INSOMNIA
Despite the traditional belief that eight hours comprise a good night's sleep, healthy individuals vary widely in the quantity of sleep they need. While the average is about seven to eight hours, others need as few as three or as many as ten hours of sleep each night to feel refreshed. Because there is no standard daily sleep requirement, insomnia or sleeplessness is considered to be of medical importance only when it compromises a persons's ability to function in everyday life. One of the three most common disorders that primary care physicians are asked to evaluate, it affects about one out of every three adults.
Major Causes
Situational/Psychological -- Emotional disturbances are the most common reasons for an inability to sleep. The stresses of modern life, financial insecurity, job worries, family discord, health concerns, excitement, etc. all may contribute to insomnia. In addition, sleeplessness is a cardinal symptom of deprssion and anxiety disorders. Classically, depressed persons have insomnia and fitful sleep, yet they awaken early in the morning. Also, an inability to sleep may be a result of major psychoses such as schizophrenia and manic-depressive illness.
Altered Sleep-Wake Cycle -- Most of us have a stable pattern of activities that relate to the solar day. If we work days, we sleep nights and vice versa. When this cycle is disrupted, insomnia can occur. Disturbances in the sleep-wake cycle may be seen in frequent travelers to distant time zones and in employees who rotate day-night/night-day work schedules.
Medical Illness -- A number of health problems produce symptoms that can disturb sleep. Ulcer pain, asthma attacks, croup and itching tend to be more frequent at night. Congestive heart failure, heartburn and sinus congestion may be aggravated when a horizontal postion is assumed. In addition, intestinal and urinary disorders which require frequent trips to the commode, and any condition that causes severe pain, can disrupt the sleep pattern.
Drugs -- Among the prescribed, non-prescription and illicit drugs that can cause insomnia are stimulants such as caffeine, diet pills and speed; tranquilizers; hormones; cancer chemotherapy; blood pressure medications; alcohol; and thyroid medicines. Sudden withdrawal of depressants (downers), alcohol, sleeping pills, narcotics, psychiatric medication and most recreational drugs can produce abstinence syndromes manifested, at least in part, by sleeplessness.
Sleep Disorders -- Three primary sleep disorders are implicated. Myoclonic syndrome refers to an involuntary nocturnal jerking of the leg muscles. The restless leg syndrome is manifested by an ill-defined nighttime discomfort in the legs that is relieved by walking. Finally, sleep apnea includes a variety of conditions characterized by repetitive episodes of sleep-induced cessation of breathing. In severe cases, heart disease and sudden death can occur.
Hospitalization -- Persons who are admitted to the hospital often have multiple reasons for insomnia: illness, medication, anxiety, noise level, environmental stress, etc.
Aging -- Sleep requirements diminish only slightly with advancing age, but the elderly may sleep less soundly. Daytime inactivity and napping may contribute to insomnia in this population.
Evaluation
The initial step is a detailed medical history and examination. Attention is paid to psychosocial problems and stress-related health complaints. Usually the diagnosis is readily apparent, but blood tests may be required. Referral to a psychiatrist, sleep center or specialist in sleep disorders may be appropriate for difficult cases which do not respond to treatment.
Treatment
The therapy must be tailored to the diagnosis, e.g. medication change, pain control, improvement in life situation. General measures include stopping caffeine and alcohol, regular exercise, relaxing before bedtime, avoidance of daytime naps and developing a sleeping routine. Use of the bedroom should be reserved only for sleeping. Specific measures include relaxation training and sleeping pills. The benzodiazepine class of hypnotic medications is commonly prescribed. In general, sleeping pills are addicting, have side effects and are ineffective after long-term use. And withdrawal syndromes may actually aggravate insomnia. These medications should be used with discretion and close medical supervision.
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