Insomnia

The glow of the alarm clock is all too familiar for many. Insomnia refers to
an inability to fall asleep or stay asleep, or a tendency to wake up too early
or experience poor sleep.

Definition
Insomnia is the feeling of inadequate or poor-quality sleep because of one
or more of the following: trouble falling asleep (initial insomnia); trouble
remaining asleep through the night (middle insomnia); waking up too early
(terminal insomnia); or nonrestorative sleep that does not leave a person
feeling rested after an adequate duration of sleep. For insomnia disorder to
be diagnosed, these symptoms must be present at least three nights per
week and the sleep difficulty is present for at least one month. All of these
symptoms can lead to daytime drowsiness, poor concentration, irritability,
and the inability to feel refreshed and rested upon awakening.

Insomnia is not defined by the hours of sleep a person gets or how long it
takes to fall asleep. Individuals vary in their need for and satisfaction
with sleep. A key feature of insomnia is that individuals experience distress
or impairment in functioning as a result of their poor sleep.

Insomnia can be classified as episodic, persistent, or recurrent. Insomnia

lasting from one month to three months is referred to as episodic. If the
symptoms last three months or longer, the insomnia is said to be
persistent. Insomnia is considered to be recurrent if it two or more episodes
occur within the space of one year. A diagnosis of insomnia can be given
regardless of whether it occurs as an independent condition or occurs
alongside another condition, such as depression.

Women, the elderly and individuals with a history of depression are more
likely to experience insomnia. Factors such as stress, anxiety, a medical
problem, or the use of certain medications make its occurrence more likely.

Approximately one third of adults experience some symptoms of insomnia,

and 6 to 10 percent have symptoms that are severe enough to meet criteria
for a diagnosis of insomnia disorder.

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Symptoms
The diagnostic criteria of insomnia disorder include difficulty initiating sleep,
difficulty maintaining sleep, and early-morning awakening with inability to
return to sleep. These sleep disturbances cause significant distress and
impairment in many areas of functioning, including social, academic,
behavioral, and occupational functioning.

People with insomnia have difficulty carrying out their daily responsibilities,
either because they are too tired or because they have trouble
concentrating due to lack of restful sleep.

Insomnia may cause a reduction in energy level, irritability, disorientation,

dark circles under the eyes, posture changes, and fatigue. Insomnia is also
associated with factors that interfere with sleep, such as physiological and
cognitive arousal. For example, a person experiencing insomnia may be
preoccupied with an inability to sleep, and the more he or she tries to sleep,
the more frustration builds and sleep is impaired. Behaviors such as
spending too much time in bed and napping and thoughts such as fear of
sleeplessness and clock monitoring can further perpetuate sleep
difficulties.

Patients with insomnia are evaluated by obtaining a detailed medical

history and sleep history. The sleep history may be obtained from a sleep
diary filled out by the patient or through an interview with the patient's bed
partner concerning the quantity and quality of the patient's sleep.
Specialized sleep studies may also be recommended.

Causes
Certain conditions seem to make individuals more likely to experience
insomnia. Examples of these conditions include:

 Advanced age (insomnia occurs more frequently in those over age

60)
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  Female gender
 A history of depression
There are a number of possible causes of insomnia:

 Jet lag
 Shift work
 Wake-sleep pattern disturbances
 Grief
 Depression or major depression
 Stress
 Anxiety
 Exhilaration or excitement
 A bed or bedroom not conducive to sleep
 Nicotine, alcohol, caffeine, food, or stimulants at bedtime
 Aging
 Excessive sleep during the day
 Excessive physical or intellectual stimulation at bed time
 Overactive thyroid
 Taking a new drug
 Alcoholism
 Inadequate bright-light exposure during waking hours
 Abruptly stopping a medication
 Medications or illicit drugs
 Withdrawal of medications

