Insomnia

Apr 11, 2006 5:12 PM

Definition

Insomnia is the perception or complaint of inadequate or poor-quality sleep because of: difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning and/or unrefreshing sleep.

Description

Over 100 million Americans are estimated to have occasional sleep problems, and about 1 in 6 have chronic insomnia and consider this a serious problem. Insomnia can be described in terms of both duration and severity. Transient insomnia can be described as lasting from one night to a few weeks and is usually caused by events that alter your normal sleep pattern, such as traveling. Short-term insomnia lasts about two to three weeks and is usually attributed to emotional factors such as worry or stress. Intermittent insomnia occurs off and on and can be attributed to a number of emotional and physical factors. Chronic insomnia occurs most nights and lasts a month or more.

Causes

Insomnia can be caused by:

• Stress-related factors – significant personal events, such as losing a job, marital problems, stress and worry.
• Psychiatric conditions, such as depression, anxiety and schizophrenia.
• Medical illness. Certain medical illness can interfere with sleep, especially disorders of the heart (congestive heart failure), lungs (chronic obstructive pulmonary disease), kidneys, liver, pancreas and digestive system (peptic ulcer). Other important physical causes include heartburn, prostatism, menopause, diabetes, arthritis, hyperthyroidism and hypoglycemia.
• Obstructive sleep apnea syndrome, where the obstruction of the airway caused by the sagging muscles at the base of the throat. The muscles obstruct the airway causing labored breathing and loud snoring. If complete blockage occurs, breathing stops and the sleeper falls silent. Opening of the blockage is signaled by a gasp and the sleeper awakening throughout the night during these episodes.
• Periodic limb movement disorder, the recurring movements of the legs.
• Restless leg syndrome, an unpleasant tickling, burning, pricking or aching sensations in the muscles of the legs.
• Psychophysiologic ("Learned") insomnia, the severe difficulty in initiating and maintaining sleep. Many people go to bed worrying about insomnia because of previous episodes, and this thinking produces an adverse association between the bedroom and sleep.
• Circadian Rhythm Sleep Disorder (Sleep-wake Disorder), which occurs when your internal clock gets out of sync with your sleep schedule.
• Biological factors. As you age, sleep becomes lighter and more fragmented. While young people tent to have problems falling asleep, older people struggle with staying asleep. During our life spans, the internal biological "clock" that regulates sleep creeps slightly forward, compelling most older people to go to sleep earlier and to wake earlier.
• Lifestyle factors. Excessive caffeine consumption, alcohol and drug abuse, poor sleeping habits, shift work change and misuse of certain medications such as anticholinergics (used for treatment of asthma), antidepressants, antihypertensives (used for treatment of high blood pressure, stroke and heart failure), antineoplastic agents, corticosteroids, diuretics, histamine blockers and respiratory stimulants.
• Environmental factors. Noise, light and stale air can cause insomnia.

Diagnosis

Laboratory observation of a patient's sleep is the best diagnostic tool, but much can be learned from careful history taking. Assessment of recent onset insomnia should focus on acute personal and medical problems. In those reporting long-term sleep disturbance, assessment should address the history as well as physical and mental status, and referral to a sleep laboratory might be appropriate. Additionally, a sleep diary should be maintained. This diary would include bedtimes, estimates of the time needed to fall asleep, number of night awakenings, and total amount of time asleep. This helps in correct diagnosis as well as monitoring the treatment.

Treatment

Treatment with Medication

• Alcohol. Commonly self-prescribed as a sleep aid, alcohol is of limited benefit. A very small amount of alcohol can be relaxing and produce sleepiness early in the evening, but tolerance and withdrawal occur very rapidly.
• Antihistamines. Over-the-counter sleeping pills (Sominex, Nytol) - are probably the most commonly used sleeping preparations apart from alcohol. They are not consistently effective. Residual difficulty with coordination and memory can persist into the daytime.
• Benzodiazepines. In prescription form these drugs are relatives of diazepam (Valium) marketed as sleeping aids. The three most common ones are trade-named Dalmane, Halcion, and Restoril. They appear to reinforce the effect of a naturally occurring inhibitor of neural activity. These drugs have little effect on breathing or on function of the heart. The side effects of using this drug are poor coordination, reduced reaction time, and impaired memory. These "hangover effects" occur when the blood level is at its peak and will vary depending on how long the drug remains in the body.
• Barbiturates were formerly the standard sleeping pills, sold under such names as Seconal and Nembutal. Barbiturates can depress the functioning of all electrically active tissue, including heart muscle. Lethal overdose is fairly frequent and combination with alcohol is particularly hazardous.
• Chloral hydrate is similar to barbiturates in the way it acts, including its tendency to leave pain perception unaffected. It is irritating to the skin, mucous membranes, and stomach but, has few severe side effects at the doses used for sleep.
• Other drugs such as ethchlorvynol (Placidyl) are likely to produce neurologic side effects when taken. Many physicians prescribe a new, short-acting drug called Zolpidem (Ambien). It is not a benzodiazepine and may produce fewer side effects.

Treatment without Medication The following methods can help alleviate sleeplessness:

• Develop a regular sleeping schedule. Avoid daytime naps and stimulating activities just before bedtime.
• Avoid stimulating drugs, such as caffeine and nicotine, particularly before going to bed.
• Exercise during the day (but not in the late evening).
• Avoid alcohol- it is a leading cause of poor sleep.
• Drink a cup of warm milk.
• Mask background noise in the bedroom throughout the night.
• Try using a sleep mask and ear plugs at night.
• Take medications that may be stimulating long before bedtime.

Additionally, there are some behavioral techniques such as relaxation therapy, sleep restriction, reconditioning and bright-light therapy. Relaxation therapy consists of techniques that help reduce or eliminate anxiety and body tension. Sleep restriction is a technique that starts with a person only allowed to get a few hours sleep a night; over time the hours of sleep are increased until a more normal night's sleep is achieved. Another treatment that may help some people with insomnia is to recondition them (reconditioning) to associate the bed and bedtime with sleep. For most people this means not using their beds for any activities other than sleep and sex. Bright-light therapy is for people with miss-set internal clocks. In the wintertime, special commercial lights provide the necessary light exposure. People who wake too early may gain from bright-light therapy in the evening and avoiding sunlight in the morning. Experts must synchronize the time of light exposure to your body temperature, so supervision is necessary.

Questions

What kind of insomnia is it? What will the body do if it is not getting enough sleep? What over-the-counter sleeping aids do you recommend? How long can a person safely take sleeping pills? Will you be prescribing any medication? What are the side effects? What other measures can be done to help me sleep better?