Gulf Coast Pain Management
Benign Pain

 
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

BETA:  Effortful problem solving (either productive or wasteful worry) is associated with fast Beta  brain waves, a
great deal of mental effort, narrow focus of attention, and the most consciousness of what we are doing.  It is difficult
to remain in Beta for a long time, and it is helpful to rest and recuperate by entering the other states.  The longer
one remains in Beta, the more one needs to recuperate in order to avoid stress reactions.
 
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-
minute 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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