Insomnia

Insomnia is the inability to obtain an adequate amount or quality of sleep. The difficulty can be in falling asleep, remaining asleep, or both. People with insomnia do not feel refreshed when they wake up. Insomnia is a common symptom affecting millions of people that may be caused by many conditions, diseases, or circumstances.

Description

Sleep is essential for mental and physical restoration. It is a cycle with two separate states: rapid eye movement (REM), the stage in which most dreaming occurs; and non-REM (NREM). Four stages of sleep take place during NREM: stage I, when the person passes from relaxed wakefulness; stage II, an early stage of light sleep; stages III and IV, which are increasing degrees of deep sleep. Most stage IV sleep (also called delta sleep), occurs in the first several hours of sleep. A period of REM sleep normally follows a period of NREM sleep.

Insomnia is more common in women and older adults. People who are divorced, widowed, or separated are more likely to have the problem than those who are married, and it is more frequently reported by those of lower socioeconomic status. Short-term, or transient, insomnia is a common occurrence and usually lasts only a few days. Long-term, or chronic, insomnia lasts more than three weeks and increases the risk for injuries in the home, at the workplace, and while driving because of daytime sleepiness and decreased concentration. Chronic insomnia can also lead to mood disorders like depression.

Causes and symptoms

Transient insomnia is often caused by a temporary situation in a person's life, such as an argument with a loved one, a brief medical illness, or jet lag. When the situation is resolved or the precipitating factor disappears, the condition goes away, usually without medical treatment.

Chronic insomnia usually has different causes, and there may be more than one. These include:

• a medical condition or its treatment, including sleep apnea
• use of substances such as caffeine, alcohol, and nicotine
• psychiatric conditions such as mood or anxiety disorders
• stress, such as sadness caused by the loss of a loved one or a job
• disturbed sleep cycles caused by a change in work shift
• sleep-disordered breathing, such as snoring
• periodic jerky leg movements (nocturnal myoclonus), which happen just as the individual is falling asleep
• repeated nightmares or panic attacks during sleep

Another cause is excessive worrying about whether or not a person will be able to go to sleep, which creates so much anxiety that the individual's bedtime rituals and behavior actually trigger insomnia. The more one worries about falling asleep, the harder it becomes. This is called psychophysiological insomnia.

Symptoms of insomnia

People who have insomnia do not start the day refreshed from a good night's sleep. They are tired. They may have difficulty falling asleep, and commonly lie in bed tossing and turning for hours. Or the individual may go to sleep without a problem but wakes in the early hours of the morning and is either unable to go back to sleep, or drifts into a restless unsatisfying sleep. This is a common symptom in the elderly and in those suffering from depression. Sometimes sleep patterns are reversed, and the individual has difficulty staying awake during the day and takes frequent naps. The sleep at night is fitful and frequently interrupted.

Diagnosis

The diagnosis of insomnia is made by a physician based on the patient's reported signs and symptoms. It can be useful for the patient to keep a daily record for two weeks of sleep patterns, food intake, use of alcohol, medications, exercise, and any other information recommended by the physician. If the patient has a bed partner, information can be obtained about whether the patient snores or is restless during sleep. This, together with a medical history and physical examination, can help confirm the doctor's assessment.

A wide variety of health care professionals can recognize and treat insomnia, but when a patient with chronic insomnia does not respond to treatment, or the condition is not adequately explained by the patient's physical, emotional, or mental circumstances, then more extensive testing by a specialist in sleep disorders may be warranted.

Treatment

Treatment of insomnia includes alleviating any physical and emotional problems that are contributing to the condition, and exploring changes in lifestyle that will improve the situation.

Changes in behavior

Patients can make changes in their daily routine that are simple and effective in treating their insomnia. They should go to bed only when sleepy and use the bedroom only for sleep. Other activities like reading, watching television, or snacking should take place somewhere else. If they are unable to go to sleep, they should go into another room and do something that is relaxing, like reading. Watching television should be avoided because it has an arousing effect. The person should return to bed only when they feel sleepy. Patients should set the alarm and get up every morning at the same time, no matter how much they have slept, to establish a regular sleep-wake pattern. Naps during the day should be avoided, but if absolutely necessary, then a 30-minute nap early in the afternoon may not interfere with sleep at night.

Another successful technique is called sleep-restriction therapy, which restricts the amount of time spent in bed to the actual time spent sleeping. This approach allows a slight sleep debt to build up, which increases the individual's ability to fall asleep and stay asleep. If a patient is sleeping five hours a night, the time in bed is limited to 5-5 1/2 hours. The time in bed is gradually increased in small segments, with the individual rising at the same time each morning; at least 85% of the time in bed must be spent sleeping.

Drug therapy

Medications given for insomnia include sedatives, tranquilizers, and antianxiety drugs. All require a doctor's prescription and may become habit-forming. They can lose effectiveness over time and can reduce alertness during the day. The medications should be taken two to four times daily for approximately three to four weeks, though this will vary with the physician and patient. If the insomnia is related to depression, then an antidepressant medication may be helpful. Over-the-counter drugs such as antihistamines are not very effective in bringing about sleep, and can affect the quality of sleep.

Other measures

Relaxing before going to bed will help a person fall asleep faster. Learning to substitute pleasant thoughts for unpleasant ones (imagery training) is a technique that can be very helpful in reducing worry. Another effective measure is the use of audiotapes that combine the sounds of nature with soft relaxing music. These, alone or in combination with other relaxation techniques, can safely promote sleepiness.

Changes in diet and exercise routines can also have a beneficial effect. Dietary items to be avoided include drinks that contain caffeine, such as coffee, tea and colas'chocolate (which contains a stimulant); and alcohol, which initially makes a person sleepy but a few hours later can have the opposite effect. Maintaining a comfortable bedroom temperature, reducing noise and eliminating light are also helpful. Regularly scheduled morning or afternoon exercise can relax the body. This should be done 3-4 times a week and be sufficient to produce a light sweat.

Alternative treatments

Many alternative treatments are effective in treating both the symptom of insomnia and its underlying causes. Incorporating relaxation techniques into bedtime rituals will help a person go to sleep faster, as well as improve the quality of sleep. These methods include meditation; massage; breathing exercises; and a warm bath, scented with rose, lavender (Lavendula officinalis), marjoram, or chamomile (Matricaria recutita). Eating a healthy diet rich in calcium, magnesium, and the B vitamins is also beneficial. A high-protein snack like yogurt before going to bed is recommended, or a cup of herb tea made with chamomile, hops (Humulus lupulus), passionflower (Passiflora incarnata), or St. John's-Wort (Hypericum perforatum) to encourage relaxation. Acupuncture and biofeedback have also proven useful.

Prevention

Prevention of insomnia centers around promotion of a healthy lifestyle. A balance of rest, recreation and exercise in combination with stress management, regular physical examinations, and a healthy diet can do much to reduce the risk.