See also: "Sleep: Difference is Day and Night"
Why We Can’t Sleep and What We Can
Do About It
Dennis B. Kottler, MD
Introduction
This is the
second part in a series looking at major health concerns that affect our society in
epidemic proportions. This current monograph
deals with the epidemic of insomnia and offers practical suggestions to combat this major
health threat. Innovative self-treatment
approaches are discussed that have proven effective in large numbers of people. The author also addresses impediments to sleep
that involve relationships with other people and personal psychological
“roadblocks.” It is hoped that many
individuals with insomnia will find this monograph of major help in finally putting their
sleep disorder to bed.
Insomnia Defined
The DSM IV
(Diagnostic and Statistical Manual of Mental Disorders – 4th ed. p. 553) states that:
“The essential feature of
primary Insomnia is a complaint of difficulty initiating or maintaining sleep or of
non-restorative sleep that lasts for at least one month and causes clinically significant
distress or impairment in social, occupational, or other important areas of functioning. The disturbance in sleep does not occur
exclusively during the course of another sleep disorder or mental disorder and is not due
to the direct physiological effects of a substance or a general medical condition.”
In primary
insomnia, the focus of this monograph, the sleep disturbance is caused by problems
involving the sleep/wake mechanism, with environment, lifestyle, and self-conditioning, as
well as genetic predisposition, frequently playing causative roles.
There are
different patterns of insomnia, although many people suffer from a mix of all of the
following:
Initial insomnia
- Difficulty falling asleep
Middle insomnia
- Difficulty staying asleep
Terminal insomnia
- Awakening earlier than
desired (not terminal in the morbid sense)
It is nearly
impossible to estimate the prevalence of insomnia in the general population, although we
do know it is an extremely common complaint and endless people approach their physicians
for relief, often requesting sleep medication (more on this later).
Although
this monograph focuses on self-help, it is suggested that those, hopefully few,
individuals who do not obtain relief from their insomnia after following the suggestions
in this monograph consider medical consultation.
The Cost of Insomnia
The damage
done by insomnia in markedly decreased quality of life, lost productivity, and
contribution to other health problems is enormous and virtually impossible to estimate. From the individual standpoint, the sufferer is
often driven to a point of desperation, willing to try any solution, again most frequently
in the form of a prescription or nonprescription drug, or “alternative” drug
remedy.
Variations in Sleep Patterns
– (What is the “Normal” Amount
of Sleep?)
The
discussion of “normal” is problematic for many physical and behavioral
conditions. For example is 5 feet 2 inches
tall a normal male height? Can it
be normal for a male to be balding at 25 years old?
Similarly, is an average of 5 or 6 hours of sleep normal.
It is
increasingly recognized that there are wide variations in “normal” sleep
requirements among individuals. Much of
this variation is no doubt genetic. Some
people are “short
sleepers”
and others are “long sleepers.” An
average duration of good, solid sleep of 7 to 9 hours is generally looked upon as a norm. However, some individuals report needing only 5 to
6 hours and at the other end of the spectrum, some individuals seem to require 10 hours. If these sleep ranges produce satisfactory results
in a given individual without complaints of daytime fatigue, irritability, diminished
concentration, depression, or excessive worry and anxiety, than they are probably
“normal” variations. Otherwise,
one must consider these as abnormal states requiring further diagnosis and treatment. Certainly, if these sleep variations are such that
they produce disruption in one’s usual occupational or social functioning, they
should become areas for further investigation and possible treatment.
Aside from
duration of sleep, there is also variation in how soundly individuals sleep. Again there are probably genetic factors at work. Some people describe themselves as having been
light sleepers their whole lives. One female
patient complained that almost anything can wake her up,
“If the proverbial pin drops…I wake up.” What aggravated her, she said, was that her
husband slept “like a log.” “Nothing
wakes him up.” She describes that her
husband slept through a 6.3 magnitude earthquake resulting in significant structural
damage to their home. Even things in the
bedroom had fallen to the floor, including one ceramic statue that was shattered when it
fell. Finally, the only thing that awakened
her husband was her screaming. She went on to
say that when it was all over she asked her husband how he could possibly have slept
through all this. He said he had no
explanation, except he did report that the night of the earthquake, he had a dream about
his parents fighting when he was a little boy and in the dream he had images of his mother
throwing plates at his father. Apparently he
had incorporated the sound of the crashing objects in the room into the dream. This man is one lucky sleeper, although
perhaps also the kind of person who could perish in his sleep. Everything has its upsides and downsides.
