Chapter 4
I Can’t Sleep a Wink: Examining Insomnia
In This Chapter
Figuring out what insomnia really is
Explaining who suffers the most
Pinpointing common causes
Reviewing the symptoms of insomnia
Visiting your doctor
Seeking treatment
Looking at movement disorders and insomnia
The occasional inability to fall asleep is so universal to the human condition that several singers have crooned Top Ten tunes about it: I Couldn’t Get to Sleep Last Night, and How Can I Sleep? to name a couple. But if you’re wideawake night after night when you’d much rather be fast asleep, probably the last thing you feel like doing is breaking out in song.
According to the National Sleep Foundation, almost half of Americans report they have experienced difficulty falling asleep or staying asleep at one point in their lives. In fact, insomnia is the most common sleep disorder, affecting about 12 percent of the population at any given time, or approximately 32 million people. Yet, a 1999 Gallup Poll found that only 7 percent of people with chronic insomnia (which is persistent for a month or more) seek medical help specifically for their sleeplessness. Another 26 percent mention their insomnia while visiting their doctors for another reason, but the vast majority of insomnia sufferers never tell their doctors they have trouble sleeping.
For whatever reason, many people who struggle with insomnia choose to suffer in silence, never seeking help for their condition. As sleep debt or the difference between the actual and ideal number of hours slept each night mounts, the person with insomnia may become less and less able to function adequately at work, have more automobile accidents, and start to act like a real bear at home. (For more on sleep debt, see Chapter 2.) So, unless you want to end up on everyone’s “least popular” list, seek out relief for your insomnia, no matter what the underlying cause.
This chapter provides an overview of insomnia, clues you in about the different types of insomnia and what can cause them, and also discusses how doctors diagnose insomnia. We also take a look at the most effective treatment options and the potential benefits and side effects of some common over-the-counter (OTC) and prescription sleep aids.
The good news is that most people with insomnia respond well to appropriate treatment. In other words, you don’t have to keep suffering! If you want to sleep like a baby and put your restless nights behind you, read on!
So What Is Insomnia, Anyway?
Simply put, insomnia is a condition characterized by difficulty falling or staying asleep. Waking in the middle of the night or waking too early in the morning and not being able to get back to sleep is also insomnia. When you sleep a full night, but awake unrefreshed or have the perception that you didn’t sleep well, that, too, is a type of insomnia.
Insomnia is the most common type of dyssomnia; that’s why we devote an entire part of this book to identifying and dealing with its symptoms. Dys is a prefix derived from Greek meaning abnormal or difficult. Somnia comes from the Latin somnus meaning sleep. So dyssomnia means difficult sleep (we discuss other dyssomnias including jet lag, narcolepsy, and sleep apnea in Part III). Oddly enough, dyssomnia has become more of a medical term not familiar to most lay persons, while insomnia has entered popular vocabulary to such an extent that almost everyone knows it means difficulty in falling or staying asleep. Even Hollywood caught on with the release of a movie in 2002 called Insomnia, a more explicit title than a previous movie titled Sleepless in Seattle .
There are three categories of dyssomnia, including:
Intrinsic sleep disorders: Caused by some problem originating from within the patient’s own body or nervous system, such as obstructive sleep apnea (OSA)
Extrinsic sleep disorders: Caused by something external, such as inadequate sleep hygiene
Circadian rhythm disorders: Caused by problems in a person’s sleep-wake schedule not synchronizing with their internal clock, such as jet lag
What you do about your problem depends on the frequency and severity of insomnia that you suffer. If you have only the occasional sleepless night and can easily pinpoint the cause — big meeting at work, leaving on vacation, daughter getting married, and so on — then don’t worry. You still do need to get your sleep, but the solution may be something as easy as taking an OTC sleep aid for one or two nights until everything settles down a bit. The key phrase here is one or two nights. We’re not advising chronic use of sedating OTCs.
When you dread going to bed because you know that all you’re going to do is thrash around and never really fall into a deep sleep, recognize you have a serious problem and seek professional medical help.
Insomnia fast facts
Check out these at-a-glance facts about insomnia:
More women than men suffer from insomnia.
Older adults (age 60 and over) suffer from insomnia more frequently than any other age group.
Insomnia is the third most frequent health complaint (pain is first and headaches are second).
People with chronic insomnia have an increased risk of mortality.
People with insomnia have a faster nighttime heartbeat than people who sleep well.
Patients with insomnia are more likely to develop depression.
People with chronic insomnia are more likely to develop alcohol and/or drug or nicotine dependence.
People with insomnia have faster nighttime brain waves than normal sleepers, possibly indicating more mental activity during the night.
Who Gets Insomnia?
Almost anyone can suffer from an occasional bout of insomnia, but statistically speaking, certain groups come in for more than their share of problem sleep. Women, older people, and people suffering from depression have insomnia more frequently. The following sections explain why.
Why women have insomnia more frequently than men
Research shows that after a woman has a baby, she automatically develops a more acute sensitivity to the sounds her baby makes, enabling her to wake up quickly if she hears a disturbing noise such as a cough or a cry. Unfortu-nately, even long after their children are grown and have moved away, women retain this heightened sensitivity to nighttime noise. If you don’t believe it, clinical studies have found that women who have never had children sleep better, even in their fifties and sixties, than women who had children.
Add to this sensitivity the constant hormonal changes going on in a woman’s body every month. Women who suffer from premenstrual syndrome, or PMS, may have a tough time sleeping when their bodies are awash in hormones. During her period, a woman’s pain from menstrual cramps or lower back pain and breast tenderness may combine to make finding a comfortable sleep position difficult.
Menopausal women may have a hard time sleeping as well because they sometimes have to contend with drenching nighttime sweats. The good news is that by the time women enter the post menopausal phase of life, when all the hot flashes and hormonal swings are finally over, men tend to catch up to them in terms of sleeplessness. In fact, post menopausal women who don’t have insomnia usually sleep longer and better than men of the same age who don’t have insomnia.
Growing older with insomnia
As people age, both the quality and quantity of their sleep tend to deteriorate. Researchers aren’t quite sure why this happens, but they suspect age-related changes in sleep phases and patterns may be to blame. They do know that the amount of time spent in light sleep increases as people get older. The accumulation of various medical conditions may play a role, especially if they’re associated with pain. An alternative explanation is that the biological sleep-wake control system centers become less effective through cell loss or transformation, just as an elderly person’s memory and physical abilities decline.
Losing sleep isn’t cheap
According to a study published in 1999 in the journal Sleep, in 1995, the direct cost of insomnia to the U.S. economy was $13.9 billion. This figure includes the cost for both prescription and over-the-counter (OTC) sleep medications, visits to healthcare providers, and nursing home care to treat insomnia in elderly patients. In addition, insomnia also produces a number of indirect costs. These costs result from lower economic output due to symptoms produced by insomnia that affect job performance, such as increased absenteeism, impaired memory and concentration, decreased ability to complete daily tasks, and decreased problem-solving abilities.
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In addition, neurological conditions such as Parkinson’s disease, Alzheimer’s disease, and some forms of dementia can cause sleep disruptions. Older people are also more likely to take a prescription drug or combination of drugs that may cause sleeplessness. They also experience a higher incidence of depression and other emotional problems that may contribute to insomnia.
