Insomnia
What is Insomnia
Introduction of Insomnia
Kinds of Insomnia
Classification and Description of Sleep Issues
Consequences of Inadequate Sleep
Quantity of Sleep as we age
How Does The Use of
Sleeping Tablets
Common Sense Cures of insomnia
Early Morning Exposure to Gentle |
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Introduction
According to American Association of Sleep Medicine, insomnia is "the
inability to fall asleep or to stay asleep." A broader definition
of insomnia is: Insomnia is difficulty initiating sleep, difficulty maintaining
sleep, early-morning awakening with difficulty resuming sleep, or unrefreshing
sleep. The subject must also suffer some degree of impairment in social,
occupational, or other important areas of daytime functioning. Daytime
symptoms may include morning grogginess, memory problems, poor concentration,
irritability, mild depression, anxiety, somatic complaints such as headaches
or aches and pains, and daytime fatigue. Insomnia lasting less than 4
weeks is considered to be transient. Insomnia lasting longer than 4 weeks
is chronic.
One in three American adults are believed to suffer from insomnia. According
to National Sleep Foundation's (NSF) 1999 Sleep in America survey, more
than half (56%) of American adults reported experiencing symptoms of insomnia
a few nights a week or more, yet only half of those people were being
treated by a healthcare provider for their condition. Transient insomnia
occurs in up to 50% of the population. The prevalence of chronic insomnia
is estimated to be about 10% to 15%.
The direct economic costs of insomnia are estimated at close to $14 billion
in the USA alone. The total cost of insomnia, including treatment, lost
productivity and insomnia related accidents, may exceed $100 billion per
year. And the statistics is comparable world-wide.
Those at greatest risk for insomnia include the elderly, women, shift
workers, and persons with comorbid medical or psychiatric disorders. Nearly
two thirds of adult psychiatric outpatients have disturbed sleep. Chronic
insomnia is, in turn, a significant risk factor for the development of
psychiatric illness. Victims of insomnia are more than twice as likely
as noninsomniacs to have psychiatric disorders and are more prone to subsequent
depressive illness, anxiety, or alcohol abuse.
Decades of scientific research have shown that sleepiness and fatigue,
as well as sleeplessness, affect everyone's health, safety, productivity
and well-being. Yet most people are slow to seek the advice and treatment
of a healthcare provider for sleep problems and excessive sleepiness.
For example, of the two-thirds of Americans experiencing sleep disorders,
only four percent are seeing a doctor.
Insomnia disturbs your waking hours as well as your sleeping hours. You
are likely to feel sleepy during the day and have trouble concentrating
on tasks after a poor night's steep.
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Types of Insomnia
Insomnia may be described in terms of both duration and severity.
It may be transient (lasting for several days), intermittent (when transient
insomnia recurs), or chronic (lasting for more than a month).
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Transient insomnia
Transient insomnia is an inability to sleep well over a period of
a few nights. This is usually brought on by excitement or stress. You
may find it hard to sleep before an important event such as a meeting,
wedding, an examination, etc. People find it hard to sleep when they are
in a new location such as in a hotel room or when they have crossed several
time zones. A vigorous exercise close to bedtime (within four hours) or
an illness can also temporarily disrupt sleep.
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Short-term insomnia
Sort term insomnia is characterized by two to three weeks of poor
sleep. It is believed to have been caused by stress. Generally, sleep
will return to normal when the stressful situation subsides or when the
sleeper becomes accustomed to it.
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Chronic insomnia
Chronic insomnia is manifested by poor sleep every night or most nights.
In most cases this is due to excessive worrying by the insomniacs. However,
not all chronic insomnia has its origin on worrying. According to a study,
physical ailments-such as disorders of breathing or muscle activity-are
the cause of more than half of all cases of persistent insomnia. |
Narcolepsy
Narcolepsy is a rare sleep disorder characterized by attacks of irresistible
drowsiness during the day, disrupting the pattern of a person's normal activity.
A narcoleptic may not sleep well at night but suffer sleep attacks during
the day, while talking, working, and even when driving a vehicle. |
Insomnia Affects Quality of Life And Health
Insomnia may be a serious problem affecting quality of life, productivity
and safety.
