Chapter 5

Dealing with Secondary Insomnia

In This Chapter

Understanding how pain causes insomnia

Figuring out the relationship with breathing problems and insomnia

Identifying the connection with heart disease

Avoiding certain foods

Looking at psychological conditions that disrupt sleep

Even if you don’t have a sleep disorder, plenty of other problems may be keeping you from getting a good night’s sleep. Any number of medical or psychological conditions can cause discomfort or distress significant enough to interfere with your sleep. These conditions include pain, arthritis, heart and lung disease, indigestion, and mental health problems like depression and bipolar disorder.

Remember that primary insomnia, as we discuss in Chapter 4, is characterized by difficulty in initiating or maintaining sleep. Primary insomnia is a condition (not a symptom) that isn’t caused by any known physical or mental condition. Secondary insomnia is a symptom (not a condition) caused by a medical, neurological, psychiatric, or psychological condition.

If you have one of these other conditions, you could try every sleeping aid known to man and still not get the sleep you need, because you aren’t addressing the real cause of your sleep problem.

Diagnosing a medical condition that’s disrupting your sleep may be easier than diagnosing a sleep disorder because the symptoms are so straightforward. If you awaken with a burning sensation in your throat and sour taste in your mouth every night, you know you probably have some sort of reflux even if you don’t have a degree in gastroenterology hanging on your bedroom wall.

Meanwhile, diagnosing a psychological condition that’s wrecking your rest may be more difficult, especially if you aren’t forthcoming with your doctor about the way you feel or the emotional symptoms you may be experiencing in addition to your disturbed sleep.

In this chapter, we take a look at some of the medical and psychological conditions that interfere with sleep. We review symptoms, steps you can take on your own to relieve discomfort and improve the quality of your sleep, and signs that tell you to see a doctor as soon as possible. And take heart, because many of these conditions respond favorably to treatment. You’ll be sleeping the night through again before you know it!

Howling at the Moon: Pain — The Great Awakener

Remember that famous western image of a coyote howling at the moon, his lean and rangy body silhouetted against a golden orb that seems like it’s resting on the ground? Some nights you may feel just like that crying coyote. You may awaken from a sound sleep in such severe pain that you feel like howling at the moon, for all the good that will do. But you don’t have to endure pain. Depending upon the underlying cause, plenty of remedies are available you can take to relieve pain and reclaim your nights. Read on for some savvy hints about nighttime pain management.

If nighttime pain is making you lose sleep, you’re not alone. Sleep disruption is the No.1 complaint of people who have chronic pain. In a study conducted by the National Sleep Foundation in 2000, 20 percent of American adults, or about 42 million people, reported that pain disrupted their sleep a few nights a week or more. Approximately 53 percent of all adults say they have suffered from nighttime pain sometime within the past year. More women than men report nighttime pain, 58 percent of women versus 48 percent of men. Among people who reported chronic pain, 70 percent said their pain woke them up every night.

Whether your pain keeps you from getting to sleep or wakes you up in the middle of the night, pain is one of the most common causes of sleeplessness. Whatever the cause — illness, injury, or a chronic condition like arthritis — pain interferes with restful sleep.

The good news: You can usually relieve pain caused by common and fairly innocuous conditions like headache and muscle strain with an over-the-counter (OTC) analgesic like aspirin, acetaminophen, ibuprofen, or naproxen.

Just be aware that these nonsteroidal anti-inflammatory drugs (NSAIDs) can cause gastrointestinal bleeding if you use them regularly, and some people who overuse NSAIDs can even develop serious kidney problems. (Overuse is defined as taking significantly more of the medication than is recommended on the package as the maximum daily dose.)

For more serious or unbearable pain, have a doctor evaluate your condition. Pain is a symptom, and if you continually mask the symptom, you may not discover what is causing it in time to get effective treatment. Discovering the source of your pain and treating it appropriately are important if you want a decent night’s sleep.

