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Insomnia is a symptom that arises from a collection of many disorders. When a person has difficulty falling asleep, staying asleep, or waking early, the sufferer begins to dread not only the night but also the fatigue, mental clouding, and irritability of the coming day.
The National Sleep Foundation sponsored a Gallup survey in 1999 that indicated that nearly 50% of adult Americans reported some problem with falling or staying asleep during the past year. Previous research had indicated that about one in six adults consider sleep to be a serious problem, with women and the elderly reporting more frequent problems. Nearly one in 10 adult Americans have chronic insomnia, defined as poor sleep during three nights or more per week that has been present for at least one month (and often much longer).
Doctors characterize insomnia as an impairment of sleep that reduces daytime function. The impairment of sleep can include the excessive time of wakefulness, but also non-restorative sleep. Defining the type of insomnia is based on two factors of time - either by the frequency of nights with poor sleep or by the most common time that the person is awake during the night.
Transient insomnia lasts for one to six nights and is most commonly due to a time zone change (jet lag) or stress from work, home or other relationships. After the stress passes or a person discovers how to cope, sleep returns to normal. Short-term insomnia involves one to three weeks of poor sleep. Life changes such as job loss, separation, divorce, or health concerns are the most common reasons for short-term insomnia.
Sometimes substances such as caffeine, decongestant/sinus medicines, or prescribed medications can cause a significant disturbance in sleep. Chronic insomnia lasts for weeks, months, or years and proves distressing and sometimes disabling to the sufferer. The causes of chronic insomnia arise from a variety of medical, psychiatric, and lifestyle problems and will be a focus of the information below.
Insomnia can also be characterized by the time of night when the unwanted wakefulness presents. Sleep onset insomnia is most commonly due to anxiety. The delay to fall off to sleep is often experienced by the person as lasting 30 minutes or longer. Sleep maintenance insomnia represents unwanted wakefulness later in the night and may be due to medical illness, primary sleep disorders, or depression. Sleep maintenance insomnia can involve one or more episodes of wakefulness or multiple brief awakenings. Early morning insomnia involves awakening one or more hours before the desired time and can be due to depression or a problem of a biological "clock" that is set to awaken too early.
Sleep specialists are not generally concerned with the specific number of minutes that a person is awake. Since people have different needs for sleep as mentioned in Sleep 101, and it is difficult for an insomnia sufferer to determine when he or she is asleep, the specialist is most interested in the impact of poor sleep on the person's daytime function. For some, the minutes of lost sleep may be small, but the level of fatigue, tiredness, mental slowing, reduced concentration, memory lapses, irritability, disinterest, decreased motivation and reduced performance may be significant.
Although each person will experience lost sleep in their own way, research has found that certain individuals are more likely to experience insomnia. Complaints of insomnia increase with age. Less than 3% of children report any serious problem of insomnia. The adolescent and young adult are more likely to be sleep deprived through a conscious decision to reduce their hours of sleep than to experience an insomnia problem (about 9% of adolescents report insomnia). Reports of insomnia increase after age 50. By age 80 or older, over 45% will report that on three or more nights per week, sleep is poor.
Women at any age report insomnia at a frequency that is twice that of men. It is also known that insomnia is more common in older single persons, in those who have been through divorce, and for those who are in lower socioeconomic categories. One's job or profession does not appear to impact the presentation of insomnia, although a person's approach or attitude to a particular job will affect sleep.
A common concern of those who sleep poorly is that lost sleep will damage their health. Such a concern may be based on animal research that shows that total or selected sleep deprivation reduces the life span of rats or mice. Recent research demonstrated that the nightly loss of four hours of sleep over 10 days in healthy young adults reduced a number of measures of immune function. Two research papers described how sleeping under five hours per night lowered the life span (although sleeping more than nine hours also did the same). Lost sleep sounds dangerous. Or is it?
Researchers have determined that the fear of an early death from insomnia is not warranted. A person does not die from insomnia (although it may feel like it). It is not a disease, but a symptom. In fact, most insomnia sufferers are not severely sleep deprived. In the 1970's, Dr. Mary Carskadon studied 130 patients who had chronic insomnia and compared their sleep to an equal number of normal sleepers. Only 10 to 15% of the insomnia group received less sleep than the normal sleepers.
Research indicates that unless someone is experiencing a severe psychiatric or neurologic disorder, it is infrequent for a person to sleep five hours or less. Perhaps it helps to know that wise old men of the past such as Leonardo Da Vinci, Benjamin Franklin, Thomas Edison, and Winston Churchill slept less than six hours per night. It is likely that they were naturally short sleepers.
Sleep specialists recognize that there are two systems that determine how and when people sleep. The first process has been called Process S or the homeostatic process. Most people learn of Process S if they have lost sleep. When a normal sleeper is deprived of sleep, they become more sleepy. When the sleep-deprived person eventually sleeps, the person sleeps more deeply and for a longer period of time. Even for people who are poor sleepers, it is possible to offer improvement in sleep quality by reducing the time in bed, a treatment called sleep restriction.