Just because you’re growing older, you don’t have to live with poor sleep. Consult your doctor. Many effective treatments are available that can help you get back to sleeping better and longer. You can help improve the quality of your sleep by using some of the tips we include in Chapters 6 and 7.
Insomnia and depression
Insomnia is so much a part of “the blues” that problems with sleep are actually described as one of the major identifying symptoms for diagnosing depression. In fact, more than 90 percent of all patients with depression report that they have difficulty falling asleep, staying asleep, or both. The problem is particularly severe for patients with recurring depression.
Early identification and treatment of insomnia in a depressed patient is important. Proper treatment not only helps the insomnia, but resolving sleep problems also seems to help patients do a better job of sticking with their treatment plans. Alleviating insomnia also improves overall functioning and performance for depressed patients.
Tell your doctor if you’re depressed and having trouble sleeping. You should avoid certain popular antidepressants, including some of the selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). They stimulate serotonin receptors in the brain and change sleep patterns, producing insomnia. However, antidepressants like mirtazapine and nefazodone that block the stimulation of serotonin recep-tors actually help people with depression get to sleep more quickly, and sleep better and longer.
Classifying the Types of Insomnia
You may be thinking, “Okay, I can’t sleep, so I must have insomnia . . . gimme some sleeping pills.” But treating insomnia isn’t that easy. Insomnia is a blanket term that actually covers many variations of sleeplessness. Make sure your doctor determines what type of insomnia you have so that he can prescribe the most effective treatment.
Insomnia can be classified in several different ways, according to
What part of the night’s sleep is disturbed
How long the sleeplessness lasts
What causes the sleeplessness
In the next sections, we look at these classifications.
According to the type of sleep disturbance
If you conjure up an image of insomnia, you probably picture someone counting sheep but never getting to sleep. This picture, however, is misleading. Several different patterns of wakefulness can interfere with your slumber, and all can keep you from getting a refreshing night’s sleep.
I can’t fall asleep
When you can’t fall asleep when you want to, the problem could be related to a number of factors including stress, environmental factors such as a hot room, or a co-existing condition like depression. A very common cause of sleep-onset insomnia is a circadian rhythm disorder called delayed sleep phase syndrome (DSPS). (See Chapter 8 for more information on DSPS.) Whatever the cause, the longer you go without being able to fall asleep easily, the more difficult falling asleep seems to become, and the more likely it is that the condition becomes chronic.
People who can’t fall asleep when they go to bed have sleep-onset insomnia. Among healthy adults, half fall asleep in 5.5 minutes or less, and the other half requires at least 10 minutes to fall asleep. People with insomnia should be so lucky. Several studies have shown that a person with sleep-onset insomnia requires an average of about 60 to 90 minutes to fall asleep after going to bed.
I can’t stay asleep
If you continually awaken for no discernible reason during the night, you have sleep-maintenance insomnia. If you fall asleep easily, but can’t stay asleep, or if you keep waking up throughout the night and lie awake for at least 30 minutes before you go back to sleep or never seem to fall back into a truly refreshing deep sleep at all, you have a general form of sleep-maintenance insomnia. This type of insomnia produces particularly poor sleep quality, and sufferers may feel exhausted and unrefreshed upon awakening in the morning.
I wake up too early and can’t get back to sleep
If you awaken too early (sometimes as early as 3 or 4 a.m.) and have difficulty getting back to sleep, you have early morning awakening insomnia (or what is unfortunately sometimes called terminal insomnia because it takes place at the “terminal” or end stage of sleep). You can fall asleep, but you just can’t stay asleep for the entire night. After you’re awake, you’re tremendously frustrated or in some cases you have a “sinking feeling of doom.” As a result, you can’t get back to sleep again no matter what you do, so you end up sleeping fewer hours than you need to feel restored, which results in extreme fatigue and daytime sleepiness.
If you have this type of insomnia, you may wake up in the middle of the night and remain wide awake for a few distressing hours before falling back to sleep. But when you wake up at your normal time, you’re groggy from having missed those restful hours.
According to the duration of symptoms
Insomnia is also classified according to the duration of symptoms, with chronic insomnia (persisting for a month or more) being regarded as most serious compared to short-term insomnia (lasting one to four weeks) and transient insomnia (lasting only two or three days). We’re not making light of short-term or transient insomnia; any condition that interferes with sleep puts you at risk for a number of things, including higher incidence of on-the-job accidents and motor vehicle accidents. But when insomnia persists and sufferers start to build up a significant sleep debt, it can have devastating effects on waking life and on personal and business relationships. The following sections look at possible causes of each class of insomnia.
Transient insomnia
Transient insomnia usually has a readily identifiable cause, such as an upcoming exciting event like the impending birth of a baby, sleeping in an unfamiliar place, or a stressful event such as an important exam, an automobile accident, or an unexpected repair bill. By its nature, transient insomnia is limited to a few nights surrounding the acutely stressful event, it generally lasts for no more than several days to a week, and it usually resolves on its own. An OTC sleep aid can help you sleep on those nights when you know that something significant weighing on your mind will likely keep you awake. However, if you regularly experience bouts of transient insomnia or your insomnia lasts more than two days, seek medical attention.
Short-term or intermittent insomnia
Short-term insomnia can last several weeks, and is usually related to a significant ongoing stressful situation, like losing a job, financial difficulties, a spouse’s death, an acute injury, or a divorce.
Is insomnia a psychiatric condition?
Many people with insomnia and even some healthcare professionals persist in the belief that insomnia is a psychiatric illness. This perspective derives from a variety of known associations:
Nearly 90 percent of patients with mood disorders suffer from insomnia.
Among individuals with insomnia who come to sleep disorders centers, 35 percent have insomnia related to a psychiatric illness; in half of those cases the illness is a major depressive disorder.
Thought disorders like schizophrenia commonly produce the complaint of not sleeping at all.
Anxiety disorders are highly correlated with insomnia.
You can easily see why psychiatric disorders are over-generalized as the cause of insomnia, but they are only one, albeit a major one, of the illnesses and conditions associated with insomnia. But keep this fact in mind: Even though insomnia is commonly associated with mood disorders, there are 37 other causes, most of which aren’t psychiatric.
Because it lasts more than just a few days, short-term insomnia can have a significant impact on daytime alertness and performance, and also negatively affect personality and attitude. Insomnia that goes on for a week or more can produce so much stress surrounding bedtime that it can actually increase the problem’s severity and duration. The idea of wanting to go to sleep but being afraid that you won’t be able to can become a significant stressor in and of itself. Talk to your primary care physician about your sleep problems. He can help you determine if you need to seek professional evaluation and treatment for short-term insomnia to keep it from becoming chronic insomnia.
Chronic insomnia
When your insomnia goes on for a month or more, you have a serious health problem. Insomnia can become a vicious circle. For example, you lose a night of sleep worrying about a real event, such as a big meeting at work the next morning. Then the following night, the meeting having gone well, you should be able to fall sleep with no difficulty. But instead, you’re unable to sleep because you’re still worrying about not getting to sleep the night before, which keeps you awake.
If your sleeplessness persists, see a doctor as soon as possible for a proper diagnosis and treatment. Left untreated, chronic insomnia can lead to a host of other health problems, including hypertension, diabetes, obesity, and heart disease. If you have chronic insomnia and have noticed significant health changes, check out the section, “Diagnosing Insomnia,” in this chapter, which looks at questions you can ask your doctor.
