by 32 people |
Insomnia Knol, as written by Rachel Manber
Rachel is Director, Insomnia and Behavioral Sleep Medicine, Stanford University. A good person to know if you have trouble sleeping. This lens is from her CC licensed Knol:
Insomnia is a common sleep disorder that can often be treated sometimes with simple common sense techniques.
Insomnia is a common sleep disorder, present in approximately one in ten adults in the United States. It has both night time and daytime symptoms. Night time symptoms include persistent difficulties falling and/or staying asleep. Day time symptoms include diminished sense of well being and compromised functioning due to fatigue. The word persistent is emphasized because many people occasionally experience disturbed sleep at night but their problem is transient. Insomnia is diagnosed when the problem persists for at least one month and chronic insomnia is diagnosed when the symptoms persist for at least 6 months.
Insomnia involves difficulty sleeping despite being sleep deprived. Most people with insomnia are not able to catch up on lost sleep even if they try napping during the day. In contrast, good sleepers who are sleep deprived are usually able to nap during the day. Interestingly, when people with insomnia are allowed to sleep only 80% of their average habitual sleep time, and therefore are more sleep deprived than usual, they are better able to nap.
Introduction
Insomnia is a common sleep disorder, present in approximately one in ten adults in the United States. It has both night time and daytime symptoms. Night time symptoms include persistent difficulties falling and/or staying asleep. Day time symptoms include diminished sense of well being and compromised functioning due to fatigue. The word persistent is emphasized because many people occasionally experience disturbed sleep at night but their problem is transient. Insomnia is diagnosed when the problem persists for at least one month and chronic insomnia is diagnosed when the symptoms persist for at least 6 months.
Insomnia involves difficulty sleeping despite being sleep deprived. Most people with insomnia are not able to catch up on lost sleep even if they try napping during the day. In contrast, good sleepers who are sleep deprived are usually able to nap during the day. Interestingly, when people with insomnia are allowed to sleep only 80% of their average habitual sleep time, and therefore are more sleep deprived than usual, they are better able to nap.
Some people naturally sleep 5 hours or less a night and report feeling alert and well throughout the day. These short sleepers do not have insomnia. They do not need more sleep. The ideal length of sleep is the amount of sleep that optimizes the sense of alertness and well being during the day. Different people need different amounts of sleep. The distribution of actual sleep time in adults is bell shaped. The 2002 Sleep in America Poll conducted by the National Sleep Foundation reports that American adults sleep an average of 6.9 hours per night on weekdays and 7.5 hours on the weekend.
Insomnia involves difficulty sleeping despite being sleep deprived. Most people with insomnia are not able to catch up on lost sleep even if they try napping during the day. In contrast, good sleepers who are sleep deprived are usually able to nap during the day. Interestingly, when people with insomnia are allowed to sleep only 80% of their average habitual sleep time, and therefore are more sleep deprived than usual, they are better able to nap.
Some people naturally sleep 5 hours or less a night and report feeling alert and well throughout the day. These short sleepers do not have insomnia. They do not need more sleep. The ideal length of sleep is the amount of sleep that optimizes the sense of alertness and well being during the day. Different people need different amounts of sleep. The distribution of actual sleep time in adults is bell shaped. The 2002 Sleep in America Poll conducted by the National Sleep Foundation reports that American adults sleep an average of 6.9 hours per night on weekdays and 7.5 hours on the weekend.
Sleepless
What promotes good sleep?
1) Attempting to sleep should be made only after sufficient time has elapsed since the last sleep period. This is seldom an issue, except for people who sleep a lot during the day.
2) Attempting to sleep should be made only when feeling sleepy and calm.
Feeling very sleepy is a sign that the biological system that promotes wakefulness is operating at a low level. The biological systems that promote wakefulness and sleep are distinct. They do not constitute a single system with an on-off switch but the two systems interact. The wake promoting system can trump the sleep promoting system. This is adaptive. It allows us to adequately respond to dangerous threats that emerge at night. Therefore, when we perceive threat in our environment, such as when we experience distress, it is difficult for us to sleep. On the other hand when our stress in sunder control at bedtime we are likely to fall asleep easily. People differ in how they respond to stress.
Individuals with insomnia have abnormalities in the biological systems that are involved in reactions to stress. For example, compared with good sleepers, people with insomnia have higher metabolic levels and heart rates and higher levels of stress hormones. The majority of people with insomnia report that they experience difficulty shutting their mind off at bedtime, suggesting that their wake promoting system is operating at a high level when they try to sleep.
