Insomnia is one of the most common sleep related complaints of patients. Insomnia is not a disease. It is a symptom. The most important step in treating insomnia is to establish the pattern of the insomnia and the cause of the insomnia. Many patients claim that they “never sleep at all.” Actually everyone sleeps. The problem quite often is the perception of not receiving sufficient sleep, or not being able to sleep at a desired time or in a desired place.
Sleep onset insomnia - This is insomnia related to difficulty falling asleep. Once asleep, the person stays asleep without difficulty.
Sleep maintenance insomnia - Patients have no problem falling asleep, but tend to awaken multiple times during the night. Key to understanding the cause is the pattern of awakening, events associated with the awakening, time of awakening, ability to fall back asleep, and subsequent sleepiness the following day.
-Phase delay syndrome. This is a condition, commonly seen in teenagers or “night owls” in which the person’s natural tendency to stay up later gradually resets the body’s internal clock to a later and later time. The person finds it difficult to go to sleep early and difficult to wake up in the morning. The sleep time itself is not disrupted.
-Phase advance syndrome. This is a condition, commonly seen in older people or “early risers” in which the person finds it difficult to stay awake in the evening and goes to bed early, also awakening in the morning very early.
-Jet lag. The need to adjust the body’s internal clock to the current time zone.
-Napping during the day will reduce nocturnal sleepiness or reset the body’s internal clock to a later sleep onset time.
-Bright light in the evening will cause changes to the body’s internal clock to reset the sleep time later.
-Primary or psychophysiologic insomnia - This is the insomnia related to stress and anxiety or depression. Generally anxiety is associated with difficulty falling asleep. Depression is often characterized by early morning awakening.
-Neurologic - Possible illnesses associated with both sleep onset and sleep maintenance insomnia include seizures or epilepsy; head injury; strokes; Parkinson’s Disease; Alzheimer’s disease.
-Cardiovascular - Congestive heart failure and angina are associated with nocturnal chest pain and difficulty breathing that disrupts sleep. Angina episodes are more frequent at night.
-Pulmonary - Asthma and emphysema generally are worse during the night with reductions in oxygen during REM sleep in the early morning hours and increased wheezing during sleep. Obstructive Sleep Apnea, though often thought of as a cause of excessive daytime sleepiness, can cause sleep disruption with insomnia. Central sleep apnea or Cheyne Stokes breathing is a cyclic type of breathing often associated with strokes or altitude, or heart failure that can culminate in insomnia. Sudden choking and stridor is probably associated with gastroesophageal reflux. It can be silent during sleep, except for the insomnia.
-Hyperthyroidism can be characterized by rapid heart rate, elevated temperature, tremor, weight loss, and trouble sleeping.
-Renal failure can result in sleep disruption from restless legs, chronic pain, and various fluid problems. Urologic conditions, such as prostate enlargement, are a major cause of sleep disruption due to nocturia or the need to urinate at night.
-Chronic pain syndromes - This is one of the most common causes of insomnia. Characteristic findings are seen on the sleep study. Therapy includes analgesics, sometimes with the additions of tricyclic antidepressants, and sedative hypnotics.
-Stimulants. Caffeine, Nasal decongestant medications, Cocaine, Amphetamines, Theophylline. All of these medications and substances can increase the level of arousal and prevent sleep onset.
-Alcohol initially shortens sleep latency, and reduces REM. There are increased awakenings. Insomnia occurs with long term abstinence.
-Nicotine can simultaneously stimulate and relax., so that insomnia can be related to acute use or withdrawal.
-Opioids can cause insomnia during withdrawal.
-Antidepressants - Reduce REM sleep. Increase eye movements in stage 2. The insomnia may improve with time, yet the sleep continuity may not be any better.
-Prednisone causes insomnia by unknown mechanisms, but it can remit with discontinuation.
-Antihypertensives have been associated with both excessive daytime sleepiness and difficulty sleeping.
The treatment of insomnia depends on addressing the primary cause. Even if the medical problem is resolved, the patient may be so conditioned that sleep onset is difficult. Sleep can not be done on command; it must come on spontaneously. Also there is no exact number of hours people must be in bed. Everybody’s sleep needs are different. A frequently successful therapy is sleep restriction therapy. Instead of fighting oneself to stay in bed and try to sleep, the amount of time in bed is restricted to night time only, and the hours in bed are also restricted to fewer hours than usual. By doing so, one winds up in bed only when one is truly tired.
