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Insomnia
Insomnia
June 2001
WHAT IS INSOMNIA?
Sufficient and restful sleep is a human need as basic as food, vital to emotional
and physical well being. In recent years, scientists have made great strides in
identifying patterns and functions of brain activity in sleep. [ See Box Healthy
Sleep.]
Insomnia is not a disease but the sensation of daytime fatigue and impaired performance
caused by insufficient sleep. In general, people with insomnia experience one
of the following:
- An inability to sleep despite being tired.
- A light, fitful sleep that leaves one fatigued upon awakening.
- Waking up too early.
Definition of Chronic Insomnia
Insomnia, usually temporary, is often categorized by how long it lasts:
Transient insomnia lasts for a few days.
Short-term insomnia for no more than three weeks.
Chronic insomnia occurs when the following characteristics are present:
- When a person has difficulty falling asleep, maintaining sleep, or has
nonrestorative sleep for at least three nights a week for one month or longer.
- In addition, the patient is distressed and believes that normal daily functioning
is impaired because of sleep loss.
Chronic insomnia may also be primary or secondary, depending on the cause:
- Primary chronic insomnia occurs when it is the sole complaint of
a patient.
- Secondary chronic insomnia is caused by medical or psychiatric
conditions, drugs, or emotional or psychiatric disorders.
HEALTHY SLEEP
Circadian Rhythm
In sleep studies, subjects spend about one-third of their time asleep, suggesting
that most people need about eight hours of sleep each day. Individual adults
differ in the amount of sleep they need to feel well rested, however. (Infants
may sleep as many as 16 hours a day.)
The daily cycle of life, which includes sleeping and waking, is called a
circadian (meaning "about a day") rhythm, commonly referred to as
the biologic clock. Hundreds of bodily functions follow biologic clocks,
but sleeping and waking comprise the most prominent circadian rhythm. The
sleeping and waking cycle is approximately 24 hours. (If confined to windowless
apartments, with no clocks or other time cues, sleeping and waking as their
bodies dictate, humans typically live on slightly longer than 24-hour cycles.)
It usually takes the following daily patterns:
- Humans are designed for daytime activity and nighttime rest.
- Additionally, there is a natural peak in sleepiness at mid-day, the
traditional siesta time.
In addition, daily rhythms intermesh with other factors that may interfere
or change individual patterns:
- The fraction-of-a-second-firing of nerve cells in the brain may be
faster or slower in different individuals.
- The monthly menstrual cycle in women can shift the pattern.
- Light signals coming through the eyes reset the circadian cycles
each day, so changes in season or various exposures to light and dark
may unsettle the pattern. The importance of sunlight as a cue for circadian
rhythms is dramatized by the problems experienced by people who are
totally blind: they commonly suffer trouble sleeping and other rhythm
disruptions.
The Response in the Brain to Light Signals
The response to light signals in the brain is an important key factor in
sleep:
- Light signals travel to a tiny cluster of nerves in the hypothalamus
in the center of the brain, the body's master clock, which is called
the supra chiasmatic nucleus or SCN.
- This nerve cluster takes its name from its location, which is just
above ( supra) the optic chiasm. The optic chiasm is a major
junction for nerves transmitting information about light from the eyes.
- The approach of dusk each day prompts the SCN to signal the nearby
pineal gland (named so because it resembles a pine-cone) to
produce the hormone melatonin.
- Melatonin is thought to act as the body's time-setting hormone.
The longer a person is in darkness the longer the duration of melatonin
secretion. Secretion can be diminished by staying in bright light. Melatonin
also appears to serve as a trigger for the need to sleep.
Sleep Cycles
Sleep consists of two distinct states that alternate in cycles and reflect
differing levels of brain nerve cell activity. During a normal night's sleep,
one progresses through these stages about five or six times:
Non-Rapid Eye Movement Sleep (NonREM). NonREM sleep is also termed
quiet sleep. NonREM is further subdivided into three stages of progression:
- Stage 1 (light sleep).
- Stage 2 (so-called true sleep).
- Stage 3 to 4 (deep "slow-wave"; or delta sleep).
With each descending stage, awakening becomes more difficult. It is not
known what governs NonREM sleep in the brain. A balance between certain
hormones, particularly growth and stress hormones, may be important for
deep sleep.
Rapid Eye-Movement Sleep (REM). REM sleep is termed active sleep
and is believed by some experts to be regulated by the circadian clock in
the hypothalamus. Most vivid dreams occur in REM sleep. REM-sleep brain
activity is comparable to that in waking, but the muscles are virtually
paralyzed, possibly preventing people from acting out their dreams. In fact,
except for vital organs like lungs and heart, the only muscles not paralyzed
during REM are the eye muscles. REM sleep may be critical for learning and
for day-to-day mood regulation. When people are sleep-deprived, their brains
must work harder than when they are well rested.
The REM/NREM Cycle. The cycle between quiet (NREM) and active (REM)
sleep generally follows this pattern:
- After about 90 minutes of NonREM sleep, eyes move rapidly behind
closed lids, giving rise to REM sleep.
- As sleep progresses the NonREM/REM cycle repeats.
- With each cycle, NonREM sleep becomes progressively lighter, and
REM sleep becomes progressively longer, lasting from a few minutes early
in sleep to perhaps an hour at the end of the sleep episode.
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WHAT ARE THE CAUSES OF TRANSIENT OR SHORT-TERM INSOMNIA?
Response to Change or Stress
A reaction to change or stress is one of the most common causes of short-term
and transient insomnia. This condition is sometimes referred to as adjustment
sleep disorder .
The precipitating factor could be a major or traumatic event such as the following:
- An acute illness.
- Injury or surgery.
- The loss of a loved one.
- Job loss.
Temporary insomnia could also develop after a relatively minor event, including
the following:
- Extremes in weather.
- An exam.
- Traveling.