The second process has to do with the "biologic clock" or circadian rhythms. This is called Process C. Process C is responsible for jet lag and is the reason why people who work night shifts will have problems sleeping during the day. The brain wants you to sleep during the "sleepy phase" of the body. For most people the "sleepy phase" is set between 11:00 p.m. and 7:00 a.m. Up to 15% of people may have a "biologic clock" that is set at a different time. If your clock runs early, you may get sleepy early in the evening and then discover that you are wide awake at 3:00 or 4:00 in the morning.
This problem is common in older people and is called Advanced Sleep Phase Syndrome. On the other side of the clock is Delayed Sleep Phase Syndrome. Teens and young adults often have this problem wherein they stay up late into the night and then will sleep in until noon or after. Changes in Process C can be made through a combination of lifestyle changes and exposure to natural or artificial light at specific times of the day. Occasionally medication may be offered.
To improve insomnia requires some understanding of what has changed in one's life. If you have had poor sleep for a short time, it will prove easier to understand and to make things better. If you have had insomnia for months or years, the original reasons for poor sleep will have become less important while your behavior and lifestyle have become more important. If you have had insomnia for a very long time, you may find it helpful to see a sleep specialist who can rank for you those changes that will offer the best likelihood of improved sleep and daytime function.
The road to better sleep should begin with a goal. Don't just say "eight hours of uninterrupted sleep." How did you sleep in the month or two before you began to have trouble with sleep? If it has been over a year since you have consistently slept well, you may have to set a goal that recognizes any changes in your sleep need. Perhaps you now find that six or seven hours of better sleep are enough to feel good and function well during the day.
Treatment for insomnia focuses on three strategies - lifestyle changes, behavioral changes, and biological treatments. Lifestyle changes involve good sleep habits. Refer to the 10 Steps to Better Sleep that can offer you improvements to better sleep. Behavioral changes include stress management techniques, relaxation methods, interrupting sleep disruptive behaviors, management of negative thoughts, and working through of negative emotional reactions. The biological treatments include the use of medications, bright light therapy, and alternative therapies.
Transient insomnia arises from sudden stress or time zone changes. The temporary disruption of sleep is best recognized as time limited. Yes, it is uncomfortable to have shortened sleep, but the sleep loss is temporary. Becoming preoccupied or upset about the sleep loss only makes it stronger and more miserable. During transient insomnia, you must remember that trying to sleep brings wakefulness. The harder you try to catch sleep, the more you make it jump away. It is like a jack rabbit: if you try to catch this soft, cuddly animal, sudden moves startle your desired comfort and off it skitters, leaving you upset and frustrated. Now you are really awake!
A single, infrequent night of insomnia is normal. Over 50% adults know the experience. If you are in an acute stressful event, help yourself by managing the stress. Reading or a hot bath in the hour or two before sleep will offer a wind down. Avoiding caffeine past 3:00 p.m. and exercising in midday will help.
If thoughts are running through your head as you arrive to bed, you need to get up, go into another room, and do something that is boring, relaxing, or both. If such mental calisthenics are a regular problem, you need to help yourself earlier in the evening. Sit down after supper with a pad of paper. Draw a line down the middle of the page. At the top of the left column, put the heading "Thought/ Feeling/ Concern." At the top of the right column, write, "What I plan to do about it." For example, a thought, feeling, or concern might be a stressful situation at work.
An action that you could do to resolve the situation at work might be to discuss the problem with your supervisor or manager. Unless the problem is an emergency, your plan of action should begin at the earliest in 24 hours. You may decide that your plan for improvement might best begin next week, or next month, or next year. If you are lying in bed and your mind creeps towards any of your thoughts, feelings, or concerns, tell yourself, "Hold it! I've taken care of that. I have considered the problem and decided on my plan of action. It's written down over there on that piece of paper. I have done what I can for now and I know what I'm going to do." Then begin a distracting method of relaxation by referring to the Tips on How to Beat Insomnia.
The answer: perhaps to the sleeping pill, but no to the wine or other alcoholic beverage. Alcohol worsens sleep in the last half of the night. It is a sedative for only an hour or two and then begins to wake people up. As to over-the-counter sleeping pills, most pills on the store shelf are sedating antihistamines. They will dry you out and often cause you to feel sedated when waking up in the morning. If you are on other medicines or have problems of the heart, eyes or prostate, antihistamines are best avoided. For this reason, the elderly should avoid such pills. If you feel the need to use these pills for more than ten (10) days, you may have other problems of sleep than transient insomnia. Consider seeing your doctor or applying some of the strategies discussed below or in the 10 Steps to Better Sleep.
If you have transient insomnia more than once per year, your doctor might consider offering you one of the prescription sleeping medications listed in the Sedative/Hypnotic Agents section to be used only if needed. If you need the prescription medicine for more than three consecutive nights, you and your doctor need to discuss any reasons why you might be having more significant insomnia problems.
Short-term insomnia most commonly arises from a major life event. It is often due to a loss or a threat. Separation, divorce, job loss or layoff, death of a loved one or medical illness are the most common causes of short-term insomnia. People who tend to worry or who like order in their lives will be awake more often during the night when faced with such major life events. There are some things that you can do to prevent your sleep from getting worse.
