Insomnia

Insomnia is the most common disorder, characterized by inability to sleep or a total lack of sleep, prevalence of which ranges from 10 to 15% among the general population with increased rates seen among older ages, female gender, white population and presence of medical or psychiatric illness. Insomnia patients may complain of some or all of the following: difficulty initiating or maintaining sleep, repeated awakenings or early morning awakenings, non-restorative sleep, daytime fatigue, lack of concentration, irritability, anxiety, depression, and muscle aches and pains.

Difficulty in falling asleep may be primarily due to behavioral and cognitive factors such as worrying in bed, or having unreasonable expectations of sleep duration. This excessive worry about sleep loss eventually becomes persistent and provides an automatic nocturnal trigger for anxiety and arousal. Further, unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, insomnia can persist indefinitely. Other behaviors in bed or in the bedroom that are incompatible with sleep may include talking on the telephone at night, watching television, using computers, exercising, eating, smoking, or “clock watching “.

Various prescription drugs may be responsible for insomnia. The drugs may include anticonvulsants, beta-blockers, antipsychotics, antidepressants and non-steroidal anti-inflammatory drugs. Chocolate, cola, coffee, energy drinks and any other substance containing caffeine should be avoided up to 5 hours before going to sleep.

Insomnia, particularly sleep disruption, is common among older people because of coexisting medical conditions. Pain related to musculoskeletal disorders, including arthritis, constitutes one of the most common causes of insomnia in this subpopulation.

Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven convincingly. A healthy diet containing magnesium might help to improve sleep in individuals without an adequate intake of magnesium.

On the far extreme, fatal familial insomnia (FFI) is a very rare inherited disease of the brain that is usually inherited. Patients may exhibit REM type brain waves, but they are not refreshing. The disease’s genesis and the patient’s progression into complete sleeplessness is untreatable and ultimately fatal.

Insomnia Therapies

Stimulus control therapy

Circadian rhythms are the natural cycles of wakefulness and sleep that the body progresses through, and although there is a general template for humans, they can vary surprisingly from one person to another.

The circadian rhythm is adjusted to the environment by external cues, the primary one of which is daylight. Stimulus control therapy is based on the premise that insomnia is a conditioned response to temporal (bedtime) and environmental (bed/bedroom) cues that are usually associated with sleep. Accordingly, the main objective of stimulus control therapy is to train the patient to re-associate the bed and bedroom with rapid sleep onset by curtailing sleep-incompatible activities (overt and covert) that serve as cues for staying awake and by enforcing a consistent sleep-wake schedule. Stimulus control therapy consists of: going to bed only when feeling sleepy, using the bed and bedroom only for sleep and sex and nothing else, getting out of bed and returning to bed only when sleepy again, maintaining a regular rising time in the morning regardless of sleep duration the previous night, and avoiding daytime napping. Sometimes melatonin as well as light therapy is used to help achieve this goal. Light therapy is based on the observation that people that spend a lot of time outdoors sleep better and are less prone to depression.

Sleep restriction therapy

Lying in bed when you’re awake can become a habit that leads to poor sleep. Limiting the amount of time you spend in bed can make you sleepier when you do go to bed. That way you’re more likely to fall asleep and stay asleep. Sleep restriction therapy consists of restricting the amount of time spent in bed to nearly match the subjective amount of time spent sleeping. For example, if a person reports sleeping an average of 5 hours per night out of 8 hours spent in bed, the initial prescribed sleep window would be 5 hours. Subsequently, the allowable time in bed is increased by 15-20 minutes for a given week when sleep efficiency (defined as ratio of total sleep/ time spent in bed × 100%) exceeds 90%.

Sleep hygiene

Sleep hygiene education targets health practices (e.g., diet, exercise, and substance use), environmental factors (e.g., light, noise, temperature, and mattress) and discipline, that may be either detrimental or beneficial to sleep. For more, see the sleep hygiene page.

Sleeping pills

For mild cases of insomnia, over the counter antihistmines (commonly taken for allergy symptoms) have a sleep inducing effect. The doctor can prescribe various pills for severe or chronic insomnia: imidazopyridines, benzodiazepines, cyclopryrrolones etc., that also come with specific side effects (including addiction, which can lead to more difficulty in falling and staying asleep). Ideally, the lowest effective dose should be used, discontinuing the medication gradually. Strong sleeping pills can prove fatal if a medical emergency occurs (for instance if the patient’s airwaves get obstructed during sleep) and the patient cannot wake up. For more, see the separate page on sleeping pills.