- Trouble at work.
In such cases, normal sleep almost always returns when the condition resolves,
the individual recovers from the event, or the person becomes acclimated to the
new situation. Treatment is needed if sleepiness interferes with functioning or
if it continues for more than a few weeks.
Female Hormonal Fluctuations
Fluctuations in female hormones play a major role in insomnia in women over their
lifetimes. Such insomnia is most often temporary.
- During Menstruation. Progesterone promotes sleep, and levels of this hormone
plunge during menstruation, causing insomnia. (When they rise during ovulation,
women may become sleepier than usual.)
- During Pregnancy. The effects of changes in progesterone levels in the
first and last trimester can disrupt normal sleep patterns.
- Menopause. Insomnia can be a major problem in the first phases of menopause,
when hormones are fluctuating intensely. Insomnia during this period may be
due to different factors that occur. In some women, hot flashes, sweating,
and a sense of anxiety can awaken women suddenly and frequently at night during
the first months of menopause. In such women, hormone replacement therapy
may be beneficial. Insomnia may also be perpetuated by psychologic distress
provoked by this life passage. In most cases, insomnia is temporary. Cases
of chronic insomnia in women after 50 are more likely to be due to other causes.
[ See What Causes Chronic Insomnia?]
Jet Lag
Air travel across time zones often causes insomnia. After long plane trips, one
day of adjustment is usually needed for each time zone crossed. Traveling west
to earlier times seems to be less traumatic than going east to a later time because
it is easier to lengthen a circadian phase than to shorten it.
Working Conditions
Working conditions can cause insomnia, as indicated by the following studies:
- In one study, people on night shifts or on schedules of two- and three-shifts
tended to suffer more from sleep-related problems, including insomnia, than
those on day shifts.
- Another study found that 53% of night-shift workers fall asleep on the
job at least once a week, implying that their internal clocks do not adjust
to unusual work times. (They are also at much higher risk than other workers
for automobile accidents due to their drowsiness.)
- A Japanese study reporting on different aspects of insomnia found that
excessive computer work was associated with all forms of insomnia. People
who were over-involved with their work tended to have trouble falling asleep
and they tended to awaken earlier than average.
Caffeine and Nicotine
Certain lifestyle habits can lead to sleeplessness.
Caffeine. Caffeine most commonly disrupts sleep.
Nicotine. Nicotine can cause wakefulness. Quitting smoking can also cause
transient insomnia. In fact, it has been suggested that if sleeping could be improved
during withdrawal from smoking, then perhaps it would be easier to quit smoking.
Partner's Sleep Habits
In one 1999 survey, 17% of women and 5% of men reported that their partner's sleep
habits impaired their own sleep. Snoring can certainly be a factor in a partner's
insomnia. In fact, in the same survey 44% of men and 36% of women reported snoring
a few nights a week and of those who snored, 19% could be heard through a closed
door.
Medications
Insomnia is a side effect of many common medications, including over-the-counter
preparations that contain caffeine. People who suspect their medications are causing
them to lose sleep should check with a physician or pharmacist.
Noise and Other Disruptions
In one study, 20% of adults reported that light, noise, and uncomfortable temperatures
caused their sleeplessness.
Effect of Light
Excessive Light at Night. It is well known that a person's biologic circadian
clock is triggered by sunlight and very bright artificial light to maintain wakefulness.
One study indicated that even dim artificial light may disrupt sleep.
Insufficient Light During the Day. Insufficient exposure to light during
the day, as occurs in some disabled elderly patients who rarely venture outside,
may also be linked with sleep disturbances. One study suggests that exposure to
bright daylight results in higher melatonin levels in response to darkness, which
aids sleep.
WHAT CAUSES CHRONIC INSOMNIA?
Psychophysiologic Insomnia after Transient Insomnia
Psychophysiologic insomnia is the revolving door of sleeplessness:
- An episode of transient insomnia disrupts the person's circadian rhythm.
- The patient begins to associate the bed not with rest and relaxation but
with a struggle to sleep. A pattern of sleep failure emerges.
- Overtime, this event repeats, and bedtime becomes a source of anxiety.
Once in bed, the patient broods over sleeplessness and all attempts to sleep
fail.
- After such a cycle is established, insomnia becomes a self-fulfilling prophecy
that can persist indefinitely.
Sometimes anxiety and the inability to sleep dates back to childhood when parents
used various threats to force their children into sleep for which they may not
have been ready. In general, this problem is easily treated within a short period
of time with relaxation techniques and cognitive therapy.
Medical Conditions and Treatments
In a 1999 survey, 22% of adults reported that health conditions, pain or discomfort
impaired their sleep.
Medical Problems. Among the many medical problems (and some of the drugs
that treat them) that can cause insomnia are allergies, arthritis, cancer, fibromyalgia,
heart disease, gastroesophageal reflux disease (GERD), hypertension, asthma, rheumatologic
conditions, Alzheimer's disease, Parkinson's disease, hyperthyroidism, and attention
deficit hyperactivity disorder.
Medications. Among the many medications that can cause insomnia are nicotine,
certain antidepressants (eg, fluoxetine, bupropion), theophylline, lamotrigine,
felbamate, beta-blockers, and beta-agonists.
Emotional Disorders
A large percentage of chronic insomnia cases prove to have a psychologic or even
psychiatric basis. The disorders that most often cause insomnia are the following:
- Anxiety.
- Depression.
- Bipolar disorder.
Some researchers have even observed that 90% of depressed patients show evidence
of disrupted sleep on electroencephalogram (in which electrodes placed on the
head measure the activity of nerve cells). It should be noted, however, that insomnia
may also cause emotional problems, and it is often unclear which condition has
triggered the other, or if the two conditions, in fact, have a common source.
[ See Effects on Emotions under How Serious is Insomnia?]