Looking at how pain disrupts sleep

Any way you look at it, pain makes sleeping difficult. It can keep you from falling asleep, it can awaken you from a sound sleep in the middle of the night, or it can send you out of your bed too early in the morning as you struggle to find some relief. People who suffer from nighttime pain often complain of waking up feeling unrefreshed. Are you shocked? Chronic or acute pain can actually keep you from ever reaching the deepest and most restorative phases of sleep. You also experience a poorer sleep quality, with more awakenings and resulting daytime fatigue. In fact, sleep deprivation caused by pain puts people at very real risk for on-the-job accidents and car accidents, and can also lead to other physical and mental health problems.

Pain affects your sleep by triggering a transition into a lighter stage of sleep, and that leads to multiple, brief (and sometimes not so brief) awakenings during the night. Naturally, waking up so frequently disturbs sleep. Your ability to perceive physical pain is known as nociception. The old definition that says, “ Pain is a physical sensation of discomfort caused by injury or illness,” assumes that every sensation of pain has a definable biological or psychological cause. Unfortunately, that definition isn’t nearly broad enough to cover every instance of pain people experience and doctors try to treat. The modern theory is that pain is a perception of discomfort people experience to a greater or lesser degree depending upon how they receive and interpret pain signals.

You may be asking yourself, “Aren’t I supposed to be impervious to all this stuff once I’m asleep?” To some extent, yes. Your sleep system is designed with an arousal threshold that protects you from the most common sources of awakening like noise or moderate changes in environmental temperature. In a sense, the mechanism controlling arousal threshold is like a big watchdog, guarding your sleep. But when pain is persistent or severe, it sends urgent signals to your brain that eventually break through and your watchdog can no longer protect you or prevent you from awakening; consequently, you wake up, whether you really wanted to or not.

Because the same brain neurotransmitters regulate both rapid eye movement (REM) sleep and the perception of pain, researchers speculate that there may be a connection between REM sleep and your ability to perceive pain. New research suggests that blocking your brain’s ability to break down the neurotransmitter acetylcholine in the sleep-regulating areas of the brain greatly decreases response to pain. This knowledge may lead to a whole new class of painkilling medication based not on the idea of deadening the perception of pain (as with opiates like morphine) but rather on blocking the perception of the pain using brain chemistry. Another advantage is that pain medications based on manipulating certain neurotransmitters aren’t addicting — a common problem with opiate drugs.

Identifying the most common causes of nighttime pain

Nighttime pain is no laughing matter. It’s the leading cause of insomnia, and the resulting sleep deprivation can lead to depression and mood swings, including extreme irritability.

A 1996 National Sleep Foundation study rated the leading causes of disruptive nighttime pain. And the winners are (or perhaps we should say losers?):

Back pain

Headache

Muscular pain other than back

Check out the following sections that take a closer look at each of these problems.

Back pain

Eighty percent of adult Americans report experiencing back pain at least once in their lives. People with chronic back pain report that their pain significantly interferes with their ability to sleep soundly.

If your pain is minor and only lasts for a short time, a few days or so, use your favorite OTC pain medication for relief. Just be aware that even though analgesics can help relieve back pain, they may also disrupt sleep, so you don’t want to rely on them for long-term relief.

A better long-term solution may be to try a program of stretching and moderate exercise to relieve back pain. Consult with your doctor before conducting any stretching or exercising regimen. If your pain is chronic and severe, such as the result of an injury like a ruptured disc or fractured vertebrae, no amount of stretching or exercise will relieve your pain entirely and may make it worse. If you have chronic severe back pain, you may want to investigate pain management therapies like TENS units (see the nearby sidebar “Portable pain relief” for more information) or cognitive behavior therapy to help you manage the pain and sleep more comfortably. For more information about cognitive behavior therapy, see Chapter 4.

Portable pain relief

A TENS unit is a patient-controlled, battery-powered electronic pain relief unit that works by gently stimulating nerves that conduct pain with mild electrical impulses. TENS stands for transcutaneous electrical nerve stimulation. TENS is especially effective for chronic pain in the neck and lower back, and for severe chronic headaches like migraines or cluster headaches, arthritis, and fibromyalgia (muscular and skeletal pain with fatigue). Although no one understands exactly how or why TENS units work, some researchers theorize that TENS blocks pain signals to the spinal cord, while others believe that TENS stimulates the release of endorphins, the body’s own natural painkiller. TENS units are medical devices, and you can only obtain them with a doctor’s prescription. Most insurance plans offer reimbursement for TENS units. You must undergo brief training in order to understand how to operate your unit properly.

