Insomnia

If you frequently find yourself staring at the bedroom ceiling at 3 A.M., you’re not alone. Millions of Americans have trouble falling asleep or staying asleep.

Everyone suffers an occasional restless night. Too much caffeine or an upset stomach may steal a few hours. But frequent insomnia often has less obvious causes, and effective therapy can be elusive. Some commonly used remedies, such as alcohol and over-the-counter (OTC) drugs, may even complicate the problem.

Common though it is, not everyone who complains of insomnia actually suffers from it. Studies in sleep-research laboratories reveal that many people sleep more than they think they do. Researchers estimate that at least one-third of all people who consider themselves insomniacs get as much sleep as people who consider themselves normal sleepers.

Some people believe they’re missing out if they sleep less than seven or eight hours. But the need for sleep varies widely from person to person, commonly ranging from as little as four hours to as much as 10. Even missing most of a night’s sleep once in a while is unlikely to have any serious effect—except for the worry about getting through the next day.

Many older people find that they just can’t sleep as they used to. Sometimes, that’s because daytime naps interfere with a full night’s sleep. Other causes include the need for frequent urination due to an enlarged prostate gland, or shortness of breath and cough arising from heart or lung disease. What’s more, the quality of sleep itself changes with age. Older people tend to spend more time in light sleep. Their sleep is often more fitful and punctuated by frequent awakenings. These normal changes in sleep patterns and physical problems that occur with aging are responsible for much of what’s perceived as insomnia.

Three Forms of Insomnia

For the millions who are plagued by insomnia, an understanding of the different forms can be the first step toward a good night’s sleep. What helps in some types of insomnia can be useless or even counterproductive in others.

Sleep-research specialists commonly sort insomnia into one of three types: transient, short-term, or chronic. Transient describes occasional episodes of insomnia among normal sleepers, who may endure a few restless nights because of jet lag, a fight with the boss, a new romance, or any one of countless anxiety-provoking or exciting prospects.

Short-term insomnia, which may last up to a few weeks, generally arises from temporary, stressful situations. It’s usually associated with the death of a loved one, job loss, fear of having a serious illness, and similar experiences.

Chronic insomnia, on the other hand, may go on for months or years, many times with no obvious explanation. In some people, it may be a result of organic illness or a symptom of an underlying psychiatric problem, such as depression. In others, it may occur in association with chronic use of sleep medication, excessive alcohol intake, or “biological clock” disturbances from shift work or jet lag. Disorders characterized by involuntary jerking or “restless” leg movements can lead to chronic insomnia. Recently, disorders of the upper airway (nasal passage, back of the mouth, and upper windpipe) have also received much attention as possible causes.

Worry about insomnia can create a self-fulfilling prophecy. After a few nights of sleeplessness, some people panic—and, as a result, are even less likely to sleep well the next night. The distress that they feel when they can’t sleep may then become associated with the bedroom itself. When they go to bed, they become aroused rather than sleepy.

Various drugs can also promote—and sustain—insomnia. Stimulants like caffeine and appetite suppressants are well-known offenders. Betablockers (atenolol, nadolol, propranolol, and others) used for hypertension can cause disturbing dreams and subsequent wakefulness. Even some drugs prescribed for insomnia can interfere with normal sleep patterns and perpetuate the condition.

With all these possibilities to consider, intensive investigation is sometimes necessary to identify and solve the underlying cause of chronic insomnia. This may require a visit to your physician or even to a sleep clinic—a center that specializes in the diagnosis and treatment of sleep disorders. Before you call in the medical cavalry, though, there are some steps you can try yourself.

Sleep Hygiene

Any number of common practices can interfere with a good night’s sleep. Accordingly, sleep-disorder specialists advise the following “sleep hygiene” measures to counter sleep-robbing habits:

  • Establish a fixed sleep schedule. Go to bed and get up at set times, and don’t try to make up for lost sleep on weekends or holidays. Eat at the same time each day.
  • Don’t nap, day or evening.
  • Never stay in bed when you can’t sleep. Instead of tossing and turning, force yourself to get up and go to another room. Do something you find relaxing—read, listen to music, watch television—until you’re sleepy.
  • Exercise regularly, preferably in the morning or well before dinner.
  • Avoid caffeine-containing tea, coffee, and soft drinks for at least four hours before bedtime. Also avoid OTC diet pills, since these products may contain phenylpropanolamine (PPA), a stimulant that also doubles as a decongestant.
  • Try to plan evening activities that are conducive to relaxation, including light exercise such as a leisurely walk. Sexual activity can also be an effective soporific for some people.
  • Minimize external distractions that may disturb you at bedtime. For example, use dark window shades or eye coverings to block out annoying light, or soundproof your room to reduce noise.