Begin improving your sleep by reviewing the 10 Steps to Better Sleep. Follow a healthy routine that lessens the stress on your body. In particular, limit your caffeine use. Take 5 to 10 minutes in the morning, afternoon and evening to do something good for yourself, something that makes you feel connected and relaxed. It could be a walk, a call to a special friend, meditation, a Bible verse, prayer, or a review of something that you consider inspirational. Such actions throughout the day will help your mind and body to prepare for sleep.
As you enter the evening, begin the wind down period, relaxing in the hour or two before sleep with music, a pleasant book, a hot bath, or relaxation methods such as meditation. As discussed in Managing Your Concerns and Worries, taking time after supper to develop a plan of actions for the next few weeks may prove helpful if your worries appear later in the night.
Behavioral strategies can be of significant value for short-term insomnia. Remember that your brain and body know how to sleep. The stress is just temporarily activating your arousal system. Managing your level of activation will make things better. Begin with your goal: To fall asleep and stay asleep as you did before the major life event. Only head to bed when you are feeling sleepy (i.e., not just because it is 10:30 or your spouse is going to bed). If the 10 Steps to Better Sleep are not yet helping, follow the 10-minute rule for falling sleep.
If you lie awake in bed for an estimated 10 minutes, get up, go into another room, relax by doing something boring, and then return to bed when you feel sleepy. Then double the 10-minute rule: if you are not asleep after an estimated 20 minutes, get up again until you feel sleepy. Over the first few days that you follow the 10-minute rule for falling asleep, you may feel a bit discouraged from being awake, but working through the 10-minute rule will make sleep a welcome time of rest and repose.
If you have practiced one of the relaxation or imagery methods listed in How to Beat Insomnia, you might find that relaxing. The 10-minute rule combined with relaxation techniques will help you feel sleepy more quickly during the night, allowing you to return to bed sooner.
Prescription medications may prove helpful if the sleep disturbance has gone past a week. Your physician will likely explore with you whether you may be in the early stages of depression. Antidepressant medication can be helpful for sleep and mood. If anxiety remains even as you use your best efforts to manage the stress, Sedative/Hypnotic Agents may be helpful to stabilize your sleep for a few weeks until the life events become more manageable.
Chronic insomnia proves most distressing. There is much frustration and loneliness that comes with being awake at night. Worry and concern about anything connected with sleep begins to preoccupy the mind. It is terrible for those who feel trapped by the vicious cycle of unwanted wakefulness that leaves their mind and body fatigued, tired, and slowed. Depression may increase, while one's ability to function in normal daily activities seems to be less. Is there help for someone who has not slept well for weeks, months or years? You bet.
People with chronic insomnia often want to know "Why can't I sleep?" A better question would be "What is keeping me awake?" Many people with insomnia can identify a life event or change that occurred about the time that they began to sleep poorly. After two or three months, the event or change will become less relevant to why unwanted wakefulness continues to occupy the time that you want to sleep. The insomnia sufferer will need to explore other possible causes that might be arising from medical illness or its treatment, psychiatric disorder, or abnormal behavioral patterns. If someone has slept poorly for years, it is common for many different disorders to have been layered on top of the original reason for poor sleep.
Here are some questions that might help you to rediscover better sleep:
Comment: Medical illness, particularly when it results in pain, lost function, or problems with brain activity, can disturb normal sleep. At times, medicines that are meant to help the medical problem worsen sleep. Refer to the section Medicines that Disturb Sleep. Sometimes the disruption in your normal routine from having been ill may also cause you to follow habits that have increased your chances to stay awake rather than to sleep well.
Recommendation: Consult your physician. If the medical illness or its treatment is causing you to sleep poorly, the doctor will have to determine whether to alter your treatment or whether to offer you sleeping medication. You should also follow the 10 Steps to Better Sleep.
Comment: Disturbance of relationships is a very common reason to develop sleep problems. Conflicts with family members or close friends, work supervisors, and other significant people in your life will increase activation and arousal of your nervous system. It appears that some people are more sensitive to such problems. Dr. Elaine Aron, author of "The Highly Sensitive Person: How to Thrive When the World Overwhelms You," describes in her book such activation or arousal by characterizing the Highly Sensitive Person. Her book provides self-assessment tests to rate tendencies to become overly activated.
Sometimes people change their lifestyle without realizing the negative impact upon their sleep. Increasing work or family demands may begin to creep later into the evening and night. The poor sleeper must protect the one to two hours of time before bed. Wind down and relaxation should be at the top of your To-Do list. People may not find the time to exercise when stressed and yet a good workout can prove a great stress reliever.
Others may begin to consume more caffeine (or other xanthines, substances that activate the nervous system) such as coffee, tea, colas, or chocolate in hopes of boosting energy and to push back fatigue. The strategy may backfire, increasing the problems of sleeping at night. Some may even begin to drink more alcohol at night, hoping to sedate themselves to sleep. Alcohol before bed is a mistake. It commonly causes the drinker to wake up in the last half of the night.
Recommendations: Begin by gaining perspective on the important relationships in your life. If you find writing helpful, keep a diary of your thoughts and feelings. Commit yourself to solving the problem as best you can. Writing an imaginal letter to the other person may prove helpful. That's imaginAL, not imaginary. It is a letter that helps you to create an honest solution in your own mind.
