InsomniaLying among tousled sheets, eluded by sleep with thoughts racing, many people wrestle with the nightly demon named insomnia. Insomnia is defined as, 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, or unrefreshing sleep (Rajput 1431). Because the definition of “poor-quality sleep” is not the same for every person, it is not easy to determine the frequency and severity of it’s occurrence (Holbrook 216). To add to the complexity of this problem, there is not even one universal treatment that can be used effectively in all cases. Many effective treatments have been discovered, but there is no “cure-all.” The two most popularly used treatment methods are pharmocological treatment and behavioral-cognitive treatment . Each of these treatments has its pros and cons and is recommended for different types of patients.
Although taking a pill every day would appear to be the simplest way of overcoming insomnia, it is, “at best a temporary solution,” and in recent years, use of drugs as a treatment has declined rapidly. Medical records show that the yearly number of prescriptions for sleeping pills peaked in 1972 and were cut in half by 1982. The reason for this decline is that a large amount of cases, insomnia has been proven to be a “symptom of an underlying . . . problem (Sweeney 231).” Drugs can be a good solution for a short period of time, but their long term use is discouraged, because a tolerance can develop after four weeks of regular use (Espie (?) 115-116).
There are three main types of drugs used for treatment–benzodiapine hypnotics, sedating antidepressants, and antihistamines. Benzodiapine hypnotics are the most prescribed drugs for treating insomnia. They are most useful when treating short term problems and have relatively few side effects when used correctly. They reduce the time for sleep onset and increase sleep efficiency. Long-term use can lead to physical and psychological dependence and abruptly discontinuing their use may cause symptoms of withdraw. (Zammit 132-135). Gradually tapering off the drug is recommended to prevent rebound insomnia. The possible side-effects of benzodiapines include inducing anterograde amnesia, excitability, agression, and symptoms of depression. (Longo 2121). Benzodiapines can be especially harmful for the elderly. They can heighten the symptoms of demensia related disorders. Pregnant women are also discouraged from taking benzodiapines because they are considered teratogens (substances that can reach a fetus and cause harm) (Myers 118).
A secondary option to benzodiapines is sedating antidepressants. These drugs can “promote sleep onset and maintain sleep (Zammit 136),” but they have not been scientifically proven to treat insomnia. There is no risk of dependence on antidepressants but it is possible for them to become ineffective after a very short time. The third drug option is antihistamines, which besides helping with allergies, are said to decrease sleep onset and reduce time in REM sleep. Many antihistamines are available without a prescription. They are not recommended for treating insomnia because they are not sedatives and very few studies have been done to show their effectiveness. There are also side effects such as dry mouth and urinary retention associated with antihistamines (Walbroehl 1911).
In addition to drugs, there are other sleeping pills available. These natural remedies are not regulated by the FDA and it is difficult to accurately jusdge their effectiveness and safety. One of these remedies, which has gained a lot of attention recently, is melatonin. This hormone, naturally secreted by the pineal gland, helps control the sleep-wake cycle. It is now sold as a dietery supplement which aids in sleep. It is still in the process of being tested as an accepted treatment for insomnia. Many results of these tests are coming back favorably, but there are still many questions about it’s safety to be answered. (Cupp ?)
An alternative to sleeping pills, cognitive-behavior therapy can sometimes be used effectively as a treatment. This therapy focuses on encouraging the patient to “eliminate behavior incompatible with sleep (Rajput 1431).” This treatment has many components, which include stimulus control, sleep restriction, relaxation techniques, and cognitive therapy (GN 103). According to _____, “all of these therapies are known to be effective in the treatment of insomnia. (103). Unlike pahrmacotherapy, these techniques do not have side effects. They do however have drawbacks. Results from using behavioral therapy techniques may not be substantially noticed for four to six weeks, and in today’s “now” society it is difficult for many patients to stick with the program that their doctor suggests. People trying this treatment are encouraged to keep a sleep log in order to better monitor their progress.
The first aspect of behavioral treatment is stimulus control. According to Macintosh (?):
If a change in a particular stimulus is always followed by the probability, amplitude, latency, or rater of a particular response, we may say that this stimulus exercised some control over tat response. The term stimulus control has come to be used as the convenient shorthand expression for describing such an observed relationship between changes in external stimuli and changes in recorded behavior.
When applying this to insomnia, these are probably stimuli that are detrimental the ideal sleep environment. For a good sleeper, laying in bed is associated with falling asleep, but for an insomniac, the bed represents a place of frustration. (Espie 158). Stimulus control therapy aims to differentiate the habits that reinforce sleep from the habits that discourage sleep. According to Espie (?), there are six rules to follow.
The first rule is that the insomniac should only lie down when they feel tired. This presents difficulty for some, because past failure to sleep has made them unsure of their ability to determine when they are tired. They may need guidance to let them know which cues for sleep they should pay attention to. Rule number two is to only use the bed and bedroom for sleeping. Such normal bedroom habits such as reading, watching television, talking, eating, smoking and drinking should be discontinued, because they are cues for being awake. Rule number three is go to another room if you do not fall asleep quickly. Quickly is defined by about ten to twenty minutes of wakefulness. However, that does not mean that the patient should watch the clock for an exact period of time. That can cause additional stress. It is recommended that the patient do something relaxing after getting out of bed. Rule number four is that rule three should be repeated. Early on in the treatment the insomniac should expect to get out of bed many times during the night. Persistence with this technique is the key. Step five suggests setting the alarm for the same time each morning. The object of this is to set a biological sleep rhythm. The final rule, rule six, discourages the insomniac from taking naps. Afternoon and evening naps are especially discouraged since sleep onset times are related to how much time has passed since a person last slept. (Espie 158-166)
Like stimulus control, sleep restriction therapy places limits on time spent in bed, but the idea behind it is different. Sleep restriction aims to make deeper sleep possible by diminishing the time spent lying in bed without sleeping. The first step is to keep a sleep log to track how many hours are spent trying to fall asleep and how many hours are spent actually sleeping per night. The next step is to calculate the average sleep time. Then it needs to be determined how much extra time is spent in bed while not sleeping. After this is calculated, use this time to determine what time you should go to bed and what time you should get up in the morning. It is important that this schedule is strictly adhered to reset your biological clock.
A very broad form of behavioral-treatment is relaxation techniques. These techniques include progressive relaxation, autogenic training, and meditation. Progressive relaxation is a sequential tensing and relaxing of the main muscle groups (Espie 107). This causes a decrease in muscle activity, blood pressure, and heart rate. Another form of relaxation is autogegnic training, where the patient rehearses simple phrases referring to warmth or heaviness of the legs and arms. In this technique the person is instructing their body to respond as if they are in a low state of physiological arousal. (Espie 110).
Insomnia in itself is a very frustration and complex condition, and sorting through the possible treatments can be an additional frustration. Since there are so few specially trained sleep specialists, many doctors will go initially with drug treatments as an “easy way out,” but as I found out, the easy way is not necessarily the best way for every patient.