According to underlying causes
During the diagnostic process, doctors further classify insomnia according to its origin or cause so they can recommend the appropriate therapy. The classifications used are primary and secondary insomnia.
Primary insomnia
All sleeplessness that isn’t due to a medical, psychiatric, neurological, or environmental cause is called primary insomnia, meaning the insomnia itself is the medical condition and isn’t just a symptom of something else.
Primary insomnia can be further classified as either conditioned insomnia, sleep state misperception, or idiopathic insomnia.
Conditioned insomnia: Also called psychophysiological insomnia, conditioned insomnia results when a person who is suffering from ongoing stress develops poor sleep habits that condition him to sleep poorly. Such patients develop a vicious cycle of self-defeating bedtime behavior; after a few sleepless nights, they begin to associate their bedrooms with not being able to sleep. The closer they get to bedtime, the more anxious they become and the more they focus on their sleeplessness. They fear they’ll never be able to get to sleep, and eventually their anxiety and frustration actually make that fear a self-fulfilling prophecy. Interestingly, these people can fall asleep on the couch, sleep better in hotel rooms than at home, and sleep well in the laboratory. This happens because
• They’re not in contact with the cue they have conditioned themselves to associate with sleeplessness — their own bed and bedroom.
• They’re not trying to sleep.
• Their self-defeating bedtime behaviors are inhibited in locations they don’t associate with sleeplessness.
Sleep state misperception: This condition results from the mistaken belief that you’re awake when you’re really asleep. People believe they can never get to sleep but are actually asleep while thinking they’re awake. Like most people, you may assume that the brain switches off when you sleep and you become unconscious. You know you’ve slept because you can’t remember anything from when you fell asleep until you woke up; at least, that’s how you interpret it. However, your brain is not “off” when you sleep. Furthermore, it can be in a very active state. Think about it . . . dreams occur during sleep, and they’re certainly a product of an active brain. Recordings of their brain activity in a sleep lab (see Chapter 3) show these people are getting a full night’s sleep, but they swear that they tossed and turned all night and didn’t sleep a wink. This is a “state” misperception. Some scientists argue that sleep recording techniques are too crude to detect features of wakefulness associated with sleep state misperception, and perhaps someday doctors will better understand why these people perceive themselves as being awake. Anxiety often increases the degree of sleep state misperception.
Idiopathic insomnia: This term refers to a condition in which a person has had trouble sleeping for most of his life, but there is no apparent or readily identifiable cause for the insomnia. It is less common than behavioral insomnia. Because the condition starts in childhood and tends to run in families, many researchers believe that some undetected brain abnormality may be to blame.
Secondary insomnia
In secondary insomnia, a medical problem, such as sleep apnea or restless legs syndrome, or an emotional problem, such as depression, causes the insomnia. The sleeplessness is considered a symptom and not a medical condition. If insomnia is secondary, your doctor should try to determine what’s causing the insomnia and treat it directly. Treating only the symptom without considering the cause can lead to a therapeutic misadventure. For example, consider a cardiac ischemia patient with chest pain who goes to the emergency room. If a doctor treats the symptom of pain but doesn’t address the cause of the pain, the disease can progress unabated.
Now consider a person with sleep-maintenance insomnia caused by sleep apnea, a condition that causes frequent interruptions in nighttime breathing (discussed in detail in Chapter 9). If the person’s doctor prescribed a sleeping pill just to treat the insomnia, the person’s undiagnosed apnea will get worse because
Sleeping pills usually suppress breathing.
Sleeping pills usually increase airway collapsibility by relaxing the muscles in the throat, tongue, and soft palate.
Sleeping pills raise the arousal threshold so the person’s apnea episodes get longer and longer.
On the other hand, if the cause is being treated, and there is still insomnia, a person shouldn’t suffer needlessly. For example, after surgery, doctors prescribe various medicines for pain, but sometimes the pain still interferes with sleep. Using a sleeping pill to help the patient sleep is a reasonable practice. Similarly, if you’re being treated for arthritis, but still awaken with pain at night even though the pain is aggressively treated, treating the insomnia in addition to the pain isn’t just merciful, it’s good clinical practice.
Pavlov’s dogs and your bedroom
Perhaps the most famous experiment in conditioned behavior was conducted by the Russian scientist Ivan Pavlov. Each time he presented his dogs with food, he sounded a bell. In the beginning, the appearance of the food caused the dogs to salivate. After a while, the dogs came to associate the sound of the bell with the food and started to salivate when the bell was rung, even though no food was presented. They had learned a conditioned response.
In much the same way, when you come to associate your bed and bedroom with sleeplessness, you have developed a conditioned response that keeps you from falling asleep in your own bed. The good news is that you can be deconditioned, so if this type of negative association is keeping you from getting a good night’s sleep, a doctor trained in stimulus control therapy can help you learn how to associate your bed with sleeping instead of not sleeping.
Anything from depression to arthritis, headache, or indigestion can cause secondary insomnia. (See Chapter 5 for more information on secondary insomnia.) Emotional problems, plus almost anything that causes physi- cal pain or discomfort, can produce secondary insomnia as a symptom. Treatment of the underlying problem can often resolve the secondary insomnia as well.
Napping — does it help or hurt?
Some people with insomnia find themselves nodding off at odd times during the day and early evening hours. Sometimes they feel so sleepy they simply can’t hold their heads up for another minute and they think a quick nap is the answer. Although it may make you feel better in the short term, napping isn’t a good idea for people with insomnia. Most doctors agree that daytime napping only exacerbates the person’s inability to get to sleep at night and decreases the effectiveness of long-term therapies such as training yourself to associate sleep with darkness and keeping a reliable bedtime.
Sleep mechanisms gone awry
You may wonder, “Why do I fall asleep?” and “Why do I wake up again?” Sleeping and waking exist in a dynamic balance. They perform a precise dance choreographed by two sleep mechanisms, homeostatic process and arousal threshold, and two wake mechanisms, circadian rhythm and autonomic nervous system activation. These mechanisms must remain in balance to provide good quality sleep.
Insomnia can also result when basic sleep-wake mechanisms go awry. The good news is that there are strong biological pressures that assert “self- righting” forces when things begin to get out of whack. This design is necessary for survival. Of course, sometimes people temporarily forgo sleep (for example, a natural disaster). Other circumstances, like air travel, may require a change in people’s sleep-wake schedule because they suddenly find themselves in a different time zone. However, if a defect or irregularity exists in one of the regulating mechanisms, sleep will become unstable and may not become normal again without some help. (See Chapter 8 for more information about sleep disorders that result from a disruption of circadian rhythm.)
Homeostatic sleep process
The most basic of all sleep mechanisms is called the homeostatic process, which means the longer you’re awake, the sleepier you get. If you continue to not sleep for extended periods of time, the pressure to sleep increases until eventually, sleep is inescapable. At that point, sleep takes over like a seizure. However, unlike a seizure, you don’t have any warning you’re about to fall asleep, which is why it can be dangerous.
Arousal threshold
After a person falls asleep, an internal biological mechanism called the arousal threshold is activated that helps preserve sleep. This guardian of sleep, probably located in the midbrain or thalamus, filters incoming stimuli to shield the brain so that it can continue to sleep. When an external stimulus like noise or internal stimulus like pain exceeds the arousal threshold’s filtering ability, you wake up.
