Insomnia

 | October 1, 2007

Insomnia

People with insomnia may be plagued by trouble falling asleep, unwelcome awakenings during the night, and fitful sleep. They may experience daytime drowsiness, yet still be unable to nap, and are often anxious and irritable or forgetful and unable to concentrate.

In a poll conducted by the National Sleep Foundation, more than half of adults said they experienced one or more symptoms of insomnia at least a few nights a week. Although it's the most common sleep disturbance, insomnia is not a single disorder, but rather a general symptom like fever or pain. Finding a remedy requires uncovering the cause.

Nearly half of insomnia cases stem from psychological or emotional problems. Stressful events, mild depression, or an anxiety disorder can keep people awake at night. With proper treatment of the underlying cause, the insomnia usually recedes. If it doesn't, additional treatment focusing on sleep may help.

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Types of insomnia

One way doctors classify insomnia is by its duration. Insomnia is considered transient if it lasts only a few days, short-term if it continues for a few weeks, and chronic if the problem persists.

The causes of transient or short-term insomnia are usually apparent to the sufferer — the death of or separation from a loved one, nervousness about an upcoming event (such as a wedding, public speaking engagement, or move), jet lag, or discomfort from an illness or injury. Chronic insomnia may be caused by a number of medications or medical conditions (see "Medical conditions and sleep problems"). In these instances, treating the condition or changing the medication may relieve the insomnia.

One common form of persistent sleeplessness is learned insomnia. After experiencing a few sleepless nights, some people learn to associate the bedroom with being awake. Taking steps to cope with sleep deprivation — napping, drinking coffee, having a nightcap, or forgoing exercise — only fuels the problem. As insomnia worsens, anxiety regarding the insomnia may also worsen, leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia.

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First-line treatment: Behavioral changes

For chronic insomnia, the treatment of choice is to change your lifestyle and habits. A careful evaluation can pinpoint habits that keep you up at night. A sleep specialist trained in behavioral medicine can help people with learned insomnia replace their bad habits with positive ones.

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Sleep restriction

People with insomnia often tend to spend more time in bed, hoping this will lead to sleep. In reality, spending less time in bed — a technique known as sleep restriction — promotes more restful sleep and helps make the bedroom a welcome sight instead of a torture chamber. As you learn to fall asleep quickly and sleep soundly, the time in bed is slowly extended until you obtain a full night's sleep.

Some sleep experts suggest starting with six hours at first, or whatever amount of time you typically sleep at night. Setting a rigid early morning waking time often works best. If the alarm is set for 7 a.m., a six-hour restriction means that no matter how sleepy you are, you must stay awake until 1 a.m. Once you are sleeping well during the allotted six hours, you can add another 15 or 30 minutes, then repeat the process until you're getting a healthy amount of sleep.

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Reconditioning

Developed in the 1970s, this technique reconditions people with insomnia to associate the bedroom with sleep. These are the rules:

Use the bed only for sleeping or sex.

Go to bed only when you're sleepy. If you're unable to sleep, move to another room and do something relaxing. Stay up until you are sleepy, then return to bed. If sleep does not follow quickly, repeat.

During the reconditioning process, get up at the same time every day and do not nap.

The idea is to train your body to associate your bed with sleep instead of sleeplessness and frustration.

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Relaxation techniques

For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame.

Relaxation techniques that can quiet a racing mind include meditation, breathing exercises, and progressively tensing and relaxing your muscles starting with your feet and working your way up your body — a technique known as progressive muscle relaxation. Such techniques can be learned in behavior therapy sessions or from books, tapes, or classes.

One way to release physical tension and relax more effectively is to use biofeedback. This approach involves using equipment that monitors involuntary body states (such as muscle tension or hand temperature) and makes you aware of them. Immediate feedback helps you see how various thoughts or relaxation maneuvers affect tension, enabling you to learn how to gain voluntary control over the process. Biofeedback is usually done under professional supervision.

Progressive muscle relaxation is a tried-and-true, drug-free technique for achieving both physical and mental relaxation.

Lie down on your back in a comfortable position. Put a pillow under your head if you like, or place one under your knees to relax your back. Rest your arms, with palms up, slightly apart from your body. Feel your shoulders relax.

Take several slow, deep breaths through your nose. Exhale with a long sigh to release tension.