People with insomnia report problems with memory and concentration.
Daytime and work performance are impaired in those suffering from insomnia
and lack of sleep.
People who suffer from insomnia are four times as likely to suffer depression.
Insomnia increases the risk of developing cardiovascular disease.
Sleep problems in the elderly have been associated with a heightened risk
for institutionalization. |
Causes of Insomnia
Insomnia can originate by any of a number of factors such as physical
illness, a stress-filled lifestyle, excessive caffeine consumption, or chronic
pain. It may simply be the result of poor sleeping habits, such as napping
during the day and going to bed at irregular hours. Insomnia can often be
linked to alcohol or drug abuse and to misuse of certain medications.
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Causes of Insomnia - Summary
| Sleep-Onset Insomnia Anxiety or tension Environmental
change Emotional arousal Fear of insomnia Phobia of sleep Disruptive
environment Pain or discomfort Caffeine Alcohol |
Sleep-Maintenance Insomnia Depression Environmental change Nocturnal
myoclonus Hypoglycemia Parasomnias such as sleep apnea, restless-legs
syndrome, etc. Pain or discomfort Drugs Alcohol |
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Psychological factors
Psychological factors account for about half of all insomnias. Numerous
mental and emotional factors can precipitate sleep disorders, especially
insomnia. These include grief, depression, anxiety, fear, and excitement.
Anxiety and depression are two common causes of insomnia. If the insomnia
is simply due to a short-term reaction to a situation in one's life, the
insomnia will normally disappear as soon as the situation changes. It is
rare to see someone who has a severe case of insomnia due to purely emotional
factors.
Sleep problems are usually a biochemical problem. Biochemical breakdown
can take place in many ways. For example, if your digestive system is stressed
and unable to digest protein, the amino acids which affect neurotransmission
will not be available to your brain. You can become ill emotionally without
having anything emotionally stressful going on in your life. |
Vulnerability to insomnia
Some people are more likely than others to experience insomnia during
times of stress. |
Persistent stress
Stress plays a pivotal role in insomnia. Causes of stress such as a troubled
marriage, a chronically ill child, or an unrewarding career can contribute
to poor sleep. |
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Call Your Doctor If
Your insomnia is associated with a life-changing event, such as the loss
of a job or a loved one. You may need sleep medication for a brief period.
You experience disturbed sleep for more than a month without apparent
cause. You may need referral to a sleep-disorder specialist to test for
underlying physical ailments.
You have been taking medication for more than a few nights without success.
Your sleep medication may not be effective. You may be at risk of becoming
addicted to the medication.
You never seem to get enough sleep and fall asleep without warning during
the day. You may be suffering from narcolepsy.
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Conventional Treatment
The first task is to determine the exact cause of insomnia. Insomnia may
be:
A sign of depression
A side effect of medication
A reaction to stress
A consequence of poor sleep habits
A response to pain or anxiety
A combination of these and other factors. |
In most cases, more than one cause for insomnia is likely. Thus, a careful
evaluation and diagnosis are important before strategies for treatment can
be determined. The underlying cause or causes should be treated, if possible.
In considering what medication would be appropriate, physicians will consider
the patient's age, medical condition, use of alcohol, and need to function
when awakened during his or her normal sleep time. |
Transient Insomnia
Transient insomnia, which may occur during travel, usually disappears
when you return to a regular sleep pattern. The usual treatment consists
of educating the patients about sleep and sleep hygiene and follow up with
temporary drug therapy. |
Education
Provide understandable information about sleep, the causes of insomnia,
and healthy sleep practices. Information about basic sleep needs, the influence
of circadian rhythms on sleep, and the effects of aging help establish realistic
expectations and goals for treatment. Tips to help patients obtain good
sleep are generally provided. Discuss with the patient what is causing the
insomnia and how to manage it. Awareness of what is the cause of insomnia
and how to manage it should help resolve the current episode and prevent
chronic symptoms and relapse in the future. |
Medication (Drug Therapy)
If education and sleep hygiene measures are not sufficient to combat
insomnia, a short-term treatment plan will be devised with sleep medication.
