Sleep Soundly Every Night, Feel Fantastic Every Day (14 page)

  
Consistent rising with an alarm every morning would help reset Tom's circadian clock.

  
No naps in the afternoon after work would make sleep more likely moving forward.

I explained the behavioral technique called stimulus control, discussed later in this chapter. This treatment focuses on reducing exposure to things that cause wakefulness at night, and the goal is to establish immediate sleep and an optimal sleep–wake cycle. If Tom did not fall asleep within 20 minutes after waking, he got out of bed and chose to stay in the living room area with no computer and read. He avoided stimulating activities, and if he got sleepy again, he returned to bed. If he still could not sleep then he was to return to the living room and do something that was relaxing.

We also used cognitive restructuring, delving into Tom's dysfunctional beliefs about insomnia. Focusing on thoughts like
this lack of sleep will give me a heart attack
only made matters worse. However, Tom could affirm his sleep as restorative and healthy.

Tom went home with several weeks of sleep logs to be filled out in the morning after he was awake and out of bed for the day. He would bring these back for his weekly appointments.

My hope was that these strategies would correct his insomnia. If not, my next step would be a sleep study to determine if sleep apnea was the root cause of the problem. Only recently have we sleep specialists come to appreciate how often an inability to remain asleep or early morning awakenings can be triggered by a primary sleep disorder such as sleep apnea and sometimes by periodic leg movements causing arousals from sleep.

If we still had not resolved the problem, I would consider placing Tom on one of the more sedating anti-anxiety antidepressant medications. I have had great success with these medications when generalized anxiety disorder has been at the root of the problem. The medications are even more effective when combined with CBT.

After a few months there was a significant improvement in that Tom was still awakening in the early morning hours after sleep onset, but he was able to return to sleep in a much shorter time. At this point, bothered by his continued awakening from sleep, I ordered a sleep study. I rarely perform sleep studies for insomnia, but when the insomnia occurs after falling asleep and is persistent despite good patient adherence to therapy, I feel a sleep study is in order.

Lo and behold, Tom did have sleep apnea that was particularly severe at 3:00 a.m. during REM (dream) sleep. This is not unusual, as sleep apnea appears to be more severe during dream sleep in many individuals, and dream sleep tends to increase significantly during the second half of the night. Treating Tom's sleep apnea was an important part of treating his insomnia.

Tom's lifestyle and stressors also contributed to insomnia. Because behavior and insomnia are closely linked, treatment must include the behavior and emotional associations surrounding bedtime and sleeping. Changing sleep practices is one part, and the transformation of feelings and thoughts into more successful habits is the second part.

In 10% of the population, insomnia is a chronic problem, lasting over three months. In fact, most studies measure the duration of the problem in years.

1.
 
Duration of longer than one month.

2.
 
Continuing symptoms on two or more follow-up visits with your health care provider.

Multiple factors contribute to a diagnosis of chronic insomnia, including:

  
Heredity in one-third of the cases.

  
Mental health disorders such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), post-traumatic stress, or bipolar disorder.

  
Substance abuse, the consistent triggering of the hyperarousal state, and certain medical conditions and medications.

If untreated, many go on to develop depression. In fact, in one study of over 14,000 patients, insomnia preceded depression in 40% of cases. That percentage still amazes me because I see that an insomniac might not clearly recognize his or her personal level of dysfunction. In addition, insomnia occurs at the same time as anxiety disorders in 38% of cases. If you leave insomnia untreated, the relapse rates of depression and anxiety are very high. It also creates high risk factors for other mental health issues, substantial health care costs, dysfunction in work and relationships, as well as decreased quality of life.

A recent study from South Korea, published in the journal
Sleep,
highlights the emotional problems associated with persistent insomnia. In this study, researchers followed over 1,000 people with insomnia for a six-year period. Researchers first eliminated those with insomnia and either depression or suicidal ideation. Over the next six years, researchers closely followed those with chronic insomnia, and screened them periodically for the development
of depression or suicidal ideation. The odds of developing depression were 2.5 times more likely and developing suicidal ideation was 1.7 times more likely in those with continuing insomnia. Other published studies that also correlated insomnia with the odds of developing depression or suicidal thoughts were higher than in the Korean study.

If left untreated, chronic insomnia can result in significant emotional consequences. Prevent any transient insomnia from progressing.

There are two major schools of thought as to why you might suffer from insomnia. The first is the physiological hyperarousal theory, which means the brain and body stay in an alert, aware state. Insomnia sufferers show faster brain waves that are characteristic of wakefulness and mental processing while asleep. They also produce more stress hormones such as cortisol, adrenaline, and noradrenaline at night. In addition, PET scans show an increase in glucose uptake in the brain while asleep compared to normal sleep patterns.

The second theory is the psychological theory. Insomnia sufferers seem to have anxiety-prone personalities, may be ruminators and worriers, and tend to internalize their emotions. Therefore, they have more trouble dealing with chronic daily stressors such as occupational or family conflicts, as well as major life events such as divorce, death in the family, or illness. For example, insomnia is a risk factor for depression. Recent research on a small sample of people with chronic primary insomnia provided the MRI evidence of the neurobiology “underlying the dysfunctional emotion regulation in people with insomnia” and linked the risk between insomnia and depression.

Obviously, the symptoms of the brain and body coexist and one can exacerbate the other. That is why one treatment does not fit all persons with insomnia. Sleep experts sometimes need to combine pharmacologic treatment with CBT, even if for a short period, to achieve the goal of getting good quality sleep such as in the example of my patient Maria.

No matter what your age or gender, insomnia can happen to you. The following is a list of inherent traits and life stressors that could increase your vulnerability to insomnia:

1.
 
Hyperarousal—chronic state of alert.

2.
 
Family history of light or disrupted sleep.

3.
 
Tendency to worry.

4.
 
Anxiety-prone personality.

5.
 
Preoccupation with well-being.

6.
 
Dramatic responses to impactful life events such as surgery, death, birth, loss of job or financial security, illness onset or chronic illness.

7.
 
Environmental factors such as living near traffic noise.

8.
 
How you deal with sleep and insomnia most often perpetuates the insomnia.

Women are two times more likely to report insomnia than are men. Why?

Sleep experts understand that women may have greater awareness of insomnia symptoms. They are more likely to talk about insomnia or mention incidents in social situations and in their roles as mother, caretaker, or wife. While biological differences in a woman's life cycle contribute to insomnia, a family history of a mother's insomnia also
likely increases the incidence. Insomnia increases with age, but women's research confirms a steep rise of insomnia in midlife.

The rise is easily understood considering the three phases of menses a woman passes through in the twenty years from age 40 to 60: perimenopause hot flashes, menopause with psychological sensitivity and distress, and post-menopausal possibility of sleep-disordered breathing. Any further factors contributing to persistent insomnia are similar to those in men.

In summary, women are at higher risk of developing insomnia than are men, and treatment considerations must include the stage of the life cycle, predisposition to mood disorders, and hormonal considerations such as nocturnal hot flashes.

The greatest news is that there are treatments for insomnia that can improve your health, function, and quality of life. The American Academy of Sleep Medicine suggests both pharmaceuticals and behavioral approaches in order to improve sleep.