Headache

Many sleep disorders produce headache as an associated complaint, including sleep apnea, sleep deprivation, or even sleeping too much. In these cases, treatment of the sleep disorder also helps to reduce the incidence and severity of the accompanying headache. But you can’t blame sleep disorders for all nighttime headaches. Migraine and cluster headaches can strike any time of the day or night, and trying to go to sleep with a tension or stress-related headache may only make the pain worse.

A cluster headache is an intensely painful headache on one side of the head. The pain is so severe that some patients think being dead would be better than enduring the pain. The headaches last from 15 minutes to three hours and occur in “clusters,” up to eight a day, hence the name, cluster headache.

For temporary relief of headache pain, you can take an OTC pain reliever, but remember that prolonged use of these types of medications can actually contribute to sleep problems. If you have a prescription for migraine or cluster headache relief, ask your doctor if the prescribed medication interferes with sleep. You ideally want to find a medication that relieves your pain without interfering with your sleep.

If you don’t want to take medication every night, you can sometimes relieve your headache pain with an ice pack or headache cooling strips or pads that you put in your refrigerator before using. Put the ice pack directly over the area of the pain, or if you have a stress headache, place the ice pack on the back of your neck, your forehead, or your temples. (You may need more than one ice pack to treat all affected areas at once.)

Cooling strips are less messy than ice packs for pain relief because you don’t have to contend with melting ice.

If you believe your headache is caused by stress, you can also try using heat applications or relaxation techniques to relieve stress and battle the pain. The application of moist heat relieves headache pain caused by stress by opening blood vessels and creating additional blood flow. Relaxation techniques help you destress and focus your attention away from your pain. Relaxation helps you relax tense muscles, which improves blood flow and reduces pain. For more information on relaxation techniques, see Chapter 6.

Other muscular pain

Whether you overdid it pumping iron at the gym, pulled one weed too many in the garden, or simply wrenched your knee getting out of the car, muscular pain of many varieties can keep you awake at night.

Ever wonder what makes muscles hurt? You can explain that pain in your hamstring or biceps in a couple of ways. When you exercise vigorously or push your muscles beyond their accustomed level of use, muscle fibers start to tear in response to the stress of the strenuous activity. Lactic acid builds up, and the result is sore muscles. If you keep pushing yourself to the point of exhaustion, where you simply can’t do another repetition of your abdominal crunches or lift one more 50-pound sack of mulch, you may have hundreds of these tiny tears in your muscles. As a result, lactic acid has reached its limit, and you hurt all over. More severe muscular stress may take the form of painful muscle spasms or stiffness.

The most common causes of muscle pain are injury, overuse, or a buildup of tension or stress in the form of knotted muscles in your neck, shoulders, back, or trunk.

Generalized muscle pain or feeling “achy all over” may be a sign of a systemic illness. If muscle pain lasts more than three days, is severe and you haven’t injured or overused it, or is accompanied by fever, swelling, bruising, or a rash, see a doctor as soon as possible! You may have a significant injury or underlying serious illness. Achiness can also result from sleep deprivation.

You can relieve muscle pain externally by applying an ice pack or analgesic rub that temporarily dulls the pain, or internally, by taking a pain relieving anti-inflammatory medication like aspirin, acetaminophen, or ibuprofen. Apply ice during the first 24 to 72 hours to reduce inflammation of the muscles as well as pain. Then switch to heat applications to continue the healing process. Massage and gentle stretching can also be helpful in dealing with muscle pain.

Your headache may not be in your head

One of the greatest mysteries of science is how so many people can suffer so badly from headaches when the brain doesn’t contain any nociceptive or pain-perceiving tissue. So your aching head isn’t a result of anything that’s actually hurting inside your brain, but rather in the structures that surround the brain. Pain in those structures, which include the skull, blood vessels, and muscles of the head, are what create the perception that you have a headache. You may perceive that you’re feeling pain in your head when what really may be happening is that you’re referring stress or discomfort from another area of your body to your head where you experience it as a headache.

