Insomnia

Chronic and persistent difficulty in either (1) falling asleep (initial insomnia), (2) remaining asleep through the night (middle insomnia), or (3) waking up too early (terminal insomnia). All types of insomnia can lead to daytime drowsiness, poor concentration, and the inability to feel refreshed and rested in the morning.

Overview & Considerations

Insomnia is not, by itself a disease, but it is an occasional problem for over 70 million Americans. Every year, 98 million dollars are spent on over-the-counter sleeping aids and another 50 million on caffeine tablets to stay wake during the day.

Everyone has an occasional sleepless night, of course, but for most people, this is not problematic. However, as many as 25% of Americans report occasional sleeping problems and insomnia is a chronic problem for about 10% of the population. In these cases, people will be unable to carry out their daily responsibilities either because they are too tired or because they have trouble concentrating due to lack of restful sleep.

Most adults do best with about 8 hours of sleep a night until age 60, after which 6 hours may be adequate. Even though the elderly need less sleep, almost one-half of people over 60 experience some degree of insomnia.

The best measure of the amount of sleep needed is how you feel. If you awaken feeling refreshed, you are getting enough sleep. For some people, this may take only 4 hours -- others can need up to 10 hours to feel rested.

The use of long-acting or high-dose sedatives as a cure for insomnia can increase daytime drowsiness -- over time, making the problem worse, not better.

The use of antihistamines (the main ingredient in over-the-counter sleeping pills) as a cure for insomnia can also lead to similar difficulties. Chronic antihistamine usage may also lead to reversible memory impairment.

Stronger tranquilizers, available by prescription, often induce drug tolerance and do not produce a natural, restful sleep. As a result, one may feel more dependent on the drug and may conclude that more of the drug is needed. The more drug used, the more side effects and tolerance develop. Upon discontinuation of these tranquilizers, rebound worsening of insomnia is very common.

A life-threatening disease is rarely the cause of problems with sleep. For many people, poor sleep habits are the cause. However, because insomnia is a key symptom of depression, you should be evaluated for depression if you are having sleeping difficulties.

Insomnia may cause a reduced energy level, irritability, disorientation, dark circles under the eyes, posture changes, and fatigue.

Counseling may be helpful for psychological disorders that lead to insomnia; antidepressants can often help both the sleeping problem and the depression. Antidepressant medications are not abusable and do not lead to the feeling of a need for increased doses the way many prescription sleeping medications can.

Nightmares and dreams that interfere with sleep may also respond to psychological interventions.

Common Causes

• jet lag
• shift work
• wake-sleep pattern disturbances
• grief
• depression or major depression
• worry
• anxiety or stress
• exhilaration or excitement
• 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 bedtime
• overactive thyroid (hyperthyroidism)
• taking a new drug (medication side-effect).
• alcoholism or abrupt cessation of alcohol after long-term use
• inadequate bright-light exposure during waking hours
• abruptly stopping a medication (such as sleeping pills).
• medications or illicit "street drugs" (for example, excessive thyroid replacement hormone, amphetamines, caffeine-containing beverages, cocaine, ephedrine, phenylpropanolamine, theophylline derivatives)
• withdrawal of medications (such as sedatives or hypnotics)
• interference with sleep by various diseases, including an enlarged prostate (men), cystitis (women), COPD, pain of arthritis, heartburn, and heart or lung problems
• restless leg syndrome

INFANTS:

Most newborn babies wake several times during the night, but by the age of 6 months they typically sleep through the night. At one year, babies will sleep an average of about 16 hours in every 24. Two to three hours of this sleep will be during the day. Causes of sleeplessness in infants may include:

• desire for parental attention
• infantile colic or other digestive problems (worms)
• indigestion
• hunger
• teething
• fever or other illness

Home Care & Treatment

ADULTS
Exhaust every possible option before resorting to drugs to cure insomnia.

Practice good sleep hygiene: avoid using alcohol in the evening. Avoid caffeine for at least 8 hours before bedtime. Give up smoking (nicotine is a stimulant).

Establish a regular bedtime, but don't go to bed if you feel wide awake. Use the bedroom for bedroom activities only. Once in bed, use creative imagery and relaxation techniques to keep your mind off unrestful thoughts. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom.

Take your TV or computer out of your bedroom. If not, your brain becomes used to the stimulation and starts to expect it when you are there. This makes it harder for you to fall asleep.

Relax by reading, taking a bath, or listening to soothing music before getting to bed.

A snack before bedtime helps many people. Foods such as warm milk or turkey have a natural sleep inducer called L-tryptophan.

Exercise regularly, but not in the last two hours before going to bed. Exercise, especially aerobic exercise, has been show to make people fall asleep faster and benefit from deeper and more restful sleep. Sex can be a natural sleep inducer and helps some people.

Avoid emotional upset or stressful situations prior to bedtime.

INFANTS
Avoid being readily available to a child during the night; otherwise, the child may become dependent on attention and become sleepless if deprived of it.

CHILDREN
For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises.

Avoid sending a child to bed as punishment which can result in poor sleep caused by fear.

Never give a child sleeping medicine without consulting the doctor first. Generally, it is unwise to treat the problem with drugs.

MEDICATION
Medication should be a last resort.

