What Is Insomnia?
Insomnia is not a sleep disorder! Rather, 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).
What Causes Insomnia?
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.
Psychophysiologic insomnia
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.
Poor sleep hygiene
means bad sleep habits. Bad sleep habits generally result from irregular sleep
schedules, excessive daytime napping, overuse of alcohol and caffeine, poor
sleep environments, or anxiety at bedtime. Teaching the patient appropriate
sleep hygiene rules can treat both psychophysiologic insomnia and poor sleep
hygiene. In fact, good sleep hygiene is the cornerstone of all insomnia treatments.
What Are The Rules of
Good Sleep Hygiene?
1. Curtail time in bed. The longer you stay in bed, the more fragmented your
sleep becomes. The less time you stay in bed, the more consolidated you sleep.
Therefore 8 hours of sleep out of 8.5 hours in bed is more efficient than 8
hours of sleep out of 10 hours in bed.
2. Get up at the same time each day. Our bodies are controlled by circadian rhythms. The circadian rhythm needs one stable point around which it can stabilize. Since you cannot control what time you fall asleep, the only time you can control is what time you wake up. Therefore it is extremely important for insomniacs to get up at the same time each day (including weekends) and to avoid “sleeping in.”
3. Avoid the bedroom clock. The first thing you do when you wake up in the middle of the night is look at your clock. The time pressure contributes to poor sleep. In addition, the acts of opening your eyes to see the clock and lifting your head to read the time wake you up even more. What difference does it make if it is 1:00am or 3:00 am? Turn your clock around or move it to the other side of the room where you won’t be tempted to look. If you wake up in the middle of the night, keep your eyes closed, and you will be more likely to go right back to sleep.
4. Avoid caffeine, alcohol, and tobacco. Caffeine has been shown to disrupt sleep, even in individuals who don’t think it affects them. The effect of caffeine remains in the body on average from 3 to 5 hours. Remember that caffeine is not just in coffee, but also in tea, chocolate, and many sodas (note that a soda does not have to be brown to be full of caffeine – read the labels.) For individuals with insomnia, it is best to avoid all caffeine after lunchtime.
And if you need one more reason to stop smoking, tobacco (nicotine) also has been shown to disturb sleep. Nicotine can have an arousing effect and therefore it makes it more difficult to sleep. Insomniacs often use alcohol to help them fall asleep. One old wives’ tale suggests having a glass of sherry before bed to promote sleep. In fact, this is just an old wives’ tale. Alcohol makes you sleepy initially but several hours later when the alcohol wears off, it can cause you to wake up (insomnia). Therefore, if you drink alcohol with dinner, you may be sleepy right after dinner, but several hours later, when it is time for bed, you may be wide awake. If you drink alcohol right before bedtime you may fall asleep quicker, but several hours later, at 1:00 or 2:00 in the morning, you may wake up again and have difficulty going back to sleep.
5. Exercise. Keeping generally fit will promote sleep. Exercising right before bedtime may make sleep more difficult, because one of our circadian rhythms is the body temperature cycle. When our body temperature drops, we become sleepy. Exercising increases our body temperature. It then takes about 6 hours for the body temperature to begin to drop; at that point it will be easier to fall asleep. Therefore, exercising about 6 hours before bedtime promotes sleep.
6. Eat a light snack. Going to bed with an empty, hungry stomach makes it more difficult to sleep. Eating a light snack, particularly one with tryptophan, helps promote sleep. Tryptophan is a naturally produced amino acid with sleep-promoting properties and can be found in products such as milk, cheese, bananas, fish, and turkey. (Why do you think you are so tired after your Thanksgiving meal?). Therefore, a glass of warm milk at bedtime may be quite conducive to sleep.
7. Adjust sleeping environment. The sleep environment should be relaxing, comfortable, and conducive to sleep. If the bedroom is too noisy, consider moving to a quieter room in the house or using earplugs. If there is too much light, try dark curtains or eye shades.
8. Do not worry right before bed. Generally, in our busy schedules, the first time we have to sit quietly and think about our day is when we get into bed. This is the wrong time to start worrying. Plan a quiet time earlier in the evening that will allow you time to think, plan and “worry” away from your bedroom, thus interfering less with sleep. If you find it helpful to write things down, this is the time to make lists of all the different options you have for the things you are worrying about.
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.
Progressive relaxation
training
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.
Breathing deeply 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.
Stimulus-Control Therapy
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
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.
Cognitive behavioral
therapy,
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 Cause Insomnia?
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 Insomnia?
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.
When Should I See My
Health Care Provider?
It is time to see your provider when your insomnia is routinely disrupting your
every day life. Remember, insomnia is a real complaint caused by real problems.
Also remember, there is help for insomnia.