Overcoming insomnia

Primary insomnia is a condition on its own

Insomnia can refer to either difficulty getting to sleep or difficulty staying asleep, or both. Problems with sleep are often associated with many conditions, including medical and psychiatric illnesses, as well as use of drugs, alcohol, and medications. However, insomnia often simply occurs on its own, and is then referred to as primary insomnia.

Insomnia can be short- or long-lasting. Transient insomnia (e.g., the sleeplessness that occurs just before a big test) is very common and is considered a normal stress reaction that typically disappears as the stress passes. Chronic insomnia, on the other hand, refers to sleep problems that have lasted over 6 months. When stress becomes long-term, or in individuals who are predisposed to insomnia (sleep complaints run in families), the insomnia may become more long-lasting and require treatment.

Insomnia sometimes causes more insomnia

Sometimes, paradoxically, the habits that people develop to cope with their nighttime sleeplessness delays the return of normal sleep patterns. These problematic habits include napping during the daytime, giving up on regular exercise because of fatigue, or drinking excessive amounts of coffee to promote alertness.

For these individuals, the practice of good sleep hygiene assists in re-establishing normal sleep patterns.

Seeking treatment for insomnia

Treatment for disturbed sleep should be sought when it has lasted more than a few days, and is associated with daytime problems such as mood changes, or difficulty focusing or staying alert. For a doctor to diagnose primary insomnia, all other possible causes of disturbed sleep have to be eliminated first. To do this, the doctor will ask detailed questions, including a sleep history (when and how long you sleep, how you feel before you fall asleep and when you wake up, specific sleep behaviours such as snoring and limb-twitching), as well as a medical and a psychiatric history. A physical examination and certain lab tests may be required.

If the sleep problem is chronic, the doctor may ask the patient to keep a sleep diary. This provides the best information about the actual sleep performance, its night-to-night variability, and its effects on daytime functioning.

Treatment of insomnia

Treatment of primary insomnia emphasizes:

• stress reduction
• good sleep hygiene
• strategic use of sleep-promoting medications (hypnotics)

Since falling asleep is a passive process that requires the body and mind to be relaxed, strategies which calm both the mind and body are very helpful in managing insomnia.

Exercise has a direct, beneficial effect on several factors that affect insomnia. It reduces the effects of stress, improves mood, and deepens sleep. Regular, daily exercise completed at least 4 hours before bedtime usually improves sleep performance significantly.

Relax before bedtime: To ensure a relaxing "buffer zone" before bedtime, it is helpful to stop all work-related tasks 90 minutes before going to sleep. Other helpful relaxation strategies include taped relaxation exercises (focusing on breathing and muscle relaxation) which are available commercially, often in drug and health food stores.

"The 20-minute rule" is a technique often used in conjunction with sleep hygiene practices. The goal is to associate being in bed with being asleep. If, after turning the lights out or waking up, the sleeper doesn't fall asleep in what feels like 20 minutes, they should get up and only return to bed when feeling "drowsy-tired." (Clock watching is an arousing activity; all clock faces should be turned away.)

This step is repeated throughout the night as necessary until the morning alarm goes. The amount of "awake" time during the night will induce a degree of sleep deprivation that will increase sleep pressure the subsequent night. In this way, over time, sleep improves.

Sleep restriction is another method that reduces the "awake" time in bed, and increases the depth and quality of sleep. First, the average current sleep time is calculated from the sleep diary and is assigned to the sleeper. This is done by subtracting all "awake" time from the total time spent in bed. This "sleep time" may be, say, 5 hours and 20 minutes. This amount of time is the new assigned time in bed. Depending on the patient's preference (morning types prefer to be up early; evening types prefer to be up late) the new arising time is set and kept constant, and the patient will go to bed 5 hours and 20 minutes before the selected get up time.

Like the "20-minute rule," sleep restriction usually results in a mild degree of sleep deprivation (daytime sleepiness and fatigue), but creates increased sleep pressure at night. Once this begins to occur, the doctor will increase the allowed time in bed by 10 to 15 minutes. In this way, the time in bed is slowly increased until sleep again becomes disrupted. Then the previous sleep time associated with no awakenings becomes the new sleep time. In patients with primary insomnia, the assigned time in bed is usually between 5½ and 7 hours.

Hypnotics should always be used for the shortest period of time possible and in the lowest dose. Patients with primary insomnia do not have significant psychiatric symptoms. Therefore, unlike patients with anxiety disorders, they should require only occasional use of hypnotics.

Specific drugs which promote sleep are the benzodiazepines such as temazepam, oxazepam, and lorazepam. Newer drugs (zolpidem in the US; zopiclone and zaleplon in Canada) act in the same way as the benzodiazepines and may have some specific advantages over the benzodiazepines, such as less daytime sedation, and little or no interaction with alcohol. However, they are more costly. To avoid daytime sedation, long-acting drugs (including non-prescription antihistamines) should not be used.

Although patients with primary insomnia may never sleep as long as people without this condition, there are a number of effective strategies which can help improve sleep quality and the subsequent day's performance.