Focus on your feet and ankles. Are they painful or tense? Tighten the muscles briefly to feel the sensation. Let your feet sink into the floor or the bed. Feel them getting heavy and becoming totally relaxed. Let them drop from your consciousness.

Slowly move your attention through different parts of your body: your calves, thighs, lower back, hips, and pelvic area; your middle back, abdomen, upper back, shoulders, arms, and hands; your neck, jaw, tongue, forehead, and scalp. Feel your body relax and your lungs gently expand and contract. Relax any spots that are still tense. Breathe softly.

If thoughts distract you, gently ignore them and return your attention to your breathing. Your worries and thoughts will be there when you are ready to acknowledge them.

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Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) teaches people new ways of thinking about and then doing things. CBT has proved helpful in treating addictions, phobias, and anxiety — as well as insomnia.

CBT for insomnia aims to change the negative thoughts and beliefs about sleep into positive ones. People with insomnia tend to become preoccupied with sleep and apprehensive about the consequences of poor sleep. This worry makes relaxing and falling asleep nearly impossible. The basic tenets of this therapy include setting realistic goals and learning to let go of inaccurate thoughts that can interfere with sleep. Common types of these thoughts include:

misattributions ("When I feel nervous during the day, it's always because I did not sleep well the night before")

hopelessness ("I'll never get a decent night's rest")

unrealistic expectations ("I need eight hours of sleep tonight" or "I have to fall asleep before my spouse does")

exaggerating consequences ("If I don't get to sleep soon, I'll embarrass myself at tomorrow's meeting")

performance anxiety ("It will take me at least an hour to fall asleep").

A cognitive behavioral therapist helps you replace these maladaptive thoughts with accurate and constructive ones, such as "All my problems do not stem from insomnia," "I stand a good chance of getting a good night's sleep tonight," or "My job does not depend on how much sleep I get tonight." The therapist also provides structure and support while you practice new thoughts and habits.

Several studies have found CBT to be more effective than sleeping pills. People with chronic insomnia who had five sessions of cognitive behavioral therapy focusing on proper sleep techniques reduced the average time it took to fall asleep from 68 minutes to 34 minutes, according to a 2004 study in the Archives of Internal Medicine.

The biggest obstacle to successful treatment with CBT is patient commitment — some people fail to complete all the required sessions or to practice the techniques on their own. Those who do make the effort are likely to be rewarded.

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Medications and other insomnia treatments

A variety of products — including prescription medications and over-the-counter preparations — can treat insomnia (see Table 2). But their effectiveness varies and some may carry unpleasant side effects, so talk to your doctor about which option is best for you.

Antihistamines . Most over-the-counter sleep aids contain antihistamines, which are also used to treat allergies and motion sickness. But physicians don't usually encourage these drugs for sleep problems because they're often ineffective and may cause dizziness, blurred vision, constipation, nausea, and next-day grogginess. (For more on over-the-counter products, see "Nonprescription sleep aids.")

Benzodiazepines. Doctors often prescribe these medications, which enhance the activity of GABA, a neurotransmitter that calms brain activity. Different benzodiazepines vary in how quickly they take effect and how long they remain active in the body. Taken at night, benzodiazepines can lead to next-day drowsiness and sedation. If your main problem is getting to sleep, your doctor may prescribe one that begins working quickly and is short-acting, such as triazolam (Halcion). If your problem is staying asleep, a drug that lasts longer — such as estazolam (ProSom) or temazepam (Restoril) — may be necessary. Some drugs in this class also act as muscle relaxants and may be prescribed for this purpose. Benzodiazepines also treat anxiety, so they are useful for patients with anxiety and insomnia that results from it.

One drawback of benzodiazepines is that they reduce how much deep sleep you get. Also, many people who use benzodiazepines develop tolerance — the need for more and more of the drug to obtain the same effect. After a few weeks, the drugs may no longer promote sleep. Another risk is that stopping the medication abruptly after long-term use can cause insomnia that's even worse than the insomnia you had before you started taking the drug (a phenomenon known as rebound). These medications should be discontinued under a doctor's supervision because withdrawal may lead to muscle tension, restlessness, irritability, or, in rare cases, convulsions.

Nonbenzodiazepines. These medications resemble benzodiazepines in their ability to enhance the sleep-inducing activity of GABA, but they have a slightly different chemical composition. While benzodiazepines affect multiple brain receptors, the nonbenzodiazepines act only on the sleep receptors in your brain, which means they cause fewer side effects. They also appear to have little or no effect on deep sleep.