You may decide never to send the letter to the other person or you may hold it for two or three days before giving it to the other person. Sometimes your feelings are confused or you don't know where to begin. Meeting with a counselor through a program at work or seeking out a therapist may prove to be the initial step to improved sleep.
When your lifestyle is getting in the way of good sleep, you need to get honest with yourself. Recognize what you think, do, eat, drink, and so on during the day will affect your sleep on the night to come. Consider keeping a diary of your patterns of eating, drinking, exercise, and relaxation. Use the 10 Steps to Better Sleep as a guide to improving your rest.
Comments: When a doctor hears that a person is sleeping poorly for more than a few weeks, questions about a brain chemical change arise. Disorders of significant depression and anxiety can be important reasons for chronic insomnia. Often insomnia is one of the earliest symptoms of depression. The reverse is also true. Poor sleep will also make people feel more discouraged and poorly focused.
To determine whether you have insomnia due to depression, think about how your thoughts and feelings have changed as you have slept poorly:
Some people continually live with worry and anxiety. It is as if their minds and bodies remain on high alert for danger or threat. Thoughts race through the mind. Fears, worries and concerns take over. Nothing seems to go just right. Everything seems to lead to the potential for disaster. Often the body responds to this chronic feeling of uncertainty and anxiety by pouring out adrenaline.
The body has a very sophisticated system of reactions to threat and stress. Unfortunately, this activation system that is meant to protect you can backfire. Besides sleeping poorly, people with overly reactive defense systems will feel tense, tight, short of breath, sweaty and weak. You may find you need to urinate more, breathe deeper, or calm down your heart. When the body lives in this heightened state of activation for too long, it becomes fatigued, less focused, and tired with any exertion.
Recommendations: Significant problems of depression and anxiety disturb the ability to fall and stay asleep. If you have any of the symptoms above, see your physician. Your doctor may offer medication or consider referring you to a mental health specialist. Medication and counseling provide significant benefit. Selecting medications for depression and/or anxiety requires consideration of side effects and other drugs that you might be taking.
Antidepressant medication with sedative properties like nefazodone (Serzone), paroxetine (Paxil), mirtrazapine (Remeron), trazodone (Desyrel), amitriptyline (Elavil and others), or doxepin (Sinequan and others) are helpful for sleep and mood. If anxiety remains even as you use your best efforts to manage your overly active nervous system, sedative/hypnotic agents may be helpful in stabilizing your sleep until you have become well practiced in good sleep habits. Going to a therapist who helps you reconnect with people can be helpful. A trained professional can also help you to explore how you think. By making changes in your beliefs about how things should work, especially before and during sleep time, can help make life better.
There are two explanations that may be causing sleepiness or wakefulness during irregular times of the day, Advanced Sleep Phase Syndrome (ASPS) and Delayed Sleep Phase Syndrome (DSPS). People with ASPS are often called "larks", while people with DSPS are termed "night owls."
People with advanced sleep phase have to fight to stay awake in the evening between 6:00 and 10:00 p.m. If their lifestyle allows, these individuals choose to go to bed at 8:00 p.m. or so. Their bodies then wake up at 3:00 or 4:00 a.m. in the morning. People with ASPS often force themselves to stay awake at night but then discover that they wake up at nearly the same early hour no matter when they went to bed. The elderly are more commonly affected with ASPS. It has also been described to cluster in specific families.
Treatment: ASPS can be helped by timing of bright light exposure. Maximizing bright light from 6:00 to 9:00 p.m. is often helpful. If an artificial light box is used, the recommended level of lux (a measure of light intensity) should be 10,000 for at least 30 minutes and likely longer. Ideally, the person with ASPS should be exposed to only low levels of light (less than 50 lux) during the first two hours after arising. Often a consultation with a specialist may be needed to assure the appropriate evaluation and treatment recommendations.
A person with DSPS is the classic night person. Even if a person with DSPS goes to bed at 11:00 p.m., he or she will not fall asleep until the body is ready. Often sleep is delayed until 3:00 or 4:00 a.m. Getting up at a "regular" time such as 7:00 a.m. is a struggle. A person who has DSPS would do just fine if the world allowed them to sleep when their body would want, like from 4:00 a.m. until noon. Some folks with DSPS will gravitate to an evening or night job. College students often have to readjust their internal clocks as they prepare to graduate and start a job that requires a 7:00 or 8:00 a.m. report time.
Treatment: Bright light can prove helpful. During the summer, the person with DSPS can force themselves up at the desired arise time and then go out into the sun for the next two hours. Combining the light exposure with a run or walk is great. Over 7 to 14 days, the body clock gets reset to the new time. The person finds it easier and easier to fall asleep and then to wake up at the appointed time. This has to be kept up for at least six to eight weeks before varying the regular arising time (that means the same arising time on weekends, too).
In the winter months, artificial bright light of 10,000 lux from a light box will need to be received for the two hours of the morning. The DSPS person would also be wise to reduce exposure to light at night. For two weeks make your living space a cave by turning off all lights except the television, night-lights, or the little book lights that shine on the page.