Arthritis

The pain, stiffness, and discomfort of arthritis can have a profound impact on both the quality and quantity of your sleep. According to a recent study, about one-third of patients report that the pain of arthritis interferes with their sleep. Unfortunately, many of the prescription medications recommended for the control of arthritis pain produce insomnia as a side effect.

Effective treatments to relieve the pain of arthritis may include a program of gentle exercise, stretching, reconditioning of stiff joints, and appropriate medications. Adding an egg crate mattress cover to your bed may help reduce pain and stiffness. Arthritis patients may also benefit from one of the new, non-addictive prescription sleep medications, but remember that these medications are recommended for short-term relief.

Fibromyalgia

With its severe and unrelenting episodes of pain and muscle spasms that are felt throughout the body, fibromyalgia can keep its sufferers awake for many hours each night. Nearly 75 percent of patients with fibromyalgia report that they have trouble sleeping at night.

The best remedies to relieve nighttime pain of fibromyalgia are stress management techniques, breathing exercises, and the use of appropriate medication to relieve pain and encourage sleep. For more information about how to deal with fibromyalgia, see Fibromyalgia For Dummies by Roland Staud, MD, and Christine Adamec (Wiley).

Alleviating pain for a good night’s sleep

Until you get a handle on what’s causing your discomfort, pain will continue to disrupt your sleep. Nighttime pain management can be a tricky business; the very medications that help relieve pain may also ultimately interfere with sleep patterns. Also, sleep deprivation lowers your pain threshold. But finding effective pain management is important because, if you lose too much sleep for too many nights, your job performance and outlook can suffer.

If you’ve tried the remedies we suggest and they don’t seem to be providing the relief you seek, schedule an appointment with your doctor. If your pain is chronic or severe, consult with a pain specialist who can help you develop a pain management program. In most cases, your doctor can prescribe medicines that relieve pain and medicines that promote sleep together. For example, one major original use of sleeping pills was to provide post-surgical in-patients the ability to sleep so that they presumably would recover faster.

Fighting for Breath — Asthma and Chronic Obstructive Pulmonary Disease

People suffering from chronic obstructive pulmonary disease (COPD) literally have to fight for every breath, while asthmatics usually experience a sudden acute onset of breathing difficulties. Sleeping can bring its own particular set of problems because lying down can make breathing even more difficult for some COPD patients, and the coughing, wheezing, and chest tightness of asthma can also disturb sleep.

People with COPD not only suffer from sleep disruptions, but also the quality and quantity of their overall sleep is diminished. The bronchodilators and steroids they take to help them breathe can interfere with sleep as well. Some people with COPD also suffer from sleep apnea. This “overlap syndrome” compounds their problems.

People with asthma have their own set of sleeping difficulties. Asthmatics may have trouble falling asleep, suffer from nocturnal coughing jags, and may also wake up too early in the morning. Asthma responds to circadian rhythms, and sensitivity to irritants that can trigger asthma attacks is much greater at night. Individuals with asthma often experience significant daytime fatigue and exhaustion if their sleep quality is poor.

Of course, the granddaddy of all sleep-related breathing problems is sleep apnea or sleep-disordered breathing (SDB). A patient with sleep apnea may stop breathing hundreds of times each night, a situation that not only disrupts sleep but can also deprive the body of vital oxygen and increase the risk of developing heart disease. For more information on sleep apnea, see Chapter 9.

How breathing problems make sleep difficult

When patients with COPD enter REM sleep, they experience a significant decrease in their oxygen saturation. Because many of these patients are already at the limits of their respiratory capacity due to their disease, even a small fall in oxygen tension can provoke large declines in oxygenation. This decrease makes the patient hypoxic, with potentially serious consequences.

Hypoxia literally means low oxygen. When a person is hypoxic, he or she doesn’t have enough oxygen reaching the body’s tissues. Hypoxia can be caused by damaged or diseased lungs that don’t take in and distribute enough oxygen, damaged red blood cells that can’t carry sufficient oxygen to the body’s tissues, or damaged circulation that prevents oxygenated blood from reaching body tissues.