Newer prescription drugs such as nonbenzodiazepine hypnotics have been found
to be effective for improving sleep with minimal morning sedation.
Zaleplon is a prescription medication that significantly reduces time to
sleep onset in adults (at 10 mg) and elderly (at 5 mg) insomniacs.
Zolpidem is another prescription medication that is effective for both sleep
onset and sleep maintenance insomnia. It should be used only at the beginning
of the night. There is a greater potential for morning residual effects
and some rebound insomnia immediately following abrupt withdrawal from dosages
greater than 10 mg.
If these medications are found to be ineffective, then benzodiazepines may
be used. Antidepressant medications may also be used especially when the
insomnia is associated with mood disorders. |
Chronic Insomnia
Chronic insomnia requires a thorough physical examination, alteration
of some life habits, and perhaps psychotherapy to identify a hidden cause.
Cognitive Behavioral therapy and drug therapy, if necessary, are the preferred
approach in this case. |
Education
Education about good sleep practices is useful, but not sufficient,
for treating chronic insomnia. |
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy has been shown to be a highly effective
approach for the treatment of primary insomnia. Cognitive behavioral therapy
for insomnia typically involves:
Stimulus control
Sleep restriction
Relaxation strategies
Cognitive restructuring |
| In a recent study of CBT versus benzodiazepine treatment, CBT was found
to be superior at long-term (2 years) follow-up. |
Stimulus control
Stimulus control is a set of instructions aimed at undoing conditioned arousal
at bedtime by reassociating the bedroom with rapid sleep onset.
Typical instructions are as follows:
Go to bed only when you are sleepy.
If you do not fall asleep within 15 minutes or wake up and can't resume
sleep within 15 minutes, leave the bedroom and return only when sleepy again.
Repeat as often as necessary.
Use the bedroom only for sleep and sex. Do not read, watch TV, work, or
eat in bed.
Get up at the same time every morning, including weekends.
Avoid daytime napping. |
Sleep restriction
Sleep restriction involves curtailing the amount of time the patient
spends in bed to increase the efficiency of sleep.
First, restrict the time allowed in bed to equal the average amount of time
the patient actually spends sleeping.
After each week, the percent of time spent sleeping in bed is calculated.
This is called sleep efficiency (SE) index.
sleep efficiency (SE) index = time spent asleep/time spent in bed x 100
If SE is greater than 85%, an additional 15 to 20 minutes of time in bed
is added to the beginning of the night. If SE is less than 85%, time in
bed is further restricted by 15 to 20 minutes. Reducing the time in bed
to less than 5 hours is not generally recommended.
Sleep restriction is very effective if followed closely. Needs discipline
on the part of patient for its success. |
Relaxation
Various relaxation techniques are useful for inducing sleep. Examples
are progressive muscle relaxation, diaphragmatic breathing, and nonguided
imagery. |
Cognitive restructuring
Cognitive therapy is used to identify dysfunctional beliefs and attitudes
patients may have about their sleep and replace them with more adaptive
substitutes.
Cognitive restructuring can be used to overcome all concerns regarding sleep
and eliminate anxieties associated with poor sleep or inability to sleep. |
Light phase shift
Used for insomnia associated with circadian rhythm disturbances. The
use of timed exposure to bright light can be very effective in shifting
the timing of the major sleep period.
Evening light is indicated if you sleep too early and wake up early (phase
advance syndrome) and morning light is used if you sleep late and wake up
late (phase delay syndrome). Natural sunlight and bright-light boxes can
be used. |
Hypnotic treatment
This is used for chronic insomnia only if non- pharmacologic approaches
have been exhausted or as a complement to these treatments.
Long-term administration of low doses of zaleplon or zolpidem.
Benzodiazepines may be useful in patients not prone to abuse, dependence,
or dose escalation. It should be monitored carefully.
Antidepressant medications are used when the insomnia is associated with
mood disorders. |
Support, counseling, or psychotherapy
Patients may require special considerations at work or school. Some may
benefit from support groups and/or marriage or family counseling. |
