Return to Insomnia (thing)

Insomnia affects approximately one quarter of the adult population. Insomnia sufferers typically report that they have trouble falling asleep, wake up frequently, tend to wake up earlier in the day, and that their sleep is unrefreshing.(1, 2)

People with insomnia generally fit into a particular profile. They prefer to sleep at a certain time (e.g. at night or during the day, whatever, as long as they would have been sleeping at the same time each day), they take approximately 30-120 minutes to fall asleep, wake up 2-4 times per night, get a total of 4-6 hours of sleep per night, and experience symptoms of insomnia more than 4 or 5 nights per week. While people suffering from insomnia do report daytime fatigue, they would be unable to fall asleep during the day when given the opportunity (e.g. they are tired, but not sleepy). In fact, some researchers report that the daytime sleepiness of insomniacs is lower than that of normal sleepers, despite less total sleep time.(3) Insomnia symptoms occur regardless of what day of the week it is (that is to say, insomnia happens regardless of whether it is a weekday or weekend).(2) In general, insomnia has little to do with how much sleep the sufferer actually gets, but rather the subjective quality of that sleep.(1)

Current research suggests that bouts of insomnia may be due to the experience of a state of metabolic hyperarousal by the insomniac.(4) People with insomnia have difficulty falling asleep simply because they are more physiologically aroused; They have higher body temperatures, increased metabolic rates, and greater levels of anxiety than normal sleepers. Examination of EEG recordings from insomnia patients just prior to and during sleep reveals that insomniacs have more powerful alpha and beta activity, and attenuated delta activity.(5) This pattern of aroused activity may explain the consistent underestimation of total sleep time and overestimation of sleep onset time that is often seen in people with insomnia, and may explain the secondary symptoms associated with insomnia (fatigue, inability to concentrate, moodiness). Interruption of sleep without hyperarousal does not produce these negative symptoms.(6)

Although insomnia can occur without any other apparent cause (primary insomnia), more often insomnia results from other preexisting conditions (secondary insomnia). In these cases, it is important to treat the underlying medical condition as well as the insomnia.(7) The most common conditions associated with insomnia are:

Insomnia also becomes more common as people age, especially among post-menopausal women.(8) Circadian rhythm disorders and disruptions in breathing (sleep apnea) are also associated with sleep disruption, but these conditions generally produce symptoms different from those of true insomnia.(2) To be more specific, people suffering from rhythm disorders and apneas do not experience hyperarousal, and therefore the disruption in their sleep activity is associated with daytime sleepiness.

The particulars of secondary insomnia vary depending upon the cause. Insomnia resulting from depression and/or anxiety generally involves difficulty falling asleep, extended awakenings, and early awakening times. The sufferer will often report a sensation that their brain "will not let them sleep." In other words, the insomniac is too cognitively aroused for sleep to occur.(7) Depression and anxiety appear to produce the same patterns of excited brain activity that have been associated with primary insomnia.(5) Among adolescents, nightmares have been associated with anxiety.(9) As a result, the experience of repeated nightmares can induce insomnia, eventually leading to the development of poor sleep hygiene

A subgroup of those who suffer insomnia because of anxiety and/or depression have what is called psychophysiologic insomnia.(7) In these cases, the patient's concern about his or her inability to sleep result in the propagation of the sleep disruption. These patients will report feelings of sleep performance anxiety. Often, they have associated feelings of failure with the time and place in which sleep occurs. These feelings increase cognitive arousal when the person is in a sleep setting, making it more difficult for the person to sleep.

Use of stimulants and sedatives (particularly if no regard is given to the time at which they are taken) can create a dependence upon the presence or absence of an artificial substance in order to regulate your sleep cycle. That's bad, because a) if you miss your regular intake of whatever substance you are using, your cycle will get all thrown off, and b) as you develop a tolerance to whatever you are using, it will be more and more difficult for you to maintain your sleep cycle even using the artificial substance.

Restless legs syndrome is characterized by an intense and irresistible urge to move the legs. The symptoms tend to get worse at night. This condition usually results from a dysfunction of the central nervous system involving the dopaminergic pathways, although it sometimes can result from an iron deficiency. This syndrome seems to effect somewhere between 5% and 15% of the population, with symptoms appearing before the age of 20 in nearly half of all patients.(10) Within the population of people suffering from this syndrome, 94% report sleep onset insomnia.


So, what can you do if you have insomnia?

First of all, change the way you think about sleep. Studies of human sleep patterns indicate that there is a lot of variability in the amount of sleep each person requires, the time it takes to fall asleep, and the conditions under which the best sleep occurs.(7) Depending on the way you are, you might be fine with as little as 4 hours of sleep per 24 hour period, or require as much as 11 hours. Don't think that you absolutely need 8 hours of sleep in order to get enough sleep. Thinking that way about sleep is likely to increase your anxiety about the situation, and therefore decrease your ability to actually fall asleep.

