Sleep Problems – How To Deal With Insomnia
Almost everyone experiences sleep problems – insomnia. Although a fortunate few routinely enjoy refreshing sleep, most of us at least occasionally suffer through less than restful nighttime hours. While individual requirements for sleep vary considerably, the optimal range typically hovers around seven hours. Either too little or too much sleep may be associated with negative health consequences.
Medically speaking insomnia refers to difficulty falling asleep, staying asleep throughout the night, awakening early and being unable to return to sleep or arising in the morning feeling unrefreshed. Generally a combination of these symptoms occur in those affected.
By definition insomnia must persist for at least three months and requires at least three weekly episodes of problem sleep together with a negative impact on an individual’s quality of life. Common use of the term however refers to even a single episode of sleep disruption.
Understanding of sleep disorders continues to advance. It seems certain that insomnia represents the interaction of biological, genetic, medical, psychological and situational factors further exacerbated by poor sleep habits.
Certain groups of brain cells originating in the hypothalamus maintain wakefulness while neighboring cells are charged with promoting sleep. These neurons interact and function in a manner similar to a see-saw with the dominant part determined by input from yet another hypothalamic chemical known as hypocretin or orexin. Additionally light entering through the eye turns off melatonin production and enhances wakefulness; darkness stimulates melatonin synthesis and moves the balance toward sleep.
Of course a variety of chemicals referred to as neurotransmitters relay messages within the brain regarding the sleep wake cycle. Adequate concentration of histamine, serotonin, dopamine, acetylcholine and noradrenaline seems intimately associated with wakefulness. Inheritance and genetic variation not only determine levels of these compounds but also the ability to transport them to their proper functional location. Disruption anywhere in these pathways may predispose to insomnia.
Multiple other genetic factors impact on sleep. Some individuals seem unusually susceptible to the effects of caffeine, alcohol or exercise while others need total darkness to sleep. All of these trace their origin to specific genes. The same situation exists with one’s ability to tolerate jet lag and rotating work schedules.
An extremely uncommon disease testifies to the importance of genetics and sleep. Fatal Familial Insomnia generally manifests itself in those affected at around age 50 with death following approximately eighteen months later. Transmitted directly from a parent in a dominant fashion, the disease involves the same underpinnings as the human variant of Mad Cow Disease. Progressively worsening insomnia leads to hallucinations and delirium which ultimately ends with Alzheimer’s-like dementia followed by certain premature death.
Sleep disorders may be categorized in a number of different fashions. Primary insomnia represents a genetic condition without other predisposing input and occurs in up to 5-10% of the population. The more common secondary insomnia relates to situational factors, stress, depression, anxiety or any of a long list of medical disorders and pharmaceutical products.
Insomnia may be considered transient occurring for short periods, acute or co-morbid lasting between 1-6 months and chronic when the duration exceeds 1-6 months. Unfortunately this fails to provide any useful information regarding the underlying condition.
Perhaps the most helpful way to consider insomnia is as a condition with three different components: predisposing factors, precipitating factors and perpetuating factors. The predisposing traits tend to involve genetic factors. Belatedly the medical profession now seems to accept the role of genetics in either providing a fertile field in which insomnia may develop under the right circumstances or alternatively providing resistance to sleep disruption under almost any condition.
Precipitating factors transfer the underlying inherited potential for insomnia – the predisposing factors – into reality. Among the common precipitating factors are medical conditions, drugs, mental health issues and a wide array of life events that cause stress, worry and discomfort.
Medical problems notoriously disturb sleep. Examples include abdominal or chest pain, acid reflux, asthma and chronic breathing problems, hot flashes and menstrual irregularities, dementia and heart failure, Parkinson’s Disease and the urge to urinate at night. Low back pain and arthritis, chronic pain disorders, pregnancy and an overactive thyroid gland are other frequent events interfering with normal sleep.