Some doctors advocate the use of melatonin 1 to 6 mg that is taken one hour before the desired bedtime as a treatment of DSPS. Others are reluctant to recommend it. Some studies have shown that it realigns the body clock to help DSPS patients fall off to sleep more quickly. The doctors, who are reluctant to recommend melatonin to their patients, do not consider the evidence to be strong enough to recommend it.
There is also an issue of safety. Currently, melatonin is marketed as a health food supplement and is not regulated by the Food and Drug Administration. Melatonin is a naturally occurring hormone secreted by the pineal gland. If you get "natural" melatonin that comes from animal brains, there is danger of getting a virus-like agent called a prion. Prions cause diseases such as "mad cow" disease. Even if a person buys a manufactured form of melatonin, the controls on its manufacture are not the same as for prescription medicine. Anyone considering the use of melatonin should follow one rule - "Buyer beware."
Comments: People who snore are at risk of having Obstructive Sleep Apnea (OSA). Apnea means that you stop breathing in sleep. The person is generally unaware or vaguely aware that they have a problem of breathing during sleep. A person with sleep apnea or one of its variants has broken and disturbed sleep of which they are only partially aware. Although OSA is an uncommon reason to cause insomnia, it represents a potentially serious medical problem that deserves evaluation and treatment. For more detailed information, refer to the Snoring and Sleep Apnea section on this website.
People who have creepy, crawly, jumpy legs may well have problems of Restless Legs Syndrome (RLS). RLS gets worse in the evening and during the first half of the night. In its most active forms, a person with RLS will have to stretch, move or walk to provide relief that may prove only temporary. The person begins to drift off to sleep only to jump awake or with the need to get up to stretch or walk.
When sleep finally comes, the person often begins flexing or moving their legs without their knowledge. It is called Periodic Limb Movement Disorder (PLMD). This involuntary movement occurs in a regular pattern of every 20 to 40 seconds and often causes disturbed sleep. There is more information about these sleep disorders in the Restless Legs Syndrome and Periodic Limb Movement Disorder sections on this website.
One of the ways to rate whether apnea or RLS might be significant is to consider how sleepy you are during the day. People with insomnia do not complain of falling asleep reading, watching TV, or at a movie. If you fall asleep during the day, there is a higher chance that you have a primary sleep disorder like OSA, RLS or PLMD.
Treatments: A sleep test, called a comprehensive polysomnogram, is most commonly used to evaluate primary medical disorders of sleep like OSA, RLS and PLMD. The testing can document the nature and severity of the problem. In general, sleep testing is used only infrequently to evaluate other reasons for insomnia, unless common treatments have offered no benefit to better sleep. The American Academy of Sleep Medicine has published specific guidelines about how sleep testing should be used in the evaluation of insomnia.
People with obstructive sleep apnea need to be seen by a specialist who can determine which treatment would be best for their breathing problem. The treatments for OSA focus on weight loss and opening up the space at the back of the mouth through a breathing machine (CPAP), an oral appliance that fits on the teeth, or surgery to open the throat. More detailed information about treatment options can be found in Samuel A. Mickelson's special feature entitled, "Self-Help Remedies and Conservative Treatments for Sleep Apnea."
OSA information on the web can be found at the American Sleep Apnea Association's site, www.sleepapnea.org, as well as here in the Sleep Apnea section of our website. Often the OSA patient with insomnia will need medication for sleep along with their treatment for apnea or one of its variants. Doxepin concentrate or amitriptyline, members of the tricyclic antidepressant class, offer improved sleep and some benefit to breathing when used at low dosages of 5 to 25 mg at bedtime.
Treatment for RLS and PLMD follow the same approach. Mild cases improve by following a lifestyle that reduces stress and caffeine use while also increasing aerobic exercise earlier in the day. For more significant problems, medication is needed. Sedative/hypnotic agents had previously been used as a common treatment with clonazepam (Klonopin) being the most frequently prescribed.
Increasingly, new medications to treat Parkinson's disease are being offered with excellent benefit. The most common are pramipexole (Mirapex), pergolide (Permax), ropinirole (Requip) and levodopa (Sinemet and others). Sometimes anti-convulsants are used. In the most severe cases, narcotics are used in the evening and at bedtime. For those needing more information about RLS, contact the Restless Legs Syndrome Foundation at www.rls.org or view our RLS section on this website.
Comments: If the reasons for your poor sleep continue to perplex and frustrate you, consider seeing a sleep specialist. Not all sleep specialists are experts on insomnia, but they will be able to give you some directions to follow. The information below may also give you some further options for improvement.
Below you will find a short description of methods that specialists who treat insomnia will offer their patients.
Stimulus Control: Dr. Richard Bootzin and colleagues popularized this effective method to break the bad habit of becoming wide awake when trying to sleep. It is a simple technique called the 10-minute rule. You have only 10 minutes to fall asleep. If you are not asleep in 10 minutes, get up, go into another room and only come back to bed when you feel sleepy. If do not fall asleep quickly after 10 minutes, get up again and return only when you feel sleepy. Repeat the process as many times as you need to. It is a chore to do it, but after 5 to 15 days of some ups and downs the person with problems of falling off to sleep will discover rapid sleep onset. If sleep onset insomnia returns, start again to get out of bed after 10 minutes of being awake.
