Insomnia: Restoring restful sleep

Nearly everyone has spent at least one night lying in bed wishing for sleep. But for many men, it's a nightly struggle. A lucky few get relief from counting sheep, watching late-night movies, or sipping warm milk (or something stronger) — but most people with insomnia need more assistance. Fortunately, lifestyle changes and behavioral treatment can help many sufferers, and medication is available for those who need it.

Normal sleep

Sleep is essential for health, providing rest and restoration for mind and body. But although it's restful, sleep is actually quite complex and busy in its own right.

Sleep is divided into two major phases, rapid eye movement (REM) sleep and non-rapid eye movement (non-REM) sleep. Good sleepers fall asleep quickly, usually in less than 15 minutes. They enter non-REM sleep first, moving gradually from light sleep (Stage 1) to deep sleep (Stage 4). During non-REM sleep, the mind slows down. The circulation slows, too, as the heart rate and blood pressure fall. Breathing is slow and steady. The muscles are relaxed, but body movements do occur.

After about 45 to 60 minutes, sleep shifts into its REM phase. Although the eyes remain closed, they move rapidly in all directions. In contrast, the limb muscles are completely limp and immobile. Breathing is very slow and may even pause briefly. But the brain is turned on; dreaming occurs only during REM sleep. Although the body is entirely relaxed, the heart rate and blood pressure fluctuate from low to high; the heart pumps less blood to the body but more to the brain. The sympathetic nervous system is active, stimulating production of adrenaline, the "stress hormone." Most men develop penile erections during REM sleep.

After about 30 to 45 minutes, sleep shifts back from REM to the non-REM pattern. The two states continue to alternate, with four to six 90- to 110-minute cycles occurring during the course of a typical night's sleep.

There is no "normal" amount of sleep; what matters is how well, not how long you sleep. Still, most middle-aged people function best on seven to nine hours of sleep, while others need up to 11 hours. Sleep requirements change during the course of a lifetime; most children need more sleep, most older adults, less.

The body's internal clock

The sleep-wake cycle is controlled by the body's internal clock. Many other bodily functions also wax and wane cyclically in response to the 24-hour circadian rhythm. For example, normal body temperature is lowest at about 5 a.m., when it averages 97° F, and highest at about 5 p.m., when it averages 99.4° F. Similarly, sodium excretion and urine output are normally higher during the day than at night. Hormone levels also fluctuate; cortisol secretion is highest during the morning. Testosterone production peaks in the morning, growth hormone at night. Melatonin, the "dark hormone," is produced by the brain's pineal gland during the night.

The daily cycles of light and darkness help set the body's internal clock. Disturbances in the normal coordination of light and darkness with wakefulness and sleep account for the temporary sleep disturbance of jet lag or the chronic disorders experienced by many shift workers. Travel is a common cause of disturbed sleep today, but similar disturbances originated long before the jet age; Robert Burton got it right way back in 1628 when he said, "Our body is like a clock, if one wheel is amiss, all the rest are disordered... with such admirable art and harmony is a man composed."

What is insomnia?

Since there is no "normal" amount of sleep, a diagnosis of insomnia does not depend on the number of hours a person sleeps. Instead, it's defined as an inadequate quantity or quality of sleep that interferes with normal daytime functioning. For some people, insomnia means difficulty in falling asleep, for others it's difficulty in maintaining sleep, and for still others it's early awakening.

Everyone has a rough night or two, and about 30% of adults have occasional or short-term insomnia. Chronic insomnia, though, lasts for more than three weeks. About 10% of American adults experience chronic insomnia, and most need treatment to get relief.

Symptoms

A restless, wakeful night is the most obvious symptom. Although that can be a miserable experience, daytime symptoms are actually more worrisome. They may include sleepiness and fatigue, which sometimes cause car crashes and other accidents. Impaired concentration, grumpiness and irritability, forgetfulness, and depression can also occur. Although insomnia itself does not lead to other medical illnesses, it can take a toll on work, family life, and personal happiness.

What causes insomnia?

Insomnia is not a disease but a symptom. And it's such a common symptom because it has many causes. Table 1 lists some of the things that can shorten sleep, interrupt sleep, or produce poor quality, nonrestorative sleep.

It's a long list; anxiety and depression belong in first place, but obstructive sleep apnea and benign prostatic hyperplasia (BPH) are of particular importance for men. And many people with insomnia don't have any of these underlying conditions. Instead, they have primary insomnia. Although doctors don't know what causes primary insomnia, they do know how to help.

Evaluation

There are no specific tests to diagnose insomnia. Still, it's very important for you to have a thorough medical evaluation. Your doctor will check your general health and review your medications and supplements. If there is reason to suspect any of the causes listed in Table 1, he may order lab tests or x-rays. In some cases, you may be asked to have a sleep study (polysomnography) or to see a sleep specialist, particularly if sleep apnea is suspected (see below).

You can help your doctor evaluate your problem by keeping a sleep diary. Table 2 lists the information you should record.

Sleep hygiene

Some simple tips can help you get a good night's sleep:

• Stick to a regular bedtime and rising time.

• Get lots of daylight, but avoid bright light before bedtime.

• Use your bed only for sleeping or lovemaking, never for reading or watching TV. If you can't sleep after 15 to 20 minutes, get out of bed and go into another room. Read quietly with a dim light but don't watch TV, since the full-spectrum light emitted by the tube has an arousing effect. When you feel sleepy, get back into bed — but don't delay your scheduled awaking time to compensate for lost sleep.

• Don't nap during the day unless it's absolutely necessary. Even then, restrict your nap to 15 to 20 minutes in the early afternoon.

• Get plenty of exercise. Build up to 30 to 45 minutes of moderate exercise nearly every day; walking is an excellent choice. Get your exercise early in the day, and then try some stretching exercises or yoga to relax your muscles and your mind at bedtime.