3) Bed time and rise time should match the biological clock that regulates sleep and wakefulness (also known as the circadian rhythm or the circadian clock). This clock operates by sending alerting signals across the 24-hour day. The signal increases during the day and at some point in the evening, it starts decreasing. The best time to go to bed is after the alerting signal starts decreasing. The magnitude of this signal keeps going down during the night time and then, approximately 2 hours before we naturally wake up, it starts going up.
Sometimes this biological clock is out of phase with society. People who describe themselves as "night owls" (approximately 10% of the adult population) often have a delayed circadian clock relative to most others. This means that the night owl's alerting signal starts decreasing later than it does for most people. Night owls who go to bed when most people do are essentially trying to sleep before the decrease of their alerting signal. At that time their alerting signals is still too high and therefore have difficulty falling asleep. But if they wait and go to bed later they fall asleep much faster because their alerting signal is already decreasing. This is because their clock's alerting signal starts decreasing later than it does for most people. "Night owls" also have difficulty waking up in the morning. This happens because at the time they try to wake up the alerting signals generated by their biological clocks are not yet strong enough. There are also individuals who have clocks that run early. They typically describe themselves as "definitely a morning person." It is possible to approximate people's circadian clock with questionnaires that determine to what extent one is a morning person versus a night person. (Laboratory procedures to actually measure the circadian clock are used in research but they are not practical outside of research settings.)
2) Attempting to sleep should be made only when feeling sleepy and calm.
Feeling very sleepy is a sign that the biological system that promotes wakefulness is operating at a low level. The biological systems that promote wakefulness and sleep are distinct. They do not constitute a single system with an on-off switch but the two systems interact. The wake promoting system can trump the sleep promoting system. This is adaptive. It allows us to adequately respond to dangerous threats that emerge at night. Therefore, when we perceive threat in our environment, such as when we experience distress, it is difficult for us to sleep. On the other hand when our stress in sunder control at bedtime we are likely to fall asleep easily. People differ in how they respond to stress.
Individuals with insomnia have abnormalities in the biological systems that are involved in reactions to stress. For example, compared with good sleepers, people with insomnia have higher metabolic levels and heart rates and higher levels of stress hormones. The majority of people with insomnia report that they experience difficulty shutting their mind off at bedtime, suggesting that their wake promoting system is operating at a high level when they try to sleep.
3) Bed time and rise time should match the biological clock that regulates sleep and wakefulness (also known as the circadian rhythm or the circadian clock). This clock operates by sending alerting signals across the 24-hour day. The signal increases during the day and at some point in the evening, it starts decreasing. The best time to go to bed is after the alerting signal starts decreasing. The magnitude of this signal keeps going down during the night time and then, approximately 2 hours before we naturally wake up, it starts going up.
Sometimes this biological clock is out of phase with society. People who describe themselves as "night owls" (approximately 10% of the adult population) often have a delayed circadian clock relative to most others. This means that the night owl's alerting signal starts decreasing later than it does for most people. Night owls who go to bed when most people do are essentially trying to sleep before the decrease of their alerting signal. At that time their alerting signals is still too high and therefore have difficulty falling asleep. But if they wait and go to bed later they fall asleep much faster because their alerting signal is already decreasing. This is because their clock's alerting signal starts decreasing later than it does for most people. "Night owls" also have difficulty waking up in the morning. This happens because at the time they try to wake up the alerting signals generated by their biological clocks are not yet strong enough. There are also individuals who have clocks that run early. They typically describe themselves as "definitely a morning person." It is possible to approximate people's circadian clock with questionnaires that determine to what extent one is a morning person versus a night person. (Laboratory procedures to actually measure the circadian clock are used in research but they are not practical outside of research settings.)
Types of insomnia
Insomnia is classified by duration:
Transient Insomnia - Less than one month.
Short-term Insomnia - Between two and six months.
Chronic Insomnia - More than six months.
Insomnia is also classified by presumed cause:
Primary Insomnia - Insomnia that is present with no other co-existing disease. Most of the studies on treating insomnia have bend done with people who have primary insomnia.
Secondary Insomnia - Insomnia that arises in the context of another medical or psychiatric condition. Symptoms typically intensify or diminish in parallel with the worsening or improvement in the medical or psychiatric disease. Sometimes having insomnia can wake the medical or psychiatric condition worse and hinder its treatment. For example, people with depression and insomnia do not respond as well to depression treatment as depressed people without insomnia.
Transient Insomnia - Less than one month.
Short-term Insomnia - Between two and six months.
Chronic Insomnia - More than six months.