An enormous assortment of pharmaceutical products – legal and not, prescription and over-the-counter – may cause insomnia. Cold medicines with decongestants are prime culprits as are some birth control pills, prednisone, cortisone and other steroids, thyroid supplements and certain asthma preparations. Some heart medicines, pills meant to treat high blood pressure and others that reduce cholesterol present danger to nighttime slumber. Pain medicines in the opioid class and even glucosamine combined with chondroitin may be at fault. Of course alcohol, caffeine, cigarettes, amphetamines and cocaine are primary sleep disrupters. Withdrawal from anti-anxiety medications, sedatives, alcohol and amazingly even sleeping pills result in poor quality sleep.
Previously thought to be the major cause of chronic sleep disorders, depression and anxiety still remain extraordinarily common but now share the spotlight with an ever expanding list of nighttime demons. Depression classically expresses itself as overwhelming sadness or hopelessness often coupled with loss of interest in formerly enjoyable activities and lack of motivation. These regularly combine together with a seemingly unending list of somatic or physical complaints falsely attributed to a self-diagnosed medical problem. Prominently included among this category of insomnia are symptoms including awakening early, being unable to return to sleep and feeling unrefreshed in the morning. Anxiety associated with worry, nervousness and internal stress characteristically interferes with falling asleep and remaining so until morning. Symptoms of PTSD and bipolar disease include insomnia.
Sleep Apnea, Restless Legs and Jet Lag
Interestingly certain sleep related disorders interrupt sleep. Obstructive sleep apnea generally occurs in overweight individuals with a relatively large neck circumference. Interference with breathing and the resulting lack of oxygen coupled with gasping, snorting and sometimes jerking lead to disrupted sleep architecture if not outright awakenings. Headache, hypertension, inability to concentrate and daytime fatigue also result.
Restless leg syndrome affects up to 10% of adults manifesting primarily as a crawling sensation, discomfort or unease especially in the legs resulting in the need to move the affected part. It tends to occur progressively more frequently later in the evening and while lying in bed. Obviously this interferes with sleep onset. A distinct but often co-occurring condition, Periodic Limb Movements of Sleep or PLMS leads to toe, foot, leg or hip movement during the night and ranks as an extremely common cause of nighttime sleep disruption.
Jet lag tends to cause temporary problems, however rotating work schedules pose the likelihood of major longstanding sleep disruptions. Financial woes, marital disharmony, a traumatic experience and job related stress add to the likelihood of insomnia, especially in those with the underlying inherited genetic predisposition. Even snoring by a bedmate or an impetuous dog or cat may be a major culprit.
Perpetuating factors catapult the precipitating factors onto a downward spiral or viscous cycle whose outcome almost guarantees long lasting problems. Individuals begin to worry not about the original problem but whether they will be able to sleep tonight. Included among the perpetuating factors are bedroom noise, excessive light in the room, inadequate temperature control and an uncomfortable mattress. These may indeed perpetuate a few sleepless nights into a chronic situation.
On realizing insomnia exists, a variety of measures may assist in control of the problem. Certainly when a disease, drug or other specific culprit can be identified as causing sleep disruption, the path toward success seems obvious. Unfortunately the situation remains less obvious in the majority of those suffering from chronic insomnia.
Health care professionals generally suggest well meaning but typically insufficient alterations in activities to achieve optimal environmental conditions conducive to sleep. These sleep hygiene measures include avoidance of alcohol, tobacco products and caffeine – coffee, tea, colas – for at least several hours before bedtime. Eating during the several hours before bedtime similarly falls into the verboten list. Exercise during this time frame is similarly discouraged. Naps in excess of twenty to forty minutes, especially after 4 p.m., remain counterproductive.
The bedroom should be quiet, dark and without lights from the television, monitor, cell phone, nightlight or illuminated clock. In order to create a proper mood, the bed should be reserved for sleep and sex. Activities such as eating, reading and television viewing should be relegated to another area. About a half hour prior to retiring, a person is advised to engage in some relaxing activity simultaneously minimizing effects of the any lingering stress.
Highly touted as a first choice for therapy Cognitive Behavioral Therapy for Insomnia [CBT-I] offers some advantages compared to a pharmaceutical approach. Typically it requires four to six sessions with a trained psychologist over a six week period. Internet options offer a less expensive and more flexible approach. CBT-I assists in shortening the time to fall asleep and extends nighttime slumber by about thirty minutes. Components include muscle relaxation, initial restriction of time in bed, learning proper sleep habits and stimulus control. Unlike with pills, benefits of CBT-I may persist long after discontinuation of therapy. Unfortunately reality suggests this type of therapy will never be routinely utilized.
