Sleep Problems and Insomnia
Contents
What Is Problem
Sleepiness?
Everyone feels sleepy at times. However, when
sleepiness interferes with daily routines and activities, or reduces
the ability to function, it is called "problem sleepiness." A person
can be sleepy without realizing it. For example, a person may not
feel sleepy during activities such as talking and listening to music
at a party, but the same person can fall asleep while driving home
afterward.
You may have problem sleepiness if you:
-
Consistently do not get enough sleep, or get poor
quality sleep;
-
Fall asleep while driving;
-
Struggle to stay awake when inactive, such as when
watching television or reading;
Have difficulty
paying attention or concentrating at work, school, or home;
Have performance
problems at work or school;
Are often told by
others that you are sleepy;
Have difficulty remembering;
Have slowed responses;
Have difficulty controlling your emotions; or
Must take naps on
most days.
What Causes Problem
Sleepiness?
Sleepiness can be due to the body’s natural daily
sleep-wake cycles, inadequate sleep, sleep disorders, or certain
drugs.
Sleep-Wake Cycle: Each day there are two
periods when the body experiences a natural tendency toward
sleepiness: during the late night hours (generally between midnight
and 7 a.m.) and again during the mid afternoon (generally between 1
p.m. and 4 p.m.). If people are awake during these times, they have
a higher risk of falling asleep unintentionally, especially if they
haven’t been getting enough sleep.
Inadequate Sleep: The amount of sleep
needed each night varies among people. Each person needs a
particular amount of sleep in order to be fully alert throughout the
day. Research has shown that when healthy adults are allowed to
sleep unrestricted, the average time slept is 8 to 8.5 hours. Some
people need more than that to avoid problem sleepiness; others need
less.
If a person does not get enough sleep, even on one
night, a "sleep debt" begins to build and increases until enough
sleep is obtained. Problem sleepiness occurs as the debt
accumulates. Many people do not get enough sleep during the work
week and then sleep longer on the weekends or days off to reduce
their sleep debt. If too much sleep has been lost, sleeping in on
the weekend may not completely reverse the effects of not getting
enough sleep during the week.
Sleep Disorders: Sleep disorders such as
sleep apnea, narcolepsy, restless legs syndrome, and insomnia can
cause problem sleepiness.
Sleep apnea is a serious disorder in
which a person’s breathing is interrupted during sleep, causing the
individual to awaken many times during the night and experience
problem sleepiness during the day.
People with narcolepsy have excessive
sleepiness during the day, even after sleeping enough at night. They
may fall asleep at inappropriate times and places.
Restless legs syndrome (RLS) causes a
person to experience unpleasant sensations in the legs, often
described as creeping, crawling, pulling, or painful. These
sensations frequently occur in the evening, making it difficult for
people with RLS to fall asleep, leading to problem sleepiness during
the day.
Medical Conditions/Drugs: Certain medical
conditions and drugs, including prescription medications, can also
disrupt sleep and cause problem sleepiness. Examples include:
Chronic
illnesses such as asthma, congestive heart failure, rheumatoid
arthritis, or any other chronically painful disorder;
Some high blood
pressure medications
Some heart
medications,
asthma medications such theophylline;
Alcohol—Although
some people use alcohol to help themselves fall asleep, it causes
sleep disruption during the night, which can lead to problem
sleepiness during the day. Alcohol is also a sedating drug that
can, even in small amounts, make a sleepy person much more sleepy
and at greater risk for car crashes and performance problems;
Caffeine—Whether
consumed in coffee, tea, soft drinks, or medications, caffeine
makes it harder for many people to fall asleep and stay asleep.
Caffeine stays in the body for about 3 to 7 hours, so even when
taken earlier in the day it can cause problems with sleep at
night; and
Nicotine from
cigarettes or a skin patch is a stimulant and makes it harder to
fall asleep and stay asleep.
Problem
Sleepiness and Adolescents
Many U.S. high school and college students have
signs of problem sleepiness, such as:
-
difficulty getting up for school;
-
falling asleep at school; and/or
-
struggling to stay awake while doing homework.
The need for sleep may be
9 hours or more
per night as a person goes through
adolescence. At the same time, many teens begin to show a preference
for a later bed time, which may be due to a biological change. Teens
tend to stay up later but have to get up early for school, resulting
in their getting much less sleep than they need.
Many factors contribute to problem sleepiness in
teens and young adults, but the main causes are not getting enough
sleep and irregular sleep schedules. Some of the factors that
influence adolescent sleep include:
Homework to be done
in the evenings;
Early wake-up times
due to early school start times;
Parents being less
involved in setting and enforcing bedtimes; and
Employment, sports,
or other extracurricular activities that decrease the time
available for sleep.