Insomnia is also classified by presumed cause:
Primary Insomnia - Insomnia that is present with no other co-existing disease. Most of the studies on treating insomnia have bend done with people who have primary insomnia.
Secondary Insomnia - Insomnia that arises in the context of another medical or psychiatric condition. Symptoms typically intensify or diminish in parallel with the worsening or improvement in the medical or psychiatric disease. Sometimes having insomnia can wake the medical or psychiatric condition worse and hinder its treatment. For example, people with depression and insomnia do not respond as well to depression treatment as depressed people without insomnia.
Is a laboratory sleep study necessary for diagnosing insomnia?
No. An over-night stay in the sleep laboratory is not necessary for a diagnosis of insomnia. However, sometimes a sleep study will be recommended in order to rule out another sleep disorder, such as sleep apnea or periodic limb movement disorder. A sleep study is also recommended when sleep is not refreshing despite of an adequate length. Sleep specialists who oversee over-night sleep studies usually practice in a sleep center.
Who is more likely to experience Insomnia?
- Individuals who have very irregular sleep wake schedules are at risk for developing insomnia because irregular sleep wake schedules weakens the signals from the circadian clock regulating sleep and wakefulness. Those whose jobs involve frequent time zone changes or shift work are at particularly high risk.
- "Night owls" who do not have a regular wake time are at risk for insomnia.
- People with some medical or psychiatric conditions are at increased risk for insomnia. Depression and conditions that are associated with pain or physical discomfort are examples for such conditions.
- People who describe themselves as "worriers" are at risk for insomnia. Learning to set one's worries aside can help reduce this risk.
- People who do not unwind from the day's stresses are more likely to sleep poorly.
- People with other sleep disorders, such as restless legs syndrome. And sleep apnea, are prone to insomnia.
- People with genetic predisposition are also more likely to develop insomnia. There are no genetic tests that can identify those at risk for insomnia but twin studies show that genetics play a role in insomnia
- Women are twice as likely to experience insomnia as men.
- Older adult are more likely to experience insomnia.
How does insomnia start?
Insomnia often develops during periods of stress. About 75% of people can identify a trigger of their insomnia. Most commonly health issues and stress related to family of work situations. Poor sleep is a common reaction to stress but there are large individual differences in how people react to and cope with stress. These differences likely play a role in the development of insomnia.
Some health conditions can disrupt sleep. The following list includes some health conditions that can disrupt sleep:
-- Conditions that cause pain at night, such as arthritis and headache disorders.
-- Conditions that are associated with difficulty breathing, such as asthma, congestive heart failure, chronic obstructive pulmonary diseases, and sleep apnea.
-- Depression, anxiety and other psychiatric disorders.
-- An overactive thyroid gland.
-- Acid reflux disorder.
-- Restless legs syndrome.
-- Conditions that increase urinary frequency, such as enlarged prostate.
-- Dementia.
Certain medications and commonly used substances can disrupt sleep. The following list includes some substances that can disrupt sleep:
-- Caffeine, nicotine and other stimulants (nicotine withdrawal is associated wit disturbed sleep.)
-- Alcohol or other sedatives that wear off in the middle of the night.
-- Some asthma medications (i.e. theophylline)
-- Some decongestants and allergy and cold medicines.
-- Some steroids, such as prednisone.
-- Beta blockers (medicine used to treat heart conditions).
Sleep disruptions that are caused by medical conditions, medications and substances can resolve when the medical condition is treated. However, this is not always the case.
Some health conditions can disrupt sleep. The following list includes some health conditions that can disrupt sleep:
-- Conditions that cause pain at night, such as arthritis and headache disorders.
-- Conditions that are associated with difficulty breathing, such as asthma, congestive heart failure, chronic obstructive pulmonary diseases, and sleep apnea.
-- Depression, anxiety and other psychiatric disorders.
-- An overactive thyroid gland.
-- Acid reflux disorder.
-- Restless legs syndrome.
-- Conditions that increase urinary frequency, such as enlarged prostate.
-- Dementia.
Certain medications and commonly used substances can disrupt sleep. The following list includes some substances that can disrupt sleep:
-- Caffeine, nicotine and other stimulants (nicotine withdrawal is associated wit disturbed sleep.)
-- Alcohol or other sedatives that wear off in the middle of the night.
-- Some asthma medications (i.e. theophylline)
-- Some decongestants and allergy and cold medicines.
-- Some steroids, such as prednisone.
-- Beta blockers (medicine used to treat heart conditions).
Sleep disruptions that are caused by medical conditions, medications and substances can resolve when the medical condition is treated. However, this is not always the case.
How does insomnia persist?
