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Understanding
and Treating Insomnia
Jim Spira, PhD, MPH, ABPP -
Navy Medical Center San Diego
You
are not alone in having trouble sleeping.
It is estimated that insomnia periodically
affects 50% of adults, and more than 90% of the population have trouble
with sleep at
some point during their lives. (Gallup,
1995). Sleep is a precious function, one which we
take for granted until it becomes difficult to sleep.
Then we notice that sleep affects
everything we do. Poor sleep
affects our thinking, resulting in less ability to concentrate,
poorer memory and difficulty solving problems
It affects how we feel, putting us in a
bad mood, making us less tolerant to stress and at the same time less
control over our
emotions and less tolerant of others.
Not getting enough sleep influences our body's
functions: we have less energy, are more sensitive to pain, more likely
to get headaches,
digestion is disrupted, sexual interest is diminished, and our immune
system functions
more poorly making it harder to fight off illness.
Finally, overall performance degrades,
and we find that we can't do things as well or as fast as we should be
able to. Even
driving becomes more dangerous.
The
only good news is that most people with sleep problems can learn to
improve their
sleep. It takes work, but
the work pays off. The
earlier you begin working to improve
your insomnia, the faster it can be corrected.
Still, a recent study in JAMA
(Edinger et al, 2001) showed that people with an average of 14 years of
insomnia were
able to improve their sleep by getting off of sleep medication and
learning what we call
sleep hygiene and relaxation skills.
This paper tells you what you can do to get control
over your insomnia. By
making a concerted effort, you can improve both your sleep
and your quality of life.
SLEEP
PROBLEMS
Before
discussing what to do to correct sleep problems, it is important to
understand
the different types and causes of sleep problems.
Types
of Sleep Problems
There
are different ways that sleep can be disturbed.
Pinpointing the problem helps
in figuring out how to correct the problem. Some have difficulty
initially falling asleep,
lying in bed for hours before finally falling to sleep.
Others have trouble staying asleep,
waking periodically throughout the night.
Many wake early in the morning, and can't
get back to sleep. Still
others claim that they sleep all night, but must not be sleeping
deeply, since they feel tired all day. Most people with insomnia have a
combination of
these.
Causes
of Sleep Problems
There
are two basic categories of insomnia, Primary Insomnia and Insomnia Due
to Other Causes.
Primary
Insomnia, insomnia without any obvious medical or psychological cause,
is quite common. It usually
begins at a time of stress at work or in the family, or with
a major change of life (such as starting a new career, family or moving
to a new city).
Many persons with Primary Insomnia may have a genetic predisposition, a
parent or
sibling also having the problem. This
type of person may have less serotonin, a
neurotransmitter, and may be a bit more high strung, sensitive to
sensations
(light, sound, smell, touch, motion), hard working, organized,
conscientious, and has
difficulty relaxing. This
person may also develop migraines, chronic diarrhea or
constipation, chronic muscle pain, and often is more prone to anxiety or
anxious
depression. Of course, some
persons with Primary Insomnia do not share these
characteristics.
Insomnia
Due to Other Causes requires taking care of BOTH the cause as well as
the insomnia - which can remain even after the initial cause has been
removed.
Insomnia is almost always present with psychological problems such as
anxiety,
anxious-type depression and chronic stress and worry following some
life-crisis.
Insomnia also frequently results from medical problems, including pain,
endocrine or
metabolic diseases (like diseases of the thyroid or adrenal glands) and
is common in
menopause. And there are
sleep-related illnesses such as Restless Leg Syndrome
(where the legs regularly jerk throughout the night) or Sleep Apnea (a
breathing
disorder where insufficient air is taken in during the night). Many
medications used to
treat medical problems also can interfere with sleep. These
psychological and medical
problems must be addressed with your doctor as a first step in
correcting your sleep.
NORMAL SLEEP
In
order to know how to correct sleep problems, it helps to understand the
normal
sleep that we are attempting to recover.
States of Consciousness: There
are four basic states of conscious.
These states actually
lie along a continuum, yet each has distinct states of consciousness and
brain functioning
(see Table 1). Each state is
associated with a different brain wave frequency, level of
mental effort, focus of attention, and different amount of conscious
awareness
(vigilance of self, environment and what one is doing).