Sleep Restriction Therapy: Dr. Arthur Spielman and colleagues demonstrated that almost any type of insomnia sufferer could improve with sleep restriction therapy. It follows a simple principle: Restrict your time in bed to only the number of hours that you sleep. Many people with insomnia stay awake in bed in hopes of capturing any potential moment of sleep. But lying awake in bed only makes insomnia worse.
You begin by recording a week of your nights in a sleep diary. Add up the column with the total hours that you slept each night and then divide by the number of nights of recording. If you averaged only 6 hours of sleep during the hours that you spent in bed, for example, then for the next week, plan to be in bed for only 6 hours. If you sleep for 85% or more of the time that you are in bed over the week, add another 15 minutes to the time in bed, e.g., you can now stay in bed 6.25 hours. If you find your wake time increasing, causing sleep to occupy less than 85%, decrease your time in bed by 15 minutes. For the first week or two you may feel sleepy during the day, but most people report that their nighttime sleep becomes deeper and more consistent.
Cognitive-Behavioral Therapy (CBT): Dr. Charles Morin has written extensively about how beliefs worsen the sleep of the chronic insomniac. CBT helps people to recognize that 1) you can function adequately on reduced sleep, 2) you sleep more than you realize, 3) you can manage the stresses of the day, and 4) you must become more responsible for your thoughts at the end of the day so that your sleep improves. Dr. Morin has demonstrated that behavioral strategies lead to more durable improvements of sleep than the sole use of medications. He has also published work to show that insomnia sufferers of any age, including 75+ year old patients, can sleep better with CBT.
Paradoxical Therapy: This approach asks the insomniac to do the exact opposite of what they are attempting. The chronic insomniac says, "I lie there and TRY TO FALL ASLEEP." In paradoxical therapy the person is told to "lie there and try to keep your mind awake." For some, the reversal of focus allows them to get out of the battle of trying to sleep since they are accomplishing the instruction to "keep awake." By transforming the battle and being positive about their efforts, sleep arrives more easily. Paradoxical therapy tends to be most effective when a therapist offers it.
Relaxation Therapy/Imagery: Methods that help to relax the mind and the body can help sleep onset. Many expect relaxation methods to put them to sleep immediately. Most insomniacs want that immediate relief. The key to success is practice and relaxation takes practice. Most of us do not know how to relax; it has to be learned. It is just like driving a car: at 16, we anticipate our time behind the wheel with much pleasure and expectation. We knew that there was much to learn about steering, braking, parallel parking, or using a stick shift. But we were ready and had months of practice (and hopefully only minor accidents), until we had mastered the many tasks of driving.
Relaxation requires the same type of daytime practice to quiet the mind and the body. You should practice a relaxation method twice a day for ten days or more before trying it at bedtime or during the night. It is often helpful to combine it with pleasant imagery. Imagery is also a talent that can be strengthened to improve your health and sleep.
Medicines for sleep include over-the-counter (OTCs) and prescribed medications. Common OTCs include Sominex, Nytol, Unisom, Simply Sleep, and others. These pills usually contain an antihistamine (generally the same medicine as in Benadryl) that causes sedation and dry mouth. OTCs should be avoided if you take heart or blood pressure medicines or if you have troubles with urination. Alternative therapies that can be found in health food stores include melatonin, 5-HTP, kava kava, St. John's Wort, valerian root and others. There are also supposed claims for magnets. OTCs and alternative therapies have been poorly studied so that most doctors have to shrug if you ask their opinion about their effectiveness. If you have had insomnia for a long time, it is unlikely that the OTCs or alternative methods will solve your chronic insomnia.
Prescribed medications include antidepressants, anxiolytics (anti-anxiety), and sedatives/hypnotics. The types and benefits of the medications are listed in the sections below.
Antidepressants: Sometimes doctors select sedating antidepressants to treat insomnia. Often the dosages used are much lower than the dosages that are required to treat major depression. The tricyclic antidepressants, such as amitriptyline, doxepin, imipramine and others, have sedating properties that often improve sleep, but also tend to have more side effects. The newer antidepressants may have fewer side effects, but are often available in dosages that do not allow easy adjustment of the sedative property of the medicine.
Antidepressants can cause insomnia and anxiety for some patients with depression. The percentages below show how often patients with depression sleep worse or feel more anxious during the first two months of treatment.