1) The bed and the bedroom become linked with wakefulness, arousal and often also with negative emotions. This is known as conditioned arousal. The bed and the bedroom become conditioned with wakefulness or arousal, often accompanied by negative emotions. In these cases the bed becomes the cue for arousal rather than sleep. For example, many people with insomnia report that they dose off while watching TV or reading in the living room, only to become fully awake when they go to bed. For these people, because of difficulty sleeping in the past, the bed has become a cue for wake rather than sleep. It is believed that conditioned arousal can develop when the main problem is in staying asleep, rather than initially falling asleep.
2) Some people react to poor sleep by trying harder. The extend the time they spend in bed, avoid evening activities that they used to enjoy, toss and turn in bad, and might even try a "night cap." These strategies do not solve the problem. In fact, these strategies make it worse. Prolonged time in bed actually promotes wakefulness. Trying to sleep harder does not work because sleep cannot be forced. The very act of trying to sleep produces frustration, increases arousal, and can become a hidden source of stress. This process is akin to a Chinese finger cuff. The harder you try to release your fingers, the more they get stuck. When you let go, you can ease your fingers out.
3) Worry about sleep is another common reaction to poor sleep. After a period of not sleeping well, apprehension and concern that the coming night will be another struggle emerge. When unable to sleep, worries about the negative day time consequences of insufficient sleep develop. Such worries, though understandable, are activating and end up making sleep even harder to get.
2) Some people react to poor sleep by trying harder. The extend the time they spend in bed, avoid evening activities that they used to enjoy, toss and turn in bad, and might even try a "night cap." These strategies do not solve the problem. In fact, these strategies make it worse. Prolonged time in bed actually promotes wakefulness. Trying to sleep harder does not work because sleep cannot be forced. The very act of trying to sleep produces frustration, increases arousal, and can become a hidden source of stress. This process is akin to a Chinese finger cuff. The harder you try to release your fingers, the more they get stuck. When you let go, you can ease your fingers out.
3) Worry about sleep is another common reaction to poor sleep. After a period of not sleeping well, apprehension and concern that the coming night will be another struggle emerge. When unable to sleep, worries about the negative day time consequences of insufficient sleep develop. Such worries, though understandable, are activating and end up making sleep even harder to get.
"An over-night stay in the sleep laboratory is not necessary for a diagnosis of insomnia."
Treating insomnia with medications
The Food and drug Administration (FDA) has approved certain medications for the treatment of insomnia. These ate called hypnotic medications or sleep medications. Below is a brief discussion of medications that are commonly used for sleep. The discussion is organized by classes of medication.
Five medications that belong to a class of sleep medications called benzodiazepines and are approved by the FDA for treatment of insomnia. These include:
-- Dalmane (flurazepam)
-- Doral (quazepam)
-- Halcion (triazolam)
-- ProSom (estazolam)
-- Restoril (termazepam)
Other benzodiazepine medication approved by the FDA for the treatment of anxiety, such as Ativan (lorazepam), Klonopin (clonozepam), and Xanax (alprazolam) are sometimes prescribed for insomnia as well. Benzodiazepines are generally recommended for short term use because of physical tolerance and dependence can develop. In addition, some medications, in this class can produce a "hangover" effect the following day.
For these reasons, newer sleep medications have been developed and approved by the FDA. Most of these newer medications work on the benzodiazepine receptors in the brain but do it more selectively than the medication in the benzodiazepine class. Therefore, the newer sleep medications are safer and have lower potential for dependence and have fewer side effects. They are called "non- benzodiazepines," a confusing name given that they still operate by acting on the benzodiazepine receptors. The "non- benzodiazepines" are:
--Ambien (zolpidem tartrate) & Ambien-CR (zolpidem tartrate extended release)
-- Lunesta (eszopiclone)
-- Sonata (zaleplon)
Some people experience grogginess in the morning even with sleep medications from this newer class. This happens because people differ in how they metabolize the medications. Grogginess in the morning occurs when a sleep medication is metabolized slowly and is still active upon waking up in the morning. Because of their safety profile and lower potential for dependence some medications in this class are approved by the FDA for continuous, long-term use.
Rozerum (rameleon) is another new sleep medication. It has a very different mechanism of action. It affects the melatonin receptors in the brain.
Sometimes doctors provide a medication that is sedating even though it was not specifically developed to help with sleep. For example, a sedating antidepressant is often prescribed to help with insomnia. The most common antidepressants prescribed to elp with sleep are Desaryl (trazodone), Sinequan (Doxepine), and Amitriptyline (elavil). These medications are usually prescribed at doses that are lower than what is required for the treatment of depression and they do not lead to tolerance or drug dependence.