The more severe your asthma, the more frequently breathing problems will awaken you. Acid reflux or heartburn at night can add to your difficulties by causing choking or spasms of your bronchial tubes.

When patients with breathing problems lie down at night, they may experience a sensation of choking or not being able to catch their breath. As a result, patients with COPD or asthma may attach significant fear to the idea of lying down and going to sleep.

Promoting better sleep in patients with breathing problems

Any program to improve the quality and quantity of sleep in patients with breathing problems has to address both the physical symptoms of their breathing disorder and the psychological symptoms (for example, the fear they experience).

Good nighttime control of asthma means finding a combination of drugs to control airway inflammation and reduce the number of nocturnal asthma attacks. If heartburn or digestive problems are present, make sure your doctor treats these symptoms in order to restore good sleep.

People with respiratory problems can help to minimize their respiratory distress by sleeping on their sides. Sometimes sleeping on the back promotes snoring.

The goal in COPD is to make sure that nighttime oxygen saturation levels remain constant and don’t fall to dangerously low levels. Patients who are fearful about sleeping may benefit from enrollment in a pulmonary rehabilitation program that literally shows them how to breathe all over again, and gives them a sense of power over their condition. Doctors can prescribe short-acting sleep medications in low doses to help COPD patients deal with insomnia.

If you have nighttime breathing problems and associated sleep disturbances, you can benefit from a program of good sleep hygiene and behavior modi-fication to overcome habits that may be contributing to or prolonging sleeplessness. (For more information on sleep hygiene, see Chapter 6.) We don’t advise using sedating medications to promote sleep because they can depress respiratory drive and raise your arousal threshold, making you breathe more shallowly and making awakening more difficult if an obstruction occurs.

Consult with your doctor if you have COPD or asthma and are also experiencing problems sleeping. He can help determine the best course of treatment to improve your sleep without undermining the treatments you’re taking for your breathing disorder.

Worrying about Heart Disease

People with heart disease frequently suffer sleep disturbances because they’re anxious, in pain, experiencing breathing problems, or just worried that they might die during the night. In addition, many studies have indicated that people who suffer from long-term sleep problems may be at higher risk for developing heart disease. Chronic sleep deprivation increases blood pressure and also alters blood sugar and hormone levels in the bloodstream, all of which may contribute to the development of heart problems. So, ironically, chronic sleep deprivation may cause heart disease just as heart disease can cause sleep deprivation.

Sleep apnea and heart disease

Scientists understand the correlation between sleep apnea and an increased risk of heart disease. The frequent cessation of breathing from sleep apnea can deprive vital organs, including the heart, of the oxygen they need to keep functioning. Blood oxygen levels that are too low may cause the heart to stop beating regularly. Furthermore, trying to breathe when the airway is closed produces increased pressure in the chest cavity. Because the heart is also in this cavity, it has to pump harder to provide the pressure needed to circulate the blood around the body. These factors put quite a lot of stress on the heart, and it can even begin beating irregularly, going into ventricular arrhythmia (V-tach). V-tach is a potentially fatal arrhythmia and essentially is a medical emergency that can be deadly if the heart doesn’t return to normal rhythm by itself or isn’t shocked back into normal rhythm in time.

Over time, a heart that’s working so hard under such adverse conditions may become enlarged as it struggles to keep up with the body’s demands. People with enlarged hearts may end up with congestive heart failure, a condition in which the heart is too weak to effectively pump the volume of blood that the body needs to keep functioning. Also, specific sleep-related breathing disorders are associated with congestive heart failure.

Breathing may wax and wane in response to oversensitivity to carbon dioxide in the blood. This pattern of breathing, called Cheyne-Stokes respiration, is associated with a high risk of mortality and needs aggressive treatment.

According to a published study, people who sleep less than five hours or more than nine hours each night have a 45 percent higher risk of developing heart disease.

You think it’s okay to cut back on sleep because . . . why?

