How to Beat Insomnia
By L. William Lauro, MD
Difficulty sleeping is one of the most common complaints made by patients each year. It is estimated that about one third of the adult population of the United States suffers from insomnia at one time or another.
Types of Insomnia
Insomnia comes in several different types. Insomnia can be characterized as: 1) a problem falling asleep; 2) a difficulty maintaining asleep (i.e. you fall asleep just fine but then a few hours later you awake and can't go back to sleep); or 3) as non-refreshing sleep (represented by daytime dysfunction or distress).
Insomnia can be a primary disorder (no apparent cause is noted) or a secondary order (caused by some other problem, such as a medical condition or a psychiatric difficulty).
Insomnia may be short term (a few nights of difficulty, which then resolves by itself) or can become a chronic disorder (difficulty with sleep several nights per week for longer than a month).
Insomnia may also result from a specific sleep disorder (in other words there is no medical or emotional problem). Examples would be sleep apnea and sleep movement disorders (e.g. restless legs syndrome). Untreated primary insomnia, particularly when severe enough to impair daytime function, significantly increases the risk of developing a psychiatric disorder, particularly major depression.
As the term implies, secondary insomnia results from a separate cause, i.e. something specific is causing the insomnia. These causes can be medical conditions (such as chronic pain, difficulty breathing at night, medication side-effects, thyroid disorders, menopause, and others) or psychiatric conditions (depression and/or anxiety, for example). Usually a trip to the physician's office will reveal the exact cause, and treatment can be very specific and effective for the underlying cause. Therefore, any person who is having recurring problems with insomnia should have a basic medical work up by a physician.
For patients with primary insomnia, no specific cause can be found to be causing the sleep disorder. As noted above, these patients do not have a medical or psychiatric cause, and they do not have a sleep disorder (such as sleep apnea or restless legs).
Patients who have sleep onset disorder (i.e. difficulty falling asleep) are usually younger, whereas those with sleep maintenance problems (one falls asleep easily but then awakes early in the morning) are usually older. There are several treatment options for primary insomnia, both medical ands non-medical.
Treatment for Primary Insomnia
Before we ever consider sleeping medications, physicians usually give instruction on proper sleep techniques. Consider these recommendations:
1) Maintain a regular sleep schedule. This means trying to go to bed at the same time each night, and getting up at the same time as well.
2) Do not nap during the day, especially a few hours before bedtime.
3) Avoid sleeping late in the morning after a bad night's sleep.
4) Do not watch the clock at night-this just causes more anxiety about not sleeping;
5) Do not lie awake in bed for long periods. If you haven't fallen asleep by 15-20 minutes, get out of bed, go to another location and read or do some other relaxing activity until you feel sleepy, and then return to the bedroom to try again. This teaches our bodies that the bed is meant for sleeping, not lying awake looking at the clock!
6) Exercise regularly, but not within 3-4 hours of bedtime.
7) Restrict excessive liquid intake in the evening or heavy evening meals.
8) Minimize or avoid caffeine, alcohol, tobacco, and stimulant intake. You would be surprised how many patients report their insomnia to be cured when they quit drinking diet Coke.
Another simple activity to help alleviate insomnia is relaxation therapy. This can be accomplished by progressive muscle relation. This involves alternately tensing and relaxing different muscle groups to facilitate relaxation and inhibit anxiety. You begin by gently tensing the muscles in your face for 5 seconds and then releasing them (start at the very top of your head - raise eyebrows for 5 seconds, and then release; next tighten eyelids, release. Gently clench jaw, release). You then move downward, holding each muscle group for 5 seconds (e.g. tighten front neck muscles, release; elevate shoulders, release; make a fist - first in your right hand, release; then the left, release). Keep moving downward - you get the picture. Each time you release a muscle group rest for a few seconds and focus on how relaxing it is to release the muscle tension.
For most patients these simple common-sense suggestions will be quite effective. However, if you try these suggestions and are still having problems, then you should know that behavioral therapy is also highly effective for treating insomnia. A usual behavioral treatment plan involves weekly sessions for about 1-2 months, and can employ a number of different behavioral strategies.
For the patient who has tried everything and still cannot get to sleep, we consider medications.
Medications for Insomnia
There are receptors in our brains (GABA receptors) that, when activated, make us sleepy. Medications have been developed that turn on these receptors and help us fall asleep. Unfortunately, like anything else in life, when you artificially stimulate a receptor over and over again, it can become less responsive to the stimulus, and then one must increase the dose of the medication to get the same effect. You can see how this can lead to habituation and dependence. This is exactly what happens in alcohol, narcotic, and stimulant abuse. And this is why the FDA has only approved most sleep medications for short-term use.
However, newer sleep medications have been developed which are much less habit forming and can be used for longer periods of time.
The original or "first generation" sleeping medications were all benzodiazepines (this is a group of tranquilizers, of which Valium is the most recognized). The sleeping medications are all refinements of the Valium-like structure, redesigned to give more of a punch for sleeping with less concern for anxiety relief. You may have heard of some of these compounds: Dalmane, Halcion, and Restoril.
The next generation of sleeping medications act like benzodiazepines but do not have the same structure, so there is less chance for habituation (but of course it can still happen). Ambien is the prototype; the newer drugs are Sonata and Lunesta. Although these agents seem to be less habit forming, Ambien and Sonata are still only approved by the FDA for short-term insomnia. Lunesta is the exception - the FDA has not specifically prohibited its long-term use for insomnia because of a favorable 6-month study that showed no significant loss of effectiveness or significant rebound insomnia when discontinued.
These newer agents wear off much faster than the older sleeping agents and thus there is little to no daytime grogginess. Sonata wears off so quickly that it can even be taken for middle-of-the- night awakening and still not cause daytime sedation.
Upon discontinuation of any of these newer agents one might experience a worsening of insomnia for a few days. This is called rebound or discontinuation insomnia. However, the chance for this to be a problem is much less than the older agents.
Most importantly, like all medications that work in the central nervous system, these compounds should not be taken in conjunction with alcohol, and should be used with caution in patients with a history of alcohol or substance abuse because of their potential for dependence.
Other Sleep Medications
Some types of antidepressant medications have, as a side-effect, sleepiness. Many physicians use these agents solely for there effect of inducing sleep. Amitrytiline and Trazadone, in low doses, are the most commonly used of the antidepressants for sleep. Side effects include dry mouth, daytime grogginess, dizziness, and weight gain. Amitrityline can be lethal in high doses.
Commonly used over-the-counter sleep medications (like the old Sominex) are basically anti-histamines. They too have worrisome side effects: daytime grogginess, dry mouth, difficulty urinating, worsening of glaucoma, raising of blood pressure. Antihistamine-based sleep agents also seem to lose their effectiveness after only 4 nights of continuous use.
Herbal medications can be quite effective. The ones I am most familiar with are Melatonin and Valerian root. Both are effective, but both can cause daytime grogginess, and both can be habit-forming. They are popular because they are cheap, do not require a physician's order, and seem to be less habituating than the first generation benzodiazepines. Long-term effectiveness is being studied.