The light
sleeper may go through life reasonably well, and even survive situations because of the
ability to awaken, in time. However,
the downside is the tendency of light sleepers to be more prone to becoming insomniacs. Conversely, the deep sleeper probably has some
genetic advantage affording a relative protection against this disorder. Nonetheless, as people age, insomnia becomes more
common, and the deep sleeper of age 30 can evolve into the insomniac at age 50 or 60.
Theories for this change involve biological processes, wherein it is
thought that the sleep mechanism of the brainstem becomes less reliable with age, as well
as mental change with increased susceptibility to be distracted by worry. Furthermore, as one ages, there is often
just that much more to worry about. The
snowball keeps growing larger and larger.
Although the
focus of this monograph is on insomnia, it should be mentioned that it is possible to
sleep excessively and this condition, hypersomnia, can also lead to significant
disruptions in one’s life. Another
condition, narcolepsy, results in paroxysmal episodes of sleep during the day and has
other accompanying symptoms as well. These
conditions are best left to a professional to diagnose and treat.
One Last Tangent
As you may
remember from the excerpt quoted above (from the Diagnostic and Statistical Manual of
Mental Disorders – 4th ed. p.
553) regarding primary insomnia:
“The disturbance in sleep does
not occur exclusively during the course of another sleep disorder or mental disorder and
is not due to the direct physiological effects of a substance or a general medical
condition.”
This cannot
be over-emphasized. It is extremely important
to ascertain that the sleep problem is in fact not a result of some other mental or
physical condition, including drug use, in which case there may be a specific treatment
approach that may resolve the problem. Appropriate
professional consultation is the only way to be sure of this.
A few
examples of physical disorders presenting as sleep disturbances are hyperthyroidism, back
problems, and anything causing physical pain. Examples
of psychiatric disorders which may result in
sleep disturbances are mood disorders, generalized anxiety disorder, panic attack
disorder, psychotic disorders, and somatic preoccupation disorders. Substance use problems include excessive caffeine
use (varies by individual) especially later in the day, alcohol, and the various
“recreational” drugs. Also, a large
number of prescribed medications have sleep disorder side effects. This category includes some antidepressants
(can also help with sleep in some cases), stimulating antihistamines, and potentially a
great number of other medications. See a
more complete listing of other causes of sleep disturbance under the heading, “Psychiatric/ Physical Impediments
to Sleep.”
Finally,
there are still other specific sleep disorders which result in lack of restful and
sustained sleep that have specific causes and are therefore viewed as distinct from
primary insomnia. These disorders
include breathing-related sleep disorder (various apneas), circadian rhythm sleep disorder
(shift work and time zone changes), and parasomnias (example: sleep walking).
Again, a professional is required to rule out and treat these specific
conditions.
It is also
important to remember that true primary insomnia by definition lasts for at least one
month and frequently becomes recurring or chronic. Transient
insomnia often occurs in response to a particular disturbing event or focus of attention
but it is not sustained and sleep soon returns to normal.
Common Characteristics of Insomnia (We’re Getting Close to the
Payoff)
Many of the
characteristics of primary insomnia also suggest possible treatment approaches. For example, insomnia is often initially
triggered by some troubling event or physical injury and then becomes an established
pattern lasting long after the initial stimulus is resolved. The person begins to anticipate that each
night will be a repeat of the last. However,
in many cases there is no obvious precipitant to the insomnia.
Whether
there is a precipitant or not, the individual becomes “conditioned” to the
difficulty sleeping. The bed may come to
represent a negative place, associated with tossing and turning and frustration. Nighttime, itself, becomes dreaded for the
same reasons. The individual may even
avoid going up to bed at all, preferring to stay up and watch television to avoid the
whole problem; of course that is the problem.
In the
opposite situation, the person attempts to confront the sleep problem head on, full force
ahead. He gets into bed and tries and
tries to sleep. He tries really hard. He is constantly checking the time on the clock. The race is on to fall asleep while there is still
enough time left in the night to get enough sleep. But
as in most such feats of great effort, the anxiety level rises and the adrenaline gets
pumping. This is fine in a real
race or perhaps in some other performance-oriented task.