Alcohol as a Cause of Insomnia
An estimated 10% to 15% of chronic insomnia cases result from substance abuse,
especially alcohol, cocaine, and sedatives. One or two alcoholic drinks at dinner,
for most people, poses little danger of alcoholism and may help reduce stress
and initiate sleep. Excess alcohol or alcohol used to promote sleep, however,
tends to fragment sleep and cause wakefulness a few hours later. It also increases
the risk for other sleep disorders, including sleep apnea and restless legs. Alcoholics
often suffer insomnia during withdrawal and, in some cases, for several years
during recovery.
Hormonal Fluctuations Associated with Aging
An imbalance in specific hormones important in sleep has been associated with
aging and may be partly responsible for the higher incidence of insomnia in older
people.
- Normal aging is associated with a blunting of regular, cyclical surges
of growth hormone. This hormone, which is normally secreted in the late night,
is associated not only with growth but with deep, slow-wave sleep. (Older
people generally have less slow-wave sleep.)
- Older people experience higher levels of major stress hormones (cortisol
and adrenocroticotropin) during the night. High levels of cortisol reduce
REM sleep.
- Melatonin levels, the hormone secreted by the pineal gland are lower, in
older people. Some experts believe that the pineal gland may harden as people
age and so release less melatonin. Some research suggests that elderly people
may have lower levels in general because many stay mostly indoors, and out
of normal sunlight.
Genetic Factors
Sleep problems seem to run in families, with approximately 35% of people with
insomnia having a positive family history, with the mother being the most commonly
affected family member.
Circadian Rhythm Disorders
Circadian rhythm disorders are defined as those that are characterized by the
inability to sleep at conventional times.
Delayed Sleep-Phase Syndrome. Delayed sleep-phase syndrome is the term
for a circadian clock that runs late but reliably. People who have this condition
(usually adolescents) fall asleep very late at night or in early morning hours,
but then they sleep normally.
Advanced Sleep Syndrome. This syndrome tends to develop in older people;
it produces excessive sleepiness in the morning and undesired awakening early
in the morning.
Nightly Leg Problems
Leg disorders that occur at night, such as restless legs syndrome or leg cramps,
are common cause of insomnia, particularly in older people. [For more information,
see the Well-Connected Report #95, Leg Disorders. ]
WHO HAS INSOMNIA?
In general, studies estimate that about one-third of American adults experience
some insomnia each year, with between 10% and 20% of them suffering severe sleeplessness.
European studies suggest similar rates. A 1999 survey conducted by the National
Sleep Foundation reported even worse statistics on sleeplessness in the US:
- Only 35% of American adults reported sleeping eight hours or more per night
during the work week.
- 56% had one or more symptoms of insomnia a few nights a week or more.
- Over half of the elderly took an hour's nap during the work week and nearly
half of 18 to 29 year olds napped.
- 60% of children, particularly teenagers, complained of being tired during
the day.
In spite of this widespread problem, however, studies suggest that only about
30% of American adults who visit their doctor ever discuss sleep problems. Conversely,
physicians seem rarely to ask patients about their sleep habits or problems.
Gender
Overall, insomnia is more common in women than men, although men are not immune
from insomnia. Sleep efficiency deteriorates equally in men and women as they
get older.
Men. One major study suggested that as men go from age 16 to 50, they lose about
80% of their deep sleep. During that period, light sleep increases and REM sleep
remains unchanged. (The study did not use women as subjects, and there is some
evidence to suggest they are not as affected.) After age 44 REM and total sleep
diminish and awakenings increase.
Women. Younger adult women suffer from insomnia because of both cultural
and biologic factors.
- In women, a number of hormonal events can disturb sleep, including premenstrual
syndrome, menstruation, pregnancy, and menopause. All these conditions are
natural, and in most cases the wakefulness associated with them is temporary
and can be ameliorated with sleep hygiene and time.
- After childbirth, most women develop a high sensitivity to the sounds of
their children, which causes them to wake easily. Women who have had children
sleep less efficiently than women who have not had children. It is possible
that many women never unlearn this sensitivity and continue to wake easily
long after the children have grown.
Older women who are not bothered by sleeplessness tend to have longer and
better sleep than men their own age.
Aging
Complaints of insomnia are remarkably higher in people over the age of 65 than
in those aged 18 to 34. As people grow older, sleep changes:
- In most older people, about 15% of their sleeping time is in stage 1, light
sleep. (In infancy, only 5% is spent in light sleep.) According to one study,
on average, a 60-year old awakens 22 times, compared to a young person who
awakens about 10 times a night.
A number of factors affect sleep in the elderly:
- Older people are more sensitive to environmental disruptions, such as light,
noise, or jet lag.
- Elderly people are more likely to be sedentary.
- Medical conditions that cause pain or nighttime distress are common in
the elderly. They include arthritis, gastrointestinal distress, urination
problems, and heart conditions.
- Neurologic diseases in the elderly, such as Parkinson's, Alzheimer's, and
other forms of dementia, can cause nighttime disorientation, confused wandering,
and delirium.
- Subtle and dramatic hormonal shifts also occur, including reductions in
melatonin and growth hormone and increases in stress hormones, creating an
imbalance that may reduce all stages of sleep. (It should be noted, however,
that some studies suggest that older adults with healthy life style factors
have the same risk for insomnia as younger adults.)
- Older people often take a number of prescription drugs whose side effects
include insomnia.
- The elderly are also prone to grief, depression, and anxiety, the handmaidens
of sleeplessness. One study found, in fact, that in healthy older adults,
psychologic factors, such as anxiety and depression, were more likely to be
the cause of insomnia than illness, medications, or living conditions.
Sleep loss among the elderly is not inevitable, however. While older people are
more susceptible to many physiologic conditions that can cause insomnia, treatments
and a healthy lifestyle, particularly regular exercises, are as useful in providing
relief to the elderly as to the young.
