakefulness so as to maximize the natural tendency to sleep during the night.

Get up at the same time every day, 7 days a week. Try to sleep only at night -- no naps.

Do not worry about one or two bad nights. Eventually, you will be sleepy enough to sleep at the appropriate time and feel rested when you wake up.

Avoid stimulating foods and drinks, particularly after dinner.

Do not use alcohol for sleep -- alcohol is a very bad sleep aid because, while it may help you feel drowsy, it wears off in 3 or 4 hours and actually wakes you up once it has been partially eliminated by the body's metabolic processes. Alcohol is second only to depression as the leading cause of waking up too early and being unable to get back to sleep.

If you do wake up at three in the morning and cannot get back to sleep, try to do something quiet and, preferably, in the dark so as not to disrupt your body's clock. Listening to relaxing music is a sensible choice.

Avoid exercise and other stimulating activities at these hours so that, even if your 24-hour wakefulness-sleep cycle is disturbed, your activity-inactivity cycle is preserved It is not usually advisable to exercise just before bedtime or if you awaken. For all humans there is a physiological tendency to have a major sleep bout once every 24 hours. Most of us begin this sleep bout between 10 PM and 1 AM. Any behavior that alerts us, such as vigorous exercise or intense intellectual and emotional activity, will act to delay the sleep bout. People who never have trouble falling asleep are probably oblivious to this effect. However, for those who are frequently troubled by difficulty falling asleep, it is wise to avoid any bedtime activity that leaves one physiologically or mentally aroused.

Sleep Maintenance Insomnia

One type of chronic insomnia is the inability to fall back asleep after awakening in the middle of the night. There are a few common causes to consider for this type of insomnia, called sleep maintenance insomnia.

In some it is just a behavior that has developed and becomes engrained in our brains.
Excessive alcohol is one of the most common causes; the answer is obviously to reduce alcohol intake.
In others it may be due to depression. People who are depressed may not recognize any other problem except early morning awakening. Most doctors can diagnose depression and begin therapy after one or two visits. The most widely accepted theory about depression is that it is a biological imbalance among the brain chemicals, called neurotransmitters that are used by brain cells to signal one another. Imbalances in these chemicals almost always affect sleep as well as mood. When the depression is controlled, the sleep problem usually goes away.

Recent studies have shown that cognitive behavioral therapy can be very helpful and avoid the use of sleeping pills in some patients. This involves some changes in sleep schedule that may seem contradictory to common sense. Many insomniacs lay in bed awake, trying to sleep, which is almost always doomed to failure. This technique involves a few steps, which may seem difficult at first but have a high success rate. This approach is very challenging at the beginning, but with support from loved ones and determination is highly successful :

Select a wake up time and stick to it 7 days per week
Estimate the total time you believe you are actually sleeping and add 30 minutes, then determine your bedtime by subtracting that from your desired wake up time. (For example, if you want to wake up at 7 a.m. and think you sleep 6 hours, then your bedtime would be 12:30 a.m.)
When you feel as if you are sleeping solidly for 85-90% of that time, but still feel sleepy during the day, increase your sleep time by going to bed 15 minutes earlier. You can add 15 minutes to your sleep every few days until you are either no longer sleepy during the day or begin to wake up in the night again.

Sleeping Pills and Sleep Aids

Despite these measures, you may not be able to reestablish good sleep. For you and with professional help, sleep-promoting medication, sleeping pills, can be very helpful. While there is no perfect pill, some medications, particularly newer ones, are quite safe and free of major side effects. Modern sleeping pills of the benzodiazepine or imidazopyridine type are often used in 'situational insomnia'. These kinds of drugs are safe and effective when used as directed. In fact, short-term use during a crisis may prevent a chronic insomnia problem from developing. They can also be helpful in long term problems as a short-term aid to reestablishing a good sleep pattern.

You must also pay attention to your environment. Loud noises during sleep such as the noises from an airport have been shown to disrupt sleep to some extent even in people who say that the noises do not keep them awake. This is because the normal brain always reacts to stimuli such as sounds or touches even during sleep. If you still cannot acclimate to your new location even with these measures, you had better think about moving. There is really no long-term remedy that would be preferable to finding a quieter location.

Another common question is whether the bed itself is crucial. In general, people sleep best on the surface that feels most comfortable to them. However, the best sleep research available shows that, after a night or two of adaptation, most people can sleep as well on a thin pad over a concrete floor as they can on the most elaborate mattress available. Of course, this is only true for people who do not have muscle or skeleton problems that require particularly soft or particularly firm surfaces to avoid discomfort. The bed should give enough support that your muscles do not have to actively hold you to maintain a comfortable position.

While research has not shown that the cost or physical properties of sleeping surfaces are major factors determining sleep quality, other psychological factors will influence what people believe about sleeping surfaces. For example, the more money and time invested in a particular mattress and/or bed, the stronger will be the belief in the superiority of this particular sleeping surface. We also know we cannot always measure all the parameters that contribute to a good nights sleep.

Conclusions

Insomnia is caused by many factors, but the common denominator is poor sleep and an impact on daytime function and well being. You do not have to accept insomnia as something you must live with. There is help available, either from your family physician or from a sleep specialist. In the majority of cases improvement does occur. Seek help early before the problem becomes even more difficult to treat.