Insomnia

When we sleep according to our natural sleep-wake cycle, we wake up feeling refreshed and well rested. When our natural pattern of sleep is disturbed, however, we experience insomnia, difficulty falling asleep or staying asleep, which can be enough to cause distress or interfere with daily functioning. Most people experience brief bouts of insomnia, often caused by stress or worries, physical discomfort, medication effects, or a change in sleep schedule (e.g., jet lag). These acute episodes of insomnia typically last only a night or two until the situation that caused the sleep disturbance is resolved and sleep returns to normal. About 10 percent of the population, however, experience chronic insomnia, sleep problems that can last for months or even years.¹

If a person experiences insomnia for a month or more, some form of treatment may be needed to restore restful sleep.

There are many factors that can disrupt the normal sleep pattern to produce insomnia. These factors are commonly divided into Primary Insomnia and Secondary Insomnia.

Primary Insomnia Secondary Insomnia Insomnia due to other sleep disorders Insomnia due to medical conditions Insomnia due to substance use or withdrawal Insomnia due to an emotional problem Treatment for Primary Insomnia Medication treatments Behavioral therapy

Primary Insomnia is a common sleep disorder. The term “primary” indicates that the insomnia is not caused by any known physical or mental condition. Primary Insomnia typically results from developed patterns of sleep behavior that interfere with the natural sleep-wake pattern. People with insomnia often complain of problems with falling or staying asleep. Many of the efforts to get more sleep can result in getting less sleep, at least over the long term. Stress, arousal, and worry about not sleeping also contribute to primary insomnia. Although those with primary insomnia may have other medical or emotional conditions, the insomnia does not appear to be caused by these other conditions.²

Secondary Insomnia differs from Primary Insomnia in that a specific medical or emotional condition is associated with the cause of the sleep disturbance. Some examples of secondary insomnia are:

Insomnia due to other sleep disorders:
Insomnia may be the result of some other sleep disorder. Sleep apnea causes sleep disturbances due to interrupted breathing during sleep. Persistent, loud snoring at night and daytime sleepiness are the main symptoms of sleep apnea. Frequent long pauses in breathing during sleep, followed by choking or gasping for breath, may also occur. This problem occurs most frequently in men or overweight people. Because sleep apnea is a potentially serious condition that can cause other medical problems if left untreated, you should consult your physician if you think that this is a possible reason for your sleep problem. Restless leg syndrome is a sleep disorder characterized by unpleasant sensations (creeping, burning, itching, pulling, or tugging) in the legs or feet that disrupt sleep. Moving the legs around tends to relieve the unpleasant feelings temporarily. Your health professional may be able to help with this problem. Parasomnias are disruptive sleep-related events, which include sleepwalking, teeth grinding, and sleep terrors (waking from sleep in a panic). Consultation with a health professional is recommended if you experience any of these problems. Sleep-wake schedule or circadian rhythm disorder is a sleep disorder caused by having sleep-wake schedules that do not match your natural sleep cycle. Shift work often contributes to this disorder. Although your natural sleep-wake cycle can be gradually adjusted, you may have to change your work schedule to fit your natural sleep cycle.²

Insomnia due to medical conditions:
Many common medical problems (and some of the drugs that treat them) can cause insomnia. These medical problems include allergies, arthritis, heart disease, hypertension, asthma, Parkinson’s disease, Attention Deficit Hyperactivity Disorder, or hyperthyroidism. Physical discomfort (e.g., chronic pain) may also cause problems sleeping. Be sure to consult your physician regarding any health conditions you have that could contribute to your sleep difficulties.²

Insomnia due to substance use or withdrawal:
Many drugs and medications can cause sleep disturbances, either while taking them or while withdrawing from them. Alcohol, stimulants, sedatives, and even long-term use of sleep medications can cause insomnia. Certain medications for asthma (theophylline) and heart conditions (beta-blockers) can also affect your sleep. If in doubt, review your list of medications with your physician or pharmacist.²

Insomnia due to an emotional problem:
Insomnia can be a symptom of a number of emotional difficulties, particularly depression. If you have experienced sadness or a loss of interest in activities for a number of weeks, consult your health professional.²

Because insomnia can be caused by so many other conditions, it is important that you talk to your physician about your insomnia and what may be causing it. Your physician will probably ask you a number of questions about your sleep pattern and history, and may order tests to make sure that there is no other medical condition causing your insomnia. It is important to know the cause of your insomnia before you consider treatments. Consult your physician before beginning any treatment for insomnia.

