How is It Treated?
Everyone has a poor night’s sleep now and then. For the occasional insomnia patient, it may be due to an acute episode of stress or anxiety such as a death or illness of a family member, school or work related stress, having caffeine too late in the day, etc. For those situations, the occasional use of a prescription sleep aid is a reasonable treatment option. However, if the condition is persistent and nightly, or nearly nightly, you should consult with your primary care physician. He or she should rule-out a medical or psychiatric condition as the cause. If poor sleeping habits are the cause of your insomnia, click here to download my Rules for a Better Night’s Sleep.
If you believe you have the condition, and would like to see a Board Certified Sleep Specialist for a thorough evaluation, CLICK HERE to contact us and arrange for a sleep center consultation with Dr. Popper.
Still Want to Know More?
So you’ve already tried following the Rules for a Better Night’s Sleep, you’ve seen your primary care doctor and no medical or psychiatric disorder causing your sleep difficulty was found and you’re still having problems sleeping. What else can be done? Several treatment options are available. Continue reading to learn about all of them or use the links below to jump straight to the topics that interest you.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy is the treatment of choice for most cases of insomnia. CBT helps you change actions or thoughts that hurt your ability to sleep well. It helps you develop habits that promote a healthy pattern of sleep. The most common forms of CBT are:
A stimulus is anything that causes a response. Over time, most patients have come to associate their bed or bedroom environment as a place that is not conducive to falling asleep. Even hours before bedtime, they are already thinking about “what kind of a night they are likely to have” or “how difficult it will be to fall asleep.” They have already come to expect that they will not easily fall asleep. The harder they try to fall asleep the less likely it is that they will fall asleep. Insomnia becomes a self-fulfilling prophecy.
The goal of stimulus control is to turn your negative thoughts about sleep (or lack of sleep) into positive thoughts (or better yet, no thoughts) when you get into your bed at night. The ultimate goal is to eradicate your self-imposed anxiety over your inability to fall asleep and to allow you to fall asleep without intrusive negative thoughts.Elements of Stimulus Control include:
- Only go to bed when you are sleepy.
- If you are not asleep after 20 minutes, then you are to get out of bed to do something relaxing in another room.
- When you feel sleepy again, then and only then, may you return to bed.
- If upon returning to bed you immediately feel wide awake or you again find yourself awake after 20 minutes, get out of bed again and do not return to your bed until you are again sleepy.
In some cases, you may need to repeat this step several times in a night. Sometimes it may take a few nights of doing this. Do not despair. Nothing terrible will happen to you. Nobody has died from a bad night or two of sleep. Remember, before you started this you were not sleeping well to begin with. Typically, once you have done this for a night or two or three, you will be truly sleepy at bedtime and you will fall asleep much more quickly than you did before.
Once this happens, most patients will find the anxiety over their inability to fall asleep just melts away. They will then become much more comfortable with the concept of going to bed only when they are sleepy knowing they will fall asleep easier for having done so.
This method restricts the amount of time you are in bed awake. Being awake in your bed creates anxiety about not being asleep when you should be asleep. If for example, you go to bed at 10:00 pm but lie awake in bed until midnight, it took you 2 hours to fall asleep. Once asleep you then slept until 06:00 am. Your total time in bed was 8 hours but your total sleep time was only 6 hours. The goal of sleep restriction is to limit your total time in bed to the actual amount of sleep you get. Since you are not falling asleep until midnight, you are probably not getting sleepy enough to fall asleep until midnight anyway and you would be advised to stay awake until you are sleepy (as above in stimulus control) or at least until midnight.
Sleep restriction is meant to deprive you of “resting in bed while awake” which will then make you sleepier at your bedtime. The goal is to consolidate your sleep and create a more stable sleep pattern. You may initially still find it takes 1-2 hours to fall asleep. After a few nights, you are likely to start to fall asleep in less time and thus increase your total sleep time (and thus the percentage of time spent asleep while in bed, known as sleep efficiency). Once you have consistently slept for more than 85% of the time spent in bed, you may attempt to go to bed 30 minutes earlier on the following nights. You may continue to advance your bedtime by 30 minutes until you are able to fall asleep in less than 20 minutes and your sleep efficiency remains greater than 85%.
If during this process your sleep efficiency falls back to less than 80%, you should again decrease your time in bed by 30 minutes by staying up later until your sleep efficiency again exceeds 85%. Sleep restriction will ultimately allow you to fall asleep more quickly and stay asleep throughout the night, improving your daytime functioning and state of well being. Daytime napping is also to be avoided as this may delay the time at which you become sleepy, making it more difficult to fall asleep at your desired bedtime.
