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In the Know- All About...Insomnia

February 2, 2017        

By Mendy Hecht, Hamaspik Gazette

An article about insomnia may put you to sleep.  But if you have insomnia, an article so boring that you fall asleep would be a good thing.

That’s because insomnia (in-SAHM-nee-uh) is a common sleep disorder that can make it hard to fall asleep.

It also can make it hard to stay asleep, or even make someone wake up too early and be unable to get back to sleep.  People with insomnia may also feel tired when they wake up, despite having had a passable night’s sleep.

Insomnia can sap not only energy levels and moods but also health, work performance and quality of life.

Now, you may be thinking something like, “That’s a diagnosis?!  What’s the big deal about not being able to fall asleep?  If something is bothering you, you can’t fall asleep!  Big deal!”

And indeed, many adults do experience insomnia for a few days or weeks at some point in their lives—and usually as a result of something major weighing heavily on them, like stress or a traumatic personal life event.

That kind of insomnia usually goes away.

But for some people, insomnia is not a life-related short-term problem but a long-term medical and/or mental-health problem for which there are established diagnoses and treatments.

Those kinds of insomnia can last a good few months or even more.

The National Institutes of Health (NIH) estimates that roughly 30 percent of the general population complains of sleep disruption, and approximately ten percent have associated symptoms of daytime functional impairment consistent with the diagnosis of insomnia.

But whichever insomnia you may have, you don’t have to put up with sleepless nights.

Definition and symptoms

Insomnia is defined as difficulty falling asleep and/or or staying asleep, even when a person has the chance to do so.

There are three general types of insomnia: acute, chronic and comorbid.

Acute insomnia, as mentioned, frequently strikes adults at some point in their lives, but is defined by lasting only a few days or weeks.  Acute insomnia is commonly a result of life circumstances (for example, when you can’t fall asleep the night before a big test, or after hearing bad news).  As such, many people may actually have experienced acute insomnia without ever getting an official diagnosis, and not that they really need to, either—acute insomnia tends to resolve without any treatment.  (That’s why this article won’t dwell on it.)

Chronic insomnia, by contrast, is defined by disrupted sleep that occurs at least three nights per week and lasts at least three months.  This long-term pattern has many causes.

Comorbid insomnia is insomnia that occurs with another condition—including mental-health symptoms like anxiety or depression, or medical conditions like arthritis or back pain.

Whatever type, each splits further down into two subcategories: onset and maintenance.

Onset insomnia means having difficulty falling asleep at the beginning of the night.  Maintenance insomnia means having difficulty maintaining sleep—meaning, waking up during the night and having difficulty returning to sleep.

Symptoms

Regardless of what definition of insomnia one meets, the symptoms are usually the same:

  • Difficulty falling asleep

  • Difficulty staying asleep

  • Difficulty falling back asleep after waking up at night

  • Waking up too early in the morning

  • Dissatisfaction with sleep; unrefreshing sleep (a.k.a. “non-restorative sleep”)

  • Fatigue or low energy

  • Difficulty concentrating

  • Irritability, aggression, impulsivity or other mood disturbances

  • Decreased performance at work/ school

  • Increased errors or accidents; slowed reaction (esp. during driving)

  • Difficulty in personal relationships, including family, friends and caregivers

     

Diagnosis

So how do you distinguish a normal, passing sleep problem from a more serious form of insomnia needing medical treatment?  Well, for starters, if it’s not a passing problem!

If insomnia has been making it hard for you to function during the day, and the cause of your nighttime insomnia is pretty clear (stress, a family situation, a traumatic event and the like), then it should be pretty clear that as those causes are resolved, addressed or fade away, so will the insomnia.  That’s acute insomnia for you right there.

But if your insomnia’s been carrying on for quite some time with no obvious psychological cause, then you should see your doctor to find its cause, and its treatment.  You may have chronic insomnia.

Diagnosing insomnia and pinpointing its specific cause(s) may include:

  • Physical exams to find signs of medical problems possibly related to insomnia

  • Blood tests to check for thyroid problems or other conditions possibly related to poor sleep

  • Sleep habits questionnaire to determine sleep-wake pattern and level of daytime sleepiness

  • Keeping a sleep log for a couple of weeks; this is a simple record of daily bedtimes, wake-up times, energy levels at wake-ups, energy levels throughout the day, and so on

  • Sleep center testing.  In many cases where the cause is unclear, a non-invasive (no needles!) test typically run overnight at a sleep center, will monitor and record a variety of body functions, including heart rate, breathing, body movements, eye movements and brain waves while you sleep.  The results will help your doctor best treat your insomnia

Causes

Chronic insomnia

Chronic insomnia is usually triggered or perpetuated by unhealthy sleep habits, unhealthy work habits, or unhealthy social behaviors, all of which disrupt sleep.  Common causes include:  

  • Disrupting your body clock.  Disruptions include: Not having a set daily wakeup and bed time, jet lag from traveling across multiple time zones, working a late or early shift, frequently changing shifts, working from home in the evenings, using screen-based personal electronics while awake in bed, naps (especially in the afternoon, regardless of how short), an uncomfortable sleep environment, eating in bed, or sleeping in late.  Any of that can make it hard to unwind, make you feel preoccupied when it’s bedtime, keep your brain more alert due to the light from your computer or smartphone screen, or otherwise confusing your body’s clock.