Shift-Workers
Shift workers are at considerable risk for insomnia. In one major 1999 survey,
65% of shift workers reported one or more symptoms of insomnia at least a few
nights a week. Workers over 50 and those whose shifts are always changing are
particularly susceptible to insomnia, although night-shift workers also have a
high rate of sleeplessness.
Other Risk Factors
The following people are also at risk for insomnia:
- People who travel frequently and cross time lines are at increased risk
for insomnia.
- Insomnia is also linked to relatively low social and economic status.
- People with tinnitus (ringing in the ears).
HOW SERIOUS IS INSOMNIA?
Sleep deprivation, and the daytime sleepiness that follows, is increasingly recognized
as a cause of mood disruption and contributor to industrial errors and motor vehicle
crashes. Insomnia costs the US approximately $13.9 billion each year in direct
medical costs and unknown billions from decreased productivity and consequences
of accidents.
Increased Risk for Accidents
As many as 200,000 automobile accidents in the US and 1,500 deaths from such accidents
are caused by sleepiness. Studies continue to report that drowsy driving is as
risky as drunk driving. The following are some examples:
- Estimates on fatigue as a cause of automobile crashes range from 1% to
56%, depending on the study.
- A large 1997 survey indicated that accidents involving motor vehicles or
machine tools occurred twice as often in persons with moderate or severe daytime
sleepiness, compared with those without daytime sleepiness.
- In a major 1995 poll, 33% of those surveyed said they had fallen asleep
while driving, and 10% of these people had had accidents because of this.
- An Australian study reported that 17 hours of sleep deprivation cause impaired
performance levels comparable to those found in people who have blood alcohol
levels of 0.10%, a level that defines intoxication in many states.
Negative Effect on Thinking and Performance
Studies suggest that insomnia worsens many waking behaviors including the following:
- Reduced concentration. Some experts report that deep sleep deprivation
impairs the brain's ability to process information.
- Impaired task performance . One study reported that missing only
two to three hours of sleep every night for a week significantly impaired
performance and mood. An Australian study reported that 17 hours of sleep
deprivation causes impaired performance levels comparable to those found in
people who have blood alcohol levels of 0.10%, a level that defines intoxication
in many US states.
- Effect on learning. One study indicated that healthy sleep is important
for learning certain perceptual skills related to visual patterns as well
as repetitive skills, such as typing. Some studies reported no difference
in test scores between people with temporary sleep loss and those with full
sleep, although a Canadian study found that students who slept after cramming
for an exam did better than those who stayed awake.
Effects on Emotions
One study reported that 20% of people with insomnia suffer from major depression.
Although stress and depression are major causes of insomnia, insomnia may also
increase the activity of the hormones and pathways in the brain that can produce
these emotional problems. Even modest alterations in waking and sleeping patterns
can have significant effects on a person's mood. Persistent insomnia may actually
be a symptom of later emotional disorders in some cases. Some evidence suggesting
that insomnia may contribute to emotional problems include the following:
- One 1997 study reported that young adults with stress-related insomnia
were at an increased risk of developing depression later in life. (Sleeplessness
unrelated to stress did not appear to be associated with later depression.)
- Another study of male medical students found that young men who experienced
insomnia were twice as likely to suffer from depression at middle age as those
who slept normally. Genetic factors may play a role in the association between
sleep disorders and depression.
- In one study of patients diagnosed with depression, family members with
certain sleep abnormalities were found to be at greater risk for depression
than those with normal sleep patterns.
- Individuals with normal sleep patterns who are from families with abnormal
sleep habits also appear to have an increased risk for mood disorders.
- Some investigators, in fact, are exploring the possibility of preventing
psychiatric disorders by early recognition and treatment of insomnia. (On
the other hand, people with co-existing depression and insomnia may find relief
from both conditions by treating depression first.) [See also Emotional Disorders
under What Causes Insomnia?]
Cause of Alcohol and Substance Abuse
Although alcohol and substance abuse can cause insomnia, the conditions may be
reversed: For example, a 1999 survey reported that 14% of American adults use
alcohol within a month to help them sleep, with 2.5% reporting frequent use of
alcohol to reduce sleep.
Effects on the Heart and Mortality Rates
Studies have not found any evidence that insomnia increases mortality rates. Studies
on the effects between heart disease and insomnia are weak but indicate a need
for further research:
- Some studies have associated a higher risk of heart disease with shift
work. This has been reported in only two studies, however, and more research
is needed to confirm this finding.
- One study reported signs of heart and nervous system activity in people
with chronic insomnia that might place such individuals at risk for coronary
heart disease. If it exists, however, this increased danger is modest compared
with other risk factors for heart disease.
- Yet another report suggested that sleep complaints in elderly people without
coronary artery disease predicted a first heart attack. Sleep disorders in
such cases may have been a marker for depression, a risk factor for heart
attacks in elderly people.
Headaches
Headaches that occur during the night or early in the morning may be caused by
sleep disorders. In one study, patients who had these complaints were treated
for the sleep disorder only and over 65% reported that their headaches were cured.
HOW IS INSOMNIA DIAGNOSED?
General Approach to Diagnosing Insomnia
Diagnosing sleep disturbance and its cause is the most important step in restoring
healthy sleep. There is little agreement, even among experts, however, on the
best methods for effectively assessing a patient's insomnia.
A major difficulty in diagnosing this problem is its subjective nature. One study
showed that people who said they were insomniacs and people who said they weren't
actually had the same sleep behavior, including sleepiness during the day and
the time it took to fall asleep. People with insomnia may have frequent brief
awakenings during sleep that appear to be a continual state of wakefulness, which
they perceive as taking longer to actually fall asleep. Some experts believe that
anyone who reports that they believe they have insomnia and are suffering daytime
fatigue, less concentration, and impaired memory should be treated aggressively.
Taking a Sleep History
In general, the recommended approach is first to take a sleep and personal history.