Some people convince themselves they can accomplish a whole lot more by going to bed a few hours later than they should. They argue that the quiet of the night is an ideal time to complete tasks and accomplish goals, made all the better by the fact that you won’t be interrupted by a ringing telephone, whining children, a demanding boss, or your other half. You’re free, or so you think.

But recent research proves that people who stalk the precincts of midnight may pay a far higher price for their freedom than expected.

Sleep deprivation causes the following problems, in order of the most severe:

Raises blood pressure

Increases the level of the stress hormone, cortisol, in the bloodstream

Lowers glucose tolerance

Leads to variations in heart rates

Now read through the previously mentioned symptoms again and try to figure out what they have in common. Here’s a hint: They’re all bad things that can happen to your heart if you continue to deprive yourself of the sleep your body needs to restore and refresh itself.

Anxiety and sleeplessness in cardiac patients

Perhaps you already have a pacemaker due to earlier problems with your heartbeat, or maybe you’ve already survived one heart attack. Living with heart disease can be very difficult from a psychological standpoint, and nagging fears about your own mortality can make getting a good night’s sleep very difficult.

Anxiety and excessive worry about your health can make lying down and drifting asleep much more difficult. If you have a heart or circulatory problem, you may worry that you might never wake up again, that you will suffer a fatal cardiac event in your sleep.

Cardiac patients whose worries are keeping them awake at night can benefit from anxiety-management training. In severe cases, your doctor may prescribe an antianxiety medication and sleep aid to help you get a good night’s sleep.

I Shouldn’t Have Eaten That Anchovy Pizza — Indigestion and Sleeplessness

Today people live at such a breakneck pace in such a busy, over-scheduled world that it’s not unusual for a husband and wife to sit down to dinner at 9 p.m. or later, or for college students cramming for finals to be scarfing down pizza at 3 a.m. Unfortunately, the human digestive system may not respond well to round-the-clock noshing, and a few minutes of late-night dietary indiscretion can make for hours of misery later on — in fact, right when you want to be sleeping.

Then there are the folks who suffer from a medical condition like gastroesophageal reflux disease (GERD). Nighttime can be absolute misery for GERD sufferers. If you have GERD, within a few minutes of lying down, or at unpredictable times during the night, you feel like you have a fire burning in your chest, or you may actually regurgitate stomach acid that leaves an awful sour taste in your mouth and burning in your throat.

Although people with GERD need special treatment to manage their symptoms, everyone, even GERD patients, can improve their sleep quality by using some of the following practical tips:

To minimize the chance of developing indigestion or acid reflux problems that can disrupt your sleep, avoid eating three hours prior to your bedtime, and don’t eat large meals near bedtime. Big meals bloat your stomach and keep your digestive system churning for hours.

Avoid alcohol because it increases the chance that you will suffer from an episode of acid reflux.

Raise the head of the bed and try to stay off your back.

Treat the condition aggressively with whatever medications your doctor prescribes.

Certain foods are just more difficult for your digestive system to handle. Avoid these notorious offenders close to bedtime:

• Chocolate

• Citrus

• Fatty or greasy foods

• Foods or beverages containing caffeine

• Spicy foods

For more information about how digestion affects sleep, see Chapter 6.

Burning the Midnight Oil — Sleep and Mental Health

People suffering from psychological problems may find establishing a regular sleep schedule exceedingly difficult. If you’ve just experienced a recent life-altering event, such as a family member’s death, a job loss, a serious accident, a divorce, or some other equally bad news, you may have trouble sleeping well. Furthermore, if you have been traumatized by sexual assault, witnessed a gory accident, or been robbed at gunpoint, you may have sleep terrors, nightmares, sleep-anxiety attacks, or some combination of these in addition to insomnia.

Depression, bipolar disorder, and other psychological conditions can also contribute to sleep problems. In fact, sleep disturbance is the No.1 complaint of people who are dealing with emotional problems or mental illness. Chronic sleeplessness just compounds the troubles of people who have psychological disorders and in some cases can even make symptoms worse. So seeking help for your sleep problems is important, because getting a good night’s sleep is an essential component of the prescription for overall wellness.

