• Insomnia

    Trouble falling asleep or staying asleep, commonly termed insomnia, plagues one in three American adults. If you have ever suffered from insomnia, you know how it can disturb your waking, as well as your sleeping, hours. It can make you feel sleepy during the day or have trouble focusing on tasks.

    Looking at both the day and the night effects of insomnia can help you and your healthcare professional understand the causes and treat the disorder. More research into psychological, lifestyle, environmental and physical/psychiatric factors behind sleep disorders is making it possible for healthcare professionals to help most troubled sleepers.

    What are Some Types of Insomnia?

    Insomnia can occur in people of all ages, usually just for a night or two, but sometimes for weeks, months, or even years. Insomnia is most common among women and older adults.

    Transcient Insomnia: Transcient insomnia is the inability to sleep well over a period of a few nights, but lasts less than four weeks. This type of insomnia is usually brought on by excitement or stress. Children, for example, may toss and turn just before school starts in the fall, or before an important exam or sports event. Adults often sleep poorly before an important business meeting or after an argument with a family member or close friend. People are more likely to have trouble sleeping when they are away from home, especially if try have traveled across time zones. Working out too close to bedtime (within four hours) or being sick can also cause this type of insomnia.

    Short-term Insomnia: Periods of ongoing stress at work or at home can result in four weeks to six months of poor sleep. When the stressful situation eases up, or when the sleeper adjusts to it, sleep will usually return to normal.

    Chronic Insomnia: More than 20 million Americans complain of chronic insomnia -- poor sleep every night or most nights for more than six months. While most insomniacs worry about their sleep, it's wrong to blame all troubled sleep on worrying. According to a nationwide study by the Associated of Sleep Disorders Centers, physical ailments -- such as disorders of breathing or muscle activity -- are often mistaken for insomnia and may account for a large number of sleep-diagnosed cases of insomnia.

    What Causes Insomnia?

    Insomnia is a symptom of another problem, much like a fever or a stomachache. It can be caused by any of a number of factors.

    Psychological Factors
    Vulnerability to Insomnia: Some people seem more likely than others to experience insomnia during times of stress, just as some people might tend to have headaches or easily get upset stomachs. Knowing that you may experience insomnia and that it will not last long can be helpful in dealing with what happens.

    Persistent Stress: Relationship problems, a chronically ill child, or an unrewarding career may contribute to sleep problems. If you suffer from these types of stress you should seek counseling to gain a new outlook on your troubles and to gain more control in your life.

    Learned Insomnia (also known as primary insomnia): If you sleep poorly during times of stress, you may worry about not being able to function well during the day. You may decide to try harder to sleep at night but, unfortunately, this determined effort can make you more alert and set off a new round of worried thoughts, causing sleep loss. Activities in and around the bedroom -- changing into your nightclothes, turning off the lights, and pulling up the blankets -- can also encourage wakefulness. Some people who have trouble sleeping in their own beds may fall asleep quickly when they don't intend to -- while reading the newspaper, watching TV, or driving. Even a few nights of poor sleep during a month can be all it takes to produce a cycle of poor sleep and increase your worry about it. Treatment for learned insomnia aims to improve sleep habits and reduce unnecessary worry.

    Lifestyle
    Use of Stimulants: Caffeine near bedtime, even when it doesn't interfere with your falling asleep, can trigger awakenings later in the night. Nicotine is also a stimulant, and smokers mat take longer to fall asleep than non-smokers. You should also be aware that the ingredients in many common drugs (including nonprescription drugs for weight loss, asthma, and colds) could disrupt your sleep.

    Use of Alcohol: You may think that have a glass of wine will help you sleep. But alcohol, while it may help you fall asleep quickly, is likely to make your sleep more broken throughout the night.

    Erratic Hours: If you do shift work (work non-traditional hours, such as nights or rotating shifts), or maintain late hours on weekends than during the week, you are more likely to experience sleep problems. Maintaining regular hours can help program your body to sleep at certain times and to stay awake at others. Establishing a routine is important.

    Inactive Behavior: You may think that a quiet lifestyle would be healthy, but people whose lifestyles are very quiet or restricted may find it difficult to sleep at night because of their inactivity during the day.

    Misuse or Overuse of Sleeping Pills: If you use sleeping pills every night, they will stop helping you after a few weeks. If you stop using them suddenly, however, your sleep may be temporarily worse. This problem can be reduced by cutting back gradually on the use of sleeping pills. Your healthcare professional should oversee this process. Studies have recently found that after gradual withdrawal of sleep medication, a person's sleep is no worse than when the individual was taking sleeping pills.

    Environmental Factors
    Noise: Passing traffic, airplanes, television and other noises can disturb your sleep even when they don't cause you to wake up.

    Light: Light comes through your eyelids even when your eyes are closed.

    These factors should be considered even though you thought you slept soundly all night.

    Physical/Psychiatric Illness
    Other sleep disorders and physical illnesses may occur during sleep, disrupt sleep, and produce symptoms that can easily be mistaken for insomnia. These other disorders require medical attention and common treatments for insomnia will not help them.

    Psychiatric Problems: Insomnia -- especially with awakenings earlier than desired -- is one of the most common symptoms of depression. If you suffer from a psychiatric disorder you may sleep poorly. Treatment of the underlying disorder, often including both medication and psychotherapy, can help improve your sleep.

