I Can’t Sleep

Click the play button to listen to my song “Insomnia”.

Note: this article was originally published at FAMILYLAWYERMAGAZINE.COM

INTRODUCTION

You don’t realize how important a good night’s sleep is until you can’t get one. It has been said that between 15-35% of adults have sleep problems ⁱ and up to 50% of people over the age of 65 have sleep complaints.ⁱⁱ Many with chronic or continued insomnia report decreased feelings of well-being during the day, including decreased attention, energy, and concentration and an increase in fatigue and malaise. This causes considerable impairment in social, occupational and other areas of functioning. Chronic insomniacs also have 2.5 times more fatigue-related automobile accidents than good sleepers.ⁱⁱⁱ

CAUSES

Insomnia is usually caused by multiple factors. Problems with sleep onset, mid-cycle awakening and early morning awakenings are very commonly associated with depression, and it has been estimated that 80% to 90% of patients with major depression experience sleep difficulty.^iv Persistently disturbed sleep may be in itself a risk factor for the development of depression and early treatment of sleep disturbance may prevent the onset of major depression. Of 70 patients with a recent heart attack 39% reported having insomnia for two weeks or longer before their MI and 48% were suffering from depression.^v Insomnia can also be related to an anxiety disorder, obsessive compulsive personality disorder, schizophrenia or another mental illness.

SLEEP DISORDER DUE TO A GENERAL MEDICAL CONDITION
Conditions like thyroid disorders, heart failure, Parkinson’s disease, Dementia, and sleep apnea are associated with problems of insomnia. Sometimes viral and bacterial infections, coughing related to lung diseases and pain from musculoskeletal disease like fibromyalgia, arthritis or even fractures can cause the beginning of disturbed sleep. Sometimes the sleep problem can continue even after the medical condition is resolved.

DRUG ASSOCIATED SLEEP DISORDER
Alcohol, coffee, tea, chocolates and soft drinks containing caffeine can aggravate insomnia. Some medications can also disturb sleep.

Substance-induced sleep disorder can occur during intoxication and during withdrawal from alcohol, amphetamines, cannabis, cocaine, opioids, caffeine, sedatives, sleeping pills and anti-anxiety medications.

PRIMARY INSOMNIA
Primary Insomnia or psychophysiological insomnia is not related to another mental disorder, an organic problem, or substance. Often these people are preoccupied with not being able to sleep, worry about falling asleep and experience an improvement in sleep when away from their usual sleep environment. These people often have poor sleep hygiene, and negatively reinforced conditioning. The more the individual tries to sleep, the more distressed and frustrated the person becomes and the less able he or she is able to sleep. Lying in bed feeling frustrated causes increased arousal and agitation.

I sometimes see patients who experience a death or major stressful life event that affects their sleep. They eventually get over the grief or stressful situation but negative conditioning, heightened arousal, and negative associations can perpetuate the insomnia after the original cause is resolved.

CIRCADIAN RHYTHM SLEEP DISORDER
Night and rotating-shift workers have shorter sleep duration and more frequent disturbances than morning or afternoon workers.

People who travel through many time zones especially eight or more time zones in 24 hours and those who travel far in an eastward direction by plane can suffer from jet lag.

“Night owls”, people who delay going to sleep until the wee hours of the night, can have trouble getting to sleep at socially acceptable hours. They also have difficulty waking up when required and often say they need many alarm clocks scattered around the room to ensure they actually get up on time. This problem is common in teenagers.

OTHER CAUSES
Patients can also have difficulty with sleep if they have nightmares, sleep terrors, restless leg syndrome, urinating many times at night or if there are environmental factors like noise, light, sleep partner or baby crying interruptions. Normal elderly people have greater difficulty falling asleep and staying asleep and their sleep is more shallow with more involuntary movements and abnormal breathing.^vi

PSYCHOTHERAPY OR COUNSELLING

Sometimes insomnia is associated with known traumatic life events. The loss of a loved one, loss of a job, marital and family breakups, losses related to accidents and operations, can cause sadness and if the grief is persistent and not resolved can lead to insomnia and clinical depression.

Counselling or psychotherapy which focus on the grief reaction, can help to advance the recovery phase and stimulate new psychological strength and personality growth. Psychotherapy can focus on the resentment and anger suppressed or turned back on the self as well as help resolve the guilty feelings which are usually self- destructive.^vii

I find learning a progressive relaxation exercise to use at bedtime and using a tape or listening to a relaxation exercise online very helpful in getting to sleep and getting back to sleep if you wake up..

SLEEP HYGIENE

1. Keep a sleep diary. If you have difficulty getting to sleep because you review past unresolved problems or are pre-occupied with future planning then write your thoughts and feelings in the diary. Having the thoughts expressed on paper sometimes prevents them from being perpetuated endlessly in your mind.
2. No heavy meals at bedtime. Limit fluids after six o’clock.
3. Avoid stimulus before retiring. No fighting in the evening.
4. Eliminate alcohol, caffeine and recreational drugs.
5. Increase the daily amount of exercise but leave at least four hours free of exercise before going to sleep.
6. Use the bed for sleep and sex only, not for watching TV, doing work or reading. Don’t sleep elsewhere in the house.
7. Go to sleep at the same time each night. If it takes longer than 20 minutes to get to sleep then get up and do something like a hobby or reading in dim light until you feel drowsy and then return to bed.
8. If you awaken at night, remain in bed and relax. Let yourself fall asleep again. If you don’t fall back to sleep get out of bed and do some quiet activity in dim light. No screen time. When you feel sleepy go back to bed.
9. Keep the hours of awakening consistent. No matter how bad the night’s sleep, have an alarm wake you up at the same time each day. Don’t oversleep.
10. Keep your clock turned away from you so you don’t clockwatch.
11. Learn a progressive relaxation exercise and even get a taped exercise to use at home. It is an important tool to quiet your active mind and relax your physical body.^viii
12. No naps during the day. Go out for a walk instead.
13. If you work a swing or night shift, stay with your regular sleep-wake schedule as closely as possible.
14. Develop bedtime rituals. eg. Lock the doors. Brush your teeth. Wash your hands and face. Get into pyjamas. Set your alarm. Close the lights. Relaxation exercise. etc.
15. Eliminate noise by soundproofing, or wearing earplugs. Set the temperature at an ideal condition for you. Make sure your bed and pillow are comfortable.
16. No one died from not sleeping but many people make themselves sick by worrying about not sleeping.
17. No screen time at least an hour before bed. No TV, cell phone, computer or video games exposure. Keep cell phones, modems and other electrical devices out of the bedroom.

ⁱBuysse DJ, Reynolds III CF, Monk TH, The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research. Psychiatry Research 1989;28:193-213

ⁱⁱMonane M, Insomnia in the elderly.[Review] J Clinical Psychiatry
1992;53 suppl:23-8
ⁱⁱⁱMendelson WB, Jain B, An assessment of short acting hypnotics. Drug Safety 1995;13:257-70

^ivFord DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders: an opportunity for prevention. JAMA 1989;262:1479

^vCarney R M et al. Insomnia and Depression Prior to Myocardial Infarction. Psychosomatic Med 1990:52:603-609

^viMcCall W.V., Management of sleep disorders among elderly persons. Psychiatric Services 1995;46:49-55

^viiBorins M, The role of insomnia in depression. Canadian Psychiatric Review 1992;1:7-11

^viiiBorins MS, An Apple a Day-A Holistic Health Primer. Wholistic Press Toronto 1980 pg 81-5