Teens and young adults who do not get enough sleep
are at risk for problems such as:
Many adolescents have part-time jobs in addition to
their classes and other activities. High school students who work
more than 20 hours per week have more problem sleepiness and may use
more caffeine, nicotine, and alcohol than those who work less than
20 hours per week or not at all.
Shift
Work and Problem Sleepiness
About 20 million Americans (20 to 25 percent of
workers) perform shift work. Most shift workers get less sleep over
24 hours than day workers. Sleep loss is greatest for night shift
workers, those who work early morning shifts, and female shift
workers with children at home. About 60 to 70 percent of shift
workers have difficulty sleeping and/or problem sleepiness.
The human sleep-wake system is designed to prepare
the body and mind for sleep at night and wakefulness during the day.
These natural rhythms make it difficult to sleep during daylight
hours and to stay awake during the night hours, even in people who
are well rested. It is possible that the human body never completely
adjusts to nighttime activity and daytime sleep, even in those who
work permanent night shifts.
In addition to the sleep-wake system, environmental
factors can influence sleepiness in shift workers. Because our
society is strongly day-oriented, shift workers who try to sleep
during the day are often interrupted by noise, light, telephones,
family members, and other distractions. In contrast, the nighttime
sleep of day workers is largely protected by social customs that
keep noises and interruptions to a minimum.
Problem sleepiness in shift workers may result in:
-
Increased risk for automobile crashes, especially
while driving home after the night shift;
-
Decreased quality of life;
-
Decreased productivity (night work performance may
be slower and less accurate than day performance); and/or
Increased risk of
accidents and injuries at work.
There Is No Substitute
For Sleep!
Many people simply do not allow enough time for
sleep on a regular basis. A first step may be to evaluate daily
activities and sleep-wake patterns to determine how much sleep is
obtained. If you are consistently getting less than 8 hours of sleep
per night, more sleep may be needed. A good approach is to gradually
move to an earlier bedtime. For example, if an extra hour of sleep
is needed, try going to bed 15 minutes earlier each night for four
nights and then keep the last bedtime. This method will increase the
amount of time in bed without causing a sudden change in schedule.
However, if work or family schedules do not permit the earlier
bedtime, a 30- to 60-minute daily nap may help.
Medications/Drugs: In general, medications do
not help problem sleepiness, and some make it worse. Caffeine
can reduce sleepiness and increase alertness, but only temporarily.
It can also cause problem sleepiness to become worse by interrupting
sleep.
While alcohol may shorten the time it takes
to fall asleep, it can disrupt sleep later in the night, and
therefore add to the problem sleepiness. Medications may be
prescribed for patients in certain situations. For example, the
short-term use of sleeping pills has been shown to be helpful in
patients diagnosed with acute insomnia. Long-term use of sleep
medication is recommended only for the treatment of specific sleep
disorders.
If You’re Sleepy—Don’t Drive! A person who is
sleepy and drives is, at high risk for an automobile crash. Planning
ahead may help reduce that risk. For example, the following tips may
help when planning a long distance car trip:
Avoid driving
between midnight and 7 a.m.
Change drivers often
to allow for rest periods.
Schedule frequent
breaks.
If you are a shift worker, the following may help:
decreasing the amount of night work; increasing the total amount of
sleep by adding naps and lengthening the amount of time allotted for
sleep; increasing the intensity of light at work; having a
predictable schedule of night shifts; eliminating sound and light in
the bedroom during daytime sleep; using caffeine (only during the
first part of the shift) to promote alertness at night; or possibly
using prescription sleeping pills to help daytime sleep on an
occasional basis (check with your doctor).
If you think you are getting enough sleep, but still
feel sleepy during the day, check with your doctor to be sure your
sleepiness is not due to a sleep disorder.
Facts About Insomnia
What Is Insomnia?
Insomnia is the perception of
poor-quality sleep due to difficulty falling asleep, waking up
during the night with difficulty returning to sleep, waking up too
early in the morning, or un-refreshing sleep. Any of these
sleep disorders can cause problem sleepiness.
Insomnia is not defined by the number of hours of
sleep a person gets or how long it takes to fall asleep.
Individuals vary normally in their need for, and their satisfaction
with, sleep. Insomnia may cause problems during the day, such
as tiredness, a lack of energy,
difficulty concentrating, and irritability.
Insomnia can be classified as transient (short term), intermittent
(on and off), and chronic (constant). Insomnia lasting from a
single night to a few weeks is referred to as transient. If
episodes of transient insomnia occur from time to time, the insomnia
is said to be intermittent. Insomnia is considered to be
chronic if it occurs on most
nights and lasts a month or more.
What Causes Insomnia?
Certain conditions seem to make individuals more likely to
experience insomnia. Examples of these conditions include:
- Advanced age (insomnia occurs more frequently in those over
age 60)
- Female gender
- A history of depression
If other conditions (such as
stress, anxiety, a medical problem, or the use of certain
medications) occur along with the above conditions, insomnia is more
likely.