| New Antidepressant |
Brand Name |
How often the Antidepressant produces: |
|||
| Insomnia |
Anxiety |
Sleepiness |
|||
| trazodone |
Desyrel |
6% |
6% |
41% |
|
| mirtrazapine |
Remeron |
6% |
? |
54% |
|
| fluoxetine |
Prozac |
16 - 33% |
12 - 14% |
13 - 17% |
|
| sertraline |
Zoloft |
16 - 28% |
6% |
13 - 15% |
|
| paroxetine |
Paxil |
13% |
5% |
23% |
|
| venlafaxine |
Effexor |
18% |
6 - 13% |
23% |
|
| buproprion |
Wellbutrin |
11 - 16% |
5 - 6% |
2 - 3% |
|
| nefazodone |
Serzone |
11% |
--- |
25% |
|
Anxiolitic (Anti-Anxiety) Agents:
The following table is a description of the properties of common anti-anxiety agents. The key provided may be helpful in explaining the terms used in the table:
| Anti-Anxiety Medication |
Brand Name |
Daily Dosage |
Speed of action |
Length of action |
Carry-over Sedation |
Daytime Problems |
| alprazolam |
Xanax |
0.25 - 3 mg |
rapid |
10-14 hours |
mild to moderate |
moderate |
| chlor-diazepoxide |
Librium |
5 - 80 mg |
fairly rapid |
30-50 hours |
significant |
moderate |
| clonazepam |
Klonopin |
0.5 - 4 mg |
rapid |
30-60 hours |
significant |
moderate |
| clorazepate |
Tranxene |
7.5 - 37.5 mg |
fairly rapid |
30-50 hours |
significant |
moderate |
| diazepam |
Valium |
2 - 40 mg |
rapid |
30-50 hours |
significant |
moderate |
| lorazepam |
Ativan |
0.5 - 4 mg |
rapid |
12-14 hours |
moderate |
moderate |
| oxazepam |
Serax |
5 - 40 mg |
slow |
6-8 hours |
mild |
mild |
Key: Daily Dosage: the typical adult dosage range to treat anxiety (taken throughout the day) or sleep disorder (taken at bedtime).
Speed of action: how quickly a medicine gets into the brain to produce an effect.
Length of action: how long a medicine continues to have an effect.
Carry-over sedation: how sleepy the medication may make you feel eight hours after taking it.
Daytime problems: symptoms may include grogginess, slow thinking, poor coordination, unsteady walking, disturbed memory, agitation, depression, and others.
Sedatives/ Hypnotic Agents: the following table is a description of the properties of common sedatives or hypnotic agents, also called sleeping pills or sleeping aids. The key provided may helpful in explaining the terms used in the table.
| Medication |
Brand Name |
Daily Dosage |
Speed of action |
Length of action |
Carry-over Sedation |
Daytime Problems |
| Estazolam |
ProSom |
1 - 2 mg |
rapid |
12 - 20 hrs |
mild to moderate |
mild to moderate |
| Flurazepam |
Dalmane |
15 - 30 mg |
fairly rapid |
40 - 120 hrs |
significant |
moderate |
| Quazepam |
Doral |
7.5 - 15 mg |
fairly rapid |
30 - 80 hrs |
significant |
moderate |
| Temazepam |
Restoril |
7.5 - 30 mg |
slower |
10 - 14 hrs |
mild to moderate |
mild to moderate |
| triazolam |
Halcion |
0.125 - 0.25 mg |
rapid |
2 - 5 hrs |
minimal to mild |
moderate |
| zaleplon |
Sonata |
5 - 10 mg |
rapid |
1 - 4 hrs |
minimal |
minimal |
| zolpidem |
Ambien |
5 - 10 mg |
rapid |
2.5 - 6 hrs |
minimal to mild |
minimal |
Key: Daily Dosage: the typical adult dosage range to treat anxiety (taken throughout the day) or sleep disorder (taken at bedtime).
Speed of action: how quickly a medicine gets into the brain to produce an effect.
Length of action: how long a medicine continues to have an effect.
Carry-over sedation: how sleepy the medication may make you feel eight hours after taking it.
Daytime problems: symptoms may include grogginess, slow thinking, poor coordination, unsteady walking, disturbed memory, agitation, depression, and others.
Cautions: Sleep laboratory studies have provided evidence of benefit for hypnotic agents for 2 to 5 weeks of nightly use. Studies with sleep diaries suggest some benefit for months. Hypnotic agents carry a risk for wandering at night, falls, increased automobile accidents, daytime memory disturbance, and paradoxical reactions. As different hypnotics have different levels of risk, the patient and their family members should speak to their physician and/or pharmacist about the risk with a specific medicine.
Agents that are available as over-the-counter agents, health supplements, and certain prescription medicines may cause insomnia in individuals whom are sensitive to the activating properties of these agents. Below find a partial list of such agents.
Here are ten behavioral strategies and three mental strategies to improve your ability to sleep. Your progress in sleeping can be enhanced by practicing these good sleep habits for at least four weeks in a row:
1. Maintain a Regular Sleep Schedule. It will be helpful for you to maintain a regular bedtime and arise time on both weekdays and weekends. Failure to do so, for example, by frequently staying up late, can reset your internal biological clock to a later bedtime, leading to a biological clock disorder called "delayed sleep phase syndrome."
It is especially important to avoid "sleeping in" in the morning after a night of poor sleep. Instead, you should arise at the same time every morning, on both weekdays and weekends, regardless of how poor the prior night's sleep has been. Although this can be difficult to initiate at first, it can, after a few weeks, help normalize your sleep-wake rhythm, and increase your sleep efficiency.
2. Get Enough Daylight. Lack of sufficient daily exposure to sunlight is often partially responsible for people's difficulty in sleeping at night (daylight is a powerful regulator of the circadian cycle). It's beneficial for you to spend at least 30 minutes per day outside, in natural sunlight, preferably during the first hour or two in the morning. If you're unable to do so, try for a minimum of 30 minutes per day in strong artificial light.