The physician may begin an interview that may include the following questions:
- How would the sleep problem be described?
- How long has the sleep problem been experienced?
- How long does it take to fall asleep?
- How many times a week does it occur?
- How restful is sleep?
- Does the difficulty lie in getting to sleep or in waking up early?
- What is the sleep environment like (Noisy? Not dark enough?)?
- How does insomnia affect daytime functioning?
- What medications are being taken (including the use of self-medications
for insomnia, such as herbs, alcohol, and over-the-counter or prescription
drugs)?
- Is the patient taking or withdrawing from stimulants, such as coffee or
tobacco?
- How much alcohol is consumed per day?
- What stresses or emotional factors may be present?
- Has the patient experienced any significant life changes?
- Does the patients snore or gasp during sleep (an indication of sleep apnea)?
- Does the patient have leg problems (cramps, twitching, crawling feelings)?
- If there is a bed partner, is his or her behavior distressing or disturbing?
- Is the patient a shift worker?
Sleep Diary. If the patient cannot answer these questions, keeping a sleep
diary is a helpful diagnostic tool. Every day for two weeks, the patient should
record all sleep-related information, including responses to questions listed
above described on a daily basis. A bed partner can help by adding his or her
observations of the patient's sleep behavior.
Measuring Sleepiness
The Epworth Sleepiness Scale. The Epworth sleepiness scale (ESS) uses
a simple questionnaire to measure excessive sleepiness during eight situations.
[ See Box The Epworth Sleepiness Scale.]
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THE EPWORTH SLEEPINESS SCALE
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SITUATION
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CHANCE OF DOZING (Indicate
a score of 0 to 3) 0 = no chance of dozing, 1 = slight chance of dozing,
2 = moderate chance of dozing, 3 = high chance of dozing
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Sitting and reading
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Watching TV
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Sitting inactive in a public
place (eg a theater or a meeting)
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As a passenger in a car for
an hour without a break
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Lying down to rest in the afternoon
when circumstances permit
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Sitting and talking to someone
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Sitting quietly after a lunch
without alcohol
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In a car, while stopped for
a few minutes in traffic
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Score Results
1-6 Getting enough sleep
4-8 Tends to be sleepy but is average.
9 and over Very sleepy and suggestive of sleep-disorder breathing. Patient
should seek medical advice. |
Multiple Sleep Latency Test. The multiple sleep latency test (MSLT) employs
a machine that measures the time it takes to fall asleep lying in a quiet room
during the day:
- The patient takes four or five scheduled naps two hours apart.
- People with healthy sleep habits fall asleep in about 10 to 20 minutes.
- The test can detect changes in sleepiness associated with sleep deprivation
in patients with insomnia.
It has limitations, however, and does not take into consideration any situations
that may affect the patients' mental state and therefore their ability to fall
asleep. It is used mainly after other sleep disorders have been ruled out and
the doctor is uncertain whether or not insomnia is a correct diagnosis.
Sleep Disorders Centers
If unexplained insomnia persists after treatment or there is evidence of a primary
sleep disorder, such as sleep apnea or narcolepsy, the physician may recommend
a sleep specialist or a sleep disorders center. Centers are accredited by the
American Academy of Sleep Medicine. Patients should investigate centers carefully,
being sure that they offer full sleep studies. [ See Where Else Can Help
for Insomnia Be Obtained?, below.]
Among the signs that may indicate a need for a sleep disorders center are the
following:
- Insomnia due to psychologic disorders.
- Sleeping problems due to substance abuse.
- Snoring and sudden awakening with gasping for breath (possible sleep apnea).
- Severe restless legs syndrome.
- Persistent daytime sleepiness.
- Sudden episodes of falling asleep during the day (possible narcolepsy).
At most, sleep disorders centers patients undergo an in-depth analysis, usually
supervised by a multidisciplinary team of consultants who can provide both physical
and psychiatric evaluations.
Polysomnography. Polysomnography may be used to rule out other sleep disorders.
It is not useful for routine screening of insomnia. The patient arrives about
two hours before bedtime without having made any changes in daily habits. The
polysomnopraph instrument electronically monitors the patient during sleep. It
tracks the following:
- Brain waves.
- Body movements.
- Breathing.
- Heartbeats.
Actigraph. A new device, the actigraph, can be worn on the wrist. It records
body movements during wakefulness and sleep. It can be used at home and therefore
is reflects more natural conditions than tests in a laboratory. It can also keep
a record over several nights rather than a single session. However, it cannot
distinguish whether the patient is awake or asleep.
WHAT ARE BEHAVIORAL AND OTHER NON-DRUG TREATMENTS FOR INSOMNIA?
Behavioral or psychologic techniques can actually cure chronic insomnia
and studies report their effectiveness in nearly all patients with primary chronic
insomnia. (Medications cannot cure this condition and prolonged use frequently
results in dependency.) Treatment goals for behavioral methods are typically the
following:
- To reduce the time it takes to go to sleep to below 30 minutes.
- Reduce wake-up periods during the night.
- The more severe the insomnia the more aggressive the treatment. If proper
sleep hygiene does not relieve sleeplessness, a number of behavioral approaches
are available that should be tried before taking medications.
Behavioral Approaches
Prevention of sleeplessness is very much dependent upon the patient's ability
to relax and learn the art of sleeping well. A number of behavioral methods are
aimed at achieving these goals. Behavioral methods are effective and work better
than drugs in all age groups, including elderly patients. Studies have reported
that between 70% and 80% of those who are treated with non-drug methods experience
improved sleep with an average treatment duration of only five hours over a four-week
period. Furthermore, studies report that 75% of those who have been taking drugs
are able to stop or reduce their use.
Experts currently recommend the following methods in order of effectiveness for
patients with chronic primary insomnia:
- Stimulus control (standard treatment, which receives a high degree of physician
support). It may also be helpful for some patients with secondary insomnia
caused by a medical or psychiatric condition.