Some people use natural remedies to treat their insomnia. Thee remedies include herbs, such as valerian, and supplements, such as melatonin and L-tryptophan. The FDA does not regulate these over-the-counter treatments. This means that their dose and purity can vary from product to product. Their safety and effectiveness are not well understood.
The best way to discontinue sleep medications that have been used for a long time is to do so gradually. Most of the newer sleep medications do not cause physical dependence but they can cause psychological dependence. An abrupt discontinuation of a sleep medication can cause a very fitful sleep on the first night or two after the discontinuation. The fitful night is often caused by the discontinuation itself and usually does not reflect the underlying insomnia. The bad nights caused by withdrawal lead many people to promptly resume the use of the sleep medication. The alternative is to slowly reduce the dose (i.e. 25% reduction a week). A small reduction in dose rarely produces noticeable difference in sleep quality. The small steps add up and before long, people can discontinue the medications altogether.
Five medications that belong to a class of sleep medications called benzodiazepines and are approved by the FDA for treatment of insomnia. These include:
-- Dalmane (flurazepam)
-- Doral (quazepam)
-- Halcion (triazolam)
-- ProSom (estazolam)
-- Restoril (termazepam)
Other benzodiazepine medication approved by the FDA for the treatment of anxiety, such as Ativan (lorazepam), Klonopin (clonozepam), and Xanax (alprazolam) are sometimes prescribed for insomnia as well. Benzodiazepines are generally recommended for short term use because of physical tolerance and dependence can develop. In addition, some medications, in this class can produce a "hangover" effect the following day.
For these reasons, newer sleep medications have been developed and approved by the FDA. Most of these newer medications work on the benzodiazepine receptors in the brain but do it more selectively than the medication in the benzodiazepine class. Therefore, the newer sleep medications are safer and have lower potential for dependence and have fewer side effects. They are called "non- benzodiazepines," a confusing name given that they still operate by acting on the benzodiazepine receptors. The "non- benzodiazepines" are:
--Ambien (zolpidem tartrate) & Ambien-CR (zolpidem tartrate extended release)
-- Lunesta (eszopiclone)
-- Sonata (zaleplon)
Some people experience grogginess in the morning even with sleep medications from this newer class. This happens because people differ in how they metabolize the medications. Grogginess in the morning occurs when a sleep medication is metabolized slowly and is still active upon waking up in the morning. Because of their safety profile and lower potential for dependence some medications in this class are approved by the FDA for continuous, long-term use.
Rozerum (rameleon) is another new sleep medication. It has a very different mechanism of action. It affects the melatonin receptors in the brain.
Sometimes doctors provide a medication that is sedating even though it was not specifically developed to help with sleep. For example, a sedating antidepressant is often prescribed to help with insomnia. The most common antidepressants prescribed to elp with sleep are Desaryl (trazodone), Sinequan (Doxepine), and Amitriptyline (elavil). These medications are usually prescribed at doses that are lower than what is required for the treatment of depression and they do not lead to tolerance or drug dependence.
Some people use natural remedies to treat their insomnia. Thee remedies include herbs, such as valerian, and supplements, such as melatonin and L-tryptophan. The FDA does not regulate these over-the-counter treatments. This means that their dose and purity can vary from product to product. Their safety and effectiveness are not well understood.
The best way to discontinue sleep medications that have been used for a long time is to do so gradually. Most of the newer sleep medications do not cause physical dependence but they can cause psychological dependence. An abrupt discontinuation of a sleep medication can cause a very fitful sleep on the first night or two after the discontinuation. The fitful night is often caused by the discontinuation itself and usually does not reflect the underlying insomnia. The bad nights caused by withdrawal lead many people to promptly resume the use of the sleep medication. The alternative is to slowly reduce the dose (i.e. 25% reduction a week). A small reduction in dose rarely produces noticeable difference in sleep quality. The small steps add up and before long, people can discontinue the medications altogether.
Treating insomnia without medications
Cognitive behavioral therapy for insomnia (CBT-I) is a form of psychotherapy that guides patients through a series of change in sleep-wake related behaviors to improve sleep. The focus is on addressing the three factors that contribute to the persistence of insomnia: 1) conditioned arousal, 2) indentifying and eliminating habits that were developed in the effort to improve sleep but have become ineffective, and 3) reducing sleep-related worry and other sources of heightened arousal. Below is a list of some of the instructions and procedures used in this therapy to address these factors.
