Insomnia is a complaint of difficulty falling asleep, difficulty staying asleep, or unrestorative sleep. The complaint of insomnia can be caused by multiple factors. The duration of the insomnia complaint is often an important clue to determining the underlying cause of the problem. Transient insomnia lasts only a few days and usually occurs in people who are otherwise healthy but are undergoing sudden stress (including positive stress such as getting ready for a wedding or a trip) or experiencing the onset of a medical or psychiatric illness, changes in medications, or jet lag. An example of transient insomnia would be trouble sleeping before an important exam or an important meeting.
Transient insomnia rarely is discussed in the doctor’s office since it usually gets better before the patient can get an appointment. Patients usually seek professional help after experiencing short-term insomnia, which can last up to 3 weeks, or chronic insomnia, which lasts more than 3 weeks.
Chronic insomnia often is a multi-level problem, reflecting multiple predisposing, precipitating, and perpetuating factors. For example, insomnia in an already anxious individual (predisposing factor) may result from nervousness about a new job (precipitating factor). This may lead to inappropriate use of alcohol and sleeping pills at night to induce sleep, as well as increased anxiety about sleep (perpetuating factors).
Insomnia usually is caused by either behavioral problems and bad sleep habits, medical problems, psychiatric problems, medications and drugs, circadian rhythm disorders, or sleep disorders (such as sleep disordered breathing or periodic limb movements in sleep.)
What Are Behavioral
Problems That Cause Insomnia?
No matter what originally caused the complaint of insomnia, behavioral problems often are the main perpetuating problem. The two more common behavioral conditions are psychophysiologic insomnia and poor sleep hygiene.
occurs when you are negatively conditioned to sleeping in your bed. For example, you experience some anxiety over an upcoming job evaluation. You go to bed and have difficulty falling asleep. The next night you tell yourself that you didn’t sleep well the night before, so you have to get some sleep tonight. You become so tense trying to sleep that you have difficulty sleeping the second night. On the third night the same thing happens. By the fourth night, even though your performance evaluation has been completed (and you received a very positive evaluation), you are very tense when you go to bed because you now know that when you go to bed you will not be able to sleep. The transient insomnia has developed into a learned response, that is, “I won’t be able to sleep when I get into bed.” In fact, these patients have no trouble sleeping in the sleep laboratory or on the sofa in the living room – their main anxiety arises when they have to sleep in their own bed. Patients with psychophysiologic insomnia experience anxiety about going to sleep at night, are tired in the day because they do not sleep well, and often nap during the day.
Are There Behavioral
Treatments For Insomnia?
Behavioral treatments, in combination with sleep hygiene, may be helpful in treating psychophysiologic and other insomnias. Relaxation training (such as progressive relaxation, biofeedback, meditation, deep breathing, or counting sheep) can be effective if practiced until relaxation becomes automatic.
is effective if your tension is physical, i.e., if you have difficulty relaxing your muscles. Lie down on your back in bed with the lights out. Close your eyes and breathe deeply several times. Continue to breathe deeply throughout the exercise. Begin with your toes. While leaving the rest of your body relaxed, tense your toes by curling them down. Notice how tight they feel. Then relax. Continue tightening and relaxing each muscle group working up the body: toes, calves, thighs, stomach, shoulders, hands, arms, neck and face. With each tightening keep breathing and pay attention to what the muscles feel like when they are tense compared with what they feel like when you relax them. Tightening the muscles acts as a pendulum, allowing you to relax more deeply than if you didn’t tense first. This exercise can be practiced during the day as well. The more often you practice the exercise, the more relaxed you will become, and the more effective the exercise will be.
and counting your breaths
(or sheep) helps relax an active mind. Take a deep breath and count one. Focus on the breathing. Take a second deep breath and count two. If your mind wanders (and it will), go back to counting from one. With practice you will be able to count to ten and be asleep before you know it.
Two other behavioral therapies have been shown to be effective for insomnia. They are stimulus-control therapy, developed by Dr. Richard Bootzin, and sleep restriction therapy, developed by Dr. Arthur Spielman. These techniques are best when done under the supervision of a behavioral therapist or sleep specialist. They are described here for informational purposes.
The aim of stimulus-control therapy is to break the negative associations of being in bed but unable to sleep. It is especially helpful for patients with sleep-onset insomnia and prolonged mid-sleep awakenings. The rules of stimulus-control therapy include:
1. Only go to bed when you feel sleepy.
2. If you don’t fall asleep within 15 minutes, get out of bed and don’t go back to bed until you think you can fall asleep. If you go back to bed and still can’t fall asleep, get out of bed again. Repeat this until you can fall asleep within a few minutes.
3. Avoid looking at the clock.
4. Get up at the same time every morning.
5. Use the bed only for sleeping, not for watching the evening news, paying bills, reading exciting books, etc.
6. Do not nap during the day.
After the first night you will be very sleepy and should be extra careful if you have to drive or use special equipment during the day. The second night you should have an easier time falling asleep. If not, repeat the instructions listed previously. In all it may take 3 to 4 weeks, but after breaking the unwanted pattern, you should have little difficulty falling asleep at night.
Sleep restriction therapy is based on the observation that the more time spent in bed leads to more fragmented sleep, and conversely, the less time spent in bed, the more consolidated sleep becomes. The rules of sleep restriction therapy include:
1. You only are allowed to stay in bed for the amount of time you think you sleep each night, plus 15 minutes. For example, if you report sleeping only 5 hours a night, you are allowed to be in bed for 5 hours and 15 minutes.