- Progressive muscle relaxation (studies and physician reports reflect a
moderate degree of confidence in its effectiveness). It may also be helpful
for some patients with secondary insomnia caused by a medical or psychiatric
condition.
- Paradoxical intention (studies and physician reports reflect a moderate
degree of certainty in its effectiveness).
- Biofeedback (studies and physician reports reflect a moderate degree of
certainty in its effectiveness).
- Sleep restriction (evidence inconclusive on its value).
- Multicomponent cognitive behavioral therapy (evidence inconclusive on its
value, although a 2001 study reported that it was significantly more effective
that progressive muscle relaxation and offered persistent benefits).
- Sleep hygiene, imagery training, and cognitive training only (experts unable
to recommend these approaches as sole therapy).
Stimulus Control. Stimulus control is now considered the standard treatment
for primary chronic insomnia and may be helpful for some patients with secondary
insomnia as well. The primary goal of stimulus control is to regain the idea that
the bed is for sleeping. It involves the following:
- Go to bed only when ready to sleep or for sex.
- If unable to sleep within fifteen to twenty minutes, get up and go into
another room. (People who find it physically difficult to get out of bed may
stay in bed, but they should do something relatively arousing, such as reading.)
- Maintain a regular wake-up time no matter how few hours are spent sleeping.
- Avoid naps.
Progressive Muscle Relaxation. Progressive muscle relaxation is another
effective technique for inducing sleep. (One 2000 study of college students reported,
however, that although it helped increase sleep time it did not improve functioning
during the day.)
It takes about 10 minutes a day and involves the following:
- Focus on a specific muscle group (for example the muscle in the right foot).
- Inhale and tense the muscle group for about eight second until the muscles
start to shake and there is some mild muscle pain. (Do this gently. It is
not intended to cause any severe muscles contraction pain.)
- Release the muscles quickly and let them become loose and limp. Stay relaxed
for 15 seconds and then repeat the same muscle group.
- Focus on the next muscle group and repeat the sequence. (Typically start
with the muscles in one foot and move progressively from each foot and leg
up through the abdomen, chest, then to each hand and arm and then to the neck
and shoulders and face.)
Paradoxical Intention. Paradoxical intention is a psychological approach
that is based on doing the opposite of what one wants or fears and take it to
extreme. The first step is to make a plan to take such a paradoxical approach
to insomnia.
• Instead of going through activities leading to sleep, the patient prepares
for staying awake and doing something energetic.
• In some cases, people may take specific psychological barriers to sleep
to an extreme limit. For example, if worry is a factor in insomnia, the patient
intensifies the worries.
Biofeedback. Biofeedback is also effective but requires being monitored
with an electroencephalogram (EEG), a device that measures brain waves. Patients
are given feedback to recognize certain states of tension or sleep stages so that
they can either avoid or repeat them voluntarily.
Sleep Restriction Therapy. Sleep restriction therapy may be effective,
although evidence is inconclusive. In one 2001 study, patients practiced sleep
hygiene and sleep restriction. Sleep hygiene was very helpful during the first
two months while sleep restriction led to sustained benefits and deeper sleep.
The approach is a systematic method for achieving sleep and restricting the time
spent in bed.
The first step is to calculate a person's sleep efficiency number :
- Keep a sleep diary for two weeks.
- Dividing actual average nightly sleep time by hours in bed. The answer,
given as a percentage, is the sleep efficiency number. (For example, if a
patient sleeps five hours out of seven hours in bed the calculation result
is .714 and the sleep efficiency percentage is 71%.)
- The patient's goal is to achieve a sleep efficiency percentage of between
85% and 90%, which means only 10% to 15% of the time is spent staying awake
in bed. (Sleep efficiency in older people may fall somewhere between 75% to
85%.)
To achieve this goal, the patient takes the following actions:
- Begin by going to bed fifteen minutes later than usual the first week.
- If 85% sleep efficiency isn't reached by the end of the week, another fifteen
minutes is added to staying up until bedtime.
- The patient must limit time in bed even when tired. (The time in bed should
not be reduced below five hours, however.)
- Once efficiency reaches 90% or more, the time allowed in bed is increased
by 15 minutes per week.
Other parts of the program include stopping any sleep medications and following
good sleep hygiene. [ See Box Sleep Hygiene Tips.]
- People using this treatment have reported lasting improvements after just
eight weeks. In one study comparing those who used sleep restriction therapy
and those who used relaxation techniques, the improvement for sleep restriction
subjects was approximately twice that of those who used relaxation methods
alone.
Cognitive-Behavioral Therapy. Cognitive behavioral therapy (CBT) is a form
of therapy that emphasizes observing and changing negative thoughts (such as,
"I'll never fall asleep";). It also employs actions intended to change behavior.
Studies have been mixed on its effectiveness. One reported that it helped people
with insomnia, even when it was caused by pain disorders, which are commonly thought
to require sleeping medications and be resistant to therapeutic maneuvers.
Sleep Hygiene. The term sleep hygiene is used to describe simple behaviors
that may help everyone improve their sleep. [ See Box Sleep
Hygiene Tips.]
Sleep Hygiene Tips
- Establish a regular time for going to bed and getting up in the morning
and stick to it even on weekends and during vacations.
- Use the bed for sleep and sexual relations only, not for reading,
watching television, or working; excessive time in bed seems to fragment
sleep.
- Avoid naps, especially in the evening.
- Exercise before dinner. A low point in energy occurs a few hours
after exercise; sleep will then come more easily. Exercising close to
bedtime, however, may increase alertness.
- Take a hot bath about an hour and a half to two hours before bedtime.
This alters the body's core temperature rhythm and helps people fall
asleep more easily and more continuously. (Taking a bath shortly before
bed increases alertness.)
