A Patient’s Guide to Insomnia

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By Elaine K. Howley

If you’ve ever lain awake at night wishing for sleep, then you’ve likely experienced some form of insomnia. For those who struggle with this common sleep disorder regularly, the feeling of missing out on sleep can be excruciating. And the paradox of it is that the more you try to sleep the further away the sweet embrace of slumber seems to slide.

As awful as sleeplessness might feel, if there is strength in numbers, then you can take some small comfort in the fact that you’re far from alone. “The data shows that between 20 and 30 percent of people will be affected with insomnia during the course of their lives,” says Dr. Alex Dimitriu, a sleep medicine specialist who’s double board-certified in psychiatry and sleep medicine and founder of Menlo Park Psychiatry & Sleep Medicine in California.

Although we know that sleep is critical to maintaining health and wellness for all of us, in some people, the drive to sleep is weaker than in others. “Not everyone has the same propensity to go to sleep,” says Dr. Jerald H. Simmons, a neurologist who’s triple board-certified in neurology, epilepsy and sleep medicine and founder of Comprehensive Sleep Medicine Associates, a clinical practice with offices in Houston and Austin. This so-called sleep drive can vary, as does each individual person’s sleep rhythm. This is why some people are night owls while others are morning people. And in some people, a weaker sleep drive is easily disrupted by any number of factors, which can lead to the development of insomnia.

Insomnia is the most common sleep disorder, but not all cases of insomnia are the same. Generally speaking, there are two major categories of insomnia – difficulty falling asleep initially and difficulty staying asleep throughout the night. And the two may be quite different in how they’re addressed. “Don’t confuse going to sleep with staying asleep,” Simmons says. “You can’t lump them all into one category and say, ‘This is the medicine I use for insomnia patients.'” Rather, many people struggling with insomnia are going to need a treatment approach tailored to their specific problem.

Insomnia – More General Information

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Cognitive Behavior Therapy for Insomnia
Sleep Deprived? You’re Not Alone
Best Doctor for Sleep Problems?
How Sleep Disorders Affect Us – and How to Lay Them to Rest
How to Fall Asleep – and Stay Asleep – the Natural Way

“In most people who have insomnia, it’s caused by something,” says Dr. Jesse Mindel, assistant professor of medicine and neurology at The Ohio State University Wexner Medical Center. And there are many factors that can cause both short-term and chronic insomnia including:

  • Changes to your work or travel schedule. Jet lag and frequent changes to your work schedule, as can happen with shift work, can induce insomnia in some people.
  • Concerns over work, school or health issues. There’s a reason why the saying “to lose sleep over it” exists. Concerns about any number of aspects of your life can lead to disrupted or poor sleep.
  • Concerns about not sleeping enough. Simmons says some people “develop performance anxiety” about sleep and their insomnia is exacerbated by that anxiety. “They’re so worried they can’t fall asleep that they can’t fall asleep,” and it becomes a self-perpetuating problem.
  • Poor sleeping habits. Engaging in stimulating activities in bed or being inconsistent in your sleep-wake pattern can lead to insomnia.
  • Food and drink. How much, what and when you eat can also disrupt the quality of your sleep. Substances such as caffeine, nicotine and alcohol can have an outsized impact on your sleep quality, especially if you’re using them in the evening or just before bed.
  • Age. Some people tend to have more trouble sleeping as they age, and many post-menopausal women report experiencing insomnia or a shift in sleeping patterns that’s related to changes in their hormone levels.
  • Medical conditions. Some medical conditions, such as sleep apnea – a breathing issue that wakes you up multiple times a night – can disrupt your sleep and lead to insomnia. Restless leg syndrome is another condition that can turn you into an insomniac.
  • Mental health disorders. Anxiety and depression can both greatly impact the quality of your sleep and your ability to fall or stay asleep.
  • Medications. Some medications, particularly certain anti-depressants, steroid medications used for asthma, allergy medications, weight loss drugs and some blood pressure medications can cause insomnia as a side effect.

For many people, insomnia is a consequence of modern life. “A lot of insomnia is related to just being forced into a schedule that’s not natural,” Dimitriu says. Busy, stressful lives filled with electric lights and electronic devices that are constantly demanding attention and shedding blue light that disrupts the body’s natural signals to sleep are all implicated in our collective inability to just get some sleep. “LED lights produce a blue light that suppresses melatonin,” a hormone that governs when we feel sleepy, and this can impact your ability to both fall asleep and stay asleep. “There’s evidence that (after exposure to LED light) melatonin is suppressed through the whole night, so late-night phone play messes up the quality of the sleep for the whole night.”

The ubiquity of these screens and their ability to become a detriment to our sleep cycle is a growing problem for many people, especially those who are prone to insomnia. “We’re living in a very tech-heavy world with clocks and other built-in hard stops” to our natural rhythms. “We’re not adjusting to that,” and the evidence of that disconnect between the demands of the waking day and the inadequacy of sleep to meet those demands becomes vastly obvious when you look at the length of the line at your local coffee shop each morning, Dimitriu says.

Most people who have insomnia are well aware of the difficulties they’re having sleeping. Common symptoms include:

  • Difficulty falling asleep.
  • Waking up during the night and having difficulty returning to sleep.
  • Waking too early in the morning.
  • Not feeling refreshed after sleeping.
  • Grogginess or tiredness during the day.
  • Depression, anxiety and irritability.
  • Cognitive issues such as difficulty focusing or concentrating on tasks.
  • Making lots of mistakes in your work or noticing an increase in accidents or clumsiness.
  • Anxiety about not getting enough sleep.

