Insomnia

Insomnia is the perception or complaint of inadequate or poor-quality sleep
because of one or more of the following:

* difficulty falling
asleep

* waking up frequently during the night with difficulty
returning to sleep

* waking up too early in the morning

*
unrefreshing sleep

Insomnia is not defined by the number of hours of
sleep a person gets or how long it takes to fall asleep. Individuals vary
normally in their need for, and their satisfaction with, sleep. Insomnia may
cause problems during the day, such as tiredness, a lack of energy, difficulty
concentrating, and irritability.

Insomnia can be classified as transient
(short term), intermittent (on and off), and chronic (constant). Insomnia
lasting from a single night to a few weeks is referred to as transient. If
episodes of transient insomnia occur from time to time, the insomnia is said to
be intermittent. Insomnia is considered to be chronic if it occurs on most
nights and lasts a month or more.

WHAT CAUSES IT?

Certain
conditions seem to make individuals more likely to experience insomnia.

Examples of these conditions include:

* advanced age (insomnia
occurs more frequently in those over age 60)

* female gender

*
a history of depression

If other conditions (such as stress, anxiety, a
medical problem, or the use of certain medications) occur along with the above
conditions, insomnia is more likely.

There are many causes of
insomnia. Transient and intermittent insomnia generally occur in people who
are
temporarily experiencing one or more of the following:

*
stress

* environmental noise

* extreme temperatures

*
change in the surrounding environment

* sleep/wake schedule problems
such as those due to jet lag

* medication side effects

Chronic
insomnia is more complex and often results from a combination of factors,
including underlying physical or mental disorders. One of the most common
causes of chronic insomnia is depression. Other underlying causes include
arthritis, kidney disease, heart failure, asthma, sleep apnea, narcolepsy,
restless legs syndrome, Parkinson’s disease, and hyperthyroidism. However,
chronic insomnia may also be due to behavioral factors, including the misuse of
caffeine, alcohol, or other substances; disrupted sleep/wake cycles as may occur
with shift work or other nighttime activity schedules; and chronic
stress.

In addition, the following behaviors have been shown to
perpetuate insomnia in some people:

* expecting to have difficulty
sleeping and worrying about it

* ingesting excessive amounts of
caffeine

* drinking alcohol before bedtime

* smoking
cigarettes before bedtime

* excessive napping in the afternoon or
evening

* irregular or continually disrupted sleep/wake
schedules

These behaviors may prolong existing insomnia, and they can
also be responsible for causing the sleeping problem in the
first
place. Stopping these behaviors may eliminate the insomnia
altogether.

WHO GETS INSOMNIA?

Insomnia is found in males and
females of all age groups, although it seems to be more common in females
(especially after menopause) and in the elderly. The ability to sleep, rather
than the need for sleep, appears to decrease with advancing age.

HOW IS
IT DIAGNOSED?

Patients with insomnia are evaluated with the help of a
medical history and a sleep history. The sleep history may be obtained from a
sleep diary filled out by the patient or by an interview with the patient’s bed
partner concerning the quantity and quality of the patient’s sleep. Specialized
sleep studies may be recommended, but only if there is suspicion that the
patient may have a primary sleep disorder such as sleep apnea or
narcolepsy.

HOW IS IT TREATED?

Transient and intermittent insomnia
may not require treatment since episodes last only a few days at a time. For
example, if insomnia is due to a temporary change in the sleep/wake schedule, as
with jet lag, the person’s biological clock will often get back to normal on its
own. However, for some people who experience daytime sleepiness and impaired
performance as a result of transient insomnia, the use of short-acting sleeping
pills may improve sleep and next-day alertness. As with all drugs, there are
potential side effects. The use of over-the-counter sleep medicines is not
usually recommended for the treatment of insomnia.

Treatment for chronic
insomnia consists of:

* First, diagnosing and treating underlying
medical or psychological problems.

* Identifying behaviors that may
worsen insomnia and stopping (or reducing) them.

* Possibly using
sleeping pills, although the long-term use of sleeping pills for chronic
insomnia is controversial. A patient taking any sleeping pill should be
under the supervision of a physician to closely evaluate effectiveness and
minimize side effects. In general, these drugs are prescribed at the lowest
dose and for the shortest duration needed to relieve the sleep-related
symptoms. For some of these medicines, the dose must be gradually lowered as
the medicine is discontinued because, if stopped abruptly, it can cause insomnia
to occur again for a night or two.

* Trying behavioral techniques to
improve sleep, such as relaxation therapy, sleep restriction therapy, and
reconditioning.

Relaxation Therapy. There are specific and effective
techniques that can reduce or eliminate anxiety and body tension. As a result,
the person’s mind is able to stop “racing,” the muscles can relax, and restful
sleep can occur. It usually takes much practice to learn these techniques and
to achieve effective relaxation.

Sleep Restriction. Some people
suffering from insomnia spend too much time in bed unsuccessfully trying to
sleep. They may benefit from a sleep restriction program that at first allows
only a few hours of sleep during the night. Gradually the time is increased
until a more normal night’s sleep is achieved.

Reconditioning. Another
treatment that may help some people with insomnia is to recondition them to
associate the bed and bedtime with sleep. For most people, this means not using
their beds for any activities other than sleep and sex. As part of the
reconditioning process, the person is usually advised to go to bed only when
sleepy. If unable to fall asleep, the person is told to get up, stay up until
sleepy, and then return to bed. Throughout this process, the person should
avoid naps and wake up and go to bed at the same time each day. Eventually the
person’s body will be conditioned to associate the bed and bedtime with
sleep.

Other Sleep Publications available from the National Heart, Lung,
and Blood Institute Information Center:

* Facts About Sleep Apnea–A
four-page brochure that discusses sleep apnea and how it is treated. (NIH
Publication No. 95-3798)

* Test Your Sleep I.Q.–This quiz tests your
knowledge about sleep and sleep-related disorders. (NIH Publication No.

95-3797)

NATIONAL CENTER O