Insomnia

Insomnia is a common problem affecting up to 30% of adults. Half of the people with insomnia think their problem is bad enough to seek professional help. Insomnia is perhaps the second most common health complaint after pain. It is twice as frequent in women as in men. It is more likely to occur as people get older.

Insomnia is not a minor problem. Chronic sleep disturbances may have a harmful effect on daytime functioning. It can cause great distress and impair one’s quality of life. It can also lead to mood, memory, alertness, attention, and fatigue problems. These problems can put jobs and relationships at risk.

Clinical Characteristics

People with insomnia have problems falling asleep, waking up in the middle of the night, and/or waking up early in the morning. According to the American Sleep Disorders Association, these problems are different from other sleep disorders. Other sleep disorders involve being too sleepy during the day (narcolepsy, sleep apnea), disorders of the sleep-wake schedule (work shift, jet lag), and the parasomnias (nightmares, sleepwalking).

Sleeping fewer hours than others does not mean insomnia. People have different sleep needs. Some people who are short sleepers may not suffer from insomnia. Others who are long sleepers may complain of insomnia.

Changes in sleep patterns also occur with aging, but insomnia is not a usual fact of getting older. Almost everyone has insomnia at some time due to stressful life events. However, a person should consider seeking help if problems falling asleep or staying asleep last for more than 1 month. A person using sleeping pills for more than 2 to 4 weeks who cannot get a good night’s sleep without using them should seek help.

Common Causes of Insomnia

Insomnia may be caused by many medical or psychological factors or by a person’s life situations. Among the most common medical factors are pain, breathing problems (sleep apnea), restless legs, and repetitive leg twitches during sleep (nocturnal myoclonus). Some medications given for physical problems may lead to insomnia as a side effect. Examples are bronchodilators for asthma and diuretics for high blood pressure.

Use of sleeping medications for a long time makes insomnia worse. Sleeping medications can be addictive. People can end up relying on them to sleep. Caffeine and nicotine are both stimulants that lead to uneven and lighter sleep. Although alcohol may help tense people to unwind and fall asleep faster, it leads to fitful and nonrefreshing sleep. Psychological problems, such as severe anxiety and depression, are common causes of insomnia. Chronic sleep disturbances may also lead to depression.

Stressful life events, such as divorce, the death of a significant other, pending surgery in the near future, and job changes, can often lead to sleep problems. Most people resume normal sleep after adjusting to these life events. However, some continue having constant sleep problems over time. Chronic stress on the job or long-term conflicts with family members can maintain sleep problems or make them worse.

Behavioral or learned factors help lead to lasting insomnia. During the early point of their sleep difficulties, people who are prone to insomnia may develop conditioned reactions that cannot exist with sleep. For example, after several poor nights of sleep, a person may relate before bedtime routines and bedtime surroundings with worries and fear of being unable to fall asleep. With repeated occurrences, these negative associations lead to increased muscle tension, worries, and difficulty falling or staying asleep. This conditioning process leads to a cycle of insomnia, fear of sleeplessness, more emotional, cognitive, and biological arousal, and more insomnia.

Some people with insomnia say that they sleep better away from home because these cues are no longer available. Some people with insomnia also say that they can fall asleep when not trying (e.g., while reading or watching TV). Some report that they can get very sleepy in the living room. However, as soon as they go to bed, they experience racing thoughts and become wide awake.

To cope with insomnia, people may also develop harmful sleep habits, such as uneven sleep/wake schedules, daytime napping, and too much time in bed.

These attempts to adapt to insomnia may briefly result in increased sleep or improved alertness. However, over the long run, they interfere with the adjusting effect of a regular and controlled sleep/wake rhythm.

Unrealistic sleep requirements, expectations, and false beliefs about insomnia and its impact on physical and psychological health can also make insomnia problems worse.

