Insomnia

What is insomnia?

Not a disease nor a diagnosis. Instead, just a word indicating that sleep is of poor quality or too limited in amount.

Why not just treat it with sleeping pills?

  • To do so would be much like giving pain pills to all patients coming into an emergency room with severe abdominal pain, and then sending them home. Serious underlying causes would be missed.
  • Furthermore, some causes of “insomnia” (such as repeated failure to breathe–sleep apnea and related conditions) are actually made worse by the administration of sleeping pills.
  • Also, chronic use of sleeping pills can perpetuate insomnia. Many of them are addicting and lose effectiveness over time. In such cases, patients may take greater and greater doses to try to sleep–with increasing risk of side effects. Sleeping pills are a major cause of insomnia in the United States, such that they have become part of the problem rather than its solution.

What are the basic types of insomnia?

It is helpful to divide insomnia problems into three groups. Ask yourself which of these types apply to you. More than one type may apply:

1. Inability to fall asleep initially, lying fully awake until sleep finally occurs.

Since people can tell what is happening to them when they are fully awake, doctors usually can sort out the cause of this difficulty simply by talking with the patient. Possible specific factors include the following:

RESTLESS LEGS SYNDROME
This involves an unpleasant, nervous or “antsy” sensation in the legs, relieved by walking, but prominent when inactive and trying to fall asleep. It can “run in families” and sometimes is related to kidney failure, peripheral neuropathies and other disorders. Most patients with RLS also have “Periodic Limb Movement Syndrome (PLMS) ” (see below).

Even small amounts of caffeine can worsen RLS and caffeine should be totally avoided. RLS is often related to even borderline low body iron stores, and it is advisable to have your doctor check a special blood test (serum ferritin level). If the result is less than 50, oral iron may be very helpful. One should not simply take iron without checking this level, since it is possible to overload the body with iron.

Treatment of RLS can be very difficult. Some patients respond to gabapentin or low dose opiates such as codeine. Drugs that are usually given for Parkinson’s disease are typically extremely effective initially but in many cases, their use over time results in a phenomenon called augmentation (with worsening of the RLS symptoms to a degree worse than before treatment was begun: often with occurence of symptoms earlier in the day and with spread to the arms and upper body. Sinemet (carbidopa/levodopa) is particularly likely to cause augmentation. The same problem sometimes occurs with other anti-Parkinson drugs such as Mirapex and Requip. Many other drugs have been tried with variable results. Some patients report benefit from a salt restricted diet.

PSYCHOPHYSIOLOGICAL INSOMNIA

This involves worrying about being able to fall asleep to the point it keeps one awake!

INADEQUATE SLEEP HYGIENE

Such as overuse of caffeine, napping, vigorous exercise too close to bedtime and erratic sleep habits.

ADJUSTMENT SLEEP DISORDER

This refers to temporary insomnia difficulties, related to acute stress, conflicts or environmental change. It may also may involve sleep disruption with early awakenings.

CHRONIC USE OF SLEEPING PILLS, STIMULANTS OR ALCOHOL

PHYSICAL DISCOMFORT

For example, chronic pain or shortness of breath.

ANXIETY AND MOOD DISORDERS can also interfere with sleep onset or ability to “stay asleep”.

DELAYED SLEEP PHASE SYNDROME

Some people are “night owls” whose “internal clocks” are not synchronized with the normal schedule in our society. Such people may be able to fall asleep and wake up readily only at times that are incompatible with a conventional day-shift schedule. For example, they may not fall asleep easily until 4 a.m., but then cannot wake up and feel well before noon. Exposure to special bright lights at specific times frequently helps reset the internal clock to a more normal schedule.

2. Waking up too early with inability to return to sleep.

This symptom can be due to depression, which if present should prompt consultation with a mental health professional. However, this type of insomnia also can result from many other possible factors that can remain hidden and escape recognition, due to their occurrence in sleep. Evaluation by a sleep medicine specialist may be needed to get at the underlying cause.

3. Difficulty falling asleep due to repeated “dozing and arousing”, or sleep that is too “light” and/or fragmented by repeated awakenings.

There are many possible medical and physical causes for this group of problems–and some of these causes are potentially serious.! Also, it often is impossible to identify these causes by history alone, since most abnormal sleep events that provoke arousals are “over with” by the time the person is fully awake, leaving no clues as to their nature! Examples include the following:

SLEEP APNEA AND OTHER BREATHING DISORDERS OCCURRING IN SLEEP. These problems are extremely common and can prove dangerous, since their complications include heart failure, heart attacks, high blood pressure and strokes. Also, they are particularly likely to be worsened by sleeping pills.

REFLUX OR REGURGITATION OF STOMACH ACID UP INTO THE ESOPHAGUS–which may not even cause symptoms of heartburn!

SEIZURES OCCURRING IN SLEEP .

PERIODIC LIMB MOVEMENT SYNDROME. (PLMS, formerly called “nocturnal myoclonus”) is quite common, particularly in older individuals and in individuals taking medication for depression. It involves repeated upward jerking movements of the toes, ankle, or entire leg at nearly predictable (usually every 20-40 second) intervals in sleep. Bed partners may complain about being kicked repeatedly! People with PLMS may note repeated awakenings, daytime fatigue, or no symptoms at all: in which no treatment may be necessary.

PATIENTS WITH HISTORIES OF PANIC ATTACKS OR CHRONIC TENSION often appear hyperarousable in sleep.

In our experience, many of these individuals experience repeated partial arousals from non-REM sleep–with up to several arousals per minute, and often with abrupt increases in pulse, flushing of the face and clenching of the teeth. These arousals, too brief for the person to recall, can result in light, fragmented sleep, daytime sleepiness or both. Some patients even experience attacks of full-blown panic from sleep: with screaming, frantic behaviors and running with serious risk of self-injury, should the individual fail to awaken during the attack.

Individuals who experience the above often seem to be extremely conscientious–perfectionists in an imperfect world. They typically appear to be striving to achieve the impossible, after which they sleep much as if they had “dragged a load of adrenaline to bed with them”. We also have noted that many seem to have “two basic speed: off and way too fast”–a number of them swing between extremes of intense work at high speed, followed by exhaustion and fatigue.

MANY OF THE CONDITIONS LISTED IN THE FIRST GROUP (difficulty falling asleep with full alertness) can also promote light, fragmented sleep with increased arousability. Sometimes bed partner observations can help pinpoint the source of the problem.

To deal with insomnia, don’t jump to sleeping pills! Analyze the problem to determine its cause.

If the problem involves inability to fall asleep initially, particularly with “difficulty turning one’s head off”:

  • Consider obtaining good stress management and relaxation training.
  • Don’t go to bed too late. Keep a regular bedtime. Follow good sleep hygiene (contact us for more details).
  • Ensure that any physical symptoms such as pain or shortness of breath receive prompt medical attention.
  • Dependence on sleeping pills, other drugs and alcohol may warrant professional assistance in their management.
  • Consultation with a sleep medicine specialist may be needed for restless legs syndrome, delayed sleep phase syndrome, and other problems–particularly if persistent.

If early awakenings are the main problem:

  • Treatment for depression may be helpful if it is present.
  • If depression is not responsible for the early awakenings, a sleep medicine consultation should be considered to determine their cause.

If instead, repeated awakenings and fragmented sleep are being experienced, assessment by a sleep medicine specialist is usually advisable.

Otherwise, the cause of the problem will be likely to escape detection. Some of the possible underlying causes are medically dangerous, and failure to identify them can render effective treatment impossible.

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