Don't do a lot of things in bed.(1) Hanging out in bed reading, watching t.v., playing cards, noding, whatever you do that isn't sleeping when you are in bed will dissociate the sleep setting from the act of sleeping. If you go to bed and find that you are not falling asleep, get up and do something else, then return to bed when you start to feel sleepy again. Eventually, you'll condition yourself to associate sleep with being in bed, and it will be easier for you to fall asleep there. Hey, if nothing else, it's a good excuse to have sex on the kitchen floor. (:

Don't use drugs to help you sleep at night or stay awake during the day. Don't drink alcohol before bed. Yes, alcohol is a sedative, so it will help you fall asleep. However, after the initial sedative effect, alcohol prevents you from achieving deep sleep, and increases the likelihood that you will wake up in the middle of the night.(11) Don't consume excessive amounts of caffeine to stay up through the day. The introduction of the stimulant into your system will make it difficult to reestablish a natural sleep cycle. Don't use sleeping pills, especially benzodiazepines.(12) They have ridiculous side effects, are addictive, and only help in the short term, and withdrawal often results in a worsening of insomnia symptoms. Don't take melatonin for any extended period of time. It causes gonadal atrophy!(2) Researchers are actually developing birth control with melatonin as the active ingredient! In fact, about the only substance I read about that had any net positive (i.e. positive effects better than negative side effects) effect on sleep was valerian extract.(12) It doesn't seem to alter how much sleep a person gets (although it may increase the amount of time spent in slow-wave sleep), but it does seem to make insomniacs more accurate when reporting how much sleep they have gotten. In other words, it doesn't really help you sleep more, but you at least feel like you've been sleeping.

If you think that your insomnia is being caused by some other problem, treat that as well as the insomnia. I said that before, but I think it's an important point. Treatment of both problems (and notice that I am not saying that only the underlying cause should be treated) leads to the most improvement in both problems. Lichstein et al (7) even reported improvement in the primary disorder when secondary insomnia was treated.

Take a bath.(11) Seriously, it heats up the brain, changing brain activity in a way so that you end up sleepy. Drink a glass of warm milk. The redirection of blood flow from your brain, and some of the stuff you digest out of the milk will help you get to sleep. There is something to be said for all of those things that your mother told you.

Don't worry about it. This one is much easier said than done. Yes, it is hard when you can't sleep. The idea of getting enough sleep can become all-consuming, as if all your other problems would be solved if you could just get a little rest. You are better off if you can manage not to think about it. Instead, try to just live. If you find that you are getting sleepy, go to bed. If you can't sleep once you get there, go do something else. Don't wonder about when you will start to feel tired, don't think about all the nights before that you haven't been able to sleep, don't try to come up with all the things you can do to alleviate the problem (note that this last suggestion is the exact opposite of what I am doing now). Just sleep if you get tired, and don't sleep if you don't, and other than that, try not to think about it.

I hope you all have better luck with these than I do. Sleep well.


1.http://www.nhlbi.nih.gov/health/public/sleep/insomnia.txt
2.Perlis and Youngstedt (2000) The diagnosis of primary insomnia and treatment alternatives. Comprehensive Therapy, 26(4), 298-306
3.Stepanski, Zorick, Roehrs, and Roth (2000) Effects of sleep deprivation on daytime sleepiness in primary insomnia. Sleep, 23(2), 215-219.
4.Bonnet and Aarand (1995) 24-hour metabolic rate in insomniacs and matched normal sleepers. Sleep, 19, 453-461.
5.Hall, Buysse, Nowell, Nofzinger, Houck, Reynolds, and Kupfer (2000) Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosomatic Medicine, 62(2), 227-230.
6.Rosa and Bonnet (2000) Reported chronic insomnia is independent of poor sleep as measured by electroencephalography. Psychosomatic Medicine, 62(4), 474-482.
7.Lichstein, Wilson, and Johnson (2000) Psychological treatment of secondary insomnia. Psychology and Aging, 15(2), 232-240.
8.Jones and Czajkowski (2000) Evaluation and management of insomnia in menopause. Clinical Obstetrics and Gynecology, 43(1), 184-197.
9.Nielsen, Laberge, Paquet, Tremblay, Vitaro, and Montplaisir (2000) Development of disturbing dreams during adolescence and their relation to anxiety symptoms. Sleep, 23(6), 727-736.
10.Hickey (2000) Restless legs syndrome. Canadian Family Physician, 46, 1762-1763.
11.Hryshko-Mullen (2000) Behavioral treatment of insomnia: the Wilford Hall Insomnia Program. Military Medicine, 165(3), 200-207.
12.Donath, Quispe Diefenbach, Maurer, Fietze, and Roots (2000) Critical evaluation of the effect of valerian extract on sleep structure and sleep quality. Pharmacopsychiatry, 33(2), 47-53.

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