(return to specializations page)

INSOMNIA

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30%-50% of the general population is affected by insomnia, and 10% have chronic insomnia.

Insomnia is a symptom that can accompany several sleep, medical and psychiatric disorders. It is characterized by persistent difficulty falling asleep and/or difficulty maintaining or staying asleep and/or experiencing sleep as being non-restorative upon awakening. The patient learns to neither avoid situations that create anxiety nor ignore the raw data of their sensory, affective, and cognitive experience. Insomnia is typically followed by functional impairment while awake.

CLASSIFICATION OF INSOMNIA

• Transient insomnia - lasts less than one week
• Short-term insomnia - lasts between one to three weeks
• Chroic insomnia - lasts longer than three weeks

Insomnia is the body's way of saying that something isn't right. Things that may cause insomnia include stress, too much caffeine, depression, changes in work shifts, and pain from medical problems, such as arthritis.

PATTERNS OF INSOMNIA

• Onset insomnia - difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
• Middle-of-the-Night Insomnia - Insomnia characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning. Also referred to as nocturnal awakenings. Encompasses middle and terminal insomnia.
• Middle insomnia - waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness.
• Terminal insomnia - early morning waking. Often a symptom of clinical depression.

INSOMNIA SYMPTOMS

Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms intertwine with those of other medical or mental conditions.

Some people with insomnia may complain of difficulty falling asleep or waking up frequently during the night. The problem may begin with stress. Then, as you begin to associate the bed with your inability to sleep, the problem may become chronic.

Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:

• Poor concentration and focus
• Difficulty with memory
• Impaired motor coordination (being uncoordinated)
• Irritability and impaired social interaction
• Motor vehicle accidents because of fatigued, sleep-deprived drivers
• People may worsen these daytime symptoms by their own attempts to treat the symptoms
• Alcohol and antihistamines may compound the problems with sleep deprivation. Others have tried nonprescription sleep aids.

CAUSES OF INSOMNIA

• Psychological Related Insomnia
• Life problems like fear, stress, emotional or mental tension, work problems, financial stress
• Anxiety
• Obsessive compulsive disorder
• Post-traumatic stress disorder
• Schizophrenia
• Mania (bipolar disorder)
• Clinical Depression

Insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness.

PSYCHOACTIVE DRUGS OR STIMULANTS

Certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, MDMA and modafinil.

RESTLESS LEGS SYNDROME

Can cause insomnia due to the discomforting sensations felt and need to move the legs or other body parts to relieve these sensations. It is difficult if not impossible to fall asleep while moving.

PAIN

Any injury or condition that causes pain. Pain can preclude an individual from finding a comfortable position in which to fall asleep, and in addition can cause awakening if, during sleep, the person rolls over and puts pressure on the injured or painful area of the body.

HORMONE SHIFTS

Such as those that precede menstruation and those during menopause.

DISTURBANCES OF THE CIRCADIAN RYTHYM

Shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Jet lag is seen in people who travel through multiple time zones, as the time relative to the rising and setting of the sun no longer coincides with the body's internal concept of it. The insomnia experienced by shift workers is also a circadian rhythm sleep disorder. Poor sleep hygiene, e.g., noise.

 

TREATMENT

Combining non-pharmacologic and pharmacologic treatment is the most effective treatment for insomnia.

 

NON-MEDICAL TREATMENT AND BEHAVIORAL THERAPY

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus control, and sleep restriction. These also referred to as cognitive behavioral therapies.

SLEEP HYGIENE

Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps can be taken to improve a patient's sleep quality and quantity. These steps include:

• Sleep as much as needed to feel rested; do not oversleep
• Regular exercise at least 20 minutes daily, ideally 4-5 hours before bedtime
• Avoid forcing sleep
• A regular sleep and awakening schedule should be kept
• Caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.) should be avoided. Avoid "night caps," (alcoholic drinks prior to going to bed)
• Do not smoke, especially in the evening
• Do not go to bed hungry

The environment in the room should be adjusted for comfort. (lights, temperature, noise, etc.).

RELAXATION THERAPY

Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.

STIMULUS CONTROL

Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.

• Go to bed when you feel sleepy
• Do not watch TV, read, eat, or worry in bed. The bed should be used only for sleep and sexual activity
• If the person does not fall asleep 30 minutes after going to bed, they should get up and go to another room and resume relaxation techniques
• The alarm clock should be set to get up at a certain time each morning, even on weekends
• Long naps in the daytime should be avoided

SLEEP RESTRICTION

Restricting the time spent in bed only to sleep. This may improve the quality of sleep. This therapy is called sleep restriction. It is achieved by averaging the time in bed that the patient spends only sleeping. Rigid bedtime and rise time are set, and the patient gets up even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation for the previous night.

 

MEDICATIONS AND MEDICAL THERAPIES

There are many medications to treat insomnia. Generally, medication should not be the only therapy for insomnia. Treatment is more successful if combined with non-medical therapies.

CLASSES OF SLEEP MEDICATION

• Benzodiazepine sedatives
• Non-benzodiazepine sedatives
• Melatonin
• Some antidepressants
• Antihistamines with sedative properties