Drawbacks of Self-Medication

Some people find an occasional nightcap or nonprescription sleep aid helpful for inducing drowsiness. But when used repeatedly, say sleep-disorder specialists, such self-prescribed remedies are either ineffectual or counterproductive.

Alcohol is the most commonly used nonprescription drug for insomnia. While it may help at first, it can disrupt your sleep patterns over time. Within a few weeks, moreover, the user usually begins to develop a tolerance to alcohol, and increasingly larger amounts may be needed to produce the same effect. This can lead to a vicious cycle in which an insomniac drinks more and more alcohol, in turn disrupting sleep further.

The active ingredients in OTC sleep aids are antihistamines, which were originally developed to treat allergies—still their primary function. One side effect of antihistamines is drowsiness—often a bane to allergy sufferers. Ever resourceful, drug companies have salvaged this unwanted side effect as a remedy for insomnia.

Antihistamines with the greatest sedative effect are diphenhydramine (found in Nytol, Sleep-Eze 3, Sominex 2, and others) and doxylamine (Unisom). Pyrilamine (Quiet World and others) generally produces less drowsiness and more stomach upset. However, individual response to antihistamines varies greatly; in fact, some people—usually children but occasionally elderly people—become aroused rather than drowsy.

Diphenhydramine is also an effective cough suppressant. Such a triple-threat (to allergy, cough, and insomnia) drug conceivably might serve one possible use: If you can’t sleep because of allergy woes and a hacking cough, a product such as Nytol might do the trick. So, too, might any remedy containing diphenhydramine.

On the other hand, if you suffer from insomnia, we do not recommend OTC sleep aids. If you really need a medication—and you may not—you should take the most effective one.

Prescription Drugs

If insomnia persists despite sleep-hygiene measures, it’s time for professional help, especially if the problem is disrupting your life. An internist or other primary-care physician is a good first choice.

If the visit is brief, and you find yourself with a quick prescription for sleep medication, you may not be getting the help you need. A responsible physician, especially when helping a new patient, will spend time taking a thorough medical and sleep history, including questions about your physical health, “restless legs” syndrome, sleepiness during the daytime, medications you take, and other possible clues. Depending on the problem, your doctor may conduct a full-scale medical exam, prescribe a short course of medication, or refer you to a sleep clinic.

The most accepted use of prescription sleeping pills is for episodes of transient or short-term insomnia—during a hospitalization, for example, or after a death in the family. Where barbiturates—phenobarbital, secobarbital (Seconal), and others—were once commonly prescribed, benzodiazepines are now the drugs of choice due to their relative safety and efficacy. Benzodiazepines are the family of tranquilizers and sleep-inducing agents that includes chlordiazepoxide (Librium), diazepam (Valium), flurazepam (Dalmane), temazepam (Restoril), and triazolam (Halcion). The choice usually depends on the properties of the drug and the patient’s needs, such as whether a long-acting or short-acting agent is preferable. All but Halcion are available generically.

Like alcohol, these drugs interfere with normal sleep patterns by suppressing the dreaming stage of sleep. Discontinuing long-term use can result in a “rebound” of dreaming, including an increase in nightmares typical of alcohol withdrawal. Also as with alcohol, tolerance to the drugs develops over time, with increasing doses required to achieve the same effect. Accordingly, most sleep specialists recommend that the drugs be used in insomnia only for limited periods, such as a few weeks. Some doctors advise their patients to take the medication every other night. The common guideline is “the smallest effective dose for the shortest time necessary.”

In short, drugs are not ideal for treating chronic insomnia. Although they are still used in some instances, the trend in sleep-disorder therapy has been to develop other strategies for relieving long-term problems.

Other Paths to Sleep

Sometimes, more hours spent in bed can mean less time sleeping. Hoping to make up for lost sleep, an insomniac may go to bed at 10 P.M. and stay there doggedly until 8 A.M. But much of the time may be spent in brief dozing and repeated awakenings. The result is a scant four or five hours of sleep for 10 hours of concerted effort.

