Insomnia is one of the most frequent complaints that a primary provider hears in the office. 50% of adults experience it in their lifetime and up to 10% of adults may suffer from long-term insomnia. It is also one of the most challenging to treat and one of the most misunderstood of the common ailments that people face. In the past this malady was poorly understood and it was felt to be a symptom of some other underlying condition, such as anxiety, depression, medical sleep disorders or medication. It was also thought that it could be improved if you addressed that underlying disorder. While all of these problems can cause sleep disturbances, we now also understand that insomnia can occur in the absence of those underlying problems or may need to be treated in addition to dealing with the underlying issues. In fact, we know that lack of sleep or ineffective sleep makes many chronic diseases more difficult to manage, and successfully treating insomnia can improve those diseases.
First of all, insomnia can present in a variety of ways. It can be difficulty falling asleep, difficulty staying asleep, or waking early and being unable to go back to sleep and in order for it to be diagnosed as insomnia, it must result in difficulty functioning during the day (for example, fatigue, sleepiness, difficulty concentrating, forgetfulness, low energy).
Short term insomnia (less than 3 months duration) is usually associated with life stress or environmental stress. This can be anything from a change in the sleep environment (light, noise, temperature) to the loss of a loved one, illness, pain or withdrawal from certain substances like caffeine or alcohol, a variety of prescription medications and illegal drugs. Jet lag and shift work are also common causes of short term insomnia. Long term insomnia is, as previously noted, often associated with chronic diseases, anxiety and depression, with some medications and illegal drugs and with the use of substances like alcohol and caffeine.
Contrary to popular belief and practice, the best treatments for insomnia do not involve drugs. A variety of behavioral treatments can be effective and are much safer in the short and long run than medications. These include sleep hygiene (get out of bed when you’re not sleeping, keep a regular schedule, don’t try to force sleep, exercise daily, avoid caffeine after lunch, deal with worries prior to bedtime, etc.), relaxation techniques, biofeedback and stimulus control (limiting time spent trying to fall asleep to 20 minutes, get up at the same time every day, don’t nap during the day), sleep restriction, cognitive therapy (developing the skill to break anxious cycles of thought that keep you awake), and even light therapy. It’s important to understand that all of the prescription medicines used for insomnia lose effectiveness over time, have potentially very serious side effects (sleep walking, eating and even driving, increased risks of falls and accidents) and most carry a risk of addiction. Overdose is also a concern, especially when these medications are combined with alcohol.
Finally it’s important to understand that not all people require the same amount of sleep and that sleep duration may decrease as a natural part of the aging process.