There are many causes of insomnia. Transient and intermittent
insomnia generally occur in people who are temporarily experiencing
one or more of the following:
- stress
- environmental noise
- extreme temperatures
- change in the surrounding
environment
- sleep/wake schedule problems
such as those due to jet lag
- medication side effects
Chronic insomnia is more complex
and often results from a combination of factors, including
underlying physical or mental disorders. One of the most
common causes of chronic insomnia is depression. Other
underlying causes include arthritis, kidney disease, heart failure,
asthma, sleep apnea, narcolepsy, restless legs syndrome, Parkinson's
disease, and hyperthyroidism. However, chronic insomnia may
also be due to behavioral factors, including the misuse of caffeine,
alcohol, or other substances; disrupted sleep/wake cycles as may
occur with shift work or other nighttime activity schedules; and
chronic stress.
In addition, the following behaviors have been shown to
perpetuate insomnia in some people:
- expecting to have difficulty
sleeping and worrying about it
- ingesting excessive amounts of
caffeine
- drinking alcohol before bedtime
- smoking cigarettes before
bedtime
- excessive napping in the
afternoon or evening
- irregular or continually
disrupted sleep/wake schedules
These behaviors may prolong
existing insomnia, and they can also be responsible for causing the
sleeping problem in the first place. Stopping these behaviors
may eliminate the insomnia altogether.
Who Gets Insomnia?
Insomnia is found in males
and females of all age groups, although it seems to be more common
in females (especially after menopause) and in the elderly.
The ability to sleep, rather than the need for sleep, appears to
decrease with advancing age.
How Is Insomnia Diagnosed?
Patients with insomnia are
evaluated with the help of a medical history and a sleep history.
The sleep history may be obtained from a sleep diary filled out by
the patient or by an interview with the patient's bed partner
concerning the quantity and quality of the patient's sleep.
Specialized sleep studies may be recommended, but only if there is
suspicion that the patient may have a primary sleep disorder such as
sleep apnea or narcolepsy.
How Is Insomnia Treated?
Transient and intermittent
insomnia may not require treatment since episodes last only a few
days at a time. For example, if insomnia is due to a temporary
change in the sleep/wake schedule, as with jet lag, the person's
biological clock will often get back to normal on its own. However,
for some people who experience daytime sleepiness
and impaired performance as a result of transient insomnia,
the use of short-acting sleeping pills may improve sleep and
next-day alertness.
As with all drugs, there are
potential side effects. The use of over-the-counter sleep
medicines is not usually recommended for the treatment of insomnia.
Treatment for chronic insomnia consists of:
- First, diagnosing and treating
underlying medical or
psychological problems.
- Identifying behaviors that may worsen insomnia and
stopping (or reducing) them.
- Possibly using sleeping pills,
although the long-term
use of sleeping pills for chronic insomnia is controversial.
A patient taking any sleeping pill should be under the supervision
of a physician to closely evaluate effectiveness and minimize side
effects. In general, these drugs are prescribed at the
lowest dose and for the shortest duration needed to relieve the
sleep-related symptoms. For some of these medicines, the
dose must be gradually lowered as the medicine is discontinued
because, if stopped abruptly, it can cause insomnia to occur again
for a night or two.
- Trying behavioral techniques to
improve sleep, such as
relaxation therapy, sleep restriction therapy, and reconditioning.
Behavioral Therapy
Techniques
Relaxation Therapy. There are specific and effective
techniques that can reduce or eliminate anxiety and body
tension. As a result, the person's mind is able to stop
"racing," the muscles can relax, and restful sleep can
occur. It usually takes much practice to learn these
techniques and to achieve effective relaxation.
Sleep Restriction.
Some people suffering from insomnia
spend too much time in bed unsuccessfully trying to sleep.
They may benefit from a sleep restriction program that at
first allows only a few hours of sleep during the night.
Gradually the time is increased until a more normal night's
sleep is achieved.
Reconditioning. Another treatment that may help some
people
with insomnia is to recondition them to associate the bed
and bedtime with sleep. For most people, this means not
using their beds for any activities other than sleep and
sex. As part of the reconditioning process, the person is
usually advised to go to bed only when sleepy. If unable to
fall asleep, the person is told to get up, stay up until
sleepy, and then return to bed. Throughout this process,
the person should avoid naps and wake up and go to bed at
the same time each day. Eventually the person's body will
be conditioned to associate the bed and bedtime with sleep.
Talk to Your Doctor About Insomnia:
Talk to your doctor if you are having trouble getting
good, refreshing sleep each night. Together you can identify
possible reasons for your sleeping difficulty and then try
appropriate measures to correct the problem.
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