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  Interference with sleep by various diseases
 Restless leg syndrome
 Stroke
 Menopause and hot flashes
 Gastrointestinal conditions, such as heartburn
 Conditions that make it hard to breathe
 Conditions that cause chronic pain, such as arthritis
 Anxiety or worry-prone personality or cognitive style
Situational or episodic insomnia can resolve on their own and generally
occur in people who are temporarily experiencing one or more of the
following:

 Stress
 Environmental noise
 Extreme temperatures
 Change in the surrounding environment
 Sleep/wake schedule problems such as those due to jet lag
 Medication side effects
Chronic insomnia is more complex and often results from a combination of
factors, including underlying physical or mental disorders. One of the most
common causes of chronic insomnia is depression. Other underlying
causes include arthritis, kidney disease, heart failure, asthma, sleep apnea,
narcolepsy, restless legs syndrome, Parkinson's disease, and
hyperthyroidism. However, chronic insomnia may also be due to behavioral
factors, including the misuse of caffeine, alcohol, or other substances;
disrupted sleep/wake cycles that may occur with shift work or other
nighttime lifestyles; and chronic stress.

Some behaviors may prolong existing insomnia, and they can also be
responsible for causing the sleeping problem in the first place:
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  Worrying about the upcoming difficulty sleeping
 Ingesting excessive amounts of caffeine
 Drinking alcohol before bedtime
 Smoking cigarettes before bedtime
 Excessive napping in the afternoon or evening
 Irregular or continually disrupted sleep/wake schedules
Stopping these behaviors may eliminate the insomnia.

Treatments
Situational or episodic insomnia may not require treatment since episodes
typically last only a few days or weeks at a time. For example, if insomnia is
due to a temporary change in schedule, as with jet lag, the person's
biological clock will often get back to normal on its own. However, for some
people who experience daytime sleepiness and impaired performance as a
result of episodic insomnia, the use of short-acting sleeping pills may
improve sleep and next-day alertness. As with all drugs, there are potential
side effects. The use of over-the-counter sleep medicines is not usually
recommended for the treatment of insomnia.

Treatment for diagnosed chronic insomnia includes identifying and stopping

(or reducing) behaviors that may worsen the condition, possibly using
sleeping pills (although the long-term use of sleeping pills for chronic
insomnia is controversial and should be a last resort), and trying behavioral
techniques to improve sleep, such as relaxation therapy, sleep restriction
therapy, and reconditioning.

Relaxation Therapy

There are specific and effective techniques that can reduce or eliminate
anxiety and body tension. As a result, the person's mind is able to stop
racing, the muscles can relax and restful sleep can occur. It usually takes
practice to learn these techniques and to achieve effective relaxation.

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Sleep Restriction

Some people suffering from insomnia spend too much time in bed
unsuccessfully trying to sleep. They may benefit from a sleep restriction
program that at first allows only a few hours of sleep during the night and
gradually increases the time until the person achieves a normal night's
sleep.

Reconditioning

Another treatment that may help some people with insomnia is to

recondition them 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. As part of the reconditioning process, the person is usually
advised to go to bed only when sleepy. If unable to fall asleep, the person
is told to get up, stay up until sleepy and then return to bed. Throughout
this process, the person should avoid naps and wake up and go to bed at
the same time each day. Eventually the person's body will be conditioned
to associate the bed and bedtime with sleep.

Cognitive Behavioral Therapy

CBT for insomnia targets the thoughts and actions that can disrupt sleep.
This therapy encourages good sleep habits and uses several methods to
relieve sleep anxiety.

For example, relaxation training and biofeedback at bedtime are used to

reduce anxiety. These strategies help you better control your breathing,
heart rate, muscles, and mood.

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CBT works on replacing sleep anxiety with more positive thinking that links
being in bed with being asleep. This method also teaches you what to do if
you're unable to fall asleep within a reasonable amount of time.

CBT may involve talking with a therapist one-on-one or in group sessions

to help you consider your thoughts and feelings about sleep. This method
may encourage you to describe thoughts racing through your mind in terms
of how they look, feel, and sound. The goal is for your mind to settle down
and stop racing.

