Insomnia

Insomnia is a widespread problem affecting between - 15% and 30% of the adult population. Half of the people complaining of insomnia consider their problem serious enough to seek professional help. Insomnia is perhaps the second most prevalent health complaint after pain. It is twice as frequent in women as in men and its incidence increases with age.

Insomnia is not a trivial complaint. Chronic sleep disturbances may have a detrimental impact on daytime functioning. It can cause considerable distress and impair the quality of life. It can also lead to mood problems, fatigue, and performance impairment (memory, alertness, concentration), which in turn can jeopardize jobs and relationships.

Clinical Characteristics

Problems falling asleep, waking up in the middle of the night, and early morning awakening are the most common insomnia complaints. According to the American Sleep Disorders Association, these difficulties of initiating and maintaining sleep are distinguished from disorders of excessive daytime sleepiness (narcolepsy, sleep apnea), disorders of the sleep-wake schedule (work shift, jet lag), and the parasomnias (nightmares, sleep-walking).

Because there are individual differences in sleep needs, reduced sleep duration alone is not necessarily indicative of insomnia. Some people who are by nature short sleepers may not suffer from insomnia, while others who are long sleepers may complain of insomnia.

Developmental changes in sleep patterns also occur with aging, but insomnia is not an inevitable fact of getting older. Virtually everyone experiences insomnia at some time due to stressful life events.  However, a person should consider seeking help if problems falling asleep or staying asleep persist for more than (one month or if he or she has been using sleeping pills for more than 2 to 4 weeks and cannel get a good nights sleep without using them.

Common Causes of Insomnia

Insomnia may be caused by a host of medical, environmental, and psychological factors. Among the most common medical factors are pain, respiratory impairment (sleep apnea), restless legs, and repetitive leg twitches during sleep (nocturnal myoclonus). Some medications specifically prescribed for physical ailments, such as bronchial-dilators for asthma and diuretics for hypertension, may trigger insomnia as a side effect.

Prolonged use of sleeping medications makes insomnia worse. Sleeping medications can be habit forming and people can become dependent on them. Caffeine and nicotine are both central nervous system stimulants producing fragmented and lighter sleep. Although a nightcap may help tense people to unwind and fall asleep faster, alcohol leads to fitful and non-refreshing sleep. Psychological problems such as severe anxiety and depression are common causes of insomnia. In turn, chronic sleep disturbances may also lead to milder forms of mood disturbances.

Stressful life events such as divorce, death of a significant other, impending surgery, and job changes can often trigger sleep disturbances. While most people resume normal sleep after adjusting to these life events, some continue experiencing persistent 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 play a major contributing role in the development of persistent insomnia. During the initial phase of their sleep difficulties, people who are prone to insomnia may develop conditioned reactions that are incompatible with sleep. For example, after several poor nights of sleep, a person may come to associate stimuli such as pre-bedtime routines and bedtime surroundings with apprehensions, 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 eventually leads to a vicious cycle of insomnia, fear of sleeplessness, more emotional, cognitive, and physiologic arousal, and more insomnia.

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

In order to cope with insomnia, people may also develop unusual sleep habits, such as irregular sleep/wake schedules, daytime napping, and excessive time spent in bed. While these attempts to adapt It) insomnia may temporarily result in increased sleep or improved alertness, over the long run they interfere with the synchronizing effect of a regular and constrained sleep/wake rhythm.

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

Evaluation

Assessment the insomniac patient will generally revolve a detailed history of the sleep problem as well as a functional analysis of the current sleep pattern focusing 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 nature and severity of the insomnia and in monitoring progress during treatment. Psychological screening tests are routinely administered to rule out milksop psychopathology as the main cause of sleep disturbances. In most cases of insomnia without medical complications, this evaluation is usually sufficient to design an individualized treatment plan specifically tailored to patient needs.

When complicated sleep disorders are suspected, a specialized all-night sleep recording, called a polysomnogram, may be recommended for proper diagnosis. The polysomnogram monitors a variety of body signs and is administered in a sleep-disorders clinic. It may be of particular use in

• Detecting covert (hidden) and documenting overt (obvious) physiological factors disrupting sleep (e.g., sleep apnea, leg movements),

• Comparing a patient's subjective report (how he or she believe it is) and objective measures (how it really is) of sleep, and

• Refining the diagnostic determination in cases that have not responded to treatment.