The dynamic model of insomnia
Arthur Spielman, a highly regarded researcher and expert in the treatment of insomnia, developed a tremendously useful model for insomnia. He postulates that a basic threshold for sleeplessness exists, and if you exceed this threshold, insomnia will occur. He notes that three dynamic factors contribute to insomnia (they all start with the letter P). The first is predisposition, or basic sleep drive. Some individuals may have a strong sleep drive and are always far from the sleeplessness threshold (we know them; they slept through The Guns of Navarone and The Empire Strikes Back).
By contrast, some people have a weak sleep drive and are close to the sleeplessness threshold even under the best circumstances. Any little event can trigger their insomnia, and sometimes they’ll be sleepless for no apparent reason. Usually, this is a lifelong problem arising from a weak homeostatic drive or an over-reactive autonomic nervous system.
The next factor is precipitation. Something happens — perhaps stress, an illness, a grief reaction, or something else. Under normal circumstances, you would expect only transient or short-term insomnia, but the insomnia continues one month, then another, and another. The precipitating event is long gone, but the insomnia remains.
If the insomnia persists long after the precipitant is gone, there’s something perpetuating the insomnia. This perpetuation factor can be conditioned insomnia, grief reaction turned to depression, dependence on alcohol to fall asleep, or counterproductive bedtime habits or routines. More often than not, the perpetuating factor is the one that requires attention, and if you can eliminate it, the sleep system will bring the sleep-wake pattern back to normal.
Sedating medications can raise the arousal threshold and thereby provide relief. The question that still hasn’t been answered scientifically is how far can the threshold be safely raised and for how long? Behavioral treatments are particularly good at addressing a variety of perpetuating factors. If you can reduce these factors, then you can return to predisposition levels. If your predisposition level is near threshold, then you probably have lifelong, chronic, unremitting insomnia that requires continued drug and behavioral therapies (but never will be completely resolved).
Circadian rhythm
Everyone has an internal clock with a period of approximately one day or 24 hours. This clock appears to be an alarm clock. Anyone who has pulled an all-nighter knows that between 3 and 5 a.m., sleepiness becomes almost irresistible. However, by 8 to 9 a.m., even though you’ve been awake longer and homeostatic drive is increased, you feel less sleepy, which means your circadian alarm clock is ringing.
Autonomic nervous system activation
The autonomic (or automatic) part of your nervous system is critical to wakefulness. Activation of the sympathetic arm of this system can
Hinder sleep.
Get you riled up quickly (but settling back down takes much longer).
Create a conditioned response. (For more information on conditioned responses, refer to the sidebar, “Pavlov’s dogs and your bedroom,” in this chapter.)
A great many of the specific causes of sleeplessness work via this mechanism. The source of sympathetic activation can be from outside the brain and body (extrinsic) or from within (intrinsic). Extrinsic activators include caffeine, stimulants, heat, and noise. Examples of intrinsic causes include fear, worry, anxiety, pain, and anger. After one of these factors asserts itself, you become hyped up, and it takes some time to return to a relaxed state. If there is a regular occurrence of autonomic activation associated with the bed and bedroom, then this activation can become a conditioned response. If you get into bed and begin to worry and therefore can’t sleep . . . eventually the bed will trigger the sleeplessness.
Considering Common Causes of Insomnia
So many different factors can cause insomnia that saying that any one reason stands out from the others is difficult. But make sure your doctor ferrets out what’s causing your sleeplessness; otherwise the prescribed treatments may not be as effective. The dynamic model (see the sidebar, “The dynamic model of insomnia,” in this chapter) provides a guide for this process. The predisposing, precipitating, and perpetuating factors and the mechanism through which they act (homeostatic, arousal threshold, autonomic, and circadian) provide the roadmap for selecting an appropriate treatment approach.
The most common reasons for wakefulness include
Anxiety or stress
Certain medications like diet pills, blood pressure, and allergy and asthma medications
Chronic medical conditions that cause pain or discomfort like arthritis or asthma
Depression or other emotional problems
Food and beverages that contain stimulants like caffeine, or that cause digestive upsets
Poor sleep habits, such as going to bed at a different time each night, or sleeping in a bed with pets
Work with your doctor to figure out what’s causing your insomnia. Carefully consider the role played by stressors, emotional problems, medical conditions, stimulants (like caffeine and nicotine), medications, sleep habits, and your sleep environment. Why take a sleep aid if the real reason for your insomnia is excessive caffeine consumption? Cutting back on the caffeine makes more sense. Pinpoint the exact cause so that your doctor can prescribe the proper treatment as well as consider and treat any co-existing medical conditions that may be contributing to your insomnia.
Focusing on the Symptoms of Primary Insomnia
You may be wondering, why review the symptoms of insomnia? I already know the symptoms of insomnia — I’m wide-awake!
Although the inability to get to sleep or stay asleep is certainly the most obvious and noteworthy symptom of insomnia, the condition does cause other symptoms that you may not even recognize as being connected to your sleep problems. In addition, insomnia itself isn’t just a condition; it may also be a symptom of another, more serious underlying condition. (See Chapter 5 for a complete discussion of conditions that can cause secondary insomnia.)Your doctor needs to check you out thoroughly so he can put the whole puzzle together and prescribe an effective treatment for your sleeplessness.
The most common symptom of insomnia is . . . (drum roll, please) sleeplessness. Did you get that right? If so, your prize will be awarded at the end of this chapter. ( Hint: Your prize is a better night’s sleep.)
Other common symptoms may include
Anxiety
“Brain fog” or difficulty concentrating
Drowsiness
Fatigue
Impaired memory
Irritability
Although you probably already knew that fatigue and drowsiness may be symptoms of insomnia, you have to admit that you may not associate your increasing anxiety or lousy mood with your sleeplessness. And very few people understand what a profound effect ongoing insomnia can have on their memory skills and ability to concentrate. Nonetheless, these are all common symptoms of insomnia. So if you’re tired, anxious, and crabby, or you can’t concentrate, but don’t remember why you can’t concentrate, look to insomnia as the underlying cause. Sleep’s function is to restore the brain. When the brain isn’t restored, both mental and coping functions can suffer.
Chronic insomnia can also cause a variety of less common symptoms, many of which you wouldn’t normally associate with insomnia. Less common symptoms may include
Apathy
Headache
Increased blood pressure
Low energy
An overall feeling of sickness or malaise
Weight gain
These less common symptoms generally only show up after a person has been suffering from insomnia for an extended period of time, at least a month or more.
Diagnosing Insomnia
When you visit your primary care physician to try and determine if you have insomnia, he or she will be most interested in discovering if your insomnia is a medical disorder in and of itself or a secondary manifestation of another condition, like arthritis or heartburn (see the “According to underlying causes” section earlier in this chapter as well as Chapter 5 for more information about secondary insomnia). Your doctor will follow several steps in order to reach a definitive diagnosis. (See Chapter 3 for more information on the diagnostic process.)
First your doctor likely will take your clinical history and ask you several questions to help her determine the quality of your sleep, including
How long have you had trouble sleeping?
Had you recently experienced significant stress or an emotional upset when it began?
How did you sleep before the sleeplessness began?
How often do bouts of sleeplessness occur?
Does anything in particular make it better?
Does anything in particular make it worse?
How long does it take you to get to sleep after you lie down?
Are you able to sleep the night through, or do you wake up several times in the middle of the night, or awaken too early?