Many physicians now prescribe these drugs in situations where they formerly prescribed benzodiazepines. Zolpidem (Ambien) was the first to gain FDA approval, in 1992, followed by zaleplon (Sonata) in 1999 and eszopiclone (Lunesta) in 2004.

All three medications make you fall asleep quicker, but only Ambien and Lunesta lengthen total sleep time. Sonata and Ambien both act quickly (within 20 minutes) and, for the most part, wear off before your typical waking time. Sonata wears off especially quickly, so it may not keep you asleep the whole night if you take it before bed, but you can take one if you wake up in the middle of the night and can't fall back asleep. Lunesta takes a little longer to take effect and also lasts longer. A long-acting version of Ambien, called Ambien CR, became available in 2005 for problems with staying asleep as well as falling asleep.

While Ambien and Sonata are both approved only to treat short-term insomnia (for up to 30 days), Lunesta is approved to treat insomnia for up to six months. This does not mean Lunesta is necessarily superior — just that its manufacturer took the time and expense to conduct studies to show the drug is safe and effective for longer use.

While nonbenzodiazepines have fewer drawbacks than antihistamines or benzodiazepines, they're not perfect for everyone. Some people find the drugs aren't powerful enough to put them to sleep. And they may still cause morning grogginess, tolerance, and rebound insomnia, as well as headache, dizziness, nausea, and, in rare cases, sleepwalking and sleep eating (see "Sleeping pills and sleep eating," below). We also don't yet know the long-term effects of nonbenzodiazepines. Even so, they have quickly become more commonly prescribed than benzodiazepines.

Antidepressants. Physicians increasingly prescribe certain antidepressant medications to people with insomnia, usually at a lower dose than typically would be used to treat depression. The serotonin modulator trazodone (Desyrel) and the tricyclics amitriptyline (Elavil, Endep) and doxepin (Sinequan) are among the most commonly prescribed for insomnia. However, antidepressants are neither approved for insomnia nor proven effective for it. Some doctors believe antidepressants have fewer side effects and are safer for long-term use than benzodiazepines, and that insomnia is often related to depression. However, no convincing evidence supports these beliefs. Also, antidepressants have fewer regulatory restrictions than benzodiazepines, so they're easier to prescribe.

Still, antidepressants do seem to help some people. Studies of depressed people who also have sleep problems show that the medication reduces sleep latency and nighttime arousals. How they work isn't clear, but sleep may result from a sedative effect. Or the drugs' ability to ease anxiety and mild depression may make it easier for people with these problems to relax and fall asleep.

Antidepressants' effect on sleep quality varies; in general, they reduce REM sleep but have little impact on deep sleep. Side effects — namely dizziness, dry mouth, upset stomach, weight gain, and sexual dysfunction — are common. These drugs also can increase leg movements during sleep. Some people find certain antidepressants make them feel nervous or restless, so the medication can actually exacerbate insomnia. It's not clear if these medications lead to tolerance or rebound insomnia.

Melatonin receptor agonist. Ramelteon (Rozerem) is a melatonin receptor agonist — the first new sleep medication class in 30 years. Rozerem is approved to treat insomnia for people who have trouble falling asleep at bedtime.

Rozerem works by attaching to the same receptors on the suprachiasmatic nucleus that the body's naturally produced melatonin does. The suprachiasmatic nucleus controls the circadian cycle of sleep and wakefulness. Rozerem has a more potent effect than ingested melatonin, which helps some people fall asleep faster and can be used to change the circadian sleep phase.

Rozerem's most common side effect is dizziness, and it may also worsen symptoms of depression. People with severe liver damage or who use the antidepressant fluvoxamine (Luvox) shouldn't take it. Rozerem has a short half-life of two to five hours. Citing clinical studies that found Rozerem did not cause tolerance, dependence, or rebound insomnia, the drug's manufacturer promotes it for long-term use.

The drug may be more likely to benefit older rather than younger people, since people produce less melatonin as they age. However, older people's primary sleep problem tends to be waking up during the night, not falling asleep at the beginning of the night, suggesting Rozerem's usefulness may be limited. More studies and clinical experience should help clarify the picture.

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Review Date: 2007-10-01

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