Insomnia

Learn About Insomnia

People who have insomnia, or insomniacs, have trouble initiating and/or maintaining sleep. Due to getting too little sleep or having poor quality sleep, they are sleepy, fatigued, or otherwise impaired the following day.  Insomnia can be an immediate response to some stressor (acute insomnia) or a more enduring sleep pattern (chronic insomnia). Insomnia can also be the consequence of some other medical condition (secondary insomnia) or an illness in its own right (primary insomnia).  The remainder of this article will concern itself with chronic, primary insomnia.

Insomnia lasting for a month or longer is termed chronic.  While the ultimate cause of chronic, primary insomnia is unknown, many life changes can trigger it, including long-lasting stress and emotional upset.  Insomnia can cause daytime sleepiness and lack of energy. It can cause anxiety, depressed mood, and irritability.  Difficulty focusing on tasks, paying attention, learning, and remembering are also common. These problems can cause distress, and impairment at work or school.  Insomnia also can cause serious problems, such as sleepiness while driving.

Primary insomnia isn't a symptom or side effect of another medical condition. It is its own distinct disorder, and its cause isn’t well understood. Primary insomnia usually lasts for at least 1 month.  Many life changes can trigger primary insomnia. It may be due to major or long-lasting stress or emotional upset. Travel or other factors, such as work schedules that disrupt sleep routines, also may trigger primary insomnia. Even if these issues are resolved, the insomnia may not remit. Trouble sleeping can persist because of habits formed to deal with the lack of sleep. These habits might include taking naps, worrying about sleep, and going to bed when not sleepy.

Insomnia is a common disorder. It affects women more often than men. The disorder can occur at any age. However, older adults are more likely to have insomnia than younger people.
People who might be at increased risk for insomnia include those who are older, female, lead stressful lives, are depressed or otherwise emotionally distressed, live an inactive lifestyle, and are of lower socio-economic status.   

Insomniac sleep is marked by lying awake a long time before falling asleep; and once asleep, there may be frequent and prolonged interruptions and, in some cases, awakening earlier than desired and being unable to return to sleep.  Upon awakening the insomniac may feel exhausted, as if not having slept at all; they are therefore tired throughout the day and may nap, which worsens the insomnia.  Even those insomniacs who manage to awaken feeling refreshed are soon fatigued early in the course of their day.  Some insomniacs have brief episodes of “micro sleep” of which they are not aware; during such times they can be very dangerous to themselves or others if driving or operating machinery.  Driver sleepiness is a factor in up to 20% of car crash injuries.  Insomniacs are frequently depressed, irritable, and anxious.  Their attention to detail is frequently limited, and their frustration tolerance is strained.  

If insomnia is causing distress or affecting daily activities, treatment may help.  A doctor might prescribe medication or psychotherapy, especially cognitive-behavioral therapy, a type of therapy in which thought and behavior patterns that produce or perpetuate insomnia are identified and modified.  

A doctor will diagnose chronic primary insomnia based on medical and sleep histories and a physical exam.  Often a sleep diary is used to prospectively gather sleep history; a sleep diary can be quite enlightening to the physician and patient both.  While spending the night (and possibly part of the next day) in a sleep laboratory can shed light on a variety of sleep disorders, it is not used routinely to diagnose chronic, primary insomnia, although it can be helpful in identifying other conditions of which the insomnia is a symptom.  

To get a better sense of your sleep problem, and to help your doctor diagnose your sleep disorder accurately, consider being able to answer questions about how often you have trouble sleeping and for how long; when you go to bed on workdays and days off; how long it takes you to fall asleep and how often and for how long you awaken during the night; how you feel upon arising; what your physical and mental stamina are like during your day; what your bedtime routine is like, as well as your sleep environment – especially with regard to lighting, noise levels, and habits that promote wakefulness in the bed, such as watching television or working on a computer.  Smoking and drinking at or around bedtime may interfere with the initiation and maintenance of sleep.

Lifestyle changes can often help relieve insomnia. These changes might make it easier to fall asleep and stay asleep.  These include not getting into bed until ready to sleep – if necessary, get out of bed and engage in some restful activity such as light reading under low-level illumination until feeling drowsy, then get back into bed.  Turning the clock around so it is impossible to keep track of all the time not spent sleeping can be quite helpful.  Other ways to make the bedroom conducive to sleep is to make sure it is dark and quiet.  Avoiding stimulants such as caffeine and tobacco before sleep is advisable.  

Psychological/behavioral approaches to insomnia involve dealing with hyper arousal, a state of psychic excitement that militates against sleep, and is seen in all cases of chronic, primary insomnia.  In fact, an alternative name for this type of insomnia is psychophysiologic insomnia, reflecting the contribution of psychological factors to the condition. The treatment approach is the same in all circumstances:  diminish the state of hyper arousal.  This can involve a variety of techniques involving thought, breathing, and visualization exercises designed to calm the anxious, active mind.  One simple technique involves making a list of everything on your mind before bedtime; when the urge to ponder these thoughts appears during the night, simply thinking about or touching the list might be sufficient to keep the mind from racing and permit the natural processes of sleep to take over.  

A type of counseling called cognitive-behavioral therapy (CBT) can help relieve the anxiety of psychophysiologic insomnia.  CBT aims to replace sleep anxiety with thinking that links being in bed with being asleep. This method also teaches what to do if unable to fall asleep within a reasonable time.  The goal is for the mind to settle down and stop racing.  CBT also focuses on limiting the time spent in bed while awake; this method involves setting a sleep schedule. At first, the schedule might result in more daytime sleepiness; but this will encourage falling asleep at bedtime.  CBT works as well as prescription medicine for many people who have chronic, primary insomnia.  For people who have both insomnia and major depressive disorder, CBT combined with antidepressants has shown promise in relieving both conditions.

Prescription medicines to treat insomnia abound. Some are meant for short-term use, while others are meant for chronic use.  The benefits and side effects of insomnia medicines vary considerably. Rare side effects of these medicines include provoking confusional arousals:  eating, walking, and even driving during sleep with no memory of having carried out any of these activities the following day.  Some insomnia medicines can be addictive.  Some over-the-counter (OTC) products claim to treat insomnia. These products include melatonin, L-tryptophan supplements, and valerian teas or extracts.  Some contain antihistamines that might well promote sleep initiation, but pose risks for some people, especially the elderly.  A doctor can advise whether these products will benefit your particular circumstances.

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