Insomnia is the most common sleep disorder in the United States. Approximately, 30% of the population complains of: difficulty falling asleep, staying asleep or early morning awakenings. There are two major schools of thought as to why someone might suffer from Insomnia. The first is the physiological hyper arousal theory. Insomnia sufferers, frequently show faster brain waves; characteristic of wakefulness and mental processing while asleep. They also seem to produce more stress hormones such as cortisol, adrenaline and noradrenaline at night. In addition, scans called PET scans show an increase in glucose uptake in the brain; while asleep compared to normal.
The second is the psychological theory. Insomnia sufferers seem to have anxiety –prone personalities. Seem to be ruminators, worriers and tend to internalize their emotions. As a result, they have more trouble dealing with chronic daily stressors, such as occupational and family conflicts. As well, as major life events; such as divorce, death in the family or illness.
I like to think that they coexist in most people and that one can exacerbate the other. That is why in Insomnia, one treatment does not fit all. We sometimes need to combine pharmacologic treatment; even if just for a short period, with behavioral and cognitive therapy to achieve our goal of getting good quality sleep.
We define Insomnia, as the inability to either fall asleep, stay asleep, early morning awakenings or a chronic feeling, that our sleep is of poor quality. This then needs, to be accompanied by daytime symptoms, that can be attributed to the poor sleep. These include irritability, moodiness and trouble concentrating. Interestingly, sleepiness is usually mentioned as well. However, most Insomniacs are not really sleepy. In fact, they will tell you that they cannot nap. This is probably due to the underlying hyper arousal; that I alluded to above. However, they do suffer from frequent and severe fatigue which is not the same as sleepiness.
In 10% of the population Insomnia is a chronic problem, lasting over three months. In fact, in most studies the duration of the problem is measured in years. If untreated, many of these people go on to develop depression. In fact, in one study of over 14000 patients Insomnia preceded depression in 40% .In addition, Insomnia occurs at the same time as anxiety disorders in 38%. Most importantly, is to realize; that if Insomnia occurs with depression and/or anxiety disorders and is not addressed, there is a very high incidence of relapse.
Treatment of Insomnia pharmacological:
There are several classes of medications available and approved by the FDA for the treatment of Insomnia. That is not to say, that this is necessarily the best approach. However, I think it is important to understand how these medications work.
First, we have the over-the-counter sleep aides for Insomnia. Most of these are antihistamines, that block the action of histamine; a stimulating wake promoting neurotransmitter. They tend to have undesirable side effects such as: constipation, urinary retention, dry mouth and daytime sedation. Most people become tolerant, meaning the drug loses its effectiveness in a short time. Additionally, there are herbal remedies and melatonin; the latter which may be effective in certain circadian disorders involving our inherent biological sleep wake schedule.
We then have the medications that target the GABAergic system. GABA (Gamma Amino Butyric Acid) is the most potent sleep promoting neurotransmitter produced in the brain. However, in addition to sleep, these medications may target brain receptor sites, that increase muscle relaxation, effect memory, and decrease anxiety. Medications such as temazepam (restoril), triazolam (halcion), Fluazepam (dalmane); potentiate the release of this neurotransmitter GABA.
Newer medications, such as zolpidem (ambien) and Eszopiclone (lunesta) are a bit more selective; in that, they target the sleep and memory centers exclusively in normal prescribed doses.
We also have medications, that were not developed for sleep and are not approved by the FDA for sleep. However, because sleepiness is a side effect; they are commonly used for sleep. These include antidepressants such as trazadone, amitryptaline (Elavil) and mirtazapine (Remeron), as well as the antipsychotic medication Quetiapine (Seroquel).
Cognitive Behavioral Therapy (CBT)
In CBT, we are attempting to address the psychological causes of Insomnia. As Insomnia becomes chronic, we tend to develop negative sleep preventing behaviors and associations with the bedroom environment; which make it almost impossible to get a good night’s sleep.
People with Insomnia begin to develop severe anxiety surrounding the rituals of going to bed and their bedroom environment. In fact, some find it easier to sleep in a foreign environment; such as a hotel or a friend’s home, because these environments do not contain stimuli that trigger their anxiety about sleep.
They develop counterproductive behaviors, which we refer to as poor sleep hygiene. Such things as: frequently looking at the alarm clock, going to bed and staying in bed when not sleepy, attempting to sleep later on weekends or non-work days, consuming alcohol to help get to sleep are but a few.
They also tend to develop numerous dysfunctional beliefs about sleep. Thoughts such as; “I know, if I don’t get eight hours of sleep; I’ll be miserable all week “, “Insomnia is going to severely impact my health”, “I just know I won’t be able to function and I’m going to lose my job” are just a few common examples; of what I hear every day from my patients.
With this mindset, is it any wonder that these people, cannot get to sleep? In fact, these negative cognitions and counterproductive behaviors, may stimulate the production of stress hormones; making it impossible to sleep.
There are several treatments available for these patients. They include relaxation techniques such as, progressive muscle relaxation and abdominal deep breathing. Behavioral altering techniques, such as stimulus control and sleep restriction therapy, which attempt to eradicate the sleep preventing behaviors and negative associations that develop around bedtime and the bedroom environment. Another is cognitive restructuring, which attempts to turn negative dysfunctional beliefs about sleep into positive ones.
On the website you will see questions and answers I have received over the years regarding Insomnia. Hopefully, you will learn how to apply these techniques to your situation.