However sleep requires just the opposite conditions. Sleep must be a surrender to passivity. The individual must allow it to happen…it
cannot be willed or achieved by brute force. It
is the result of a relaxed state, free of physical and mental stimulation.
Ok, So You Have Insomnia, Now What?
Certain
specific principles, if followed carefully, will in most cases of primary insomnia result
in the re-establishment of a satisfactory sleep pattern.
I will list and discuss each of these principles:
1.
Set
a consistent time to go to bed and to wake up:
Treat
yourself as well as you treat your children or as you were treated as a child. “Too much freedom can be a very
disrupting thing.” The brain’s
internal clock (circadian rhythm device in the brainstem) runs best without interference. It awakens the body, normally with the early
morning light, and induces sleep as the sun goes down.
However,
technology has modified this normal sleep/wake schedule dramatically with the advent of
artificial light. The electric light bulb allows us to be active far beyond the bedtimes
that were observed for the million years previously.
This latter fact probably has more to do with insomnia than anything else. We feel that, since we have light available, we
might as well work a little later, party a little later, or just plain stare at the light
bulb itself (TV?). Soon we are pushing our
bedtime later and later and creating circadian rhythm shifts…and insomnia. So set a consistent bedtime and try
to stick to it! An try to make this bedtime and
“arise” time reasonably correspond to the natural daylight. (Ok, I’ll let you stay up a few hours after
dark).
(This is
skippable but you may be interested to know: Theory
has it that bright light, as in the morning, triggers a neural pathway starting in the
retinas of the eyes and ending in the pineal gland. The
final effect of the bright light exposure is to suppress the production of
melatonin,
thought to be produced by the pineal gland. For
many years we had no idea what this small pea-shaped structure did. It seems the melatonin is a sleep inducing
substance and its suppression allows the body to wake up.
This starts the “awake part” of the circadian cycle. Before the light bulb, the dimming of light
into nightfall would gradually lead to the unsuppression of melatonin from the pineal and
sleep would ensue. Whether melatonin taken in
pill form has the same effect is debatable, since it has to go through the digestive
system and then cross the blood-brain barrier.
Anyway, many have tried it with mixed results).
2.
Develop
a consistent sleep “routine.”
Treat
yourself again as well as a child is treated. It
is no coincidence that in a great many societies there is some form of ritual to help
children fall asleep. In our society it often
involves reading a bedtime story with a parent (or at least we used to do this) or
watching that last television show, brushing the teeth, kissing the dog goodnight (maybe
the other way around), getting into bed, a good night kiss from mommy, tucking the covers
around the feet, and falling asleep. I
bet you’re tired just reading this last sentence.
Anyway you get the idea. Find
some reasonably adult-feeling routine to do consistently each night. It might incorporate such useful rituals as
locking the doors and windows, laying out the clothes for tomorrow, grinding the coffee
for the morning, brushing the teeth, getting into bed, a good night kiss from somebody
(?), tucking the covers around the feet, and falling asleep. Believe me these things help.
(This is
skippable but you may be interested to know: Tucking
the covers around the feet may have a specific sleep-inducing value beyond the ritual
value. There have been studies showing that
warming the feet actually is associated with inducing sleep and some have recommended
heavy socks, for example, to achieve this. Perhaps
warming the feet dilates vessels in the skin and redirects blood flow to the extremities,
a technique often used in “relaxation exercises” (an oxymoron).
3. Under no circumstances become a “Clock
Watcher.”
This is bad,
bad. If you do awaken during the night,
and it happens, sometimes several times a night even in people without sleep problems, do not
look at the clock. Clock watching only
increases the anxiety level and feeds the dread that, “I’m not asleep, it’s
already 4 am, and in three more hours I’ll have to meet with my boss and I’ll
sound like a total moron. And now I’m so
worried about this that I can’t sleep.” Please
place that unpleasant intrusion of modern civilization someplace where it won’t be
noticed until the alarm finally goes off.
4. Limit time in bed to time actually spent
sleeping.
This idea
may sound counterintuitive at first, but it has a lot of value. Many people try to make up for their chronic
lack of sleep by going to bed earlier and earlier, or sleeping later in the morning. Generally this is a bad approach. One ends up with a longer period in bed
experiencing fragmented sleep, marked by short periods of sleep interspersed with fits of
wakefulness. Also sleeping later in the
morning on a regular basis seems to frequently invite other problems. The person often wakes up tired, even though he
apparently “slept” until 10 or 11 am.