-- Stimulus control: This set of instructions addresses conditioned arousal. They are designed to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. The key instructions are:
1) Establish a regular morning rise time. Theis will help strengthen the circadian clock regulating sleep and wakefulness. Ideally, bedtime should also be regular, but for people with insomnia it is impossible to actually fall asleep around the same time nightly. When insomnia resolves, regular bed time can further strengthen the circadian rhythm.
2) Go to bed only when sleepy. This will increase the probability that you will fall asleep quickly. It is important to distinguish between fatigue and sleepiness. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dosing off while watching TV or as a passenger in a car involve sleepiness. People with insomnia often feel tired but "wired" (i.e. not sleepy) at bedtime.
3) If unable to fall asleep either at the beginning or in the middle of the night, get out of bed and only return to bed when sleepy again.
4) Avoid excessive napping during the day. A brief nap (15 to 30 minutes), taken approximately after 7 to 9 hours after rise time, can be refreshing and is not likely to disturb nocturnal sleep
-- Sleep restriction: This procedure is designed to eliminate prolonged middle of the night awakenings. It has several steps. This first step consists of limiting the time spent in bed to the time that one is actually sleeping. Subsequent steps consists of gradually increasing the time spent in bed.
For example, consider a person tat goes to bed at 11:00 pm and gets out of bed at 8:00 am but sleeps on average only about 6 hours per night. During the first step of this procedure, this person will only be in bed for 6 hours (12:00 am to 6:00 am). This sounds harsh but after a week or so there will be a marked decrease in time spent awake in the middle of the night. Usually people experience marked improvement in the quality of sleep. They also realize that they are not getting enough sleep. The next step is to gradually extend the time spent in bed by 15 to 30 minutes, as long as the wakefulness in the middle of the night remains minimal.
Each new extension of the time in bed is followed for at least a week before progressing to the next extension. Many people with insomnia discover a point which they do not need to extend the time spent in bed because they get enough sleep to be optimally alert during the day. It is recommended that the time allowed in bed should not be less than 5.5 hours per night. This procedure works best when it does not increase anxiety about restricting sleep. There are several variants of sleep restriction from which the therapist can choose based on individual patient's needs.
-- Skills for reducing arousal at bedtime: These include a variety of relaxation techniques, stress management skills, and reducing sleep related worries. In addition, the following changes of sleep related behaviors are recommended:
-- Use the hour before bedtime to unwind from the day's stresses. This down time will allow sleepiness to come to the surface and will therefore facilitate sleep onset. This is a time to engage in activities that are enjoyable yet calming.
-- Avoid clock watching. Turn the clock around so you cannot see the time yet you can still use it as an alarm. A recent study showed that volunteers who were asked to monitor a digital lock at bedtime took longer to fall asleep than those monitoring a similarly looking device that displayed random digits.
-- Avoid exercise 4 hours before bedtime.
-- Make sure that the sleep environment is safe, quiet, and pleasant.
-- Stimulus control: This set of instructions addresses conditioned arousal. They are designed to strengthen the bed as a cue for sleep and weaken it as a cue for wakefulness. The key instructions are:
1) Establish a regular morning rise time. Theis will help strengthen the circadian clock regulating sleep and wakefulness. Ideally, bedtime should also be regular, but for people with insomnia it is impossible to actually fall asleep around the same time nightly. When insomnia resolves, regular bed time can further strengthen the circadian rhythm.
2) Go to bed only when sleepy. This will increase the probability that you will fall asleep quickly. It is important to distinguish between fatigue and sleepiness. Fatigue is a state of low energy, physical or mental. Sleepiness is a state of having to struggle to stay awake. Dosing off while watching TV or as a passenger in a car involve sleepiness. People with insomnia often feel tired but "wired" (i.e. not sleepy) at bedtime.
3) If unable to fall asleep either at the beginning or in the middle of the night, get out of bed and only return to bed when sleepy again.
4) Avoid excessive napping during the day. A brief nap (15 to 30 minutes), taken approximately after 7 to 9 hours after rise time, can be refreshing and is not likely to disturb nocturnal sleep
-- Sleep restriction: This procedure is designed to eliminate prolonged middle of the night awakenings. It has several steps. This first step consists of limiting the time spent in bed to the time that one is actually sleeping. Subsequent steps consists of gradually increasing the time spent in bed.
For example, consider a person tat goes to bed at 11:00 pm and gets out of bed at 8:00 am but sleeps on average only about 6 hours per night. During the first step of this procedure, this person will only be in bed for 6 hours (12:00 am to 6:00 am). This sounds harsh but after a week or so there will be a marked decrease in time spent awake in the middle of the night. Usually people experience marked improvement in the quality of sleep. They also realize that they are not getting enough sleep. The next step is to gradually extend the time spent in bed by 15 to 30 minutes, as long as the wakefulness in the middle of the night remains minimal.