Evaluation

Assessment of the insomniac patient will generally involve a detailed history of the sleep problem. This analysis will focus on factors that make the insomnia better or worse. The patient will usually be asked to record his or her sleep/wake habits in a daily sleep diary. This will help in evaluating the type and severity of the insomnia. This also helps in watching progress during treatment. Psychological screening tests are often given to rule out major mental disorders as the main cause of sleep problems. Unless there are medical problems, this evaluation is usually enough to design an individual treatment plan made to fit the patient’s needs.

When complicated sleep disorders are suspected, a polysomnogram may be recommended. This is a specialized all-night sleep recording. The polysomnogram watches a variety of body signs. It is administered in a sleep-disorders clinic. It may be useful in several ways. It may detect and record both hidden and obvious biological factors disrupting sleep (e.g., sleep apnea, leg movements). It may compare a patient’s beliefs about sleep problems to objective measures of sleep. It may help in figuring out cases that have not responded to treatment.

Treatments

Insomnia has usually been treated with sleeping pills. Unfortunately, many sleeping medications are effective only briefly. A person needs more and more to have an effect. In addition, they give many side effects. Widely advertised over-the-counter medications (e.g., Sominex, Sleep-Eze, Unisom) produce little effect on sleep beyond a placebo effect. A placebo effect is the feeling that “since I took a pill, I will now be able to fall asleep.”

Research has shown that cognitive behavioral therapy is effective for treating chronic insomnia. Its benefits also last longer than medication treatments. Most cognitive behavior therapists and sleep clinics will offer a full treatment program, including one or more of the following treatments.

Stimulus Control Therapy

This treatment offers instructions to end behaviors that get in the way of sleep. It also instructs how to fix sleep-wake schedules. Specifically, it involves the following instructions:

• Go to bed only when sleepy.
• Get out of bed when unable to fall asleep or unable to return to sleep within 15 to 20 minutes.
• Use the bed/bedroom for sleep and sex only. No reading, eating, TV watching, working, or worrying.
• Get up at the same time every morning apart from the amount of sleep the previous night.
• Do not nap during the day.

Stimulus control therapy focuses directly on sleep-related behaviors as the target of intervention. It is currently the treatment of choice for most patients with difficulties initiating or maintaining sleep.

Sleep-Restriction Therapy

To get enough sleep, people with insomnia often spend a lot of time in bed. While this sometimes works for a time, it often makes the sleep problem worse. Sleep-restriction therapy limits the time spent in bed to the actual amount of time slept. For example, if you spend 8 hours in bed but are asleep for only 5 hours, the initial treatment will allow you to spend only 5 hours in bed. Time in bed will then be gradually increased until adequate sleep time is achieved. While the initial cutting of time in bed may lead to daytime sleepiness, this method will improve nighttime sleep.

Cognitive Therapy

For best results, it is often necessary to teach insomniacs how to go over their thoughts and beliefs about sleep. They then learn to change their attitudes about sleep. For example, beliefs such as “everyone needs 8 hours of sleep” or “insomnia is bad for physical and mental health” only create more anxiety about sleep. This worsens sleep problems.

It is also important, especially for older people, to understand some of the changes in sleep patterns that take place as we get older. Sleep education about the effects of diet, exercise, and substance use is usually an important part of most behavioral treatment programs for insomnia.

Stress Management

Stress or tension is often related to poor sleep. Thus, stress-reduction methods such as relaxation training, biofeedback, meditation, and guidedimagery are sometimes useful. These methods have common aims. They all decrease muscle and mental tension and control excessive bedtime worries and intruding thoughts, which interfere with falling asleep or returning to sleep.

Effective nondrug methods are available for treating insomnia. Cognitive behavior therapy is aimed at teaching skills to insomniacs so they can regain control over their sleep patterns. Treatment programs conducted either individually or in group format have had promising results in overcoming insomnia. They usually require 6 to 8 weeks of treatment. The average rates of improvement range between 50% and 70%. The benefits are usually sustained over time.