Relaxation Training and Biofeedback
Relaxation Training teaches you how to relax both your mind and your body. This helps you to reduce any anxiety or tension that keeps you awake in bed. This method can be used both during the day and at bedtime. It involves training you how to better control the following functions:
- Muscle relaxation
- Mental focusing
Biofeedback may be used along with relaxation training. The process of sleep involves your brain, your breathing, your heart and your muscles. Biofeedback teaches you how to be more in touch with and control these bodily functions:
- Muscle tension
- Brain waves
- Blood pressure
- Heart rate
- Body temperature
Cognitive Control and Psychotherapy
These methods are designed to help you identify unhelpful attitudes and beliefs about sleep. Through educational means, the goal is to change your attitudes and beliefs about sleep in order to decrease the anxiety that results in your insomnia.
- Changing Attitudes and Beliefs About Sleep – Often a patient will believe that something terrible will happen to them if they don’t get 8 hours of sleep. Most of these patients haven’t been getting a good night’s sleep for years before they have sought medical help. True they may not feel as rested or energetic in the daytime, they may not function at 100% of their capabilities, but nothing terrible has happened to them. It is these negative thoughts and irrational beliefs about sleep and the consequence of a poor night’s sleep that keep patients awake. CBT can help patients rationally address the fear and anxiety they have about their sleep and allow them to sleep better.
- Scheduled and Structured “worry time” – This is best performed in the afternoon or early evening, several hours before bedtime. Often a combination of talking with a therapist and keeping a diary to process the kind of stresses of the day or upcoming events that cause you to worry and cause you to have a wandering mind when you are trying to sleep are dealt with. Patients are encouraged to talk or write about these events and work out a plan for dealing with them, to clear their mind so there will be less to think about during the sleep hours.
- Guided Imagery – This is a method in which patients are encouraged to place themselves within an imaginary story or situation and visualize pleasant thoughts, feeling and sounds. Within this imagery, their mind and body relaxes and they are easily able to fall asleep.
- Sleep Hygiene – This is a method in which the things you do on a daily basis that disturb you sleep are modified into good sleep promoting habits that are more conducive to allowing for better quality sleep. CLICK HERE to download my Rules for a Better Night’s Sleep.
Prescription Sleeping Pills and Sleeping Aids
Sleeping pills or hypnotic agents are frequently prescribed by primary care doctors to treat insomnia. Patients may initially sleep better. However, if the underlying cause of the insomnia is not addressed, sleeping pills often become ineffective over time. Some patients develop tolerance to the medications and escalate the dose to regain effectiveness. This often leads to side effects and in some cases, accidental over dosage. Some of the more commonly used prescription hypnotic agents include:
A variety of sedating anti-anxiety and anti-depressant agents has also been used to treat insomnia. Some of the more commonly used agents include:
Over the Counter Sleeping Medications and Homeopathic Remedies
Most OTC sleep aids have not been well studied, cause potential side effects and are not recommended by the American Academy of Sleep Medicine. Nonetheless, millions of patients use them either intermittently or on a nightly basis with mixed results and increased risk of side effects.
Antihistamines – are the most common ingredient in sleep aids that you can buy at a local drug store. Some of the most commonly used ingredients include:
- Diphenhydramine hydrochloride (also called Benadryl®)
- Diphenhydramine citrate
- Doxylamine succinate (may be in some cold formulas such as Maximum Strength Nytol® or Unisom®)
- Triprolidine hydrochloride (may be found in allergy or cold medications such as Actifed®)
Side effects of Antihistamines include drowsiness, grogginess, tiredness, dry mouth and weakness.
Other Allergy and Cold Products – may contain antihistamines. They may also contain other ingredients that affect sleep. Some of these ingredients may cause sleepiness. An example is dextromethorphan. It is often added to cough and flu products.
Other ingredients may have the opposite effect and cause insomnia. An example is pseudoephedrine. This is also called Sudafed®.Many allergy and cold products have more than one of these ingredients. It is important to read the labels. You may not be sure if your allergy or cold product contains something that can make you sleepy or cause insomnia. Ask your doctor or pharmacist.
Melatonin – is a hormone that is released by the brain and is strongly linked to the sleep-wake cycle. Most studies have shown Melatonin to have a relatively weak or no effect for most patients with insomnia. Melatonin is not regulated by the FDA and therefore the quality and purity of the product is not known.
Herbs – many herbal supplements are available with claims of helping to treat insomnia. Some of the widely available supplements contain:
- Valerian root
- Passion flower
- Jamaican dogwood
- California poppy
- Lemon balm
- St. John’s wort
- Kava kava
- Wild lettuce
- Patrinia root
Valerian root is the only herb with some data to show that it helps treat insomnia. The long-term effectiveness of herbs has not been studied. It is unclear what effects (good or bad) may ocur if they are used for more than two weeks. Herbs may interact with other medicines or with other herbs. Like melatonin, the quality and purity of the products may vary as their manufacture is not regulated by the FDA.
Vitamins and Minerals – such as those listed below have been claimed to help patients with insomnia. Scientific studies are lacking to support the routine use of these substances in the treatment of insomnia. Many of these products have side effects.
- Vitamin A
- Vitamin B12