    Breathing Disorders: Certain disorders can cause repeated pauses in breathing during sleep. This can wake a sleeper dozens or even hundreds of times a night. Pauses can be as short as 10 seconds and may no be remembered in the morning. They are sufficient, however, to produce restless sleep. Severely disrupted breathing during sleep (sleep apnea) may affect people who breathe normally while they are awake. Breathing-related sleep problems are most common in men, overweight people, and older adults.

    Severe cases of sleep apnea often benefit from a treatment known as positive airway pressure (PAP). This treatment keeps the breathing passages open with a steady stream of air flowing through a mask worn over the nose and mouth during sleep.

    Period Leg Movements: Brief muscle contractions can cause leg jerks that last a second or two and occur roughly every 30 seconds (often for an hour or longer) several times a night. These movements can cause hundreds of brief interruptions of sleep each night, resulting in restless sleep. Periodic limb movements become more frequent and sever are we grow older. Treatment can include medication, evening exercise, a warm bath, or a combination of these. Iron replacement may be helpful if you have an iron deficiency, especially if you also experience restless legs.

    Waking Brain Activity that Persists During Sleep: Sleep monitoring during the night has shown that some people who complain of light or less restful sleep fail to sink fully into sleep.

    Gastro Esophageal Reflux: Back up of stomach contents into the esophagus can awaken a person several times a night. This is commonly known as heartburn because of the pain or tightness it produces in the mid-chest area. When reflux occurs during the day, a few swallows and an upright position will usually clear the irritating materials from the esophagus. During sleep, less frequent swallowing and a lying-down position causes more reflux, making the sleeper wake up coughing and choking. If you experience this problem, try elevating your head, or raise the head of the bed (head-board) on 6- to 8-inch blocks. Medications can also provide relief.

    What is Secondary Insomnia?

    When insomnia is caused by a psychiatric disorder (most often depression) or a medical disorder (most often chronic pain) it is termed secondary insomnia. Secondary insomnia may be relieved by successful treatment of the primary psychiatric/medical disorder. Or direct treatment of the secondary insomnia with behavioral methods (described below may be successful and may provide some relief for the "primary" disorder.

    When Should I Seek Help?

    If you sleep has been disturbed for more than a month and interferes with the way you feel or function during the day, see your healthcare professional, or ask for a referral to a sleep disorders specialist. Your medical history, a physical exam, and some blood tests may help identify certain causes. Your bed partner and other household members may have useful information about your sleep, such as whether you snore loudly or sleep restlessly. Your healthcare professional will also need to know whether insomnia makes you sleepy or depressed or affects your life in other ways.

    Sometimes insomnia can be helped through education and information. Some people naturally sleep less than others, and merely need to give up the idea that everyone needs eight hours. Counseling can help people whose insomnia stems from poor sleep habits. In other cases, medication or evaluation at a sleep disorders center may be recommended.

    If you are advised to get an evaluation at a sleep disorders center, you may be asked to keep a sleep diary showing sleeping and waking patterns for a week or two. If you attend a sleep center, you can expect thorough physical and psychological examinations.

    Can Sleeping Pills Help?

    Sleeping pills offer sounder sleep and can improve alertness the following day, but this relief is only temporary. Sleeping pills are not a cure for insomnia. Sometimes sleeping pills can be dangerous when treating insomnia symptoms that may arise from another disorder, such as that resulting from breathing disorders. Insomnia needs to be properly diagnosed and treatment options discussed with a healthcare professional before treatment with medications is undertaken.

    There are many classes of sleeping pills, including over-the-counter medications that are mainly sedative antihistamines. Different types of medications vary with respect to their advantages and disadvantages. For example, some are 'short-acting' and works best for trouble at first falling asleep. Others are 'long-acting' and work best for maintaining sleep in the middle of the night. Consult your physician to find out which kind of sleep medication is best for you.
    Sleeping Pills May Help with the Following Conditions:
    Jet Lag: Change of several hours in sleep and wake times can trigger both insomnia and daytime sleepiness. For one to three nights, while the body adjusts to time zone changes, taking a sleeping pill may improve sleep and minimize daytime fatigue.

    Shift Work Schedule Changes that Affect Sleep Time: Shift workers sometimes find sleeping pills make it easier to fall asleep and stay asleep for one to three nights during a shift change. This may prevent chronic "occupational jet lag."

    Acute Stress: Sleeping pills may prevent persistent sleep problems by helping people prone to insomnia through stressful times, such as a death in the family or the start of a new job.

    Predictable Stress: People who always toss and turn the night before a monthly sales meeting or before giving a speech may rest better if they take a sleeping pill at such times.

    Chronic Insomnia: Having sleeping pills on hand can help ease poor sleepers through periodic flare-ups and reduce the worry that goes along with sleeplessness. It is important to know that sleeping pills work best when they are used for short periods, usually less than three weeks.

    What are Some Behavioral Treatments?

    There are four suggested behavioral treatments that have been well-tested with insomnia. These are usually given by sleep specialists.

    Sleep restriction: aims to shrink the margin between bedtime and morning awake time so that the sleep period follows your own biological sleep need. Insomniacs may stay in bed hoping this will produce more sleep time. Instead, excess time in bed spreads sleep over a longer period, breaks up sleep, and increases frustration.

    Stimulus control: Seeks to set up the bedroom as an inviting setting for sleep. For some, the bedroom becomes a place things such as paper work and worrying take place. These activities and thoughts are at odds with sleep. At bedtime, these associations encourage wakefulness. Stimulus control procedures remove non sleep-related activities, including awake time in bed, from the bedroom. This is done in order to improve the chances of falling asleep quickly.

    Courtesy of the American Academy of Sleep Medicine (http://www.aasmnet.org)

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