Counting Sheep? Sleep Expert Outlines Help For Insomniacs

In the March 2000 issue of Postgraduate Medicine, Hrayr P. Attarian, M.D., reviews ways to diagnose and treat insomnia, a symptom of several sleep disorders. "Insomnia is a prevalent and serious condition that is often missed or dismissed. Most of the time, it is treated with ineffectual means, frustrating both patient and physician," says Attarian, an assistant professor of neurology at Washington University School of Medicine in St. Louis and a member of the school's Sleep Disorders Center.

Insomnia is lack of quality sleep, not lack of sleep per se - some lucky people rise and shine after only a few hours. And though it often is regarded as just a nuisance, it can have serious consequences. They include excessive use of prescription medications, alcohol abuse, self-treatment with over-the-counter stimulants, headaches, stomach upsets, motor-vehicle accidents and impairment on the job.

Causes of insomnia

Attarian lists some common causes of insomnia:

• Conditioning - you lie awake for a few nights worrying about the bills and condition yourself to lie awake for many nights thereafter.

• Lifestyle - people who don't sleep well may drink coffee to prop open their eyes during the day and alcohol to numb their senses at night, making it harder, not easier, to break the pattern.

• Restless legs - one in 10 Americans get uncomfortable sensations that make them move their legs, and it's not easy to sleep when your legs are roaming around.

• Apnea - if air can't get in or out of your nose or throat while you're asleep, you may develop a potentially life-threatening condition that interrupts your breathing and also can produce insomnia.

• Abnormal rhythms make some people sleep when other people are awake; then they're awake when other people are asleep.

• Medical conditions, including Parkinson's and other neurodegenerative diseases, pain, allergies and asthma, can deprive people of sleep.

• Menopause disrupts the sleep of nearly half of middle-aged women, especially those who don't use hormone replacement therapy.

• Old age can take its toll by altering brain function so people fall asleep early in the evening, wake early in the morning, or nap a lot.

• Medications, including the newer antidepressants, prednisone (an anti-inflammatory drug) and some anticonvulsants, can deprive you of sleep.

• Psychiatric conditions, such as anxiety focused on sleep, occasionally cause insomnia. But contrary to popular belief, psychiatric disorders are more likely to result from sleep problems than to cause them.

Getting help

The first step to getting help, says Attarian, is to see your primary physican, who may refer you to a sleep disorder expert. The expert will take a clinical history and then may use a variety of tools to make a diagnosis. For example, patients may be asked to record the times they are awake and asleep for two to three weeks. A doctor also may give a patient a wristwatch-like device called an actigraph, which records periods of sleeping and waking by detecting movement. Surprisingly, such tests reveal that some patients who think they never sleep actually sleep very well. Some people with insomnia also may need to be evaluated in a sleep lab that provides more sophisticated tools for diagnosis.

Attarian lists the following rules for a good night's sleep:

• Restrict the time you spend in bed so you're tired when you try to fall asleep.

• Don't nap.

• Leave your bedroom if you've been awake for more than 15 minutes.

• Don't overachieve right before bedtime - no housework or balancing the checkbook.

• Increase the amount of exercise you get each day.

• Remove clocks from your bedroom.

• Use distracting activities when you're trying to get to sleep.

• Cut down on coffee, and avoid nicotine and alcohol.

• Go to bed and get up at the same time each day, even on weekends and even if you haven't slept.

• Use prescribed medications, but don't dose yourself with over-the-counter sleep aids.

Note: For more information, see Attarian HP, "Helping Patients Who Say They Cannot Sleep - Practical Ways To Evaluate and Treat Insomnia," Postgraduate Medicine, 107(3): 127-142, March 2000.