Each new extension of the time in bed is followed for at least a week before progressing to the next extension. Many people with insomnia discover a point which they do not need to extend the time spent in bed because they get enough sleep to be optimally alert during the day. It is recommended that the time allowed in bed should not be less than 5.5 hours per night. This procedure works best when it does not increase anxiety about restricting sleep. There are several variants of sleep restriction from which the therapist can choose based on individual patient's needs.
-- Skills for reducing arousal at bedtime: These include a variety of relaxation techniques, stress management skills, and reducing sleep related worries. In addition, the following changes of sleep related behaviors are recommended:
-- Use the hour before bedtime to unwind from the day's stresses. This down time will allow sleepiness to come to the surface and will therefore facilitate sleep onset. This is a time to engage in activities that are enjoyable yet calming.
-- Avoid clock watching. Turn the clock around so you cannot see the time yet you can still use it as an alarm. A recent study showed that volunteers who were asked to monitor a digital lock at bedtime took longer to fall asleep than those monitoring a similarly looking device that displayed random digits.
-- Avoid exercise 4 hours before bedtime.
-- Make sure that the sleep environment is safe, quiet, and pleasant.
Recommendations related to foods and substances:
--Avoid alcohol close to bedtime. Alcohol speeds the sleep onset but this positive effect is counteracted by increased wakefulness in the second half of the night.
--Avoid stimulants. Caffeine has a rather long half life (about 6 to 8 hours). People's sensitivity to the effects of caffeine is variable. Those with caffeine sensitivity should be particularly careful to avoid caffeine after lunch. Certain prescription and non-prescription drugs contain caffeine and when feasible should be avoided close to bedtime. Nicotine and nicotine withdrawal can also interfere with sleep.
--Avoid a heavy meal close to bedtime and avoid eating in the middle of the night. Digestion slows down during sleep and indigestion can disrupt sleep.
Cognitive behavior therapy for insomnia is usually provided by psychologists with special training in the treatment of sleep disorder. The therapist makes a thorough assessment and decides which specific recommendations are most relevant to the individual patient. This means that patients can concentrate their energy on changes that are most likely to provide improvements in their sleep. The therapists also helps people overcome obstacles to making the necessary, often difficult, changes in sleep-related behaviors. When the patient's circadian clock is not aligned with his or her desired bedtime and wake time, the therapist recommends properly timed exposure to bright light in order to shift the circadian clock in the desired direction. Best results are achieved when patients are able to shift their attitudes from "trying hard to sleep" to "allowing sleep to happen". The therapist can help patients make this shift.
The majority of patients respond to this treatment is fairly quickly. Some experience significant improvement after only two therapy sessions. Most improve after 4 to 6 sessions but a few night need additional sessions. Both group and individual treatment sessions are effective.
The American Academy of Sleep Medicine has established certification in Behavioral Sleep Medicine.
--Avoid stimulants. Caffeine has a rather long half life (about 6 to 8 hours). People's sensitivity to the effects of caffeine is variable. Those with caffeine sensitivity should be particularly careful to avoid caffeine after lunch. Certain prescription and non-prescription drugs contain caffeine and when feasible should be avoided close to bedtime. Nicotine and nicotine withdrawal can also interfere with sleep.
--Avoid a heavy meal close to bedtime and avoid eating in the middle of the night. Digestion slows down during sleep and indigestion can disrupt sleep.
Cognitive behavior therapy for insomnia is usually provided by psychologists with special training in the treatment of sleep disorder. The therapist makes a thorough assessment and decides which specific recommendations are most relevant to the individual patient. This means that patients can concentrate their energy on changes that are most likely to provide improvements in their sleep. The therapists also helps people overcome obstacles to making the necessary, often difficult, changes in sleep-related behaviors. When the patient's circadian clock is not aligned with his or her desired bedtime and wake time, the therapist recommends properly timed exposure to bright light in order to shift the circadian clock in the desired direction. Best results are achieved when patients are able to shift their attitudes from "trying hard to sleep" to "allowing sleep to happen". The therapist can help patients make this shift.
The majority of patients respond to this treatment is fairly quickly. Some experience significant improvement after only two therapy sessions. Most improve after 4 to 6 sessions but a few night need additional sessions. Both group and individual treatment sessions are effective.
The American Academy of Sleep Medicine has established certification in Behavioral Sleep Medicine.