3. Avoid Post-lunch Caffeine. Most people know that the intake of caffeine and similar stimulants in the afternoon and evening can interfere with falling asleep and remaining asleep at night. Most doctors therefore advise avoiding caffeinated coffee, tea, and carbonated beverages for the rest of the day after lunch, as well as caffeine-like substances found in chocolate, cocoa, and in some weight-control aids, pain relievers, diuretics, and cold and allergy remedies. Some individuals are highly sensitive to caffeine and should avoid its use entirely.
4. Avoid Daytime Napping. With some exceptions (for example, in some cases of insomnia in the elderly), daytime napping solves only a short-term problem of fatigue and can contribute to the long-term development of insomnia at night by disrupting normal sleep-wake rhythms, as noted earlier. In most cases, you should eliminate napping.
5. Make Your Bedroom Quiet and Comfortable. Insomniacs often overlook the fact that their bed and bedroom may not be as comfortable or as quiet as they could be to promote restful sleep. It's wise to assess the room for any disruptive lights, sounds, temperatures, or touch sensations and adopt whatever measures are necessary to reduce or eliminate these discomforts (for example, using eyeshades, earplugs, a low-volume background sound, or a new mattress or pillow). A bedroom temperature of 65° F is recommended for good sleep.
6. Avoid Alcohol Within Three Hours of Bedtime. Aside from the risk of developing alcoholism, it's not productive to use alcohol as a sleeping aid, despite the popular notion that an evening "nightcap" promotes sleep. Research has shown that although one to two drinks within two or three hours of bedtime may assist with falling asleep, it tends to disrupt subsequent sleep by increasing later wakefulness.
Also, alcohol intake prior to bedtime tends to relax the muscles of the throat and to suppress awakening mechanisms, thereby making snoring and sleep apnea episodes more likely, sometimes to the point of being life-threatening.
7. Avoid Smoking Nicotine Products Within Two Hours of Bedtime. Aside from the health risks associated with smoking, it's not productive to smoke up until bedtime. Like caffeine, nicotine is a central nervous system stimulant, and evening smoking tends to increase heart rate and blood pressure as well as stimulate brain activity in ways that are incompatible with sleep. Also, nicotine withdrawal symptoms during the night can contribute to wakefulness. People who stop smoking are likely to sleep better after 10 days of abstinence.
8. Avoid Large Meals Within Two Hours of Bedtime. Although a light snack before bed can be beneficial, consuming large meals in the late evening is not recommended. It can be sleep-incompatible to assign your gastrointestinal tract the task of digesting a large meal at night, and it can increase the risk of heartburn during the night.
9. Avoid Exercise Within Two Hours of Bedtime. As part of the circadian cycle, core body temperature begins to decrease in the late evening, and this assists with falling asleep and remaining asleep later. Engaging in vigorous exercise within two hours of bedtime can be counter-productive because it tends to raise core body temperature and activate the nervous system. In the interest of improving sleep, the best time to exercise is in the late afternoon.
10. Wind Down Before Bedtime. Insomniacs commonly complain of physical tension and mental alertness when they should be sleeping. In the interest of physical relaxation and mental calm, it's wise for you to wind down for one to two hours before bed by engaging in an enjoyable, relaxing activity. During this wind-down period, you should avoid working, studying, talking on the telephone, arguing, watching exciting television shows, reading exciting books, and so forth.
1. Avoid Worrying, Clockwatching, Trying. Clinicians routinely prescribe only two activities for the bedroom: sleep and romance. Virtually all other activities belong outside the bedroom, both by night and by day. It's not useful for a person to mentally associate sleep-incompatible activities with the bedroom.
This holds particularly true for insomniacs who engage, in the bedroom, in sleep-preventing activities like worrying, watching the clock, and trying to force the onset of sleep - all of which generally serve only to increase body tension and mental alertness. It is better to conceal the clock from your view and to leave the bedroom when you are awake in bed.
2. Leave the Bedroom When Unable to Sleep. One way to stop mentally associating the bedroom with non-sleep-inducing activities is to leave the bedroom after roughly 10 minutes (20 minutes for people age 60 and over) of sleeplessness, in order to write down your worries, watch television, or read in another room, for as long as it takes to feel sleepy. Then return to the bedroom with positive expectations of sleeping.
This sequence should be repeated in a given night as many times as necessary to achieve sleep. Although this so-called "stimulus control" technique can be difficult to initiate at first, it can be very helpful after at least four weeks of practice.
3. Associate the Bedroom with Relaxing. Good sleepers cultivate strong mental associations of physical relaxation, mental calm, and good sleep with their bedtime, their bed and bedroom, and their bedtime rituals (like tooth brushing and setting the alarm clock). You can learn to become a good sleeper by establishing and strengthening these same associations.
Practicing muscle relaxation, deep breathing, and focusing on relaxing mental imagery, while in bed, can help - particularly in conjunction with listening to relaxing, recorded guided imagery programs.
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Talk About Sleep, Inc.
14480 Ewing Ave So. Suite 102
Burnsville, MN 55306
Telephone (952) 358-7070
Fax (952) 358-7077