MHz
0
4 8
12 16
<--------------------------------------------------------------->
Delta
Theta
Alpha
Low Beta High
Beta
<--------------------------------------------------------------->
low
high
eeg frequency
cognitive effort
attentional focus
reflective
consciousness
__________________________________________________________________________
Table
1. EEG states of
consciousness
ALPHA:
Calm, clear attention (meditation, listening to a concert or
a lecture, or
watching a movie) is associated with moderately fast Alpha brain
waves, modest mental
effort, broader attention, and less conscious reflection about what we
are doing. In this
state, it is easier to become absorbed in the sensation we are watching
or listening to.
It is possible to stay in Alpha states for long periods of time,
but eventually, one needs to
recuperate even from this state.
THETA:
Letting-go of effortful focused attention to one's
environment and allowing
oneself to creatively daydream is associated with slower frequency Theta
eeg brain waves.
This is a recuperative state that allows us to reflect creatively about
what has been or
what could be.
Typically,
persons flow through Beta, Alpha and Theta throughout the
day, as all these
states are needed in normal human functioning.
A healthy person spends about equal
time in each, and problems occur when one spends too much time in any
one of these.
Too much Beta is associated with stress and lack of creativity
and enjoyment. Too much
Theta is associated with day-dreaming, and not being able to
express one's dreams. Too
much Alpha and one is not as creative or expressive as one could
be. Still, Alpha is a
good "standard" state to be in, and is optimal for walking and
driving and listening and
watching - things we do in between working and daydreaming.
DELTA:
Deep sleep is associated with low frequency Delta eeg
brain waves. This state
should be the most effortless, unfocused and unconscious state we enter.
Although there
are some slow Delta waves during the day, they are usually
minimized, and come out
more during our nightly sleep.
In
fact, all these states are always occurring to more or less of an
extent. Problems with
sleep occur when we get "stuck" in one or more brain states,
maintaining higher
frequency states during our sleep state, where delta waves should be
high and other
frequencies should be minimized. We
need to have a balance of the non-Delta
frequencies during the day to insure reduced non-Delta activity
during sleep, when
Delta should be largest.
Stages
of Sleep
We
go through four distinct stages of sleep.
These are simply called Stage I, II, III and IV,
or “non-REM” sleep. Delta
sleep occurs at the deepest levels, stage III and IV.
Each
sleep stage has specific characteristics, ranging from light sleep
(Stage I) to deep sleep
(Stage IV). Normally, we
cycle through all four stages over a 90-minute sleep cycle,
and we have four or five of these complete sleep cycles each night (See
Table 2).
__________________________________________________________________________
Awake
Beta
Alpha
pm
am
Theta
.
.
Stages
Light I
.
pr.
. pr.
. pr.
. pr.
.
.
Of
Sleep Sleep
II
. .
. .
. .
. .
.
.
Delta III
.
.
. .
. .
. .
. .
Deep
IV
. .
. .
. .
. .
. .
Sleep
__________________________________________________________________________
Table
2. Stages of Sleep.
Normal sleep includes cycling through four stages of sleep
every ninety minutes, and entering REM (rapid eye movement sleep) during
which time
we experience neuro-muscular paralysis, or paralytic REM (pr).
Stage
I is a light sleep stage, one we enter into upon initially
falling asleep, and again
when we emerge from deeper stages of sleep throughout the night.
It is at these lighter
stage of sleep that we have dreams that we may remember, and we dream
with
Rapid Eye Movements (REM) during this stage.
Also, we become momentarily
"paralyzed" during this REM activity.
Many of us have had the experience of being
awakened from some outside source (alarm, phone, child, etc) during this
phenomenon,
and being somewhat scared that we could not move.
Of course, we could force ourselves
to move out of this and wake up completely.
It is speculated that this paralytic REM (pr)
is a normal recuperative state. Indeed,
persons who do not enter this state develop
problems, ranging from Fibromyalgia (chronic muscular pain) to psychotic
hallucinations.
Clearly, paralytic REM should be welcomed as a much needed nightly
occurrence!.