Treatment for Primary Insomnia

Medication treatments include over-the-counter (OTC), hormonal, and prescription drugs. OTC and hormonal therapies are widely available but have little to no effect on chronic insomnia. The active ingredient in most over-the-counter sleep medications is diphenhydramine (Benadryl®), a common cold and allergy medication that also produces drowsiness. It can help occasional sleep difficulties (e.g., acute insomnia), but is not effective for chronic insomnia. Melatonin, a natural hormone, is also used to promote sleep but has very limited effects on chronic insomnia. Prescription sleep medications (sedative-hypnotics) are commonly used to treat insomnia. These medications are effective for treating insomnia, but have been shown to be less effective than behavioral treatments, particularly over the long term. Prescription sleep medications also have a number of potential problems. Most of these medications are dependence-producing and can be addictive. Over time, you may need to take more of the medication to get the same effect, and stopping the medication can make the insomnia worse. In addition, sleep medications tend to cause drowsiness and difficulty waking in the morning, and can affect concentration, memory, and reaction times. For all of these reasons, most physicians and sleep experts do not consider prescription sleep medications to be the preferred treatment for chronic insomnia. If you are currently taking prescription sleep medications, continue to follow your physician’s instructions, especially if you feel that these medications are helping your insomnia. If you have concerns about the sleep medications you are taking, consult your physician.

Behavioral therapy is considered by the medical and scientific community to be an effective treatment for primary insomnia. There are several studies to indicate that cognitive-behavioral treatment of insomnia is effective.³   A comprehensive behavioral treatment for primary insomnia generally includes the following components:

Sleep hygiene: Certain lifestyle and environmental factors can disrupt normal sleep. Eliminating or reducing disruptions to normal sleep (e.g., loud noises, temperature changes) or activities that negatively affect sleep (e.g., drinking caffeine, smoking cigarettes, engaging in excessive activity or exercise before bed) can improve the quality and quantity of the sleep you get.¹

Cognitive restructuring: Although some problems are resolved by trying harder to fix them, trying harder to sleep can make it more difficult to do so. By changing your thoughts and beliefs about sleep, particularly unrealistic sleep expectations, you can reduce the pressure to get a good night’s sleep and make it easier to fall asleep.¹

Relaxation training: Tension and anxiety are often associated with insomnia. The use of relaxation techniques before bedtime can help to reduce tension and help the body fall asleep more easily.¹

Stimulus control: The “stimulus” or signal to fall asleep should be lying down in bed. Unfortunately, over months and years of lying in bed awake, people with insomnia have learned that lying in bed is a trigger for being awake, not for falling asleep. By using the bed primarily for sleep—and getting out of the bed if sleep does not occur after a short time—the bed and bedroom can again become the signal for your body to fall asleep.¹

Sleep restriction and scheduling: As sleep difficulties arise, many people try even harder to “catch up” on missed sleep by sleeping later, taking naps during the day, or going to bed early. Unfortunately, these efforts only serve to further disrupt the normal sleep-wake cycle and result in a worsening of the insomnia. By setting a consistent wake-up time and delaying time to bed, a regular sleep pattern can be re-established. Delaying time to bed also makes you more ready to fall asleep when you finally go to bed. As sleep improves, the amount of time in bed is then increased gradually until a normal sleep pattern is restored.¹

A number of scientific studies have shown that these behavioral strategies are the most effective approach for chronic primary insomnia. Unfortunately, very few health or behavioral health professionals are trained to provide this treatment, so most people do not have access to this effective treatment for insomnia.³

Sources:

1. Hauri P., & Linde S. (2000). No More Sleepless Nights. New York: John Wiley and Sons.
2. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders – 4th edition. Washington, D.C: American Psychiatric Association.
3. NIH State-of-the-Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults, Final Report. http://consensus.nih.gov/2005/2005InsomniaSOS026html.htm