2. You must get up at the same time each day. If you sleep for 5 hours and generally get up at 5:00am, you are allowed to be in bed from 12:45am until 6:00am.
3. Do not nap during the day.
4. When you are asleep for 85% of the time you stay in bed, you can increase the amount of time in bed by going to bed 15 minutes earlier. (You still have to get up at the same time in the morning.)
5. Repeat this process until you are sleeping for 8 hours or the desired amount of time.
This procedure also takes 3 to 4 weeks to be effective. Be aware that, as with stimulus-control therapy, you may be very sleepy during the day and should be extremely careful driving, etc.
Are There Other
Types of Non-Drug Treatments of Insomnia?
Another approach to treating insomnia, often done in combination with behavioral therapy, is called cognitive behavioral therapy (CBT). Insomnia may be exacerbated by what people believe. For example, if you think you will get sick if you don’t sleep 8 hours each night, this belief can cause you to worry if on some nights you get less than 8 hours sleep. This anxiety can make insomnia worse. Or if you think that any change you experience in your sleep means something is wrong, this too can cause insomnia. Another example might be the belief that because your wife falls asleep immediately, there must be something wrong with you because it takes you longer to fall asleep. So what we believe and what we think can be a part of our sleep problem. Insomniacs often have unrealistic sleep expectations, don’t understand the cause of their sleep problem, and engage in catastrophic thinking about the effect of their sleep problem.
A type of therapy explored in detail by Charles Morin and his colleagues, consists of a combination of the behavioral therapies described in the previous material (such as sleep restriction or stimulus-control therapy) in addition to providing the individuals with alternative beliefs and changing their attitudes about sleep and about the effect lack of sleep has on daytime behavior. Cognitive behavioral therapy involves three steps: (1) to identify the dysfunctional beliefs (“I must sleep 8 hours or I will get sick”); (2) to challenge those beliefs (“Have you ever gotten sick because you only slept 6.5 hours?” or “What is the evidence that you will get sick?”)’ and (3) to teach new beliefs that are more realistic (“If I don’t get enough sleep tonight or tomorrow night, I may be fatigued during the day, but I won’t get sick and my body will eventually take the sleep it needs.”). The cognitive restructuring is aimed at decreasing the difference between the patient’s reality and their beliefs about sleep. The main focus is to break the vicious cycle of worrying about loss of sleep, fear of sleeplessness, anxiety over not sleeping, and more insomnia.
What Type of
Medical Problems Cause Insomnia?
Insomnia can result from any medical problem that causes pain or discomfort. This could include illnesses such as heart disease, pulmonary disease, cancer, or arthritis. It is important to determine if the insomnia complaint is related to the medical problem by examining the time course of each. For example, if the complaint of poor sleep is worse when the pain of arthritis flares up, then it is likely that the insomnia is secondary to the pain. The first line of therapy in this type of situation is treating the medical problem and any bad sleep habits that have developed.
Patients with rheumatologic disease, which causes pain during the night, usually have no difficulty falling asleep but may experience more awakenings during the night, less overall time asleep, and more time spent in stage 1 (light) sleep. Patients taking benzodiazepines (a type of sleeping pill) have reported sleeping better and experiencing less pain at night, but their complaints of morning stiffness increase. The use of aspirin in combination with a sedative-hypnotic alleviates the morning stiffness. Tricyclic antidepressants (such as amitriptyline) also have been used successfully to treat this disorder.
Other examples of medical illnesses that are known to disturb sleep include:
What Type of
Psychiatric Problems Cause Insomnia?
Almost all patients with psychiatric disease complain of insomnia. The severity of the insomnia generally varies with the severity of the psychiatric problem. For example, early morning awakenings are associated with depression, and trouble falling asleep is associated with generalized anxiety. As with the medical conditions, treatment includes treating the primary psychiatric problem in combination with any bad sleep habits that have developed. Depression is one of the most common causes of insomnia. Patients with depression experience fragmented sleep, difficulty falling asleep, and frequent awakenings during the night. They have decreased amounts of stage 3 and 4 (deep) sleep, decreased time to the first REM period, and increased REM sleep activity.
How Can Drugs
Many medications have an effect on sleep. Many drugs are stimulating and if taken in the evening, cause insomnia. Other drugs are depressants and if taken in the day, cause daytime sleepiness. Sleeping pills, with long-term use, may even cause insomnia. If you are taking sleeping pills and suddenly decide to stop, you will experience rebound insomnia. This means that for the first night or so, your insomnia actually gets worse. A natural reaction is to think, “Oh, I can’t sleep without my sleeping pill,” and you go back to taking the drugs. In fact, it takes some time for your body to adjust to the rebound insomnia, and if you are patient and give yourself a few nights of bad sleep, you actually may begin to sleep better.
How Common Is
In data collected by the Gallup Poll for the National Sleep Foundation, 9% of the population reported chronic insomnia and 27% reported transient or intermittent insomnia during the course of a year. The complaint of insomnia is more common in women than men, increases with age, and is more common in lower socioeconomic classes. The most common problem reported was waking up feeling drowsy. Chronic insomniacs reported more difficulty enjoying family and social relationships, more difficulty concentrating, more problems with memory, greater frequency of falling asleep while visiting friends, and more automobile accidents resulting from sleepiness. Younger insomniacs generally have a complaint of difficulty falling asleep, whereas older insomniacs generally have a complaint of staying asleep.
I See My Health Care Provider?
It is time to see your provider when your insomnia is routinely disrupting your everyday life. Remember, insomnia is a real complaint caused by real problems. Also remember, there is help for insomnia.
Sleep: Are You Getting Enough?
Good Sleep Hygiene