Insomnia

Everyone has been troubled by insomnia at one or more points in their lives. I define insomnia as difficulty in either initiating sleep or in remaining asleep throughout the night. But before discussing causes and treatments for insomnia, I would like to impart some general information about sleep.

Sleep is a habitual, easily reversible, mental state that is characterized by very deep relaxation of one’s muscles and a low responsiveness to external events, meaning that when you are asleep, you are not very aware of external stimuli such as noises, tactile sensations, etc. the way you are when awake.

Researchers have differentiated five distinctly different stages of sleep, using recordings made from brain waves. A person, on the average, cycles through these five stages of sleep about four or five times a night.

Stage One is, not surprisingly, the lightest stage of sleep. During Stage One sleep, a person’s EEG (electroencephalographic) or brain wave recordings register low voltage, regular, four to six cycles per second waves. Brain waves occurring at this frequency are called alpha waves. This stage of sleep is very short, lasting only from a few seconds to a few minutes.

Stage Two EEG recordings show bursts of what are called sleep spindles, as well as alpha waves. Sleep spindles are spindle-shaped bundles of brain waves occurring at 13 to 15 cycles per second.

In Stage Three sleep, delta waves are beginning to appear. These are high voltage, large EEG waves that have an activity level of .5 to 2.5 cycles per second.

In Stage Four sleep, long, slow delta waves are the predominant type of brain wave recorded.

Stage Five sleep is similar to the first stage of sleep, in that alpha bursts are found in EEG recordings and rapid eye movements (REM) can be found. This stage is referred to as REM sleep, or paradoxical sleep. It has been called paradoxical sleep because one’s pulse, respiration, and blood pressure are high, often higher than when one is awake, during paradoxical sleep. Yet, EMG electromyography or muscle recordings show the least amount of arousal. Thus, while many physiological indicators point to the person being highly aroused (and incidentally this is the stage when nocturnal penile erections occur), the person is unable to move a muscle. This is the stage where most dreaming occurs.

The first period of REM sleep usually lasts less than ten minutes. However, by the end of the night, the REM sleep period may be up to half an hour in length.

Stage Four sleep is also very interesting. Remember that Stage Four sleep is characterized by slow, deep brain waves. Most Stage Four sleep occurs during the first third of the night. If a person in Stage Four sleep is awakened, he/she tends to be disoriented, to not know where he/she is or, perhaps, even who he/she is. It is during Stage Four sleep that bed-wetting, sleepwalking, and nightmares occur.

So much for a brief overview of sleep. Now, what happens when a person has insomnia? Firstly, remember that about a third of the population will actually seek medical attention for insomnia over the course of a year. So, this is a very common complaint. Secondly, some people just function well on an average of only four or five hours of sleep a night. Others will go through periods where they don’t sleep more than five hours a night, interspersed with periods in which they will sleep longer. All of these patterns can be normal with no cause for alarm.

But, if a person who is used to going to bed, falling asleep within a reasonably short time, and staying asleep except for maybe one brief trip to the bathroom, all of a sudden has trouble sleeping for several nights, into weeks, then the etiology of this insomnia is worth pondering.

Of course, anxiety is a chief cause of insomnia in physically healthy individuals. Knowing that one has an important interview, meeting, or examination impending can cause several nights of disturbed sleep.

Also, what can happen is then a person becomes conditioned to view the bed and nighttime as stimuli associated with insomnia. For whatever external reason the insomnia may have begun, the person then associates the bed with restlessness and has trouble sleeping. Often such people can sleep better in strange beds away from home where insomnia-producing cues are not present. Some people are just the opposite and never sleep well away from home.

Similarly, other physically healthy people can become conditioned not to sleep because they are afraid of recurrent nightmares. Still, other compulsive, chronically tense people who have trouble “letting go” may be afraid of the deep relaxation that accompanies sleep. When I do relaxation training with such patients they seem to confuse relaxation physiological responses with fatigue.

Insomnia is also one of the most important somatic signs professionals look for in diagnosing mental depression, along with loss of appetite and lack of mental energy.

Many factors can cause insomnia. Among these is alcohol use – anything more than one drink a night disrupts the sleep cycle to some degree – and withdrawal from tranquilizers, antidepressants, or barbiturates, to name a few drugs. The consumption of coffee, tea, or carbonated beverages can also produce insomnia, although many people say they drink coffee until late at night with no ensuing sleep difficulties. I privately wonder if such individuals do not wake up several times during the night, but just for such short periods that they are not cognizant of these awakenings in the morning. I personally don’t drink anything with caffeine in it after about five o’clock in the afternoon, unless I plan to have a very late evening.

Hyperthyroidism also causes disrupted sleep, as can deep lower brain malfunctions such as tumors and injuries. Age also is associated with insomnia. In general, as one grows older, one needs less sleep and will tend to awaken more often during the night.

There are several other, more esoteric causes of insomnia, such as nocturnal myoclonus. This is a convulsive twitching, usually of the leg muscles that occurs during the night. Even if it does not cause the perpetrator to have insomnia, it may well cause his/her bed partner to experience sleep difficulties. Sometimes leg cramps at night, especially in older women, are associated with a lack of potassium.

Treatments for insomnia are as variable as the causes. However, it is not good practice to use sleeping pills on a regular basis. Such medications lose their effectiveness after a while, necessitating increasingly stronger doses, and can result in severe withdrawal symptoms.

There is a naturally occurring tranquillizer found in foods such as milk (remember when the cup of warm milk before bedtime was in vogue?). This is an amino acid called L-tryphtophan, which is available in health food stores. L-tryphtophan is a clinical precursor of serotonin, a brain neurotransmitter. Studies have shown that, given in small, regular doses at bedtime, it reduces sleep problems in insomniacs. Melatonin is a similar, natural sleep-onset remedy. Chamomile tea induces a mild degree of relaxation as well.

Moderate exercise is also a good sleep inducer. Such exercise is best if done in the afternoon or early evening and not immediately before bedtime. Sexual activity does not need to be restricted temporally; it is often a good sleep inducer.

Certainly, if the degree of the insomnia is severe, a consultation with one’s family physician is recommended, lest a serious physical condition be present.