Do you awake feeling refreshed or groggy?
How many times a night do you wake up?
How long does getting back to sleep take you after you do wake up?
Do you have problems with fatigue and sleepiness during your regular daytime activities?
Is your daytime sleepiness hurting your mental sharpness and job performance?
Does your insomnia adversely impact your waking life, your mood, and your relationships at home and work?
Your doctor may also ask you about your eating and drinking habits to rule out factors such as over-consumption of caffeine as a possible cause. Your doctor will also want to know if you’re taking any drugs, prescribed or not, that could possibly cause insomnia as a side effect and whether or not you exercise regularly and what time of day you exercise. Finally, your doctor will look for any co-existing medical or psychiatric conditions that could be triggering your insomnia.
Sleep history
When your doctor asks about your sleep history, your sleep diary (see Chapter 2) becomes very valuable. If you don’t keep one, your recollection of your sleep disturbances may be so vague that your doctor can’t offer any help. In addition to reading through your sleep diary, your doctor will ask your bedmate for his or her impression of your sleep problems. Sometimes a bedmate has a more accurate take on the situation than the person suffering from insomnia.
Your doctor will check your diary for some of the same information she collected in your clinical history — for example, how long it takes you to get to sleep, whether or not you wake up too soon or too frequently, and how you perceive your sleep quality. Make sure you record all this information in your sleep diary
Your doctor will also want to know when the problem started, how long it’s been going on, and whether you have any easily identifiable triggers, such as emotional disturbances or substance abuse. Finally, she’ll ask you about your sleep habits — whether or not you have a regular bedtime, a comfortable bed in a comfortable room, and so on.
Then your doctor will perform a complete physical examination in order to identify and/or rule out any co-existing medical conditions that may be causing your insomnia. She may also order blood and urine tests that may help rule out underlying medical causes for your sleep problems.
Sleep studies
Your doctor won’t send you to a sleep lab for a polysomnograph or other testing (see Chapter 3) unless he suspects a co-existing condition including sleep apnea, periodic limb movement disorder, and sleep-related epilepsy, to name a few. Sleep studies aren’t usually helpful for diagnosing insomnia, because when a patient is in a sleep lab, some of the triggers that may be responsible for her insomnia aren’t present. A patient leaves behind the hot room, the frisky pet, the snoring bedmate, the neighbor’s barking dog, and many other factors that can contribute to insomnia when he or she comes to a sleep lab.
After your doctor determines what type of insomnia you have and figures out what’s causing it, he will prescribe one of the treatments described in the following sections.
Treating Insomnia
After you’ve completed the diagnostic process, your doctor will prescribe a variety of treatments for your insomnia depending on its seriousness and the underlying cause. Doctors generally adhere to the protocols in Table 4-1 to help their patients manage insomnia (we discuss each treatment option in detail in the following sections).
| Insomnia Type | Treatment Options | |
|---|---|---|
| Transient insomnia | Prescription for a non-benzodiazepine hypnotic | |
| Short-term insomnia | Prescription for a non-benzodiazepine hypnotic, plus | |
| sleep hygiene education and possibly stimulus control | ||
| therapy | ||
| Chronic insomnia | Prescription for a non-benzodiazepine hypnotic, plus | |
| possible referral for a sleep study (if the doctor suspects | ||
| there’s something going on more than just insomnia), | ||
| sleep hygiene education, sleep restriction, stimulus | ||
| control, relaxation training, biofeedback, imagery | ||
| training, sleep restriction therapy, and/or cognitive | ||
| behavior therapy |
If you’ve been diagnosed with secondary insomnia, your treatment will focus on the underlying medical problem that’s disturbing your sleep; when that problem has been resolved, your insomnia should get better as well (see Chapter 5). However, in some cases the insomnia will be treated at the same time with one of the approaches listed in the “Chronic insomnia” section earlier in this chapter.
Using prescription sleep aids
One of the reasons it may be so difficult for people with insomnia to get the help they need is that many doctors still believe that all sleeping pills are dangerous and addictive, which is simply no longer the case. Yes, many decades ago the only sleeping pills available were barbiturates, and those were addictive and even lethal with an overdose. But today, prescription medications are available to help people battling insomnia get a decent night’s sleep, and these meds help insomniacs get to sleep without posing significant risk of addiction or making people wake up the next morning feeling like they’ve been hit by a truck.
Prescription sleep aids are available in the following categories:
Benzodiazepine hypnotics
Non-benzodiazepine hypnotics — have most of the benefits of the benzodiazepine hypnotics without the undesirable side effects
Sedating antidepressants, anticonvulsants, and antipsychotics — sometimes used for the treatment of insomnia, but can have signifi- cant side effects and may create additional problems when the patient stops taking them
The history of sleeping pills
Sleep-promoting substances have evolved over the years. Since ancient times, people used opiates and alcohol to induce sleep, long before anyone knew much about their addictiveness and side effects. However, in the 1860s, the first hypnotic medication was developed — chloral hydrate (essentially alcohol in tablet form). Then at the turn of the century, barbiturates came on the scene and dominated the market as the leading sleep-inducing medication until the 1960s. Barbiturates are dangerous and addictive; therefore, the safer and less addictive benzodiazepines were a welcome replacement and quickly supplanted barbiturates as the leading prescribed sleep-promoting substance. In the last two decades, non-benzodiazepine hypnotics have been developed and appear to be even safer and less habit forming.
The “ideal” sleep medicine
The ideal sleep medication has a rapid onset of beneficial effects, is rapidly eliminated from the body with no lingering side effects the next morning, doesn’t change the patient’s sleep architecture, doesn’t cause lingering sedation or a “hangover effect,” doesn’t cause side effects, is non-addictive, doesn’t cause rebound insomnia when a patient stops taking it, and has a very low potential for abuse and overdose. Unfortunately, the ideal sleep medicine has yet to be created, but several drug companies report that they are making good progress toward its development.
Hypnotics — benzodiazepines
A class of hypnotics called benzodiazepines was introduced in the 1960s. They’re very effective in promoting sleep, and are used for short-term management of insomnia, but they do have some side effects including daytime sedation and dependence with long use. They suppress the hyper-arousal associated with insomnia, but may also disrupt sleep architecture.
Benefits
A benefit of benzodiazepines is that they’re very effective in promoting sleep.
Drawbacks
They can be addictive
They can alter sleep architecture.
Sleep architecture is a fancy way of describing the overall pattern of your sleep, the relationship of the various REM (rapid eye movement) and NREM (non-rapid eye movement) sleep stages, and cycles of sleep. These features are compared to get an overall picture of both the quality and quantity of a person’s sleep. (See Chapter 1 for more about REM and NREM sleep.)
They have muscle relaxant, antianxiety, and anticonvulsant properties, which the patient may not require.
They can depress breathing. (If you have sleep apnea along with insomnia, depressed breathing can be bad.)
They may cause dizziness or problems with speech and movements like walking.
Long-acting ones may take longer to clear from the body, which can cause daytime sleepiness and cognitive and motor impairment.
They can produce tolerance and require a larger and larger dose of the drug to achieve the same effect.
They can cause rebound insomnia (a worsening of sleep problems) and other symptoms of withdrawal when a patient stops taking them.