Persons with Fibromyalgia bring too much alpha activity into
their sleep, limiting normal
deep sleep and restricting paralytic REM, thus contributing to or even
causing their
painful condition. It has
even been reported that persons with Fibromyalgia who undergo
surgery and receive general anesthetic (and are thus paralyzed for a
time) have no
symptoms of Fibromyalgia for several days following the surgery.
Stage
II is a deeper level of sleep, one which most
people fall into just after stage I
sleep, and then again just before re-emerging from deeper sleep into
Stage I sleep.
While we probably dream during this stage of sleep, it is more difficult
to recall these
dreams unless abruptly awakened from it.
Many medications help move one into
stage II sleep.
Stage
III and IV sleep are the deepest levels of sleep, and
important for feeling rested
recuperated when you wake up the next morning.
We recall little of what we dreamed
while at these levels. Unfortunately,
most persons with insomnia do not get to stage III
and IV sleep very often or for sufficient time during each sleep cycle.
Many drugs and
over the counter medications also tend to restrict these deeper stages
of sleep, although
they can ease one into the lighter stages of sleep – see Table 4 (Dingemanse,
1995;
Kupfer, 1997; Tsoi, 1991; Parrino, 1996).
Disruption
of Normal Sleep:
Problems with sleep occur when these normal sleep cycles are disrupted.
Disruption
can occur in several ways, as mentioned above:
-
Trouble falling asleep:
one might have difficulty initially falling asleep.
This usually
involves bringing too much Beta (problem solving or worry) or Alpha
(vigilant attention)
rhythms into one's bed.
-
Trouble staying asleep: Many
persons wake repeatedly throughout the night.
If this
happens after a complete 90-mnute cycle, at least one is getting some
sleep benefit,
and it is somewhat tolerable if one can go back to sleep and continue to
get more of
these complete sleep cycles. Those
who must wake up to urinate at night or to feed
their baby often have this experience.
However, if one wakes repeatedly and has
difficulty falling back to sleep, sufficient full sleep cycles are
probably not being achieved.
-
Trouble sleeping deeply:
Perhaps the most troubling type of insomnia is when one
sleeps so lightly that they rarely enter deep stage sleep.
When one only enters stage I
and II sleep, without achieving normal stage III and IV sleep, not only
do they not get the
recuperative benefits from these deeper levels, but they probably don't
get good paralytic
REM either. REM is dependent
upon the normal sleep cycle, and any disruption in this
cycle causes a disruption in REM. People
experiencing reduced deep sleep and REM
usually have more significant difficulties with mental, emotional and
physical problems
(which both cause and result from these sleep problems).
Most often these sleep
problems are caused by bringing more high frequency brain waves (beta
problem solving
and worry, and alpha vigilant attention) into one's bed.
All
of the above can be improved through healthy sleep habits, what we call Sleep
Hygiene
and improving your health in general through living a healthy
lifestyle.
-
Trouble due to medical problems:
Restless leg syndrome, sleep apnea, hormonal
changes and pain all can cause a reduction of sleep in the ways
described above. They
must be addressed directly, along with ways to improve sleep.
ARE YOU REALLY READY TO BEGIN
Before even beginning with techniques
for improving sleep patterns, it is important to
first address how willing you are to achieve better sleep!
-
Motivation to do whatever it takes: It WILL
take a lot of effort, in terms of life
changes and personality changes to overcome this problem.
The good news is that
these changes will result in improved quality of life and physical
health (even for those
who don't have insomnia). You
may feel you don't have the time to make these changes.
But just remind yourself how much time you are losing - not to mention
the poor quality
of your time - due to the insomnia.
-
Willingness to let-go.
. Many people with insomnia have a need to remain vigilant.
But sleep is about letting-go of vigilance!
It is necessary to be able to address one's fears
of letting go of vigilance, giving up to a greater power than your
consciousness (be that
your body's wisdom, the natural processes of the world, or God).
Bottom line: if you’re
afraid to let go of your conscious vigilance, you won’t achieve a
restful sleep. To the
extent to which you can let-go of conscious vigilance, you will
achieve a restful sleep.
-
Attentional Retraining: Persons who have a
baseline anxiety come to believe that
“if I worry about the saber-tooth tiger, I can keep it at bay.
If I ever stop worrying about it, it will
pounce on me and eat me alive.” Yet
while worrying about something can be useful if you
can act on it to make it better, worrying about something without acting
on it is simply
neurotic, and will only make things worse.