  • Eating too much late in the evening.  Having a light snack before bedtime is alright, but eating too much may cause you to feel physically uncomfortable while lying down.  Many people also experience heartburn, a backflow of acid and food from the stomach into the esophagus after eating, which may keep you awake.

  • Medications for other conditions.  Medications—both over-the-counter (OTC) and prescription—such as those taken for asthma, the common cold, depression, heart disease, high blood pressure, nasal allergies, pain management, thyroid disease or weight loss can interfere with sleep and otherwise cause insomnia.

Comorbid insomnia

Comorbid insomnia is usually caused by underlying medical or mental-health problems (all of which can also worsen existing cases of insomnia).  These problems include:  

  • Aging.  Insomnia becomes more common as people get older.  This is largely due to changes in sleep patterns, changes in daily physical and social activity patterns, changes in health (especially pain and other sleep-interfering conditions), and increased usage of medication(s) and resulting insomnia side effects.

  • Anxiety.  For some adults, trouble sleeping because they feel worried or nervous can become a pattern that interferes with sleep on a regular basis.  Anxiety symptoms that can lead to insomnia include getting caught up in thoughts about past events, excessive worrying about future events, feeling overwhelmed by responsibilities, or a general feeling of being revved up or overstimulated.  Anxiety may be associated with onset insomnia or maintenance insomnia.  In either case, the quiet and inactivity of night itself can often be what brings on stressful thoughts or even fears that keep a person awake.  Additionally, when this happens for many nights (or many months), a person may begin to feel anxiousness, dread, or panic at the very thought of bedtime, because of the sleeplessness that bedtime has become.  That is how anxiety and insomnia can turn into a vicious cycle.

  • Depression.  Depression can make it hard to sleep.  Indeed, the risk of severe insomnia is much higher in patients with major depressive disorders.  But insomnia itself can also cause changes in mood, and studies have shown that insomnia can also trigger or worsen depression.  What’s more, shifts in hormones and physiology can lead to both depression and insomnia at the same time.  (In a related vein, post-traumatic stress disorder (PTSD) can cause insomnia.)

  • Restless legs syndrome.  This neurological condition, in which a person has an uncomfortable sensation of needing to move the legs, can lead to insomnia.  Patients with restless legs syndrome typically experience worse symptoms in the later part of the day, during periods of inactivity, and in the transition from wake to sleep, which means that falling asleep and staying asleep can be difficult.

  • Sleep apnea.  This is another sleep disorder linked to insomnia.  With sleep apnea, a person’s airway becomes partially or completely obstructed during sleep, leading to pauses in breathing and a drop in oxygen levels.  This causes a person to wake up briefly but repeatedly throughout the night—causing some people with sleep apnea to have insomnia.

  • Chemical stimulants.  Afternoon consumption of products containing stimulants like alcohol, caffeine and nicotine can keep people from falling asleep at night.  (While alcohol is notoriously associated with falling asleep, it prevents deeper stages of sleep and often causes late-night awakenings.)

  • Other medical conditions that can cause insomnia are: Alzheimer’s; arthritis; asthma; cancer; chronic pain; diabetes; gastroesophageal reflux disease (GERD); heart disease; hyperthyroidism; low back pain; nasal/sinus allergies; and Parkinson’s disease.

     

Treatment

How much sleep is enough varies from person to person, but most adults need seven to eight hours a night.

Treatment for insomnia depends, of course, on what kind of insomnia. 

Treatment can include behavioral, psychological, medical components or some combination thereof.  

Treatment begins with reviewing your health to see if any underlying medical issues or sleep disorders could be part of sleep problems.  In some cases, there are simple steps that can be taken to improve sleep (see side bar).

The next step is to talk to your doctor about your particular insomnia situation, history and possible causes to decide on the best treatment plan.  For the most custom-tailored plan, your doctor may also recommend an overnight stay at a sleep center, where the resident specialist will gather personal medical data needed for personalized insomnia treatment.

In the meantime, here are the most common treatments by insomnia type.