Comparing sleep with medication with non-medication treatment of insomnia
Both insomnia medications and cognitive behavioral therapy for insomnia, discussed in the previous chapter, are effective. The two have yield very similar levels of improvement at the end of 6 to 8 weeks of treatment. Sleep medications start working right away, whereas the benefits of cognitive behavior therapy for insomnia are slower to emerge. On the other hand the effects of this therapy are longer lasting. Six to 24 months after the end of treatment people originally treated with cognitive behavior therapy for insomnia sleep better than those originally treated with medication.
Several self help books describe this therapy. These books provide information on how to overcome some common difficulties encountered when implementing the recommendations outlined above.
Several self help books describe this therapy. These books provide information on how to overcome some common difficulties encountered when implementing the recommendations outlined above.
The following are a few of many good self help books for insomnia for adults:
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Insomnia - Wikipedia, the free encyclopedia
Offers information about insomnia, its treatments more...2 points
Insomnia - MayoClinic.com
Insomnia %u2014 Comprehensive review covers sympto more...1 point
Are these 7 mistakes killing your sleep?
Take the quiz and beat insomnia1 point
American Insomnia Association
Insomnia, defined as trouble falling asleep or sta more...0 points
Insomnia? 41 Simple Tips to Help You Get to Sleep - Insomnia ...
41 simple tips for dealing with insomnia and getti more...0 points
ADHD and Sleep Disorders
Is ADHD the cause or an effect of insomnia?0 points
Practice Self Hypnosis as Treatment for Insomnia
Insomnia Hypnosis - A natural remedy and cure for more...0 points
http://www.squidoo.com/insomnia-hypnosis-treatment
Insomnia is a sleep disorder in which a person has more...0 points
Sleep Apnia
All about sleep apnea0 points
Insomnia headquarters Headquarters
Sleep disorders and Insomnia solutions
Sleep is ab more...0 points
A wise person said:
It's all about the placebo effect. If you think you're going to sleep, you probably will.
If none of this works...
You can always rent a movie.
Insomnia (Widescreen Edition)
Amazon Price: $5.99 (as of 07/05/2009)
This is a tongue-in-cheek suggestion from Seth, your host. After reading all this about insomnia, I don't know about you, but I'm going to have trouble sleeping.
Your Turn: Meds or no meds?
Many people have had enough...
What about sleeping meds?
Fetching blurbs now... please stand byNo! Overhyped pharma solution to a natural problem
fefe says:
I was helped by a cd with delta waves that helps me fall asleep and do not have anymore problems sleeping. Maybe some do need meds but I would like to avoid them.
Posted May 26, 2009
monarch13 says:
I was in Pharma Sales for 9 years in my previous life and sold a new sleeping pill. I have finally seen the light and while medications can be lifesaving, they all too often hide the symptoms while ignoring the underlying cause.
Posted August 23, 2008
hesika says:
To sleep well, it needs to say good bye to the thoughts of the days (if there is not a physical problem). That you can reach with a walk before go to bed, to eat an apple or simply not to watch TV or movie with horrible content before going to bed. Be calm and fill you with good thoughts. Then you always will sleep like a baby.
The meds are for the pharmacy industry can earn tons of Dollars - and they mostly destroy your boddy.
Posted July 25, 2008
CherylK says:
At the end of a particularly busy or stressful day I'm almost guaranteed insomnia unless I take an hour or so before going to bed to do something quiet...sometimes I work sudoku puzzles or write to a journal or read poetry. I will not, under any circumstances, take meds.
Posted July 24, 2008
Frankster says:
Some meds made my problem worse. Others did nothing. When I practice good sleep hygiene (no naps, to bed same time every night, no caffeine after 5:00 pm, no fluids after 8:00 pm, etc.), I sleep like a baby.
Posted January 18, 2008
Yes! Let me sleep...
getbackup says:
I take them occasionally. If I can't sleep, or am worried & stress & know I won't sleep, I'd rather take them than be up all night & exhausted the next day.
Posted November 29, 2008
jacklhasa says:
I take my meds every night. Amitriptyline, always(for depression and sleep), and Ambien for the nights when even that is not enough.
Posted November 25, 2008
Joodie says:
I take three types of meds, a prescribed sleep med, an anti-anxiety med and an over the counter sleep aid. And I'm still not sleeping well. The only way I can ensure sleep is by having a miserably exhausting day. :-
Posted August 13, 2008
Or you can watch the video...
Have you lost a night's sleep in the last month?
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Seth Godin is the bestselling author of ten books. He writes about marketing, the spread of ideas and managing both customers and employees with respe... (more)