Treatments

Insomnia has traditionally been treated with sleeping pills. The newest and most commonly prescribed of these are flurazepam (Dalmane), triazolam (Halcion), and temazepam (Restoril).

Unfortunately, most sleeping medications are effective only temporarily, produce side effects, and often lead to tolerance and dependence. Widely advertised over-the-counter medications (e.g.. Sominex, Sleep-Eze, Unisom) produce little impact on sleep beyond a placebo effect - in other words, the feeling that since I took a pill I will now be able to fa11 asleep. Although short-term use of sleeping pills may be indicated for acute sleep problems, the role of hypnotics in the treatment of chronic insomnia has not been proven.

Extensive research has shown that cognitive behavioral treatments are effective for the management of chronic insomnia. Most behavior therapists and sleep clinics will offer a comprehensive treatment program including one or more of the following treatment components.

  Stress Management

    Because stress or tension is often associated with poor sleep, stress-reduction methods such as relaxation training biofeedback, meditation, and guided-imagery can be useful in overcoming insomnia. These methods have a common objective, which is to decrease muscular and mental tension and to control excessive bedtime worries and intruding thoughts, which interfere with falling asleep or returning to sleep.  

Stimulus Control Therapy

This treatment method consists of a set of instructions aimed at curtailing behaviors incompatible with sleep and at regulating sleep-wake schedules. Specifically, it involves:

• Going to bed only when sleepy.

• Getting out of bed when unable to fall asleep or unable to return to sleep within 15 to 20 minutes.

• Using the bed/bedroom for sleep and sex only (no reading, eating, TV watching, working, or worrying).

• Getting up at the same time every morning regardless of the amount of sleep obtained on the previous night.

• Refraining from napping 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 achieve enough sleep, insomniacs often spend all excessive amounts of time in bed. While this strategy is occasionally effective for a while, it generally makes the sleep problem worse. Sleep restriction therapy consists of restricting the time spent in bed to the actual amount of time slept. For example, if you spend 8 hours m 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 duration is achieved. While the initial curtailment of time spent in bed may produce daytime sleepiness, this clinical procedure will improve nighttime sleep.

Cognitive/Educational Component

To maximize improvement, it is often necessary to teach insomniacs methods to re-evaluate their thoughts and beliefs about sleep and to change their attitudes about insomnia. For example, beliefs such as "everyone needs 8 hours of sleep to function well during the day" or "insomnia is necessarily detrimental to physical and mental health" only create performance anxiety and worsen sleep problems.

It is also important, especially for older people, to understand some of the changes in sleep patterns that naturally take place over the course of the life span. Sleep hygiene education about the effects of diet, exercise, and substance use is usually an integral component of most behavioral treatment programs for insomnia.

Effective non-drug methods are available for treating insomnia. Cognitive behavior therapy is aimed at teaching self-management skills to insomniacs so they can regain control over their sleep patterns. Short-term treatment programs conducted either individually or in group format and typically lasting 6 to 8 weeks have yielded promising results in overcoming insomnia. The average rates of improvement range between 50% and 70%, and the benefits are usually well maintained over time.

What is Behavior Therapy?

Behavior Therapy is a particular type of treatment that is based firmly on research findings. It aids people in achieving specific changes or goals.

Goals might involve:

• A way of acting: like using the bedroom only for sleep;

• A way of feeling: like understanding how stress affects sleep;

• A way of thinking: like learning that 8 hours of sleep isn't necessary for everyone;

• A way of dealing with physical or medical problems: like integrating diet and exercise to promote sleep; or

• A way of coping: like training people in self-management skills.

Behavior Therapists and Cognitive Behavior Therapists usually focus on the current situation, rather than the past. They concentrate on a person's views and beliefs about their life, not on personality traits. Behavior Therapists and Cognitive Behavior Therapists treat individuals, parents, children, couples, and whole families. Replacing ways of living that do not work well with ways of living that do work, and giving people more control over their lives are common goals of behavior therapy.