Non-benzodiazepine hypnotics
In the 1980s, scientists developed non-benzodiazepine hypnotics, and these compounds are now the preferred medications for treating insomnia. The non-benzodiazepine hypnotics have the benefits of the benzodiazepine hypnotics without some of the undesirable side effects. As a group, they represent a major advancement in the treatment of insomnia.
The first one available in the United States was Zolpidem, more commonly called Ambien. The most recently approved is Zaleplon, known as Sonata. Pharmaceutical companies are constantly researching and testing new sleep medications, looking for something that gives better results with fewer side effects. By the time you read this, other approved non-benzodiazepine hypnotics will likely be available on the market.
Benefits
The benefits of non-benzodiazepine hypnotics include
They help people fall asleep more quickly.
They increase total sleep time.
They don’t alter sleep architecture, and may even improve it in patients with insomnia.
They clear from the body quickly; even some people with sleep- maintenance insomnia can use them in the middle of the night.
They don’t cause sedative effects that linger to the following day.
They give a doctor more flexibility to tailor a medication schedule for a patient’s particular needs.
They don’t have much muscle relaxant, antianxiety, and anticonvulsant properties.
They don’t cause rebound insomnia and other symptoms of withdrawal when a patient stops taking them.
Drawbacks
Although non-benzodiazepine hypnotics are extremely beneficial for most patients, they do have some drawbacks:
Because they clear so quickly, patients may still awaken too early.
They may require increasingly larger doses to maintain therapeutic benefit with long-term use.
Long-term high-dose use may result in development of hangover effect, which means the drug’s sedating action persists past the normal hours of sleep, making a person groggy and disoriented during the day.
Sedating antidepressants, antipsychotics, and anticonvulsants
Even though scientists haven’t tested these medications for safety and efficacy in treating insomnia, sometimes doctors prescribe them because they produce sleepiness as a side effect. The sedating antidepressants, including trazodone, amitriptyline, and doxepin, are the most commonly used in this group.
Benefits
A benefit of these medications is that they, you guessed it, produce sleepiness.
Drawbacks
Drawbacks include
They can produce adverse effects on the heart.
They cause hangover sedation.
They can alter your sleep architecture, in particular suppressing REM sleep.
You have a higher chance of overdose than with the hypnotics.
Some of these compounds are associated with significant withdrawal symptoms.
Using OTC sleep aids
Insomnia is such a widespread problem that many pharmaceutical companies market some variation of an OTC sleep aid. Although OTC remedies are of little use to people who are battling chronic insomnia and should be avoided, they may be effective for a single night on occasion.
Most of these products contain antihistamines. Although antihistamines do make you drowsy, they can also cause many undesirable side effects including dry mouth, a hangover effect, nausea, blurred vision, and constipation. Before buying an OTC product, check the warning label or ask a pharmacist. If a particular medication says that it may cause nervousness, jitteriness, or sleeplessness, look for another formulation without the unwanted side effects.
Using herbal sleep aids
Many different varieties of natural sleep aids and herbs have been touted for use as sleep aids. Some have fairly reliable clinical proof that they do work such as melatonin; others like chamomile have little more than anecdotal evidence to recommend them.
Melatonin
Melatonin is a natural hormone produced by the pineal gland in the brain that regulates sleep cycles and seasonal changes within the body (we discuss seasonal affective disorder, or SAD, in Chapter 5). The hormone became very popular as a sort of “magic bullet” sleep aid a few years back, but less popular after its side effects including depression, weepiness, and headaches became known. It’s usually one of the major ingredients in “natural” sleep remedies.
If you do decide to try melatonin, use a very small dose (1 to 2 mg), not because high doses are dangerous but because they render subsequent doses of melatonin ineffective. Also, use only totally synthetic melatonin. You don’t want to use melatonin whose source is harvested pineal glands off slaughterhouse floors or concentrated organic melatonin from cow regurgitate — yuk! By the way, it’s illegal to feed cow-brain melatonin to your livestock — if you had any — because of regulations designed to curb mad cow disease. So if it is not good enough for your cows, it is probably not good enough for you.
The benefits of melatonin include the following (keep in mind that many users don’t report any benefit whatsoever):
It decreases time required to fall asleep.
It doesn’t affect sleep architecture.
It may help to normalize irregular sleep-wake patterns.
Drawbacks to consider include the following:
Grogginess
Headaches
Lowered sex drive
Mild depression
Nightmares
Wild mood swings, including crying jags for no apparent reason
Valerian Root
Valerian Root has a long history of use as a calmative and sleep aid. Patients find Valerian Root beneficial in treating mild cases of insomnia.
In addition, Valerian Root may cause the following side effects:
Headaches
Indigestion or stomach ache
Restlessness
Chamomile tea
For centuries people have used chamomile tea to treat a variety of health complaints, sleeplessness among them. Germans are so fond of it they call it “alles zutraut,” meaning “capable of anything.”
Chamomile tea reportedly helps to promote a deep sleep and produces a soothing feeling of relaxation and calmness. But before you run to the store, consider the following drawbacks:
It causes contact dermatitis or other allergic reactions in susceptible individuals.
It interferes with antiepileptic medications.
If you’re on aspirin therapy or taking a blood-thinning medication like Coumadin, heparin, or warfarin, don’t take it. It can increase the risk of bleeding and hemorrhage when taken with these drugs.
Inhaling the sweet smell of sleep
A study recently conducted by researchers at Wheeling Jesuit University in West Virginia suggests that the scent of jasmine may help people sleep better. Researchers monitored the subjects during three nights while very faint whiffs of jasmine or lavender scent were blown into their rooms. (Subjects also were allowed to sleep with no scent at all.) Subjects in the jasmine- scented rooms slept better than subjects in the lavender-scented and unscented rooms and reported feeling less anxious when they awoke. In addition, upon awakening, they completed tests of mental function more quickly and accurately than did subjects who slept in the other rooms. Although these results are encouraging, a larger scale multicenter trial is needed to confirm the findings.
Effective behavioral treatments
The following sections describe three proven, effective treatments your doctor may recommend if you have short-term or chronic insomnia — cognitive behavior therapy, sleep restriction, and stimulus control — as well as two sections on other possible steps you can take to help you overcome your insomnia.
Cognitive behavior therapy
Cognitive behavior therapy (CBT) is relatively new in the world of sleep disorder care. It combines effective cognitive behavior techniques that work to correct a person’s negative way of thinking with effective behavior therapy treatments that work to correct self-destructive and damaging behavior. Therapists have found that using cognitive and behavior therapy together is very effective in helping patients who are dealing with a variety of mental health issues like obsessions and phobias, chronic anxiety or stress, depression, eating disorders, substance abuse, and many other conditions. CBT has also been found to be helpful in treating certain types of insomnia.
The goal of CBT in insomnia is to help patients change bad sleep habits that prolong insomnia for good habits that promote healthy sleep — mainly to change the patient’s perception of his or her bedroom as a place associated with sleeplessness to a place associated with sleep. CBT is designed to help patients weaken or even break the psychological connections they may have built up between distressing situations like chronic insomnia and their habitual reaction to those situations. CBT helps patients control self-defeating and damaging behaviors by showing them how to calm themselves so they can think more rationally and make better decisions.
Through CBT, patients discover how their patterns of thinking can actually give them a distorted picture of what is happening to them. This negative thinking can trigger episodes of anxiety, depression, or even anger when there is no actual reason for the patient to feel that way. Patients who operate in this mode of habitual negative thinking tend to make bad choices and engage in self-defeating behaviors without realizing what they’re doing. CBT helps them to stop their behavior and develop more positive and beneficial behaviors.