This makes
it hard to “get going” most of the day, for many people, until the nighttime
when they wake up again. In effect, one is
shifting the sleep cycle, often later and later. And
it does seem to matter when one sleeps. The
sleep cycle functions best when it can be coordinated with the natural cycle of daylight
and nightfall. As explained above in item #1,
light triggers the circadian clock and keeps the sleep/wake cycle functioning properly. Of course if one does night work, this
coordination of sleep with daylight is problematic and one has to attempt to create
“artificial” night and then wake up to bright artificial sunrise, to get the
brain working properly.
The
recommended approach for the insomniac is to restrict time in bed for several weeks, to
the time actually spent in sleep. This may
require the person stay up later and maybe get up earlier.
This will result in defragmenting the sleep pattern and consolidating the
actual time spent sleeping. (A useful image
for computer buffs: Imagine defragmenting the
hard drive by consolidating all those little file fragments into one continuous storage
space, the machine runs a lot better). Going
to sleep later may cause some initial additional sleep deprivation, but the individual
will begin to experience a much better quality of sleep and less interrupted sleep. Of course if one cannot get to sleep until 3 am
and awakens at 10 am, the sleep restriction might have to come off the morning end of
things.
5. As much as possible
confine bedtime activities to sleeping
This advice
in general helps in combination with everything else discussed. Reserve the bed for sleep and sex, assuming this
latter activity is somewhat sleep-inducing. This
is not a firm “rule” and if it helps to fall asleep by reading in bed,
especially a heavy, hardback book (don’t drop it on your face) or one that is
somewhat boring, by all means continue to do so. Other
activities like eating, chewing gum, playing the guitar, and fighting with your spouse,
are best done somewhere else and not when trying to sleep.
6. Develop a system to track and deal with
worries during the day.
Many people
find it helpful to go over the problems of the day, each day, well in advance of bedtime,
and perhaps create a list of problems and courses of action. The course of action need not be a solution, some
problems are not readily soluble. It could
just be a step that will be taken the next day or a decision to table the matter until
another time. At any rate, each issue should
have some “disposition” made, and then forget about it until the morning. When the “notebook” closes on this
problem list, it is out of mind. Leave the
problems in the notebook.
7. Get exposure to early morning, bright light.
This is a
helpful suggestion for everyone. The bright
morning light is helpful in sustaining and, if necessary, restarting the normal sleep/wake
cycle. Have the morning coffee (if you must)
or cereal on the patio. Or begin the day with
a nice walk in the morning light, a short walk is adequate.
If morning light is not available (shift workers) try to create the same
effect with bright light in the house…commercial light boxes are actually sold for
this purpose.
8. Avoid bright light prior to bedtime.
A corollary
to the item above is the avoidance of bright light in the evening. Some people are particularly sensitive to the
sleep disturbing effects of such light. Remember,
light turns off the melatonin release from the pineal and this triggers the awake state.
9. Devise a plan with your physician to
eliminate hypnotic drug use.
If at all
possible, and it almost always is, work out a plan with your physician to taper off
hypnotic drugs, prescription and non-prescription alike.
These medications are like laxatives. After
awhile you can’t go without them. The
downside is that eventually they lose their effectiveness, especially the prescription
drugs, and you are seduced into ever higher dosages.
The non-prescription sleep aids generally incorporate diphenhydramine
(Benedryl) which is all right to use at times, but generally is very drying and can leave
one with a fuzzy feeling in the morning. Some
of these sleep aids combine diphenhydramine and acetaminophen (Tylenol) which exposes the
person to gratuitous acetaminophen, a potential liver toxin if taken in significant
quantities over a period of time.
10. Avoid daytime napping
This is
intuitive. Sleep during the day, pay at
night. Or don’t complain about not
sleeping, since if you add up all the naps, you didn’t do so badly after all. Yet most nappers aggravate about being
“unable to sleep.” They are sleep
experts, just at the wrong time.
11. Include any bed partners in the treatment
plan.
Again, this
should be obvious. If it is not, read the
examples below, in the next section, about how a bed partner can sabotage your sleep. Even if sabotage is not the problem, the emotional
support and encouragement of a friend, spouse, or whatever, is always helpful.