To break that cycle, psychologist Arthur Spielman, director of the Sleep Disorders Center at the City College of New York, devised a technique called “sleep restriction.” A person who ekes out only five hours of sleep is allowed only five hours in bed; a four-hour sleeper, just four hours. In this approach, the patient typically goes to bed several hours later than usual but arises the same time each morning, sleepy or not. Daytime naps are prohibited, even if the person has to move about repeatedly to stay awake. If the quality of sleep improves—fewer awakenings, for example—the time in bed is gradually extended until the patient achieves the amount of sleep desired. Early studies indicate that the method can be effective.

When a person’s problem involves an inability to fall asleep until early morning hours, an approach called “chronotherapy” may be used. It gradually adjusts the hours of bedtime and arising until the desired sleep time is achieved.

As a sleep strategy, nutritional tactics may seem least worrisome, though not necessarily most effective. For years, studies have suggested that L-tryptophan, a naturally occurring amino acid in food, may help to promote sleep. Foods high in carbohydrates, such as cereal or crackers, increase the level of L-tryptophan in the blood. Protein-rich foods tend to decrease it. L-tryptophan is also marketed in pill form, at up to $15 a bottle in some health-food stores. Many sleep specialists keep an open mind about L-tryptophan, but few suspect it will ever play more than an ancillary role in relieving insomnia. There’s no harm in trying some cookies, a bowl of cereal, or a glass of warm milk. When L-tryptophan is taken in supplement form, though, large doses initially tend to produce nausea. Doses low enough to be tolerated seem to work best in people with only mild insomnia, who would be just as likely to benefit from good sleep hygiene.

Often, the professional treatment of insomnia requires nothing more than various aspects of sleep hygiene. Sedentary insomniacs may be urged to take up daily regimens of vigorous exercise. Frequent nappers may be instructed to eat a light breakfast and lunch to reduce daytime drowsiness. A significant number of patients, however, need more than hygienic measures. Insomnia arising from psychiatric disorders may require extended investigation and treatment of the underlying problem. And some patients need special evaluation at a sleep clinic—especially those with symptoms of sleep apnea.

Sleep Apnea—Deadly Snoring

Sleep apnea is a potentially life-threatening syndrome accompanied by loud snores, violent snorts, and desperate gaspings for breath. Most commonly, it involves an obstruction of the upper airway during sleep; in other cases, the respiratory muscles temporarily stop working. Victims of the ailment may stop breathing anywhere from dozens to hundreds of times a night. Despite the disruptive episodes, sleep-apnea victims are usually unaware of their plight. Pronounced daytime drowsiness is usually the only telltale clue—although chronic insomnia is another possible symptom in some cases.

Severe sleep apnea can cause death from cardiac arrhythmias that may occur during an episode. Alcohol and sleep medications can prolong the apnea and may increase the risk of death as a result. The condition occurs most commonly in obese people, especially men. The frequency among women increases with age.

People who experience excessive daytime sleepiness without apparent cause should suspect sleep apnea, particularly if they are heavy snorers. (An estimated 2.5 million of the roughly 30 million American snorers experience sleep apnea.) Bedmates may be aware of the episodes that the victim sleeps through. If so, an immediate visit to a physician is in order. Patients with symptoms of sleep apnea will often be referred to a sleep-disorders center, where the diagnosis can be confirmed and the exact cause pinpointed.

Treatments for sleep apnea include medication, weight loss, and surgery. Many patients also obtain relief from a mechanical device, worn like a face mask, that forces air through the nose and prevents obstruction of the airway during sleep.

When to Visit a Sleep Clinic

If good sleep hygiene and your physician’s best efforts fail to relieve your insomnia, then it’s time to consider a sleep clinic. During your initial evaluation, specialists in neurology, psychiatry, and pulmonary medicine may interview you, take your medical and psychiatric history, and review your symptoms and complaints. The findings will suggest whether you need any of several overnight tests. During sleep, the tests record various physical responses such as brain waves, breathing, and eye and muscle movements. The results help to identify the source of your insomnia and offer clues for appropriate therapy.

Sleep clinics are run by many large medical centers. An initial consultation and evaluation can cost anywhere from $50 to $300. Laboratory testing, such as an overnight sleep study, adds considerably more (some tests can cost nearly $1000). Most are covered by medical insurance, but insurance companies vary in their reimbursement policies. Be sure to check your coverage in advance.

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