- Do something relaxing in the half-hour before bedtime. Reading, meditation,
and a leisurely walk are all appropriate activities.
- Keep the bedroom relatively cool and well ventilated.
- Do not look at the clock. Obsessing over time will just make it more
difficult to sleep.
- A light snack before bedtime can help sleep, but a large meal may
have the opposite effect.
- Eat light meals and schedule dinner four to five hours before bedtime.
- Spend a half hour in the sun each day. (Take precautions against
overexposure to sunlight by wearing protective clothing and sunscreen.
The best times are early or late in the day.)
- Avoid fluids just before bedtime so that sleep is not disturbed by
the need to urinate.
- Avoid caffeine in the hours before sleep.
- Quitting smoking not only brings many health benefits to any smoker,
it eliminates the effects of nicotine that contribute to sleep loss.
- Patients who cannot sleep after 15 or 20 minutes should get up and
go into another room, read or do a quiet activity using dim lighting
until they are sleepy again. (Don't watch television, for it emits too
bright a light.)
- One study showed that sleeping alone is more restful than sleeping
with another person. If a person with insomnia is distracted by a sleeping
bed partner, moving to the couch for a couple of nights might be useful.
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Exercise
Exercise may be one of the best ways to achieve healthy sleep. One study found
that exercise is as good for promoting sleep as the use of benzodiazepines, a
prescription sleep aid.
Light Therapy
The circadian rhythm is more a function of darkness and light rather than actual
time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness,
day or night. The use of a special light box may be helpful. A light-box can be
purchased for about $300. [For some suppliers, see Where Else Can Help
be Obtained for Insomnia?]
In general people using the light box should do the following:
- Sit a few feet away from a light box that emits very bright fluorescent
light (over 2000 lux) for about 30 minutes every morning.
- Avoid bright light in the evening.
The following people might benefit from light therapy in specific ways.
- Shift workers. Light should be maximized during hours they are at work
and minimized when they need to sleep.
- Frequent travelers. Light therapy may be useful for adjusting to new time
zones and reducing jet lag.
- People with delayed sleep-phase syndrome. (These people have a natural
tendency to fall asleep very late at night or in early morning hours, but
then sleep normally.)
Everyone should check with their physician before using light therapy. The following
people should avoid it or use it only under a physician's direction:
- Anyone with eyes or skin that are highly sensitive to light.
- Anyone taking medications that increase the risk for photosensitivity.
- People with bipolar disorder.
Psychotherapy
Many people are reluctant to consult with a psychologist or psychiatrist, yet
insomnia is commonly caused by emotional disorders that can be successfully treated.
In a study of chronic insomniacs who were referred to therapists, only one-third
followed through with appointments, but of those who did, about three-fourths
benefited from psychotherapy. It might be useful when sleep loss is associated
with unconscious conflicts, such as those that involve loss of control, injury,
self-exposure, aggression, and sexuality.
Unconventional Therapies
Chewing Gum. One interesting study reported that people who chewed gum
from midnight until morning reported less sleepiness than those who also stayed
up and didn't chew. Although not a remedy for insomnia, it may help people who
have lost sleep the night before to stay alert.
Low-Energy Emission Therapy. A novel approach called low energy emission
therapy (LEET), uses radio waves transmitted through a spoon-like device that
a person with insomnia inserts into the mouth before sleep. Very early studies
suggest that it may have actual benefit for some people.
Other Methods. Other approaches that may be helpful for some patients
include hypnosis, meditation, guided imagery and other imagery methods, and acupuncture.
WHAT ARE DRUG TREATMENTS FOR INSOMNIA?
Guidelines for Drug Treatments for Insomnia
According to a 1999 survey, about 30% of American women and 20% of men report
taking a medication to help them sleep at some time during the course of a year.
Over half of these drugs are over the counter medications. It should be stressed
that only behavioral or psychologic techniques can actually cure insomnia,
whereas prolonged use of sleeping pills can only result in dependency. Most sleeping
pills become less effective over time and require higher doses. Many can cause
rebound insomnia if withdrawn rapidly.
Sleep medication should generally be used only to prevent the vicious cycle of
psychophysiologic insomnia in people with transient or short-term insomnia when
non-medical treatments have failed. In addition, the following precautions are
important in taking sleeping pills:
- Drugs used specifically for improving sleeping are called hypnotics.
Start with non-prescription medication. If using prescription hypnotics, start
with as low a dose as possible.
- In general, do not take either prescription nor non-prescription sleeping
pills on consecutive days or for more than two to four days a week.
- If insomnia is still a problem after stopping the drug and continuing with
good sleep hygiene, this pattern can be repeated again, but for no longer
than four weeks.
- Medication should be withdrawn gradually and the patient should be aware
of the possibility of rebound insomnia when stopping medication.
- Alcohol intensifies the side effects of all sleeping medication and should
be avoided.
- If chronic insomnia is a companion to depression or anxiety, treating these
problems first may be the best approach.
Note: Sleeping pills are often used in nursing homes, where the institutional
setting, nighttime light and noise, and the underlying medical problems of older
patients worsen sleeplessness. It is in the staff's interest to have sleeping
times as regimented as possible, so as to promote good sleep. The chronic use
of sleeping pills in the elderly, however, can produce side effects, such as impaired
memory and alertness, urinary incontinence, daytime sleepiness, and imbalance,
that can make care even more difficult in the long run.
Common Non-Prescription Drugs
Over-the-counter and prescription sleeping medications are very commonly used
medications.
Brands with Antihistamines. Antihistamines cause drowsiness and many over-the-counter
preparations are available that might help transient insomnia.
- Most over the counter sleep aids use antihistamines ingredients, most commonly
diphenhydramine. They may simply contain diphenhydramine alone (Nytol, Sleep-Eez,
Sominex) or contain combinations of diphenhydramine with pain relievers (Anacin
P.M., Exedrin P.M., Tylenol P.M.).