Although poor sleep habits can be a symptom of psychological problems, they can also be a cause or, at the least, a contributing factor to ongoing emotional distress. In other words, get your sleep problems resolved, and that may help to resolve your underlying psychological issues as well.

Going to sleep each night involves a gradual winding down of the brain and body’s activity level, and that includes ratcheting down the thoughts swirling around inside your head as well. If you’re in the throes of a psychological disturbance like depression, anxiety, paranoia, or something else, getting to sleep and staying asleep throughout the night can be difficult.

Battling the blues — sleep and depression

Nearly 85 to 90 percent of people suffering from depression report that they also suffer from insomnia. When they finally do get to sleep, their sleep quality may be so poor that they don’t feel refreshed when they wake up the next morning.

Even after people resolve their depression, people who have developed poor sleep habits while depressed may still have some sleep difficulties to address. Depression is most often recurrent. If you notice sudden increases in sleeplessness, it may be an indication of a pending relapse. Scientists are conducting research to determine if treating insomnia aggressively can help prevent depression recurrences. Finally, patients with depression have an increased risk of suicide during particularly bad bouts of insomnia; therefore, attending physicians and family members should carefully monitor changing sleep patterns in such individuals.

Depending upon the exact nature of the sleep disturbance, your doctor may advise behavioral modification therapy to help you establish good bedtime routines once again, or relaxation therapy to help you wind down at bedtime. (See Chapter 6 for more information on behavior modification therapy and relaxation therapy.) If your chronic sleeplessness during depression has thrown your brain’s clock out of whack so that you’re having trouble falling asleep or waking up when you want, your doctor may recommend bright-light therapy to reset your internal clock and get you back on a more desirable sleep-wake schedule. (See Chapter 8 for more information about bright-light therapy.)

Because your doctor knows that antidepressants alter your sleep architecture, he may want to adjust your medication dose or try a different antidepressant to see if it controls your depression without significantly impacting your sleep patterns. (For more on sleep architecture, see Chapter 4.) You may also get a prescription for a sleep medication.

Who’s that hiding underneath my bed? Paranoia

Paranoia is a symptom characterized by delusions of persecution; in other words, paranoid people think that “everyone is out to get them.” A variety of psychiatric conditions have paranoia as one of the features. Some people with paranoia develop a fear of going to sleep.

Paranoid people are very fearful and suspicious, and may perceive danger around every corner, or under every bed. They suspect, with no basis in reality, that everyone around them is engaged in some sort of deception aimed at tricking, exploiting, or even harming them. Their suspicions and doubts dominate the bulk of their waking thoughts. Even the most benign comment from a friend or family member may be taken as an attack and may trigger a torrent of rage and recrimination. Some paranoid people refuse to go to bed because they fear that someone will try to harm them while they sleep.

Paranoia may appear as one of the symptoms of schizophrenia, depression, or dementia. It can also be a side effect of drug abuse or extreme stress. Paranoid personality disorder is diagnosed when a person displays many symptoms and behaviors consistent with paranoia, but has no other co-existing illness like schizophrenia.

Treatment involves psychotherapy to help the patient control his thoughts and behavior. Paranoid patients tend to look at drugs with suspicion; they may believe the drugs are an attempt to poison them or gain control of their minds. But, if they can be persuaded to take them, antianxiety medications can help them manage their negative feelings. If the patient has a co-existing disorder like schizophrenia or depression, appropriate treatment for that disorder may also help to diminish the distressing symptoms of paranoia.

Too wired to sleep, or too sad — bipolar disorder

Bipolar disorder (or as it used to be called, manic-depression) is a mood disorder in which a person swings back and forth between wild euphoria and frenetic bursts of energy (the manic phase) to such deep, dark, and overwhelming depression that the person may contemplate or attempt suicide. The disorder can have profound effects on sleep.

Individuals who battle bipolar disorders know all too well the havoc it can wreak on their sleep schedules. When they’re in the depressive phase, they may sleep 12 to 14 hours a day or more, but when they’re in the manic phase, they may go for days without sleeping at all. Neither extreme is good. People with bipolar disorder who force themselves to adhere to a regular sleep schedule may be pleasantly surprised to discover that regular sleep also improves their bipolar symptoms.

