Sleep Disorders

Glossary

"It’s been a hard day’s night
I’ve been workin´ like a dog
It’s been a hard day’s night
And I’ll be sleepin´ like a log…. "

(John Lennon and Paul McCartney)

Insomnia

About one-third of Americans have symptoms of insomnia but less than 10% of those are identified by their doctors. Insomnia tends to increase with age and affects about 40 percent of women and 30 percent of men. Insomnia includes not only difficulty falling asleep (this is called sleep-onset insomia) but also waking up to early and not being able to fall back asleep (sleep-maintenance insomnia), frequent awakenings, and waking up feeling unrefreshed.

Symptoms of insomnia include sleepiness, fatigue, decreased alertness, poor concentration, decreased performance, depression during the day and night, muscle aches and an overly emotional state. Temporary insomnia can be brought on by stress, illness, pain, diet, medications and disruptions to circadian rhythms. When symptoms occur more than a few times a week and affect daily functioning, the person should consult a health care provider. Experts say that chronic insomnia is a greater mortality risk than smoking, high blood pressure and heart disease.

Treatment for insomnia can include medication and behavioral strategies. Depending on how severe the case, doctors may prescribe non-benzodiazepine hypnotics, antidepressants and hypnotics. Behavioral strategies are:

Sleep restriction — only sleeping in the bed and only staying in bed when sleeping (falling asleep within 25 minutes of lying down);
Stimulus control — reserving the bedroom for sleep and sex only;
Relaxation techniques;
Avoidance of caffeine and alcohol;
Cognitive behavioral therapy with the help of a psychologist.

How much sleep does a person need?

Sleep onset insomnia is when a person can't get to sleep when he or she wants to. In chronic conditions, when the person also has difficulty getting up in the morning, this can be classified as delayed sleep phase syndrome. In this case, the person's clock is just off: when the body wants to sleep is not the same as when the mind wants to sleep.

More frequent and pedestrian sleep onset insomnia is just caused by having a lot on your mind or by being nervous. Anxiety-induced insomnia is also called Psychophysiological Insomnia. This is usually short term. In severe situations, this type of insomnia can often be treated with behavioral therapy. The person learns to relax or medidate or systematically clear the mind.

Sleep maintenance insomnia results in frequent and prolonged nocturnal awakenings, especially in the second half of the night. Many of the new sleep medications introduced in recent decades address sleep maintenance more than falling asleep.

Sleep onset insomnia is more common in young adults while sleep maintenance insomnia is common in the elderly. Delayed sleep phase syndrome usually strikes in adolescence, so it makes sense that young adults are more prone to sleep onset insomnia.

Primary insomnia is traditionally defined as difficulty sleeping that does not have a separate condition causing the loss of sleep. A person kept awake by pain from a broken bone would have secondary insomnia. The causes of secondary insomnia are legion, and include everything from alcohol and drug ingestion, to many medical and psychiatric problems.

Primary Insomnia

Primary insomnia is sleeplessness that cannot be attributed to some other cause. An estimated 10% of the population has primary insomnia.

A patient with primary insomnia must experience difficulty in falling asleep, difficulty in staying asleep, early awakening, or non-restorative, poor quality sleep. The trouble sleeping must be associated with daytime symptoms. These can include fatigue, trouble concentrating, memory or mood disturbances, tension headaches, and other types of daytime impairments or symptoms.

The pathophysiogical mechanisms underlying primary insomnia are usually unknown, and medical practioners address the insomnia directly. Sleep researchers believe that hyperarousal, circadian dysrhythmia, and homeostatic dysregulation underlie chronic insomnia. But as a practical matter for doctors, patients just want a good night’s sleep.

The first line of attack for primary insomnia is almost always drug-free. Good sleep hygiene is always recommended, and those suffering from sleepless nights are advised to take another look at their bed practices. Often turning down the air temperature in the room is all it takes to facilitate unbroken sleep.

You often see that statement: insomnia is not a condition; it is a symptom. This is to encourage readers (patients, health care providers, etc.) to look at the underlying cause of insomnia, which is often another illness. However, like so much in sleep, the literal validity of that statement is not so clear. Doctors distinguish between “primary insomnia” and “secondary insomnia”. Secondary insomnia is indeed considered a symptom or a side effect of other phenomena in the body, but often the insomnia itself is considered the main problem, the main thing worth attacking and treating. When the insomnia is considered an illness itself, not an effect of some other etiology, it is called primary insomnia. More on the pathophysiology of primary insomnia.

Chronic insomnia – insomnia that goes on for a month or more – is often considered primary insomnia. Doctors attack insomnia directly (rather than an unknown “underlying cause”) to help the patient achieve a better quality of life.

Secondary Insomnia

Secondary insomnia is a result of other causes – illness, drugs (including caffeine and alcohol), excessive worrying, pain, etc. Depression is a leading cause of secondary insomnia. If the doctor and patient can figure out the underlying condition, treating it is often more productive than attacking the insomnia directly. Many depressives start sleeping much better as soon as they begin taking antidepressant medication, even though those medications have no effect on the sleep patterns of non-depressed people. Pain relief medications often produce drowsiness as a side effect. This is most obvious in the very strong opiate pain medications, and opium has been known for millennia to induce sleep. (Indeed, morphine was named after Morpheus, the god of sleep). Less strong over-the-counter pain medications are often mixed with antihistamines. The strongest example is Tylenol PM, which is a mixture of the pain reliever acetaminophen (the ingredient in regular Tylenol) and diphenhydramine HCl., an antihistimine that promotes sleep.

Opiate medicines such as percodan as well as OTC preparations like Tylenol PM disrupt the sleep cycle to some extent, so they are not suggested for long term treatment of insomnia. But they can effectively address sleeplessness if the patient needs pain relief medication for other reasons.

Secondary insomnia causes include stress, arthritis, and drinking too much coffee. The insomnia is a sequela of another problem. Secondary insomnia is more common than primary insomnia.

Treatment

Pills

Medical professionals are ambiguous about recommending or prescribing sleeping pills. Some have no reluctance, thinking of sedatives and hypnotics as technologies that are practical and safe and effective when used correctly. Others feel pills are a surrender – an admission that the underlying etiology could not be found or directly addressed,. Primary insomnia – the type where the insomnia is not obviously a symptom of another condition – is frustrating for the diagnostician. Pills are a fix even if an unsatisfying one for getting to the root of the problem.

All sleeping pills have side effects. All. As with any drug, different people react differently, and sometimes the side effects are not significant compared to the benefits the patient derives. Sleeping pills on the market today are safer than the barbituates used 50 years ago. The main side effects of modern pills are drowsiness when you don’t want to be drowsy (difficulty getting up and staying alert in the morning) and a disruption in the sleep cycle. You’ll still have all five stages of the sleep cycle when you take the drug, but it may cause you to stay in stages 1 and 2 longer than normal.