“I have difficulty falling asleep,” “I wake up frequently and cannot easily go back to sleep” and “I wake up too early in the morning” are by far the most common sleep disturbance complaints we hear in sleep medicine. When accompanied by daytime consequences of fatigue, tiredness, lassitude and foggy thinking, the diagnosis is insomnia.
What defines insomnia?
Most people will occasionally sleep poorly at times of illness, stress or strange sleeping conditions; however, when this complaint occurs at least three nights a week and has been going on for at least three months, the term “chronic insomnia” is used. It can be very distressing and is a serious problem. The National Sleep Foundation surveys indicate that 10 to 15 percent of Americans report having chronic insomnia.
What causes insomnia?
Chronic insomnia can be the result of a variety of causes including medical conditions such as chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux and Parkinson’s disorder. Restless leg syndrome and sleep apnea also can present as insomnia. Medication used to treat these and other conditions may further lead to poor sleeping. Therefore, the onset of insomnia coinciding with starting a particular medication should always be considered.
Psycho-social conditions often cause poor sleep as well. This is especially common in a variety of depressive and psychotic disorders. Less commonly, the cause of apparent insomnia is a misalignment between an individual’s circadian rhythm (internal body clock) and the desired sleep-wake schedule. Examples of this are extreme night-owls and morning larks. Night owls, for example, may not be able to fall asleep until 1 a.m. or 2 a.m. and then not naturally wake up until 11 a.m.
My first step in managing the chronic insomnia patient is to make certain that these known causes for poor sleep are addressed. Finally, in many cases I see in my sleep medicine practice, there is no clear cause. This is particularly common in long-standing insomnia of several years. When this occurs, attention is shifted from the precipitating cause to identifying any perpetuating factors unknowingly taking place that are contributing to and maintaining the insomnia.
Unhelpful sleep practices you should avoid include:
Getting into bed before there are any signs of drowsiness. Often people feel they should go to bed early to catch up on sleep. However, you should not get into bed to get sleepy, but rather first get sleepy and then get into bed. If you are not sleepy, stay out of bed.
Obsessing about mental exercises to clear your mind. Often the exercise of trying to relax the mind can heighten the pressure to fall asleep and adds to the anxiety about not sleeping.
Waking up in the middle of the night quite alert, staying in bed and lying awake for hours. It is a better choice to get out of bed and go into another room and sit in a comfortable chair and read (something interesting, but not stimulating). If you happen to fall asleep in the chair, you will still benefit from that sleep.
Using alcohol to help fall asleep. Alcohol will likely lead to worsening sleep issues in the middle or end of the sleep period as the ethanol is rapidly metabolized in the bloodstream.
Making a sudden transition from active mental tasks to trying to sleep. I well recall a patient of mine, a woman in her 70s, who complained about sleep-onset insomnia. When I asked her what she did just prior to getting into bed, she mentioned that she watched the late evening news. She also mentioned how upset she was with all those politicians. Building a 15-30 minute calm period into your pre-bedtime routine can be very helpful.
Trying to achieve fixed and unreasonable goals and expectations about your sleep. These inappropriate thoughts and feelings compromise better sleep. For example, it’s not true that you must get 8 or 9 hours of uninterrupted sleep or your health will be seriously compromised (a very stressful goal for those with insomnia).
Are sleeping pills the answer?
With any discussion of Insomnia, the role of sleep pills for treatment must be addressed. Until about 10-15 years ago, sleep pills were the major approach to treating insomnia. While there remains a limited role for using prescribed hypnotic drugs, especially in patients with transient insomnia, sleep physicians have moved to other ways of managing chronic insomnia.
The reasons to avoid sleep medications are many, but the three main ones include:
- There is a high incidence of accommodation seen with most sleeping pills. They stop working after several weeks or months.
- These medications are often accompanied by acute side effects such as abnormal behaviors in sleep, falls when getting out of bed and a morning “drugged-feeling.”
- Increasing numbers of studies may indicate an increased incidence of chronic diseases including cognitive impairment with chronic use of hypnotics.
The recommended choice for insomnia treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) has now become the recommended therapy of choice by the American Academy of Sleep Medicine and the American College of Physicians. CBT-I is a structured program that helps identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Today, most full-time sleep practitioners can provide this treatment which has been found to have a longer effect in treating insomnia with virtually no negative side effects.
If ignored, chronic insomnia will compromise your daytime activities and may lead to depression, pain syndromes and other chronic disease states. Insomnia should not be ignored by you or your primary care physician. Help is available and most cases can be improved, but there is no magic pill and changes will not occur overnight.