Insomnia

Sleep problems can be frustrating and exhausting. Sometimes a person can have trouble sleeping for no apparent reason, and with no other associated symptoms.

More commonly insomnia is a symptom associated with another medical or psychiatric problem. Here are some of the causes of insomnia:

A) Physical Medical Problems
Here's a partial list:

• any painful condition

• infectious diseases (anything from a common cold to any more severe disease)

• endocrine disorders (e.g. hyperthyroidism)

• respiratory diseases

• bladder or kidney problems (e.g. causing a need to use the bathroom in the night)

• heart disease (e.g. in heart failure it may be very uncomfortable to lie flat)

B) Psychiatric Problems

• depression

• anxiety

• psychotic disorders

• mania

• situational stress

• substance use disorders

• specific sleep-related disorders such as sleep apnea or narcolepsy

• post-traumatic stress disorder (e.g. in which the past trauma occurred at night)

C) Environmental Problems

• uncomfortable bed, bedding, or pillow

• noisy bedroom at night

• too much light in the bedroom (e.g. street lights shining through a window)

• too hot, too cold, poor air quality, etc.

• sleeping next to someone who snores loudly or moves around a lot during sleep

In the management of insomnia, it is important to consider all of the above categories. A medical check-up to rule out or start treatment for physical diseases will be important. All possible improvements to the bedroom environment should be made. Evaluation and treatment of other psychiatric symptoms or conditions is important. If there is any question of breathing problems during sleep, or of a specific sleep disorder such as narcolepsy, then other tests may need to be done, such as an overnight sleep study.

For some people with allergies, I have found at times that a simple measure--such as starting a nasal spray at night which allows for easier breathing, or starting an antihistamine--can be a remarkably effective relief for insomnia and resulting mood/energy problems.

Beyond this, there are specific ways to manage sleep problems:

1) Careful documentation of exactly what is happening with sleep:
A sleep log can be very useful. In the sleep log, you can keep the following records for each day:
a) what time you went to bed
b) what times you were actually asleep
c) what time you got out of bed
d) what times you spent in bed or asleep during the daytime
e) your assessment of how good the quality of your sleep was
You can keep your log in the form of a chart, with sleep times indicated by a solid bar going across the chart, and times spent awake represented by interruptions in that solid bar. Here are some examples of a sleep log:
https://www.healthatoz.com/ppdocs/us/cns/content/atoz/tl/misc/sleeplog.pdf
http://www.snoozeorlose.com/index.php?id=40

2) Behavioural treatments:

• maintaining a constant wake time: it may be impossible to control when you fall asleep, but it is possible (even if difficult) to control when you wake up and get out of bed. If you are out of bed at the same time every morning, you will be more sleep-deprived after a night of insomnia, and will therefore have an easier time sleeping the next night. If you allow yourself to sleep in after a night of insomnia, you will not be as sleepy, and will have a harder time sleeping the next night.
  
• If you have a hard time waking and getting out of bed at the same time every morning, external stimuli can help, such as a timer circuit which turns on a bright light next to your bed in the morning, or even an automated coffee machine which starts at the same early time.
  
• leaving the bedroom if you are having a hard time sleeping. Otherwise there is a conditioning effect in which your brain associates your bed with being awake. Go back to your bed when you feel more sleepy.
  
• avoiding wakeful activities in the bed, such as watching TV or reading. Do these things in another place.
  
• avoid or minimize napping. If you must nap, keep it earlier in the afternoon if possible, and as brief as possible.
• sleep restriction: for example, if you are in bed for 9 hours per night, but are only asleep for 5 of those 9 hours, then you can try going to bed exactly 5 hours before your planned wake time. This strategy is intended to cause you to become more sleepy before you go to bed, to have deeper sleep while you are in bed, and to spend less time lying awake in bed. If this strategy works, a next step can be to gradually start going to bed earlier in order to extend the total number of sleep hours. It is harder to adjust to an earlier bedtime, so this process has to be very slow, perhaps trying a bedtime 15 minutes earlier than your previous bedtime, then sticking with it for a week or so, before adjusting again.
  
• morning exercise -- here's a link to a study showing this: (http://www.ncbi.nlm.nih.gov/pubmed/14655916)
  

3) Cognitive Treatments

• There are many thoughts which occur in the midst of insomnia; some of these thoughts can perpetuate the insomnia, or be part of a vicious cycle. For example, as you lie awake you might think:
• - "oh, no, not again! I'm still awake! I'll never be able to function tomorrow!"
• -"It's 3:21. I've been awake for 57 minutes. I have only 3 hours and 39 minutes before I have to get up."
• -"I can't slow down my thoughts! I'll never fall asleep!"
• -"No matter what I do, I still can't sleep."
• In working on insomnia cognitively, it is important to "talk back" to all of these thoughts in a way which is brief, without becoming an inner intellectual debate (this would be another example of a cognitive process which would keep you awake). Much of the "talking back" might involve reassuring yourself, accepting the thoughts and then letting them go, letting go of the need to control your thoughts, and accepting that sleep will happen on its own without your intellectual input, or regardless of whether your thoughts are active or not.
  

There is some solid evidence that cognitive-behavioural techniques are effective in treating insomnia. Here are some references:
http://jama.ama-assn.org/cgi/reprint/295/24/2851
http://jama.ama-assn.org/cgi/reprint/285/14/1856
http://archinte.ama-assn.org/cgi/reprint/164/17/1888

4) Other physical treatments

• Light therapy: use of a 10 000 lux light box for 45 minutes in the morning can help with night-time insomnia. Here's a reference:http://www.ncbi.nlm.nih.gov/pubmed/15172210
• There is some evidence that using a light box in the EVENING can help "early morning awakening insomnia". In depressed states, waking too early in the morning is a frequent sleep disturbance. It could be an interesting and low-risk therapy for this to use evening bright light. Here's a reference: http://www.ncbi.nlm.nih.gov/pubmed/16171276
  
• There is a lot of evidence that sedative medications are effective short-term treatments for insomnia. Mind you, some of the evidence is not as robust as one might think it should be. Unfortunately, most of these sedatives tend to be habit-forming or addictive. And tolerance tends to develop to the sleep-promoting effects.
  
• Sedating antidepressants (e.g. trazodone, amitriptyline, doxepin, mirtazapine) could be useful in selected cases. Sedating antipsychotic medications in low dosages can also help sometimes (e.g. quetiapine). There is some current interest in very low-dose doxepin for treating insomnia, because it appears to have a very selective antihistamine effect at these doses; here's a link to an abstract about this-http://www.ingentaconnect.com/content/apl/eid/2007/00000016/00000008/art00014
  
• Melatonin: There is some modest evidence that melatonin can help with insomnia, with few side-effect problems. Here's a link to a study, in which they were looking at the effectiveness of 2 mg of prolonged-release melatonin: http://www.ncbi.nlm.nih.gov/pubmed/18036082