You have control over what you pay attention
to, and you can learn to pay attention to what is healthy and ignore
what is neurotic.
Rule
#1: Whatever you pay
attention to, you enhance. If
you pay attention to worry,
you will worry more. If you
pay attention to something pleasant and comfortable, you
will worry less. Sure, the
problem you are worrying about won’t go away, but worrying
about it won’t make it go away either, and in fact will only make you
more sick, and less
able to handle real problems tomorrow.
Rule
#2: You become what you
pay attention to. If you
pay attention to worries,
your nervous system gears up to handle an emergency, and you become more
aroused
and nervous (especially if you can’t act on anything).
If you pay attention to something
comforting (like the breath, the softness of your bed, a warm bath,
music, etc.) you
become more comfortable, as your nervous system gears itself to relax.
-
Don’t wait!
If you wait until you feel like exercising, until you’re
“ready” to set a
regular schedule, and until you are have enough time to practice
relaxation, it will
probably never happen. It is
necessary to “just do it.” Just
starting to follow the
regular schedule you lay out for healthy sleeping will begin to make you
feel better,
perhaps not right away, but soon.
SLEEP
HYGIEN
Now that you understand the nature of
sleep, and are motivated to do whatever it
takes to regain healthy sleep, here are some important rules for
regaining healthy sleep
(Bootzin, 1992).
What
to do:
-
Stop working and relax an hour before going to bed.
-
Go to bed and wake up at the same time every night, as
consistently as possible
-
Do a relaxation exercise (see Table 3, below) just before
getting into bed.
-
Continue to focus on your breathing when you get into bed.
Rather than focus on your thoughts, focus on your breath.
-
Use the bed for sleep (and sex) and that’s all.
-
Have a comfortable environment, no TV blaring, computers
humming, etc.
-
If you have an important thought, that you can act on in
the morning, write it down on a pad of paper you keep next to your bed
for such “emergencies!”
-
If you wake up at night,
o
first do the relaxation exercise (Table 3), in bed.
o
if still awake after 20 minutes, get up and out of bed and
do something active
in a different room, such as reading, dishes, clothes, etc (try not to
watch TV,
which can keep you in an alpha state, keeping you up longer than you
would if
you did more active tasks).
o
When you feel
tired, do your relaxation exercise again, in a chair and continue
it in bed, lying down.
o
Repeat this cycle as often as you need to, never staying
in bed, awake, for more
than 20 minutes.
What
NOT to do:
-
Don’t take naps during the day.
It may be rough for the first few days, but it will
soon pay off.
-
Don’t drink caffeine, especially after 2pm.
-
Don’t drink alcohol, certainly not within three
hours of going to bed (alcohol
causes a rebound effect. It
will get you to sleep faster, but it typically wakes you up
several hours later)
-
Don’t read, watch TV, do work, argue or do
anything else in bed, except sleep
and sex.
-
Don’t exercise within three hours of going to
bed.
-
Don’t eat spicy food at night.
-
Above all, don’t worry.
It only makes things worse.
Healthy
Lifestyle
Sleep
hygiene will set the stage for healthy
sleeping. However, leading a
healthy
lifestyle and learning to regularly rest and recuperate are necessary
before healthy
sleeping can resume.
Regular
Exercise: Daily moderate
exercise, best done earlier in the day, every day,
at the same time will help tremendously.
Moderate exercise means that you spend at
least 20 minutes in an activity that causes you to slightly perspire
over your entire body
and breath heavier, so that it is a bit difficult to talk.
When aerobic exercising is not
possible, then 20 minutes of stretching or at least walking is second
best.
Regular
Eating: Eating healthy (non-fatty, non-sweet, non-excessive) meals,
including
a healthy breakfast and a dinner that is not too late at night, is
important as well. Eating
healthy foods on a regular schedule tells your metabolism when to gear
up, and when to
gear down. It also keeps your
blood sugar at a stable level.
Regular
Recuperation: Spending
as much time in Alpha and Theta as you do in Beta
(see Table 1) will allow you to let-go of always being “aroused”
and focused on work.
