Chronic Insomnia Disorder: Everyone has a bad night here and there. You have an important event the following day and you are so excited, so you have a hard time winding down. Or something genuinely distressing or upsetting happens at work or with family/friends and you can’t stop mulling over and you can’t calm your emotions enough to allow your mind to drift into sleep. Insomnia becomes Chronic Insomnia Disorder when this problem with sleep occurs a lot and even occurs when the patients thinks they have no worries or think they are not under much stress.
Definition: Chronic insomnia is difficulty falling or staying asleep or waking up too early that is accompanied by daytime impairment (fatigue, concentration problems, mood instability, etc) and these problems occur at least three times per week and have been going on for at least three months.
Diagnosis: Insomnia is a clinical diagnosis which means there are no tests that we use to determine if patients have insomnia. They explain their problem to their doctor and from this clinical history, the doctor can determine if insomnia is the likely diagnosis. When sleep physicians order a sleep test for a patient who presents complaining of insomnia, then that means they suspect that the patient might, in fact, have a different, or at least, an additional disorder such as sleep apnea. Patients often ask me if we test neurotransmitters or do EEG to test brain waves in order to diagnose or to find the cause of insomnia and the answer is: No. There are research studies which try to use these types of tests to elucidate the cause and pathology of insomnia, but such tests have not been shown to be useful in the clinical setting.
Causes: We do not know. We call it a disorder of hyperarousal and know that many patients have physiologic parameters that indicate increased activity of the sympathetic nervous system (fight or flight) such as increased heart rate, increased metabolic rate, elevated cortisol, increased body temperature, increased high-frequency EEG activity during non-REM sleep. However, these are not thought to be causing the problem with sleep; they are biomarkers associated with stress response and with increased arousal and vigilance. We assume that the neurotransmitters in the brain are not functioning in a way that allows for sleep, but this is not well understood.
We have a behavioral model for insomnia, called The Three-Factor Model developed by Spielman and colleagues in 1987. It a conceptual framework that attempts to explain how insomnia develops and why it persists. It postulates that patients have: 1. Predisposing Factors which include genetic, psychological, environmental factors that lend an underlying susceptibility to a sleep/wake disturbance; 2. Precipitating Factors are acute occurrences that trigger the insomnia and they include medical illness, acute psychological stress, or sudden change in sleep habits/environment; 3. Perpetuating Factors refer to many maladaptive strategies that people adopt in an attempt to deal with the acute onset of insomnia. The two most common behaviors that perpetuate insomnia are spending increased time in bed in order to “try” to get more sleep and an increase in non-sleep promoting activities in the bed, for example, watching TV, working on a laptop, texting or playing games using a smart phone.
Demographics: Studies consistently show that approximately 10% of the adult population suffer from chronic insomnia. Many studies that just focus on seniors, find much higher rates of 40-50%. Most studies also show that insomnia is more common in women. However, that may be due to a reporting bias, i.e. women are more likely to go their doctors complaining of sleep problems such as insomnia.
Treatments: There are 4 broad categories of treatment:
- CBT-I: Cognitive Behavioral Therapy for Insomnia
- Herbal Remedies
- Non-Medicinal Therapies
- Pharmacologic Therapies
Cognitive Behavioral Therapy for Insomnia
This should be the first-line approach for the treatment of chronic insomnia. We have more than 30 years of research data showing that, in the short term, this is just as effective as medication, and in the long-term it is far superior. The problem is that this has traditionally been offered by psychologists and there are not enough of them trained in CBT-I to serve the 30 million Americans who suffer from chronic insomnia. Sleep physicians do not usually offer CBT-I even though most of us are trained in it during our sleep fellowships and most of us have had extensive further training through our professional sleep society.
CBT-I usually consists of 6-8 sessions, usually done once a week, that focus on sleep hygiene, sleep restriction, stimulus control, cognitive restructuring and various types of relaxation techniques.
Herbal Remedies (including foods, vitamins/minerals)
- Valerian Root
- Passion Flower
- Saffron Extract
- Ashwagandha Root
- Tart Cherry Juice
NOTE: Please do not start herbals without consulting with a physician. Even some herbal remedies can be harmful if mixed with pharmaceuticals and are especially dangerous when taken at high doses. Also, we need to remember that herbals are not regulated by the FDA. It is important to buy from reputable companies that manufacture their products in the U.S, Canada, Europe. I will be reviewing different manufactures under Product Review.
- Meditation/Mindfulness/Relaxation CDs and APPs
- Weighted Blanket
- Fisher Wallace Stimulator: A neurostimulator FDA approved for treatment of insomnia as well as depression and anxiety
- Hoom Band: Audio headband with its own APP that has stories, visualizations, guided meditations, white noise, and it can block out the snores of your bed partner
Note: I will be adding to this list and reviewing some of the items under the Product Review tab. Please know that I do not have a financial relationship with any of these companies (except if they want to send a free sample to try out). If I were to have a financial arrangement with a company, I will be transparent about and will fully explain the nature of the relationship.
Pharmacological Therapies (i.e. Prescription Drugs)
- Melatonin Agonists
- ramelteon (Rozerem)
- Benzodiazpiene Receptor Agonists
- zolpidem (Ambien): my least favorite sleep medication due to common risk of dangerous sleepwalking episodes
- eszopiclone (Lunesta)
- zaleplon (Sonata)
- Sedating Anti-depressants
- Sedating Anti-psychotics: weight gain is a common side effect
- quetiapine (Seroquel)
- olanzapine (Zyprexa)
- Anti-histamines: caution in elderly patients and patients with history of glaucoma or urinary obstruction/prostatic hypertrophy
- hydroxyzine: can also help with anxiety
- diphenhydramine (Benadryl) is over the counter
- gabapentin: a sedating anti-epileptic also used to treat Restless Legs Syndrome
- baclofen: a sedating muscle relaxant
- Benzodiazepienes: They get a bad reputation because they are Schedule II meds (like opiates), and do have the risk of tolerance, dependence and addiction. However, with judicious use and with an experienced physician doing close follow up, old-fashioned benzos which have been around for more than 60 years, can be a safe and effective choice since they affect multiple Benzo sub-receptors that aid sleep and relaxation.
- alprazolam (Xanax): short half-life. There are many other short-acting benzos.
- lorazepam (Ativan): medium half-life. There are many other benzos with a medium half-life
- clonazepam (Klonopin): long half-life. There are many other benzos with long half-life e.g. Valium