Insomnia

Insomnia is a complaint rather than a diagnosis. It is formally defined as a difficulty in initiating or maintaining sleep that results in significant distress or impairment in functioning. What one person calls insufficient sleep may not qualify for another. Thus, in diagnosing insomnia, the patient’s subjective experience of inadequate sleep is more important than whether there are 3 or 8 hours of sleep each night. Some people only need 3 or 4 hours of sleep a night.

Virtually all of us have experienced at least a few nights of not getting enough sleep, so the condition is universal. But when insomnia becomes chronic, lasting more than a month, it requires special handling. It is believed that 15% of Americans have chronic insomnia. The incidence in postmenopausal women reaches as high as 35% by the age of 70.

The complaint of insomnia calls for a discovery process of possible causative factors. Pain from an injury or a repeated arthritic condition can certainly cause insomnia. Depression, anxiety and other psychologic disturbances are at least partially responsible for in at least 50% of cases in many surveys undertaken. Alternatively and importantly, insomnia can cause disturbances just as easily as to result from them. This fact may necessitate treating the psychologic problem first or simultaneously while addressing the insomnia to be effective in treatment of both conditions.

Other precipitating factors include changes in sleep-wake schedule, medical conditions and their treatments, other sleep disorders (sleep apnea or restless legs), and substance use (caffeine, steroids, antihypertensives, and certain antidepressants. Finally, a recent study found that family, health, and work- or school-related events were the most common precipitating factors for insomnia.

Once insomnia is a regular feature affecting the life of an individual, perpetuating habits can interfere with recovery. People worry about the health effects of inadequate sleep and this worry is insomnia promoting. They may have misconceptions about their true sleep needs, commonly leading some insomniacs to go to bed too early or take daytime naps that actually lessen the quality or quantity of sleep gotten in a 24-hour period.

Complicating this process of the evolution of an insomniac is our healthcare system that tends to promote medications for chronic use to address chronic problems. In many cases, a sleep aid is useful to address acute insomnia but becomes less than ideal for a long-term solution. Some persons do actually achieve lasting benefit from chronic use of sleeping pills; many others do not. Cognitive/behavioral strategies have been found to be successful to assist the majority of people not helped by chronic sleeping pill usage or those who want to be off meds even though they were initially helped by them.

At Optimal Sleep Health, our goal is to address the complaint of insomnia and to allow the patient to establish the direction of the therapy. Sometimes a medication is all that is called for, especially in the more acute cases. At other times a cognitive and/or behavioral approach is really most appropriate. In still other cases, an individual would prefer to have options at home: most of the time to utilize a nonmedicinal approach and for special circumstances to have a sleep aid on the bathroom shelf. Each case will call for an individualized approach.

References
Byles JE, G Mishra, and M Harris. The experience of insomnia among older women. Sleep 2005; 28(8): 972-9.
Eichling PS and J Sahni. Menopause related sleep disorders. J Clin Slp Med 2005; 1(3): 291-300.
Morin C, J Culbert, and S Schwartz. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiat. ’94;151(8): 1172-1180.
Nowell PD, S Mazumdar, D Buysse. Benzodiazepines and zolpidem for Chronic insomnia: a meta-analysis of treatment efficacy. JAMA 1997;278(24): 2170-2177.
Silber MH: Clinical practice: chronic insomnia. NEJM 2005; 353(8):803-10

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