12. If still not sleeping well, consider the
suggestions below in, “When Nothing Else Works.”
External
Environment: Aids/Impediments to Sleep
Some of
these environmental aids and impediments are obvious and some are more subtle. In solving the sleep problem rigid rules
often do not work; the trick is identifying what works for a given individual and staying
with it. Thus a radio in the background may
do wonders for some people and be a total distraction for others. Generally anything too stimulating, for example an
interesting talk show, is counterproductive to sleep since it tends to engage the mind too
much. On the other hand, soft music
(preferably nice and monotonous without commercial interruption) or white sound, such as
soft static between radio stations or that produced by any of various “sleep
machines” is helpful. Such nonverbal,
soothing, background noise interferes with the ability to have an internal dialog in the
mind, but yet is low-keyed enough not to pose a disruption to sleep.
Regarding
light, the conventional wisdom is lights off. However
some individuals may be conditioned positively, perhaps from childhood, to sleep with a
night light on. If it works, do it. Of course, all these matters have to be
negotiated with a sleep partner if there is one.
Hard beds,
soft beds, one pillow or seven, prone or supine position, whatever works, works. Some people seem to fall asleep if they put a
pillow between their knees. Others find that
warming their feet with heavy socks helps. As
discussed above, there have been several articles recently regarding feet warming and
sleep, suggesting that this soporific effect may have some physiological basis!
What about
other people? Many individuals do not sleep
alone. This can be both an aid and a
hindrance. Some find comfort in the close
physical contact of the sleep partner. This may be a person, but it may equally well be a
dog, real or stuffed. I knew of one man who
slept with a blow up doll, and it was a perfectly platonic relationship, he assured me. Yet it helped him sleep. It only created a problem when his morbidly
obese wife rolled over onto the doll and destroyed it beyond repair. The man was furious and accused his wife of
doing this on purpose, out of jealousy. This is not a joke. Whatever works, works.
There is an
interesting phenomenon of induced sleep disorder. One
person complained that she always slept well until several years into her marriage. It turns out that this individual’s spouse
seemed to need very little sleep, sometimes only 5 or 6 hours a night. The person who previously had no sleep problem,
starting staying up late to keep her spouse company and because she did not wish to go to
sleep alone. After a period of time she
started feeling exhausted during the day, but she persisted in depriving herself of sleep. This continued for many months and the woman had
in fact developed a form of insomnia by example. However,
one might argue it was not true insomnia, since once this person recognized the pattern of
sleep deprivation and decided to do something about it she had little trouble returning to
her usual sleep habits. Curiously, she
did get a divorce a few years later, nothing to do with the sleep issue, she insists (?).
Internal
Environment: Aids/Impediments to Sleep
Some people
fall asleep quite well if they direct their thoughts, while in bed, to certain subjects. Some find this works much better than thinking
about the tranquil beach scene. One patient
told me she hates the beach and thinking about the beach aggravated her. But being compliant, she attempted to
use this image, not wanting to hurt the feelings of the therapist who had suggested it. She also thought that, “look I’m paying
this person $$$ to help me, she must know what she is doing.” A better therapeutic approach would have been for
the therapist to have the patient come up with images that are pleasing and then encourage
her to use these. There is no canned
approach here. What works, works.
Another
individual, who has an interest in mechanical things, found that trying to design an
alternative to the internal combustion engine while in bed inevitably resulted in sleep. Quite conveniently the engine problem never
got resolved so it was always available to ponder the next time. In fact, he had so conditioned himself around this
particular thought content that just starting to think about it would result in sleep,
sometimes in a few minutes. Extending this
concept, ask yourself what are interested things to think about that would not be too
frustrating or disturbing. There
is no formula, since one person’s pleasant thoughts are another person’s
“nightmare.” Generally, thought
content that helps is directed along the personal interests of the individual. Mathematicians may find it helpful to
ponder math problems; others would try this and get up screaming, or perhaps just be bored
enough that they fall asleep. Try out various
different sleep-thoughts. And if you have
come upon something that produces results use it.
If the mind starts aggravating itself over some worry, trivial or not so trivial,
and sleep is impossible, change the internal channel, use the sleep-thought. Whatever works, works.