Practically however many simply reach for a pill. Readily available over-the-counter antihistamines remain extremely popular even though these long acting drugs linger into the next morning and frequently lead to grogginess, sleepiness, lack of mental focus and inability to concentrate. Diphenhydramine or Benadryl and Doxylamine pose additional risks for seniors and may lead to difficulty urinating and predispose to traumatic hip fractures. Examples include Sominex, ZZZ Quil, Tylenol PM, Unisom and Costco Sleep Aid.
Popular lore suggests advantages for a seemingly unending list of herbal remedies such as valerian, chamomile, lavender, passion flower and even L-arginine. With a placebo effect approximating 50%, these might indeed offer relatively significant and reasonably safe alternatives to prescription drugs. Unfortunately adequate studies do not confirm their benefits. Proponents also claim cannabis provides assistance; this similarly remains inadequately studied.
Melatonin appears to fall into a parallel category. This hormone produced naturally by the brain’s pineal gland certainly plays a role for some in treating insomnia related to jet lag and rotating work shifts. Supposedly it assists with realignment of the body clock. Evidence for its role in other sleep disorders remains rather sketchy with significant variations existing in product quality, dose and adulterants. Rozerem, a prescription compound acting on melatonin receptors in the brain offers limited effects at an extraordinarily price. Non24 or Hetlioz, the highly advertised melatonin-related product retails for nearly $200,000 a year and qualifies as an insurance company rip-off.
Typical sleeping pills include the benzodiazepines and the related and basically similarly effective non-benzodiazepine drugs. Included among the former are Restoril [temazepam] and Halcion [triazolam] while the later, frequently referred to as the Z’s because of their generic names, are typified by Ambien [zolpidem], Sonata [zaleplon], and Lunesta [eszopiclone].
While initially the Z’s were touted as safer and more effective, differences between the agents lack confirmation. Since they even target relatively close areas on the same receptor, they may be considered interchangeable in effectiveness, side effects and potency. Some pills shorten the time to initiating sleep while others function more in the realm of it’s maintenance. Depending on individual metabolism, some longer lasting pills may lead to a hangover effect creating problems with morning activities such concentration, learning and safe driving.
Risks versus Benefits
Experts argue about whether the potential risks of the pills exceed their benefits. While the overwhelming majority of consumers luxuriate in more restful sleep, studies cast doubt on whether the pills actually increase total sleep time beyond 10-15 minutes. Effectiveness for more than several weeks to months remains questionable. However since the array of sleep related disorders remains so broad, one may reasonably argue their ongoing benefits may provide those with genetic or primary sleep disturbance a measure of relief beyond dispute.
Other options include anti-depressants prescribed in low dose for those without depression while individuals suffering from mood disorders require more traditional drug levels. Actually studies of Doxepin, Elavil [amitriptyline], Pamelor [nortriptyline], trazodone and Remeron remain less than ideal. Side effect potential seems greater than with the more traditional benzodiazepines.
People regularly fear addiction along with other harmful consequences of sleeping pills. However it seems adverse effects of inadequate sleep on daytime function dwarf any potential negative impact of commonly prescribed therapy. Attention to sleep hygiene, appropriate attention to stress reduction, treatment of underlying medical disorders and avoiding drugs known to cause problems certainly seems appropriate. Alternatively for those with a strong genetic component, long term benzodiazepines or the so-called Z’s appear a reasonably safe option.
Health Consequences of Poor Sleep
Critics argue that sleeping pills carry some definable health risk. Unfortunately these same experts neglect the long list of major health concerns associated with insomnia. Feeling tired and generally ill, difficulty concentrating, irritability and mood swings frequently accompany insomnia. Breathing disorders, high blood pressure, tension headaches along with an enormous number of intestinal complaints may trace their origin to difficulty sleeping. A greater incidence of motor vehicle accidents, worsening of anxiety or depression, a negative impact on school or work and even weight gain count among the consequences of inadequate sleep.
For more information, please refer to my video blogs on Sleeping Pills.