CBT also focuses on limiting the time you spend in bed while awake. This
method involves setting a sleep schedule. At first, you will limit your total
time in bed to the typical short length of time you're usually asleep. This
schedule may make you even more tired because some of the allotted time
in bed will be taken up by problems falling asleep. However, the resulting
tiredness is intended to help you get to sleep more quickly. Over time, the
length of time spent in bed is increased until you get a full night of sleep.

For success with CBT, you may need to see a therapist who is skilled in
this approach weekly over two to three months. CBT works as well as
prescription medicine for many people who have chronic insomnia. It also
may provide better long-term relief than medicine alone.

For people who have insomnia and major depressive disorder, CBT
combined with antidepressant medication has shown promise in relieving
both conditions.

Tips for a Good Night's Sleep:

Set a schedule

Go to bed at a set time each night and get up at the same time each
morning. Disrupting this schedule may lead to insomnia. Sleeping in on
weekends also makes it harder to wake up early on Monday morning
because it resets your sleep cycle for a later awakening. If you can, avoid
night shifts, alternating schedules, or other things that may disrupt your
sleep schedule.

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Physical activity

Try to exercise 20 to 30 minutes a day. Daily exercise often helps people

sleep, although a workout soon before bedtime may interfere with sleep.
For maximum benefit, try to get your exercise no later than five to six hours
before going to bed. Sex can be a natural sleep inducer and helps some
people. 

Avoid caffeine, nicotine, and alcohol

Avoid caffeine for at least eight hours before bedtime. Sources of caffeine
include coffee, chocolate, soft drinks, non-herbal teas, diet drugs and some
pain relievers. Quit smoking: Smokers tend to sleep very lightly and often
wake up in the early morning due to nicotine withdrawal. Avoid using
alcohol in the evening. Alcohol robs people of deep sleep and REM sleep
and keeps them in the lighter stages of sleep. Don't eat heavy meals before
bedtime.

Relax before bed

A warm bath, reading or another relaxing routine can make it easier to fall
asleep. You can train yourself to associate certain restful activities with
sleep and make them part of your bedtime ritual. 

Sleep until sunlight

If possible, wake up with the sun, or use very bright lights in the morning.
Sunlight helps the body's internal biological clock reset itself each day.
Sleep experts recommend exposure to an hour of morning sunlight for
people having problems falling asleep.

Don't lie in bed awake

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If you can't get to sleep, don't just lie in bed. Do something else, like
reading, watching television, or listening to music until you feel tired. The
anxiety of being unable to fall asleep can actually contribute to insomnia.

Control your bedroom environment

 Avoid bright lighting while winding down.

 Use comfortable bedding.
 Limit noises and possible distractions, such as a TV, computer, or a
pet. 
 Reserve the bed for sleep and sex.
 Make sure the temperature of your bedroom is cool and comfortable.
See a doctor if your sleeping problem continues

If you have trouble falling asleep night after night, or if you always feel tired
the next day, then you may have a sleep disorder and should see a
physician. Your primary care physician may be able to help you; if not, you
can find a sleep specialist at a major hospital near you. Most sleep
disorders can be treated effectively.

Sleep research is expanding and attracting more attention. Researchers

now know that sleep is an active and dynamic state that greatly influences
our waking hours, and they realize that we must understand sleep to fully
understand the brain. Innovative techniques, such as brain imaging, can
now help researchers understand how different brain regions function
during sleep and how different activities and disorders affect sleep.
Understanding the factors that affect sleep in health and disease also may
lead to revolutionary new therapies for sleep disorders and to ways of
overcoming jet lag and the problems associated with shift work. We can
expect these and many other benefits from research will allow us to truly
understand sleep's impact on our lives.

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References

 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Revised
 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
 National Heart, Lung, and Blood Institute Information Center
 National Institute of Neurological Disorders and Stroke
 National Institutes of Health - National Library of Medicine

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