Psychological
Impediments to Sleep
Some of the
more insidious, but nonetheless powerful impediments to sleep, involve internal,
psychological conflicts. It is sometimes
possible to discover these oneself by self-reflection.
Perhaps some insomniac readers will relate to one or more of the situations
described in this section.
Strange as
it may seem, but the human mind is strange after all, some of the people who so
desperately wish to sleep are actually resisting sleep, usually on an unconscious level. One example of this concerns the individual who
has a morbid fear of sleep. Such a person may
associate sleep with death: “If I fall asleep, I may never wake up again.” Again this fear may not be fully conscious. This particular fear might occur, for example, in
someone who fears a heart attack in his sleep; perhaps this happened to a friend or
parent. Perhaps there are other less obvious
reasons for this fear to develop related to childhood.
In another
case, of a fully conscious sleep avoidance, the problem might be one of not wanting to go
to bed. In this case, a person may dread the
sexual advances of a spouse (or other partner) and will stay outside the bedroom, watching
television, perhaps, until the other person is soundly asleep. If the sleep partner happens to be an insomniac,
the wait could be quite lengthy and set up the sexual avoider for a case of conditioned
sleep disturbance.
In a
different scenario, the problem might not involve avoiding sleep so much, as not wanting
to give up the night (different emphasis but the same effect). Some people pride themselves on being
“creatures of the night.” They may
boast about how little sleep they (think) they need.
This may verge on “macho” pride. A
variant of this is the individual who savors the late night hours. This person feels most comfortable when
everyone else is asleep and he can have “peace.”
There are no ringing telephones, salesmen at the door, or demanding children
(or spouses). In fact, it feels to this night
bird that he is the only one awake on the entire earth.
Sometimes the night might be a haven for the asocial, other times it is a
very welcome relief from the distractions of the day.
It is a time to relax without intrusion or to get some work done. The inevitable consequences of this lifestyle are
daytime fatigue (many times denied) and often increasing “sleep debt” with
symptoms of irritability, depression, low energy, and sometimes even aggressive behavior. Such people often become aware of their increasing
sleep problem and periodically resolve to “get to bed earlier” but they keep
slipping back into the old pattern.
Another form
of psychological impediment to sleep involves certain personality traits, which may
actually interfere with going to sleep. Such
an individual might be strongly anti-authoritarian and defy rules even though to do so is
clearly self-destructive. This individual
might insist on not wearing a seat belt, because “no one is going to tell me what I
have to do in my own car.” Similarly,
the whole concept of a “bedtime” might be reprehensible to this person. This individual avoids rules, and a
consistent “bedtime,” because any such routine feels like “someone is
telling me what I have to do.” Again
this problem may not be fully conscious. A
clue to its existence did occur in one case I remember when a concerned wife kindly
suggested to her “up all night” husband that it would be a good idea to get to
bed (it was 3:00am). The loud retort came
back from the computer room where he was cyber-surfing:
“No one tells me what to do, not you, my mother, or anyone else,
understand.” The humbled wife
back-pedaled, “Ok. Ok. I
was only trying to help.”
Another
personality impediment to sleep involves the obsessive-compulsive person and sometimes
also, the “type A” person. In
either case, and these disorders can coexist, the individual does not want to give up what
he is doing and go to sleep. He is
continually busy, always having to do “one more thing,” sometimes stretching out
to 3 or 4 am. There is sometimes a compulsive
rigidity that seems to drive this individual. There
are sometimes also fears that “if I don’t get this done now I will forget what I
have to do.” Curiously the activity
might just as well involve something trivial as something important. The pattern is not rational, and certainly the
sleep deprivation the next day cancels out any productivity gains made the night before,
but we already agreed the mind often works in mysterious ways.
These are
but a few examples of psychological impediments to sleep and I am sure there are numerous
more. Some serious self-reflection might be
in order and than an all out attempt to defeat the “demon” within (excuse the
dramatics).
Psychiatric/
Physical Impediments to Sleep
There are of
course many psychiatric and physical conditions which have as one of their symptoms sleep
disturbance. This subject was touched on
above in “One Last Tangent.” In
these cases the primary psychiatric/physical condition should be treated first and
hopefully the sleep disturbance will resolve. Of
course, professional medical attention will be required.