Chronic insomnia

Changing your sleep habits and addressing any issues that may be associated with insomnia, such as stress, medical conditions or medications, can restore restful sleep for many people.  If these measures don't work, your doctor may recommend cognitive behavioral therapy, medications or both, to help improve relaxation and sleep.

Comorbid insomnia

By treating its underlying cause, insomnia can largely be eliminated if not significantly reduced.  Treatments for comorbid insomnia include:

  • Sleep restriction.  This is a strict schedule of bedtimes, wake times and using your bed for sleeping only.

  • Counseling.  It’s important to know depression (low energy, loss of interest or motivation, feelings of sadness or hopelessness) and insomnia can be linked, and one can make the other worse.  The good news is that both are treatable regardless of which came first.  Anxiety-driven insomnia can be treated with cognitive behavioral therapy for insomnia (CBTi).

  • Relaxation training. Also known as progressive muscle relaxation, this teaches the person to systematically tense and relax muscles in different areas of the body—helping to calm the body and induce sleep.  Other relaxation techniques that help many people sleep involve breathing exercises, mindfulness, meditation techniques, and guided imagery.  Many people listen to audio recordings to guide them in learning these techniques.  They can work to help you fall asleep and also return to sleep in the middle of the night.

  • Stimulus control.  This helps to build a mental association between the bedroom and sleep by limiting the type of activities allowed in the bedroom.  An example of stimulus control is going to bed only when you are sleepy, and getting out of bed if you’ve been awake for 20 minutes or more—helping break an unhealthy association between bed and being awake.

  • Light therapy.  In light therapy, you sit near a special light box for a certain amount of time each day.  The light from this box mimics outdoor light.  Exposure to this light helps to adjust your body’s 24-hour circadian rhythm.  Light therapy has helped some people with insomnia.

  • Medication.  There are a number of drugs that help treat insomnia, a.k.a. sleep aids, including over-the-counter (OTC) and prescription medications.  These include hypnotics (both benzodiazepine and non-benzodiazepine) and melatonin receptor agonists.  Examples include Ambien, Edluar, Intermezzo, Lunesta, Rozerem, Sonata and Zolpimist.  But sleep aids can have a number of serious side effects, including daytime grogginess, and other health problems, so it’s best to use them only after consulting with your doctor.

  • Alternative medicine.  Although in many cases safety and effectiveness have not been proven, some people try such OTC supplements like melatonin or valerian, treatments like acupuncture, physical disciplines like yoga or tai chi,Yoga or tai chi, or simply meditation.

Prognosis

That sleep is a critical part of daily life goes without saying—people spend an average of one third of their lives sleeping.  Insomnia, whether chronic or comorbid, disrupts that healthy sleep. 

But the good news is that most cases of insomnia can be treated. 

By following a customized treatment plan provided to you by your doctor and/or a sleep specialist, including simple changes in your daily—and nightly—habits, you should, within a few weeks, be able to put insomnia to rest.

Hamaspik thanks [name of doctor here], [credentials here], for critically reviewing this article.

Mujibur Majumder, M.D., M.P.H., F.C.C.P., staff pulmonologist at Brookdale Hospital and the Suffern-based Rockland Sleep Center,


 

The Healthy Sleep Fitness Test

Healthy nightly sleep is a critical part of health.  But a lot of people think that sleep problems are normal, or otherwise don’t pay attention to their sleep.  Don’t be one of them.

Talk to your doctor about sleep.  At minimum, include it in your annual check-up conversation. 

Before you talk to your doctor about your sleep, do your homework: there may be things in your medical history, or current life, which are causing sleep problems that you didn’t even notice.

Here are some things to look for when you review your sleep habits:

·       What time do you go to bed? 

·       What time do you wake up?

·       Do you sleep alone, or with a spouse or roommate?

·       Is your bedroom dark and quiet?

·       Is your mattress/pillow comfortable?

·       Do you nap during the day?

·       Is your weekend sleep schedule different than your weekday schedule?

·       Does your work schedule require you to adjust your sleep at all?

·       Do you have any nighttime sleep disruptions, such as young children in the house?

 

Stabilizing any or all of these factors with consistent healthy habits can often eliminate insomnia.

If you have trouble sleeping…

·       Be specific: is it trouble falling asleep, staying asleep, or waking up too early?

·       How many times a week do you have trouble sleeping?

·       What do you do when you can’t sleep?

·       Is there anything you’ve done in the past that’s helped you sleep?

·       How long have you been having this problem?  Is it a new problem, or has it been on and off for as long as you can remember?

·       Do you lie awake feeling anxious or worrying about responsibilities and tasks?

·       Have you had any recent major changes or stressful circumstances in your life (change in marital status, a move, a new job, or financial troubles)?

·       Do you have any medical conditions?