Sleep restriction
Sleep restriction helps people with insomnia by matching the amount of time they spend in bed more closely to the amount of time they actually sleep. First, you figure out how much time you actually sleep by keeping a sleep diary (see Chapter 2). Then your bedtime schedule is set according to your sleep time, not your previous bedtime. For example, if you only sleep five hours during an eight-hour bedtime, then your schedule is set to five hours (for example, midnight to 5 a.m.). In other words, if you’re tossing and turning and staring at the ceiling, with sleep restriction, you have a set shorter bedtime in which to toss and turn. If you do toss and turn, you wind up being very sleep deprived which makes you sleepy the next night.
Sleep restriction works by actually creating a state of sleep deprivation, thereby increasing the sleep drive that makes you feel sleepier. Sleep restriction concentrates sleep time, reduces sleep interruptions, and minimizes awake time in bed. As you begin sleeping a greater percentage of the time (85 percent or more) that you’re in bed (because you are so sleepy), increase the time in bed by 15- to 20-minute increments until you’re spending a full night of restful sleep in bed.
Stimulus control
Stimulus control therapy, which Richard Bootzin at the University of Arizona developed, is designed specifically to treat conditioned insomnia (see the “According to underlying causes” section earlier in this chapter). The therapy trains you to associate your bedroom only with sleep, so that when you get into bed, you’re able to fall asleep more rapidly. You move all other behavior (except for romance) to a more appropriate room. For example, you restrict eating to the kitchen and TV viewing to the family room. To help achieve this goal, remove the phone, TV, books, and your computer from your bedroom. In addition:
Go to bed only when you’re sleepy.
Get out of bed and go to another room when you’re not able to fall asleep or get back to sleep after awakening, and do something boring. Don’t return to the bedroom until you feel sleepy again. (
Note:
No clock watching is allowed; put the clock under the bed or turn it toward the wall.)
Get up at the same time every morning, regardless of the amount slept.
Avoid napping during the day.
If you’re feeling sleepy, don’t drive!
Sleep hygiene education
You may not even realize that some of your own behaviors are contributing to your inability to sleep well. Sleep hygiene education instructs you about the importance of watching your caffeine intake, timing exercise so that it doesn’t interfere with sleep, discovering how to relax before bedtime, and creating a comfortable, inviting, and serene bedroom atmosphere that encourages restful sleep. Furthermore, sleep hygiene informs you about behaviors that may trigger insomnia, such as smoking and excessive drinking. For more on sleep hygiene and tips to “clean up” your bedroom and your sleeping habits, see Chapters 6 and 7.
Other insomnia treatments
Your doctor may also recommend one or more of the following techniques to help you combat insomnia, particularly if you don’t want to take sleeping pills (we discusses these techniques in more detail in Chapter 6):
Biofeedback uses special equipment to teach people how to gain voluntary control over certain bodily functions like brain waves, blood pressure, muscle tension, and breathing, in order to achieve a more relaxed state.
Deep breathing oxygenates your blood more richly, which decreases fatigue, stress, and anxiety.
Imagery training helps people substitute pleasant and relaxing images in place of the stressful and anxiety-producing images they may have swirling in their heads.
Progressive muscular relaxation teaches people to relax tense muscles in a certain order to promote feelings of relaxation and prepare for sleep.
Don’t even think of trying these really bad self-treatments
Over the years, people who are desperate for a good night’s sleep have come up with a number of ways to try and trick themselves into nodding off. Check out the following self-treatments you shouldn’t try at home, because no matter what your friends and coworkers tell you, these are bad sleep habits. You may be able to sleep in spite of doing them, but not because of them.
Watching television or reading in bed. No matter how boring, if you have insomnia, books and TV just won’t make you fall asleep. They may take your mind off the struggle to fall asleep, but if you want to read or watch TV, do it in another room. Keep your bedroom activities confined to sleep and romance so that you’ll associate your bed with rapid sleep onset. If you bring a lot of other activities like reading, talking on the phone, eating, or TV viewing into the bedroom, you may associate them with the bed and bedroom instead of rapidly falling asleep (see the section “According to under- lying causes” earlier in this chapter). Doing these activities in bed only makes falling asleep more difficult. And if you do eventually fall asleep with the TV on, when those loud infomercials start at 2 or 3 in the morning, they’ll probably wake you up.
Taking naps. Even if you’re utterly falling over into your coffee, taking a daytime nap just makes falling asleep that night that much more difficult because it reduces your homeostatic drive to sleep. Thus, when it comes time to go to bed, you aren’t sleepy enough to enter la-la land.
The alcohol and cigarette cure. Yes, alcohol is sedating and may help you fall asleep but no, drinking won’t solve your problem with insomnia; it only will add the problem of alcohol dependency. In fact, drinking on top of extreme insomnia-induced fatigue makes a dangerous mix. If you don’t want a DWI or to be involved in a tragic accident, lay off the booze. And as for that bedtime or middle-of-the-night cigarette? Smoking won’t solve your sleep problem. Nicotine is a stimulant and although it may reduce your cigarette-withdrawal discomfort, it keeps you buzzed and wide-awake long after you wish you’d fallen asleep.
Sheer force of will. No matter how hard you try, you can’t force yourself to fall asleep if you have insomnia. In fact, the harder you try, the less likely it is that you’ll actually drift off. The effort you exert actually excites the nervous system and acts to prevent sleep.
Eating or drinking late at night. Because foods like turkey and milk contain the sleep-enhancing amino acid L-tryptophan, some people think that loading up on such foods close to bedtime will help them sleep. However, if you consume them close to bedtime, these foods have the opposite effect. By activating your digestive system late at night, you make it harder for your brain to relax enough to enter a sleep state. It’s too busy processing that turkey sandwich to focus on sleeping.
Staying in bed later than usual. If you think you can make up for the sleep you’ve lost during the week by staying in bed later than usual on the weekends, you can — but at a price. By sleeping late, your amount of time awake when bedtime rolls around is less than usual. This means that your drive for sleep is less, and a weakened drive to sleep may be inadequate to pay the entry fee to the Land of Nod. Additionally, this change in your sleep schedule further disrupts your circadian rhythm, which may already be out of whack if you’re suffering from insomnia.
Exercising at bedtime. Some people with insomnia think that exercising close to bedtime will wear them out so they can fall asleep faster and sleep better. Exercise may indeed tire the body, but exercising too close to bedtime is counterproductive because nighttime exercise increases metabolism and brain activation at the exact time your brain is trying to slow down in preparation for sleep. So bedtime exercise may actually contribute to increased wakefulness instead of sleepiness.
Sleeping with music playing or the television on. Some people think that background noise can help them fall asleep more readily. Not so. Anything other than white noise will keep your nervous system stimulated and may prevent or delay sleep.
White noise combines approximately 20,000 tones, or every sound frequency discernible by the human ear, to produce a pleasant, soothing sound that can mask other, more disturbing sounds. It works by producing so many sounds that the brain can’t pick out one single sound to pay attention to. Many people enjoy sleeping with fans on not only for the cool breeze, but because the noise of a fan approximates white noise.