It is also of course possible to have a primary insomnia coexist with
a diagnosed psychiatric or medical condition. These
conditions include the following (there are many others):
Psychiatric
Conditions Interfering with Sleep:
Major
Depression
Bipolar
Disorder
Generalized
Anxiety Disorder
Panic
Disorder
Posttraumatic
Stress Disorder
Schizophrenia
Obsessive-Compulsive
Disorder
Toxic
Metabolic States
Dementia
Physical
Conditions Interfering with Sleep:
Hyperthyroidism
Back Pain
(Sometimes worse at night)
Various
Breathing Disorders (e.g. Obstructive Apnea)
Sinus Pain
(Often worse at night in the supine position)
Headaches of
various types – tension, cluster, migraine
Moderate to
Severe Pain of any kind
Tumors of
the Brainstem (very rare)
Pheochromocytoma (a very rare tumor of the adrenal gland)
“Substances”
Interfering with Sleep:
Excessive
Caffeine Intake (especially towards evening)
Chocolate
(contains stimulants, especially if “natural”
chocolate)
Cocoa
(contains stimulants)
Various
Natural Remedies (e.g. St. John’s Wart)
Ephedrine
Hallucinogens
Stimulants
such as Cocaine
Pharmaceuticals–
both prescribed and over the counter:
Ritalin
(especially if taken late in day or evening)
Dextroamphetamine
(especially if taken late in day or evening)
Antidepressants
(e.g. Prozac, Zoloft – also often sedating)
Antihistamines
(especially if have caffeine or pseudoephedrine)
Opiates/Opioid
drugs (Vicodin, Loricet ) – sleep inducing but disrupt normal patterns
This list is
very incomplete, and any of a number of medications/substances could be a factor in
insomnia. Furthermore, a medication that may
generally be sedating or neutral may cause insomnia in a particular individual.
Finally,
withdrawal effects from any of a number of medications/substances can initiate insomnia. This is true of sedative medications, some
antidepressants in my experience, barbiturates, and certainly alcohol.
In general,
if one experiences insomnia (or excessive sleep for that matter) and is taking a substance
or medication, prescribed or over the counter, it is a good idea to try to eliminate this
first as a cause of the sleep disturbance. Consultation
with a pharmacist or physician may be necessary. Do
not stop the drug without prior professional consultation.
When Nothing Else Works
There no
doubt some diehard non-sleepers for whom applying all the ideas in this monograph do not
produce restful sleep. Sometimes consciously
or unconsciously (for various idiosyncratic reasons, some of which are described above)
these people are unwilling to follow the principles outlined. They may even have plunked down the money for the
monograph, or attended a self-help workshop, or even attended individual counseling. For these individuals I offer the following
potpourri of ideas.
Hypnosis – Sometimes learning hypnosis,
which actually teaches you to hypnotize yourself, can be the solution to the insomnia. Often this works by teaching a person how to relax
and how to block out everything else.
Biofeedback -
This technique utilizes various electronic devices to detect physiological
responses to stress/anxiety and to give audible/visual feedback which the person can use
to learn relaxation. Often the biofeedback therapist gives various
exercises, physical as well as mental, to aid in relaxation and sleep induction.
Drugs – Not my first choice, but
medications often work when all else fails and can be useful as a temporary means to break
the abnormal sleep pattern. The shorter
acting medications, such as Restoril (intermediate), Ambien (intermediate to short),
Halcion (short acting), and Sonata (very short acting) are generally preferable to the
older, longer acting medications, such as Dalmane, which often resulted in daytime
sedation. If the problem is initial insomnia
(getting to sleep) the very short acting medications are often best. However if one awakens during the night, an
intermediate acting drug might be preferable. These
are only temporary adjuncts to the behavioral approaches suggested above.
Warm Milk,
Warm Feet (see above), and Reassurance.
Conclusion
I have
attempted to provide an overview of the insomnia problem, as it is experienced in its many
forms, by vast numbers of people in our society. In
addition, I have offered what I believe to be practical suggestions that can be applied to
the individual who wishes to finally put this problem to rest, so to speak. It is my hope that the reader of this monograph
will look back in 3 or 4 weeks or so and feel that the time and expense involved was well
worth it and that I may have contributed in some small measure to an improved quality of
life. Future monographs will be
forthcoming and will address a range of common health problems.
Dennis B.
Kottler, MD
Please e-mail the author with your
feedback at: doc@psychiatrix.com