- Doxylamine (Unison) is another antihistamine used in sleep medications.
- Certain antihistamines indicated only for allergies, such as chlorpheniramine
(Chlor-Trimeton), diphenhydramine (Benadryl), or hydroxyzine (Atarax or Vistaril)
may also be used as mild sleep-inducers.
Unfortunately, most of these drugs can leave patients drowsy the next day and
may not be very effective in providing restful sleep. Side effects include the
following:
- Daytime sleepiness.
- Dizziness.
- Drunken movements.
- Blurred vision.
- Dry mouth and throat.
In general, they should be avoided by people with angina, heart arrhythmias, glaucoma,
problems urinating, or while taking medications to prevent nausea or motion sickness.
Some, such as those containing doxylamine should also be avoided by patients with
chronic lung disease.
Common Pain Relievers. When sleeplessness is caused by minor pain, simply
taking an acetaminophen (Tylenol) or an NSAID, such as ibuprofen (Advil, Motrin)
can be very helpful without causing any daytime sleepiness. The extra "P.M.";
antihistamine found in combination products is simply an extra, needless chemical
in these situations.
Natural Remedies
Melatonin. Although melatonin is now commonly taken for insomnia, its actual
effects are still unclear. Some studies have found that although many people fall
asleep faster with melatonin, it has no effect on total sleep time or daytime
feeling of sleepiness or fatigue. Different studies on its effects in specific
groups have reported the following:
- Shift-workers. In a study of emergency medicine personnel who worked night
shifts, 1 mg of melatonin was no more effective than placebo in improving
sleep quality.
- Elderly people. It appears to help some older people with insomnia. (Although
all older people experience a drop in melatonin levels, melatonin supplements
do not appear to make people sleepy who do not already experience insomnia.)
- In blindness. A 2000 study reported that melatonin can help people without
sight retrain their circadian cycle so that they can sleep at regular hours.
The best dosages and timing, however, need to be clarified. High doses (10
mg) may be needed to start with, but can probably be reduced over time.
- Travelers and Jet Lag. The studies on benefits of melatonin for jet lag
are mixed. It is unclear, for instance, if certain dosages and timing may
be beneficial while others are not.
- During Withdrawal from Other Sleeping Pills. One 1999 study suggested that
melatonin might help people withdraw from benzodiazepines, the more potent
class of prescription sleeping-drugs, while maintaining good quality sleep.
- Delayed Sleep Syndrome. A 2001 study indicated that it might be somewhat
helpful for people with delayed sleep phase syndrome.
One difficulty in assessing study results is that there are no consistent standards
on melatonin dosages or when it should be taken. Some studies suggest that 0.3
mg may be the most effective dosage in many people with insomnia. In fact, higher
doses (3 to 5 mg) may have an opposite effect. (A study on blind people, however,
suggested that much higher doses may be needed for this group, at least at the
beginning of treatment.)
High doses of melatonin have been associated with the following adverse events:
- Mental impairment.
- Drowsiness.
- Severe headaches.
- Nightmares.
- It may increase the risk for seizures in children with existing neurologic
disorders.
- Of note, melatonin is structurally similar to L-tryptophan, another natural
agent that has been used for insomnia. Contaminants in L-tryptophan have been
linked with a rare, sometimes fatal illness. No cases of this illness have
been linked to melatonin, however. [ See Box Warnings
on Alternative and So-Called Natural Remedies.]
- Interactions with other drugs are not completely known.
It should be stressed that melatonin is currently classified as a dietary supplement
and not as a drug, so its quality and effectiveness is uncontrolled in the US.
(The United State is the only developed nation that does not regulate this agent.)
Melatonin is a powerful hormone that can have major effects, many still unknown,
on all parts of the body. The bottom line is that there is little evidence yet
that this agent has any major benefits and its long-term safety is unknown. At
this time, people who take melatonin are experimenting on themselves.
Other Herbal Remedies. Many people attempt to combat insomnia by using
herbal medicines, including the following:
- Valerian root. Some studies suggest that valerian may be helpful but evidence
is inconclusive. It should be noted that high doses of valerian can cause
blurred vision, excitability, and changes in heart rhythm.
- Kava kava may help alleviate anxiety and promote sleep in some people.
Allergic reactions have been reported.
- Chamomile.
- Lemon balm.
Although these herbs are generally safe, it is important to note that, as with
melatonin, they have not been well tested, their benefits are not proven, and
they can sometimes be harmful. [ See Box Warnings
on Alternative and So-Called Natural Remedies.]
Warnings on Alternative and So-Called Natural Remedies
It should be strongly noted that alternative or natural remedies are not
regulated and their quality is not publicly controlled. In addition, any
substance that can affect the body's chemistry can, like any drug, produce
side effects that may be harmful. There have been a number of reported cases
of serious and even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard prescription
medication. Most problems reported occur in herbal remedies imported from
Asia, with one study reporting a significant percentage of such remedies
containing toxic metals. Even if studies report positive benefits, most,
to date, are very small. In addition, the substances used in such studies
are, in most cases, not what are being marketed to the public.
The following are of particular importance for people with insomnia.
- Jin Bu Huan. Reports of a few cases of acute hepatitis have
occurred from Jin Bu Huan, a Chinese herbal remedy sold as treatment
for pain and insomnia.
- Sleeping Buddha. The herbal remedy Sleeping Buddha actually
contains a benzodiazepine, the major ingredient in many prescription
sleeping pills and therefore has the same side effects and risks for
dependency.
- Tryptophan and 5-HTP. Structurally similar to melatonin,
tryptophan, an amino acid used in the formation of the neurotransmitter
serotonin, was formerly employed as a self-remedy for insomnia. In 1989,
contaminated batch of tryptophan supplements was responsible for an
outbreak of a rare disorder called e
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