Antihistamines such as Sominex, Nytol, and Compoz (all approved by the FDA) are available without a prescription. These medications are not without side-effects: some people complain of a "hangover" effect the next morning.

If these fail, you may want to ask you health care provider to recommend other options.

Avoid all sedatives, including the benzodiazepines, during the first 3 months of pregnancy.

The Insomnia Program at the Pulmonary & Sleep Center of the Valley

Most of the physician and self-referrals to the Pulmonary and Sleep Center of the Valley (PSCV) for evaluation and treatment of insomnia complaints are assigned PSCV Associate Director Augustin de la Peña, PhD, an American Board of Sleep Medicine-certified psychologist having nearly 30 years of experience in evaluating and treating insomnia complaints, and widely published in the area of the psychophysiology of insomnia complaints. In his work with individuals voicing insomnia complaints, Dr. de la Peña employs an approach to evaluating and treating insomnia complaints described in his 1978 chapter on the topic, combining his conceptual approach with American Association of Sleep Medicine guidelines described in various “Practice Parameters” publications listed at the bottom of this page, and employing the diagnostic and coding schema published in the latest version of the International Classification of Sleep Disorders diagnostic and coding manual.

Patients voicing one or more insomnia complaints (difficulty initiating sleep; difficulty maintaining sleep; light, unrefreshing sleep; difficulty returning to sleep after awakenings; early morning awakenings with difficulty returning to sleep, shortened sleep, etc) can expect the following sequence of events:

At least two weeks prior to the scheduled consultation visit with Dr. de la Peña, patients are sent a sleep packet containing a one week sleep log/diary, a validated mood-state questionnaire, and a general sleep and medical history questionnaire. Patients are requested to bring the completed questionnaires to the consultation visit. Dr. de la Peña reviews the questionnaires immediately prior to meeting with the patient. A comprehensive physical exam and evaluation is performed by one of Dr. de la Peña’s medical sleep specialist colleagues either immediately before or after the consultation visit.

Patients will generally have from one-six sessions with Dr. de la Peña; most will have two-four sessions/visits. The initial consultation will usually be of 60-90 minutes duration. If the consultation visit discloses the suggestion of sleep-disordered breathing and/or periodic limb movements, the patient will be recommended to undergo a nocturnal polysomnogram (overnight sleep recording), which will be conducted at the PSCV sleep facility. Depending on the diagnosis/diagnoses assigned after the consultation and/or NPSG, Dr. de la Pena imparts and/or provides one or more of the following treatments: (1) education about “good sleep hygiene”
(2) review of basic facts about sleep and insomnia complaints so as to help allay the patient’s anxiety/preoccupation with his/her impression of poor/shortened sleep (3) one or more of the various cognitive behavioral therapies (CBT), with techniques individualized and tailored to complaints, including CBT for insomnia complaints associated with boredom and/or depression (4) education about the effects of medications on sleep and of difficulties that can obtain with every-night/long-term use of hypnotics, including provision of individually-structured plans for medication reduction/withdrawal, (5) appropriate treatment for sleep disorders uncovered and/or documented by the NPSG evaluation, and (6) appropriately-timed light therapy for insomnia complaints associated with circadian rhythm sleep disorders. Follow-up visits are generally of 45-60 minutes duration and will be scheduled at optimal temporal intervals, usually at two-four week intervals. Sleep logs, instructional sheets, and readings tailored to the individual patient are given the patient at the conclusion of each patient visit; the patient is requested to review the readings, fill out sleep logs each morning upon getting out of bed, and carry-out assigned procedures/homework prior to the next scheduled clinic visit. The homework is brought to the next scheduled sleep clinic visit.

In formulating an optimal evaluation and treatment plan tailored to each patient’s presenting symptoms and objective findings, Dr. de la Peña will often refer the patient to medical, psychiatric, psychological, and/or other allied health professional specialists for additional evaluation and/or treatment. Patients who are assessed to require a more in-depth and/or long-term exposure to CBT are generally referred to a local clinical psychologist having an established reputation as an expert provider of specific types of CBT. Patients whose insomnia complaints have not responded to the PCSV Insomnia Program treatment schema will be referred to local area sleep specialists for second opinions and imparting/delivery of alternative treatment approaches/strategies.

Practice Parameter Publications: Use of Polysomnography in the Evaluation of Insomnia. Sleep 18(1): 56-57, 1995. A. Chesson et al. Evaluation of Chronic Insomnia. Sleep (23(2): 2000. A. Chesson et al. Nonpharmacologic Treatment of Chronic Insomnia. Sleep 22 (8): 1-6, 1999. M. Thorpy et al. Use of Actigraphy in the Clinical Assessment of Sleep Disorders. Sleep 18(4): 285-287, 1995. A. Chesson et al. Light Therapy in the Treatment of Sleep Disorders. Sleep 22 (5): 641-648, 1999. M. Litner et al. Dopaminergic Treatment of Restless Legs and Periodic Limb Movement Disorder. Sleep, 27(3): 557-559, 2004.
 

Call Us if

• a sleeping problem becomes persistent and unbearable despite home treatment.
• if sleeping problem occurs more than 3 nights per week for more than 1 month
• if the insomnia is accompanied by other worrisome symptoms such as chest pain or shortness of breath.