If you spend 8 hours of actual focused, effortful work, then plan to
spend at least that
amount of time on attending to sensations (Alpha activities, such
as music, art, exercise,
etc.) or day-dreaming (Theta activity, such as creative
imagination, remembering, etc,
but on non work-related activities). Finally, plan to spend at least
5-10 minutes on a
relaxation exercise at various times of the day, such as:
o
When you wake up
o
Sitting in your car before going into work
o
Before lunch
o
Before you go into your house after work, or before dinner
o
Before bed.
These five minute “mini-breaks” can help your nervous system
regulate itself throughout
the day, and leave you feeling more restful, focused and energized
during the day, and
more prepared to sleep deeply at night.
Sit in a comfortable chair, with your hands on your belly:
-
Feel your body sinking into the chair
-
Feel your legs sinking into gravity, and all the muscles
letting go of tension
-
Feel your body sinking into the chair, and all your back
muscles melting
-
Feel your arms sinking into gravity, and all the muscles
letting go of tension
-
Feel your head, resting on your shoulders, and your facial
muscles melting
Focus on the breath, flowing into and out of
your nose for six breaths:
-
Feel the soft cool air flowing in, and the warm
comfortable air flowing out
-
If your attention is distracted by thoughts or sounds, let
them go and return your
focus to becoming absorbed in your breath.
Focus
on the breath, expanding and releasing your chest for six breaths:
-
Notice your entire rib cage filling and emptying all
around, like a balloon
-
Don’t try and breathe, simply let the breath breathe
you.
-
And every time you exhale, let go of the breath a little
bit more, and a little bit longer,
at the bottom of each exhale
Focus on the warmth of your
hands, for six breaths
-
Blending with the warmth of your belly
-
Rocking forward and back with the breath moving your belly
Finally, just sit and feel the breath breathing you, everywhere,
effortlessly,
for at least six breaths.
Table
3. Rapid Deep Relaxation
Exercise.
Severe
Insomnia - when nothing else works.
Most people improve their sleeping in
a matter of days or weeks by:
a)
being motivated to do whatever it takes, and are willing
to let go of worry
b)
following sleep hygiene guidelines
c)
improving and having a regular healthy lifestyle (exercise
and nutrition)
d)
resting and recuperating throughout the day, and
especially before bed.
Yet
there are some people (and probably some times for all people) who,
despite their
best efforts to improve their sleep through the methods described above,
may need
temporary medication to get them through a particularly difficult time.
In such cases,
the use of sleep restriction or medication may be necessary.
Sleep
restriction
-
You have attempted all the sleep guidelines, discussed
above, for at least one month,
and you continue to implement these sleep guidelines.
-
Don’t let yourself go to sleep until you are really
exhausted. That is, if you
try to go
to sleep, but keep getting up after 20 minutes (as discussed above), and
this happens
night after night, then
-
Calculate the number of hours you typically sleep, and
then
-
Don’t let yourself go to bed until you are ready to get
that amount of sleep
(e.g. if you only get four hours sleep, and wake up at 5am, then don’t
let yourself
go to bed until 1am)
-
Keep this up for several nights, and then begin going to
bed 15 minutes earlier every
couple of nights
YOGA
POSES
If
you are still having difficulty falling to sleep, there is an old Yoga
trick that is sure to help. Lying
in a slightly inverted position, with legs above hips, and hips above
your head physiologically induces a state of relaxation after about 10
minutes (it puts gentle pressure on the baroreceptors in the
neck, which trigger a slowing of the heart rate and breathing, and a
corresponding relaxed mental state).
Inverted Pose: There
are two easy ways to get into this Yoga pose.
Method
1: Place two large pillows on the floor
next to your bed. Lie on
your back on the
floor,
with your lower legs on the bed (make sure to
rest your entire lower legs on the
bed). Put two
pillows under your hips so they are slightly
raised.Your upper back and
head will rest on
the floor, but make sure that your shoulders are
relaxed and pressed
down toward your hips, and
that your neck is slightly pressed downward
toward the floor.
You can place
your hands on
your solar plexus. Stay in this
position for at least 10-15
minutes,
and do your breathing awareness exercise (see above).
Method
1: is easier to do for most people than method 2 (below), but the problem
is
you have to get up off the floor and into bed.
When you do so, make sure to keep
focusing on your breathing.
