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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Help for Insomnia


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

Almost every man has spent at least one night lying in bed wishing for sleep. For some, 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 help. Fortunately, behavioral treatment and medication, if necessary, can eliminate sleepness nights for many people.

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What is Insomnia?

Insomnia is defined as an inadequate quantity or quality of sleep that interferes with normal daytime functioning. Insomnia includes:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Waking up without feeling rested or refreshed

A diagnosis of insomnia does not depend on the number of hours a person sleeps because there is no set amount of sleep that's right for everyone.

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. For more than half of the sleep-challenged, insomnia is a long-term problem. About 10% of American adults experience chronic insomnia, and most need treatment to get relief.

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What Are the Symptoms?

The most obvious symptom of insomnia is a restless, wakeful night. Although that can be a miserable experience, daytime symptoms are actually more significant. They may include:

  • Sleepiness and fatigue, which can lead to car crashes and other accidents
  • Impaired concentration
  • Grumpiness and irritability
  • Forgetfulness
  • Depression

Although insomnia itself does not lead to other medical illnesses, it can take a toll on work, family life and your personal happiness.

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What Causes Insomnia?

Insomnia is not a disease, but a symptom. And it's such a common symptom because it has many causes. Many things can shorten sleep, interrupt sleep or produce poor quality, non-refreshing sleep, such as:

  • Medical illnesses — Gastric reflux with heartburn, chronic obstructive lung disease and asthma, congestive heart failure, menopausal hot flashes, arthritis and other causes of chronic pain, enlarged prostate gland and other urinary conditions, and overactive thyroid
  • Neurological disorders — Parkinson's disease, strokes, and dementia
  • Sleep disorders — Obstructive sleep apnea, periodic limb movement disorder, and restless legs syndrome
  • Psychological conditions — Depression, anxiety, stress, and over-stimulation or overload
  • Stimulants — Caffeine and nicotine
  • Medications — Decongestants, bronchodilators, certain antidepressants, steroids, beta-blockers, and diuretics

Although this is a long list, many people with insomnia don't have any of these underlying conditions. Instead, they have primary insomnia — insomnia that can't be attributed to anything physical, mental, or environmental. Although doctors don't know what causes primary insomnia, they do know how to help.

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Diagnosing Insomnia

There are no specific tests to diagnose insomnia. Still, it's important for you to have a thorough medical evaluation. Your doctor will check your general health and review your medications and supplements. In some cases, you may be asked to have a sleep study (polysomnography) or to see a sleep specialist.

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Treating Insomnia

There are four approaches to treating insomnia:

  1. Sleep Hygiene — Bedtime practices and habits that can affect your sleep are known as "sleep hygiene." Here are some suggestion for improving your sleep hygiene and helping you get a good night's sleep.
    • Use your bed only for sleeping or lovemaking, never for reading or watching television. 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 television 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 wake-up time to make up 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 30-45 minutes of moderate exercise nearly every day; walking is an excellent choice. Get your exercise early in the day, then try some stretching exercises or yoga to relax your muscles and your mind at bedtime.
    • Whenever possible, schedule stressful or demanding tasks early and less challenging activities later, so you can wind down at the end of your day. 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 might 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, it can actually impair your 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. Don't keep track of the amount of time you spend trying to sleep unless you are keeping a sleep diary. Instead, just rest quietly and peacefully. Try not to lie in bed reviewing your problems and plans. If you're feeling overloaded, get out of bed and make a list, then return to bed and think of something relaxing and pleasant.
  2. Behavioral Therapy — If good sleep hygiene doesn't solve your problem, 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 — Go to bed later to limit your time in bed to the estimated total time you actually sleep in an average night — determined by keeping a sleep diary. (Make sure it's a minimum of five hours.) 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 with positive ones. Instead of "I'll never get to sleep tonight," "I'll be a wreck tomorrow," or "I'll get sick unless I sleep eight hours a night," try "If I relax peacefully in bed, my body will take care of itself."
  3. Supplements — Although many dietary supplements are promoted to improve sleep, none is subject to U.S. Food and Drug Administration (FDA) standards for purity, safety, or effectiveness. The two most popular 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.
  4. Medications — Whether you treat yourself with an over-the-counter medication or use a drug prescribed by your doctor, you should follow several basic guidelines:
    • Use medication only as a back-up 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

Many brands of sleep medications are available over-the-counter. 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 — a particular worry for men with enlarged prostates.

Your doctor will decide if you need a prescription sleep medication and which one is best for you. Your doctor will also explain its proper use and potential side effects. The FDA now requires that drug manufacturers warn consumers about additional side effects, such sleep-driving and other unusual behaviors.

Safer, more effective drugs have almost enirely replaced older barbiturates and sedatives, which could be habit-forming, and lethal if someone overdosed. Certain antidepressants can help promote sleep. But now doctors usually choose between three groups of medications.

  • Benzodiazepines (temazepam, oxazepam, estazolam — These older drugs were once the mainstays of insomnia therapy. Excessive use can be habit-forming and some of the longer-acting pills can cause daytime sleepiness.
  • Imidazopyrines (eszapiclone, zaleplon, zolpidem)— These newer medications act on the same receptor in the brain as the benzodiazepines, but they tend to act more quickly and leave the body faster. They are less likely to be habit-forming or cause daytime drowsiness, but they can sometimes cause bizarre behavior.
  • Melatonin receptor agonist (ramelteon) — 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 be habit-forming or cause rebound insomnia.

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Sleep Tight

Nearly everyone can benefit from improving their 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.

Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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