If you’re experiencing symptoms of sleeplessness, it might be time to visit your doctor for an evaluation. There can be a lot of factors contributing to your specific experience of insomnia, and your doctor will likely perform a physical exam and take a medical and sleep history to understand what’s going on.

You may also be administered a sleep test, which sometimes can be done at home but in other cases may need to be conducted in a sleep lab. These tests typically involve sleeping with sensors attached to your body to monitor your vital signs and look for other indications of physical disruption, such as changes in breathing or heart rate that could be causing you to wake up throughout the night. These tests monitor what you do in your sleep and are often helpful in diagnosing obstructive sleep apnea, restless leg syndrome and other conditions that can disrupt sleep.

Ruling out underlying medical conditions should be a primary goal of any visit you make to a sleep specialist. “First and foremost, I want to rule out any other causes that could be feeding into the insomnia,” Dimitriu says. These other conditions may include:

  • Depression.
  • Anxiety.
  • Restless leg syndrome.
  • Sleep apnea.
  • Thyroid problems.
  • Use of substances such as alcohol or drugs.
  • Other medical conditions.

“As a physician, first I need to eliminate all treatable medical issues. Then I look at substances” and other extenuating circumstances such as living too close to a source of late night noise or light. “Once you’ve eliminated those variables, you discover some people just have pure insomnia. This may be schedule-related or circadian rhythm related. Once we’ve eliminated all the scary stuff that could be treated medically, using a little medication or behavioral intervention can get people sleeping again,” Dimitriu says.

Treating insomnia and making sure that you’re getting enough sleep is an important aspect of overall health and wellness. While there are many things you can do to help ease yourself to sleep, one of the most important things is habituating your body to sleep and the ritual of sleep. “Rhythmicity is key, so having a regular bedtime and wake time and not deviating from that at all,” says Dimitriu. That, alas means “no sleeping in on the weekend, and no napping during the day.” The idea is that by forcing your body to stay awake during the day and adhering to a strict bedtime and wake time regardless of what else is going on, you can retrain your body to accept sleep when it’s most appropriate.

Simmons says many people who deal with insomnia have “poor sleep hygiene,” which means “they’re doing all the wrong things. They’re drinking caffeine in the evening. They’re taking naps in the middle of the day if they have the opportunity to,” and so on. Those sorts of actions “throw their biologic rhythm off. Those individuals need to wake up at a regular time in the morning. They shouldn’t sleep in and they need to get bright light exposure that will lower melatonin levels.” You want to increase the naturally occurring levels of melatonin in your brain at bedtime, and then help them drop in the morning when it’s time to get up and get going.

Other elements of good sleep hygiene include winding down from the day and creating a ritual around bedtime that helps your brain get ready to sleep. Switch off the television and step away from any other screens. Keep your bedroom cool, dark and quiet.

Simmons also recommends taking a hot bath shortly before bedtime to help you relax and get ready for sleep. “As we get drowsy our body temperature drops, and you’re going to sleep better in a cool room. So, if you take a hot bath before bed, that enhances that change in body temperature.” Just be sure to make it the last thing you do before bed. “That window of opportunity where the cooling will help is only 45 minutes to an hour,” he says.

If you’re still having trouble sleeping, it might be time to see a sleep specialist for further testing or more specific treatment. Simmons says that for some people, particularly those who engage in shift work, a consultation with a sleep specialist might help them develop a good strategy for dealing with or avoiding insomnia. “Seek out a consultation with a psychologist or physician who is well versed in sleep disorders to work on a unique plan that’s tailored to your needs,” he says.

Sleep medicine was only recognized as a specialty field of medicine in 2007. Although the science is still young it is expanding, and today there are a growing number of specialists who can help you with sleep problems with a variety of techniques. Simmons says some sleep specialists are now using cognitive behavioral therapy, an approach common in treating mental health problems that can retrain the brain to sleep properly.

Another technique called neurofeedback is a form of “biofeedback using brainwave activity (to) train someone to put themselves into a state conducive to falling asleep,” Simmons says. Using this approach, patients “learn how to relax and we train the brain through this feedback process on how to wind down and go to sleep without medication.” It’s a process that’s similar to meditation. In fact, Simmons says “I jokingly refer to it as meditation on steroids.”

Dimitriu uses similar CBT and meditation techniques to help patients retrain their bodies and brains to accept sleep. The challenge with some of these approaches is that they take time and practice. But tired people aren’t generally well known for being the most patient among us, especially when it comes to sleeping more. “A lot of people say, ‘I slept well last night, why am I still tired?’ The answer is sleep debt takes time to replenish – on the order of about one to two weeks.” That’s why it’s important to keep at it and not give up if you don’t seem to have solved your insomnia problem after just a few nights. Think of it like dieting – it takes a while for your efforts to add up to results, but if you stick with it, you’ll likely see an improvement.

That’s why Dimitriu says it’s important to keep practicing and trying to sleep without the assistance of medication as much as possible, especially when the stakes are low. “It’s easier to practice driving in the parking lot than to practice driving on the highway. By the time you have a big meeting the next day and you can’t fall asleep, meditation can help, but you’d better be good at it by then.” Therefore, he says it’s best to “practice when it’s easy” and you don’t have that pressure of getting to sleep immediately.

There’s a multitude of meditation and sleep-inducing apps and programs available online these days, or a sleep specialist can design a program specific to your needs. And remember to be patient. “If you can learn to meditate, you’re pretty likely to solve your insomnia problem, but that takes time and effort,” Dimitriu says.

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