• Wind down late in the day. Whenever possible, schedule stressful or demanding tasks early and less challenging activities later. Establish a regular bedtime and a relaxing bedtime routine, such as taking a warm bath or listening to soothing music.

• Eat properly. Avoid caffeine, especially after mid-afternoon. Try to avoid all beverages after dinner if you find yourself getting up at night to urinate. If you enjoy a bedtime snack, keep it bland and light. Avoid alcohol after dinnertime; although many people think of it as a sedative, alcohol can actually impair the quality of sleep.

• Be sure your bed is comfortable and your bedroom is dark and quiet. It should also be well ventilated and kept at a constant, comfortable temperature. Try using a sleep mask, earplugs, or a white noise machine to compensate for problems in your sleeping environment.

• Above all, don't worry about sleep. Watching the clock never helps. Except when keeping a sleep diary, don't keep track of the amount of time you spend trying to sleep. Instead, just rest quietly and peacefully. Try not to lie in bed reviewing your problems and plans. If you really are overloaded, get out of bed and make a list, then return to bed and think of something relaxing and pleasant.

Treating insomnia: Behavioral therapy

If good sleep hygiene doesn't solve your sleeping problems, behavioral therapy may. Here is a quick summary of some techniques:

Relaxation training. Learn deep breathing, progressive muscular relaxation, or meditation. Relaxing your mind at bedtime will help you drift off to sleep.

Stimulus control therapy. Go to bed only when you are sleepy. Don't read, watch TV, snack, or listen to music in bed. Get up at the same time every day, no matter how little you've slept. Avoid daytime napping.

Sleep restriction therapy. Reduce your time in bed to the estimated total time you actually sleep in an average night by going to bed later, but don't go below five hours. Make the change by getting into bed later, not getting up earlier. Get up at the same time every day. Maintain the same bedtime every night for a week, and then move it 15 minutes earlier every week until you get a satisfying, refreshing amount of sleep. Then maintain the same schedule every day.

Cognitive therapy. Learn to replace negative thoughts about sleep ("I'll never get to sleep tonight;" "I'll be a wreck tomorrow;" "I'll get sick unless I sleep eight hours a night") with positive thoughts ("If I relax peacefully in bed, my body will take care of itself").

Treating insomnia: Supplements

A number of dietary supplements are heavily promoted to improve sleep. None is subject to FDA standards for purity, safety, or effectiveness. The two most popular supplements are melatonin and valerian. Melatonin is a hormone produced by the brain's pineal gland; in low doses, it may have some benefit for temporary insomnia due to jet leg. Valerian is an herb; there is little evidence that it helps.

Treating insomnia: Medications

Sleeping pills are available over the counter or by prescription. Whether you're treating yourself or using a drug prescribed by your doctor, you should follow several basic guidelines:

• Use medication only as a backup to behavioral changes.

• Use the lowest dose that is effective.

• Don't take a pill every night. Instead, use medication only when an uninterrupted night's sleep is really important. Even then, restrict yourself to two to four tablets per week.

• Try to stop using medication after three to four weeks.

• Discontinue medication gradually to avoid rebound insomnia.

Over-the-counter medications. Many brands are available. Most contain antihistamines such as diphenhydramine or doxylamine. Most sleep experts discourage the use of these products, particularly long-term use. Side effects include daytime sedation, dry mouth, constipation, and difficulty urinating.

Prescription medications. Your doctor will decide if you need a sleeping medication, then determine which drug is best for you and instruct you in its proper use, precautions, and potential side effects. The FDA has recently required stronger warnings about daytime sedation, untoward behavior such as sleep-driving, and allergic reactions. Many medications are available. The older barbiturates and sedatives have been almost entirely replaced by safer and more effective drugs. Certain antidepressants can help promote sleep, particularly if depression is also present. Examples include trazodone (Desyrel), doxepin (Sinequan and Adapin) and amitriptyline (Elavil and others). But doctors today usually choose among three groups of medications:

Benzodiazepines. Temazepam (Restoril), oxazepam (Serax), estazolam (ProSom), and many others. These older drugs were once the mainstays of insomnia therapy. But excessive use can be habit forming, and some of the longer-acting preparations can cause daytime sedation.

Nonbenzodiazepines. Eszopiclone (Lunesta), zaleplon (Sonata), zolpidem (Ambien). These newer medications act on the same receptor in the brain as the benzodiazepines, but they tend to act more quickly and to leave the body faster. They are less likely to cause daytime sedation, habituation, and rebound insomnia.

Melatonin receptor agonist. Ramelteon (Rozerem). This medication acts on the same brain receptors as the hormone melatonin. It is fast acting but very short lasting. It does not appear to cause habituation or rebound insomnia.

Sleep tight

According to the National Sleep Foundation, the average American adult gets 6.9 hours of sleep on weeknights and 7.5 hours on weekends. But about 70 million of us sleep poorly, and for more than half, it's a long-term problem. Nearly everyone can benefit from improved sleep hygiene. Men with sleep disorders should work with their doctors to diagnose the problem and treat conditions that may be responsible. If your doctor diagnoses primary insomnia, consider behavioral therapy first, and then discuss the proper use of prescription sleeping pills.

Good nights make good days and vice versa. The best way to get the sleep you need is to take good care of yourself, day and night. Be sure your daytime activities include good health habits such as regular exercise, sound nutrition, and stress reduction. Good sleeping habits will help at night. Use medications only as a temporary supplement to the lifestyle that will help keep your days healthful and your nights restful.

The key is a balanced approach. It's important advice, but it's hardly new; some 2,400 years ago, Hippocrates wrote, "Disease exists if either sleep or watchfulness be excessive."