Ever-changing bedtimes. Part of the problem with people suffering from insomnia is that they have no reliable bedtime; going to bed whenever they feel like it only reinforces the lack of a regular schedule. If you go to bed at approximately the same time every night and wake up at the same time every morning, you condition your brain to expect sleep at that time, and such a regular schedule is conducive to better sleep. (This means no weekend sleep-ins to try and catch up on your sleep!) Going to bed and waking up willy-nilly any time you feel like it only makes getting into and maintaining a good sleep schedule more difficult.
Self diagnosis and medication. Treating your insomnia with something you heard about standing around the water cooler isn’t a wise idea. Don’t mix herbal remedies with OTC sleep aids. Your doctor is best qualified to diagnose your insomnia, discover what’s causing the problem, and prescribe a treatment protocol tailored to your particular situation that combines appropriate medication with sleep hygiene education, cognitive behavior therapy, and other helpful measures.
Kicking the Sleep Habit — Movement Disorders and Insomnia
Among the most frequent causes of insomnia are two movement disorders, restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). These disorders involve involuntary movement that prevents sleep onset, and/or makes restful sleep very difficult.
Some people think that RLS and PLMD are just two different ways of saying the same thing. However, these are two distinct disorders with different symptoms. Although the two conditions are related, they don’t always occur together.
The creepy crawlers — RLS
People with RLS experience unusual, crawling sensations in their legs (usually their calves). RLS sufferers move their legs constantly, seeking relief from the strange feelings. For people with severe RLS, the urge to move their legs is almost irresistible because moving does relieve their discomfort, however briefly.
About 8 percent of Americans suffer from RLS. Although symptoms can occur any time during the 24-hour day, the discomfort is most noticeable and troublesome when the person becomes inactive or lies down to sleep. Some people only have symptoms when they try to sleep at night, while others have symptoms beginning in the early evening, becoming progressively worse as night approaches. RLS can make falling and staying asleep difficult, if not downright impossible.
RLS-related fatigue and exhaustion interferes with family relations, job performance, and overall quality of life. Because people with RLS may be chronically sleep deprived, they suffer all the usual symptoms of sleep deprivation including irritability, mood swings, inability to concentrate and perform routine tasks, and memory lapses.
In most cases, the cause of RLS is idiopathic, or unknown. RLS runs in families, accounting for about half of all cases, but a deficiency of vitamin B12, folate, or the mineral iron can also cause it. Recent evidence suggests an abnormality of iron metabolism in the basal ganglia of the brain. Iron supplements can help in these cases. People with diabetes, Parkinson’s disease, kidney failure, or nerve damage in the limbs (known as peripheral neuropathy ) are more prone to develop RLS.
The disorder becomes more common as people grow older, and symptoms have a tendency to become more severe over time. However, some documented cases have shown where the disorder actually improved without any special treatment.
Up to 15 percent of women may experience symptoms of RLS during pregnancy, perhaps due to anemia or folate deficiencies, or underlying mineral imbalances brought on by the pregnancy. The symptoms may resolve on their own after a woman gives birth.
Symptoms
People with mild RLS may hardly notice they have a problem, while people with moderate or severe cases do suffer significant sleep disruption and insomnia.
The symptoms of RLS include
Odd sensations deep inside the legs (between the knee and ankle) and feet, and occasionally, in the arms. The sensation usually feels like something crawling inside or up the leg. However, sometimes it feels like itching, burning, tugging, or pulling.
Restlessness.
Symptoms get worse when a person is sitting still or resting.
Unusual daytime sleepiness.
Many physicians persist in ascribing the symptoms of RLS to nervousness, attention deficit hyperactivity fisorder (ADHD), arthritis, muscular injuries or cramps, insomnia, or aging. As a result, many people are reluctant to discuss their symptoms with their doctors.
Some common drugs can aggravate the symptoms of RLS, including calcium channel blockers, many antidepressants and tranquilizers, antinausea, antiseizure, and antipsychotic medications, and some cold and allergy medications.
If you start experiencing new or worsening symptoms of RLS after you start taking a new drug, chances are the RLS could be a side effect. Talk with your doctor about switching medications to reduce or eliminate RLS symptoms.
Treatment
When an underlying medical condition like diabetes causes or aggravates your RLS, treating the primary condition can bring some relief of RLS symptoms.
If a vitamin or mineral deficiency is causing your RLS, your physician will suggest appropriate supplements and a dosage schedule to help relieve symptoms.
Moderate exercise like walking seems to lessen symptoms; aggressive exercise seems to make them worse for some people but, paradoxically, can be very helpful in others. Experiment to see what works best for you. Other possibly beneficial measures include leg massages and taking a hot bath close to bedtime.
Although no drug is specifically approved for use in RLS, doctors have found some success in using low doses of drugs approved for treating Parkinson’s disease, for example, pramipexole. Alternatively, some anticonvulsants medications and even some sleeping pills have been used with varying success. Your doctor can design a medication program that is best suited to your individual needs.
Shake a leg — PLMD
Up to 80 percent of patients with RLS also have PLMD, which involves involuntary movements of the legs and sometimes the arms while a person is sleeping. PMLD is distinct from sleep starts because the movement isn’t jerky, occurs throughout the night and not just when a person is falling asleep, and the movement recurs fairly regularly, sometimes as often as every 20 seconds. PLMD movements happen primarily during non-REM sleep. Needless to say, people who have PLMD may not feel rested in the morning.
Doctors don’t really understand what causes PLMD, and as a result, currently available treatments are designed to address the symptoms and not the under-lying cause of PLMD. PLMD can also arise in association with other conditions, including spinal cord tumor, diabetes, anemia, uremia, narcolepsy, or sleep apnea. Certain drugs like tricyclic antidepressants and SSRI antidepressants can also cause PLMD. The incidence increases as people age, rising from approximately 4 percent of people ages 30 to 50, 25 percent of people ages 50 to 65, all the way up to 44 percent of people age 65 years or older.
Symptoms
Unlike RLS, which can produce leg movements around the clock, PLMD movements only occur while the person is sleeping. PLMD produces distinct movements that begin as a flexing of the great toe but sometimes involve the ankle, leg, and hip. Each flex usually lasts from 1/2 to 5 seconds. Because the movements recur so frequently, typically in a 20- to 90-second cycle, PLMD can be a great sleep disruptor. Catching 40 winks when you’re moving like a Radio City Rockette isn’t easy. In some cases, the movements don’t disturb sleep, but others may have 20, 30, 40, or more brief arousals per hour throughout the night.
Often the person with PLMD complains of sleep-maintenance insomnia or non-restful sleep. Sometimes he or she complains of daytime sleepiness. Many patients aren’t aware of their constant nocturnal movement and don’t believe their bedmates when they complain about being kicked all night.
Treatment
PLMD doesn’t require treatment unless it’s interfering with sleep. When non-restful sleep is prominent or insomnia and/or sleepiness adversely affect the patient, treatment is usually a prescribed medication. Sometimes your doctor will prescribe the same medicines for PLMD that she uses to treat RLS (that is, low doses of drugs used for Parkinson’s disease). However, some doctors have prescribed sleeping pills called benzodiazepines to alleviate the symptoms of PLMD and improve sleep quality. Patients also benefit from employing the principals of good sleep hygiene, including a regular bedtime and a comfortable sleep environment. (See Chapter 17 for ways to establish a sleep paradise in your bedroom.) Regular exercise, such as walking and nightly stretching, and limiting the intake of caffeine and alcohol seem to help.