Method
2: Put two large pillows on your bed, next to the wall.
Lie in bed with two
pillows under your hips and your legs
stretched up against the wall. You
have to be
a bit more stretched out to do this, but the results are even
better. It also has the
added
benefit of you already being in your bed.
After 10-15 minutes of doing your breathing
awareness exercise in
this position, you can simply drop your legs
and go to sleep.
Temporary
Medical Support
As
mentioned above, some sleep medications are more helpful for achieving
deep restful
sleep (stage III and IV) than others (See Table 4).
As long as a person is trying everything
they can to improve their sleep, occasional use of sleep aids may be
necessary. In such
cases (probably less than 25% of all chronic insomnia) it is recommended
that:
-
You have attempted all the sleep guidelines, discussed
above, for at least one month, and you continue to implement these sleep
guidelines.
-
Sleep Restriction has been attempted
-
Medication can be used 2 times/week (maximum) to
“catch-up”
The problem with sleep medications is that even the better
ones (the one’s that allow for
all four stages of sleep plus paralytic REM) begin to develop a
tolerance in many persons,
requiring higher and higher dosages, until they no longer work.
And even the best sleep
medications do not allow for perfectly normal sleep.
__________________________________________________________________________
Medications
Most Restrictive of Deep Stage Sleep and Paralytic REM:
Alcohol (often results in a “rebound” of wakefulness several hours
later)
Narcotics
(MS Contin, Vicodin, Percoset, etc)
Benzodiazapines
(Vallium, Xanax, Klonopine, Ativan, etc.)
Antihistamines
(Benadryll, Atarax, etc.)
Medications Least Restrictive of Deep Stage Sleep and Paralytic
REM:
Sonata (2 hours duration; useful for initial sleep difficulties; waking
up once and can’t
falling
asleep again; fairly mild)
Ambien
(3-4 hours duration of action; same uses as Sonata, but lasts longer)
Trazadone
(8 hours duration, good for sleep with multiple wakings; strong)
Elavil
(similar to Trazadone for purpose and duration, also good for pain)
Paxil
(shorter duration, and gentler; useful for concurrent anxiety)
Serzone
(longer duration, stronger than Paxil; useful for concurrent depression)
Remeron
(longer duration, stronger than Paxil, useful for concurrent depression)
Note:
Treatment of Anxiety or Depressive Disorders with a less sedating
antidepressant
(Prozac, Zoloft, Celexa, Wellbutrin, Effexir) can help reduce insomnia
secondary to those
disorders.
__________________________________________________________________________
Table
4. Sleep medications and
other medications useful for sleep.
CONCLUSION
Both understanding about sleep and what can
go wrong with sleep, as well as knowing
what steps you can take to improve your sleep will arm you with the
skills you need to
achieve deep restful sleep. However,
such knowledge and skills are only half the battle.
The other half is actually implementing these skills.
Don’t fool yourself – it is rarely
easy. The longer you have
had the sleep difficulties, the longer and harder you will have
to work to correct the problem. The
good news is that these recommendations work for
most people suffering from insomnia.
And besides improving your sleep, these methods
also help improve your mental and physical health and overall quality of
life.
So
don’t suffer any longer. Take
control over your sleep and begin taking action right
now to get the sleep you need, and deserve!
References:
Bootzin RR, Perlis ML:
Nonpharmacologic treatments of insomnia. J Clin Psychiatry
1992; 53:37-41
Dingemanse
J: Pharmacotherapy of insomnia: practice and prospects. Pharm World Sci
1995; 17:67-75
Edinger
JD, Wohlgemuth WK, Radtke RA, et al. Cognitive behavioral therapy for
treatment of chronic primary insomnia: a randomized controlled trial.
Apr 11 2001,
285(14) p1856-64.
The
Gallup Organization: Sleep in America: A National Survey of U.S. Adults.
Washington, DC National Sleep Foundation, 1995
Kupfer
DJ, Reynolds CF III: Management of insomnia. N Engl J Med 1997;
336:341-346
Parrino
L, Terzano MG: Polysomnographic effects of hypnotic drugs: a review.
Psychopharmacol 1996; 126:1-16
Tsoi
WF: Insomnia: drug treatment. Ann Acad Med 1991; 20:269-272
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