Insomnia-what we know and how to treat it
Nitin K Sethi, MD, MBBS, DNB (Int Med), FAAN
In this blog post I shall address insomnia. Insomnia is a rather common medical problem for which patients consult doctors and sleep physicians. Broadly speaking insomnia can be of two types: sleep onset insomnia (the person finds it hard to fall asleep. Normal sleep latency is usually around 10 to 15 mins. Patients with sleep onset insomnia lie in bed sometimes for hours but sleep eludes them) and sleep maintenance insomnia (normally humans should be able to maintain sleep for 6 to 8 hours, though some of us are short sleepers and others long sleepers. People with sleep maintenance insomnia are unable to maintain sleep waking up multiple times during the night and struggling to fall back asleep again). One of the most common type of insomnia is psychophysiological insomnia and this is what I shall address in detail.
Psychophysiological insomnia (PPI)-these are people who cannot “shut their brains down at night”. At night when they settle down to sleep, their mind races (they are thinking about various things-work, personal issues and so forth). As a result they cannot sleep and keep looking at the clock. Over time this behavior gets reinforced to the extent that sleep itself becomes an anxiety provoking stimulus. Meaning they are anxious at night. Most of the people who suffer from PPI also suffer from anxiety and depressive disorders.
How to diagnose psychophysiological insomnia-usually a good history is sufficient in helping to diagnose PPI. Do you think a lot when you are lying in bed? Do you find it difficult to shut/power your brain down? Do you feel anxious in your own bed? Do you suffer from anxiety disorder and depression? Are your insomnia problems chronic (lasted more than 6 months)? Were other causes of insomnia ruled out such as insomnia due to medical problems (congestive heart failure, COPD, nocturnal asthma), insomnia due to certain medications and so forth. Your doctor may order a sleep study. The sleep study is done to rule out obstructive sleep apnea as a cause of disturbed sleep. It also helps your doctor get an idea of your sleep architecture (how much time you spent in different stages of sleep-light Vs. deep Vs. REM). Your doctor may also ask you to maintain a sleep diary. This is a record of your sleeping habits for a period of usually 2 weeks and helps the doctor better understand your sleep quality and hygiene.
Treatment of psychophysiological insomnia-treatment of PPI can be extremely challenging for the physician and frustrating for the patient. There is no good treatment but let us talk about what is out there, what helps and what does not.
- Cognitive behavioral therapy (CBT-I) for insomnia is probably what works the best. CBT-I is usually administered by a psychologist and involves several sessions spread over weeks. The therapist attempts to figure out what thoughts keep the patient awake at night and addresses them. Instructions to help structure sleep and wake up times is an important component of CBT-I. CBT-I takes time to act but in the long term is probably equally if not more effective and safer for treatment of PPI than sleeping pills (sedative-hypnotic medications).
- Sedative-hypnotic medications (sleeping pills)-there are numerous on the market both over the counter (OTC) ones such as Benadryl, Zzz Quil (to name a few) and prescription ones such as Ambien, Lunesta, Sonata, Belsomra, clonazepam, diazepam, Xanax (to name a few). These medications do work and they work by increasing chemicals in brain that promote sleep namely GABA. Belsomra is a new drug which was launched recently. As compared to other drugs, it works by decreasing chemicals in the brain that keep us awake. Sleeping pills have the advantage that they work quickly but they have 2 big problems. Regular/nightly use of sleeping pills makes the patient dependent upon them. The other problem with regular/nightly use is tolerance (example initially 5 mg of Ambien works great but then it stops acting and the patient needs a higher dose of Ambien say 10 mg to achieve sleep).
- Sedating anxiolytic-antidepressant medications: examples include Trazodone, Doxepin and amitriptyline. These medications are taking on a nightly basis and the goal is to address PPI by treating the patient’s anxiety disorder. The sedating qualities of these medications initially is useful in helping patient’s fall asleep.
- Non-sedating anxiolytic-antidepressants medications: examples include Paxil and Celexa to name a few. Goal here is to treat the patient’s anxiety/depression. Since these are not sedating, they are administered during the day.
- Entraining the circadian rhythm: one important thing which is ignored when insomnia is treated is entrainment of the patient’s circadian rhythm. In the hypothalamus of the brain there are a group of brain cells (called suprachiasmatic nucleus) which helps to maintain circadian rhythm (sleep wake cycle). Many patients with insomnia have poorly entrained circadian rhythm with no regular sleep-wake times. They are frequently night owls and so when they get into bed early say around 11 pm, they are unable to fall asleep since the sleep drive is not there (their brain may be geared to fall asleep around 1 pm). So it is important to structure sleep with the establishment of regular sleep wake times. The circadian rhythm is entrained by light and exercise. Patients should be encouraged to expose themselves to sunlight in the morning after waking up. Exercise in the morning is also helpful.
- Steps to improve sleep hygiene: Use the bed only for sleeping or sex. Do not carry your work to bed. Do not use laptops, smart phone while in bed. Your brain should associate your bed with sleep and not work. Half an hour before bedtime, room lights should be dimmed. TV, computers and smart phones should be tuned off and one should engage in activities that relax and calm the brain. This may be reading a book, meditating or even watching TV if that relaxes you. A hot shower before bedtime, drinking hot decaffeinated tea or warm milk increases the core body temperature and promotes good sleep. Deep slow breathing exercises are also very helpful (you can find some of these on the Internet).
I hope you find this blog posting on sleep and insomnia helpful. Sweet dreams everyone!