Research has proven that giving in to the urge to stay up late for just one night — to catch a late movie, chat online, or just catch up with household chores — can actually trigger a manic episode in a person suffering from bipolar disorder. One difficulty in treating this disorder is that patients usually don’t complain when they’re manic. By the time a doctor sees the bipolar person, the patient is in the depressed phase, which may look like other forms of hypersomnia.

If you’re bipolar and you want to cut back on the frequency and severity of mania, make sure you hit the bed on time every night. If you’re in a manic phase, do everything in your power to get to sleep because sleep deprivation during a manic episode can actually prolong or worsen the attack.

The internal clocks of people with bipolar disorder seem to be more subject to disruption than the clocks of people without the disorder. Even one incident of disruption of their sleep schedule can precipitate a whole chain of undesirable behaviors. If you deprive yourself of the sleep you need and then go into a manic phase, you lose even more sleep, and sleep deprivation makes manic episodes worse and also makes them last longer.

The bipolar patient can improve his or her sleep quality by maintaining a regular schedule for sleeping and waking up. Sticking to schedules and avoiding late nights can moderate the frequency and severity of mood swings.

Fretting the night away — anxiety disorders

People suffering from an anxiety disorder feel continually keyed up or on edge. They fret and worry endlessly about everything and frequently experience sleep disturbances in the form of insomnia because their anxiety disturbs sleep. Their anxiety exists independently of other psychological disorders and isn’t the result of drug abuse or another medical condition.

If you have an anxiety disorder, follow your doctor’s recommendations. You may find it’s helpful to establish a comforting bedtime routine that helps you wind down and go to sleep. You can also try guided imagery to strip your mind of your daytime worries in preparation for sleep. (See Chapter 6 for more information on using imagery to manage stress.) How-ever, you may need sleep medication, in addition to daytime antianxiety treatment.

It’s happening again — post traumatic stress disorder

When you’ve suffered through a traumatic event like being attacked, surviving an accident or natural disaster, or serving on the front lines in a war, your brain can retain vivid memories of those upsetting events. You may have coped with the stress brilliantly at the time it was happening, doing everything to minimize disastrous consequences. Then, months or years later, a nightmare whose content can be closely or loosely related to the original event crops up again when you try to sleep.

This problem is called post traumatic stress disorder (PTSD). Soldiers returning from war and people who have survived horrific events like 9/11, a plane crash, or physical assault frequently suffer from PTSD. People with PTSD suffer from chronic sleep disturbances including sleep terrors, nightmares, nocturnal panic attacks, difficulty falling asleep and staying asleep, and excessive thrashing about while they’re sleeping. Both the quality and quantity of their sleep are greatly diminished compared to normal sleepers.

If you have PTSD, your brain appears to be unable to remain in a diminished level of arousal. As you swim up toward awareness, you may be overtaken by violent or frightening images from the event you survived. Researchers aren’t sure if these dreams are part of normal REM sleep imagery that most people don’t remember because they sleep right through them, or a byproduct of the stressful event you experienced.

Treatment is a double-edged sword. If you take medication to calm the anxiety of PTSD, you may actually increase the number of vivid nightmares. On the other hand, if you don’t take the medication, you may suffer from more nighttime panic attacks. Currently, the best treatment options are supportive psychotherapy, group therapy, and medication.

Wintering the storm — seasonal affective disorder

Although about everyone who lives in the Northern Hemisphere may wrestle with a bit of the “winter blues” as light changes with the seasons, the 10 percent of Americans who suffer from seasonal affective disorder (SAD) may experience profound, debilitating depression when winter rolls around. For unknown reasons, women are far more subject to SAD than men. Sleep disturbances are common in patients with SAD; they sleep less in the summer and more in the winter.

Scientists believe that individuals who suffer from SAD are more sensitive to light changes than other people. Your doctor can treat your SAD quite effectively with light therapy and cognitive behavior therapy. In the most severe cases, an antidepressant can help SAD patients make it through the winter.