10 Reasons You Can’t Sleep & How to Fix Them

by David DiSalvo, contributor

Having trouble sleeping?
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Below are 10 of the most common reasons why with suggestions on how to correct them.
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1. Your room isn’t dark enough.

Ideally, your bedroom shouldn’t have any lights on, especially light emitted from a TV or any electronic device. When your eyes are exposed to light during the night, your brain is tricked into thinking it’s time to wake up and reduces the production of melatonin, a hormone released by your pineal gland that causes sleepiness and lowers body temperature. Light emitted by electronic devices is especially troublesome because it mimics sunlight.

darkroom1

2. Exercising too late.

If you exercise within three hours of trying to sleep, you’ll overstimulate your metabolism and raise your heart rate causing restlessness and frequent awakenings throughout the night. Try to exercise in the morning or no later than mid to late afternoon, which will result in sounder sleep.

3. Drinking alcohol too late.

We tend to think of alcohol as a sleep inducer, but it actually interferes with REM sleep, causing you to feel more tired the next morning. Granted, you may feel sleepy after you drink it, but that’s a short-term effect. Here’s a great video at WebMD about alcohol and sleep.

alcohol

4. Room temperature too warm.

Your body and brain wants to cool down when you sleep, but if your room is too warm you’ll thwart the cool-down process. Having a fan in your room is a good idea because it will keep you cool and produce a consistent level of white noise that will help you fall asleep. Just don’t get too cold, because that will disrupt sleep as well. (You can also try cooling your brain.)

cantsleep1

5. Caffeine still in your system.

The average half-life of caffeine is 5 hours, which means that you still have three-quarters of the first dose of caffeine rolling around in your system 10 hours after you drink it. Most of us drink more than one cup of coffee, and many of us drink it late in the day. If you’re going to drink coffee, drink it early.

coffee1

6. Clockwatching.

Though it’s hard not to do, don’t look at your clock when you wake up during the night. In fact, it’s best to turn it around so it’s not facing you. When you habitually clockwatch, you’re training your circadian rhythms the wrong way, and before long you’ll find yourself waking up at exactly 3:15 every night.

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7. Getting up to watch TV until you’re sleepy.

This is a bad idea for a few reasons. First, watching TV stimulates brain activity, which is the exact opposite of what you want to happen if your goal is to sleep soundly. Second, the light emitted from the TV is telling your brain to wake up (see #1 above).

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8. Trying to problem-solve in the middle of the night.

All of us wake up at times during the night, and the first thing that pops into our heads is a big problem we’re worried about. The best thing you can do is stop yourself from going there and redirect your thoughts to something less stressful. If you get caught up on the worry treadmill, you’ll stay awake much longer.

problemsolving

9. Eating protein too close to bedtime.

Protein requires a lot of energy to digest, and that keeps your digestive system churning away while you’re trying to sleep — bad combination. Better to have a light carbohydrate snack.

eating2

10. Smoking before bedtime.

Smokers equate smoking with relaxing, but that’s a neurochemical trick. In truth, nicotine is a stimulant. When you smoke before trying to sleep, you can expect to wake up several times throughout the night; much as you would if you drank a cup of coffee.

smokingcigs

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(contributor_data.name)!?html   David DiSalvo is a science, technology and culture writer who contributes to Forbes, Scientific American Mind, The Wall Street Journal, Psychology Today, Esquire, Mental Floss and a smattering of other publications. His first nonfiction book, “What Makes Your Brain Happy and Why You Should Do the Opposite” (Prometheus, 2011) is available in paperback and Kindle, and his second book, “The Brain in Your Kitchen” is now available for Kindle. More at his website: www.daviddisalvo.org. The opinions expressed are those of the writer.

http://www.forbes.com/sites/daviddisalvo/2012/10/11/10-reasons-why-you-cant-sleep-and-how-to-fix-them/

BREATHING AND YOUR BRAIN by David DiSalvo

http://www.forbes.com/sites/daviddisalvo/2013/05/14/breathing-and-your-brain-five-reasons-to-grab-the-controls/

_____________________________________________________________________________________________________

Related Information to Why You Can’t Sleep:

coldwaterfish2

Top 10 Foods Containing Protein:  (avoid these foods too close to bedtime)

1. Turkey

2. Fish (tuna, salmon, halibut)

3. Cheese

4. Pork Loin Chops

5. Tofu

6.  Beans

7.  Eggs

8.  Yogurt, Milk

9.  Soymilk

10. Nuts, Seeds

almonds

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Drinking Alcohol late at night not only causess insomnia.  Check this out:

alcohol1 alcohol2 alcohol3

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David DiSalvo’s Popular Posts

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FORBES Real-Time Billionaires scoreboard tracks the biggest holdings for 50 of the world’s wealthiest people. See who’s up & who’s down right now »

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Sleep well, everyone. 

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All About Sleep Apnea

SLEEP APNEA IS A COMMON SLEEP PROBLEM THAT CAN BEGIN AT ANY AGE. BREATHING IS REPEATEDLY INTERRUPTED DURING SLEEP. 

THE TIME PERIOD FOR WHICH THE BREATHING STOPS OR DECREASES IS USUALLY BETWEEN 10 AND 30 SECONDS.  WHEN THESE EPISODES OCCUR REPEATEDLY, SLEEP APNEA CAN SERIOUSLY DISRUPT THE QUALITY OF SLEEP.

 IT AFFECTS MILLIONS OF PEOPLE AND HAS BEEN LINKED TO HIGH BLOOD PRESSURE, HEART ATTACK, AND STROKE, and JUST LAST WEEK, CANCER (SEE ARTICLE LINK BELOW).

DR. CHARLES BAE TREATS SLEEP APNEA PATIENTS AT CLEVELAND CLINIC’S SLEEP DISORDERS CENTER .

HE SAYS MANY PEOPLE WITH SLEEP APNEA DON’T EVEN KNOW THEY HAVE IT.

“There is, throughout the night, a collapse of the upper airway. So, essentially you stop breathing multiple times, while you’re sleeping, even if you’re not aware of it.”

DR. BAE SAYS PEOPLE WHO HAVE SLEEP APNEA DON’T ALWAYS WAKE UP WHEN THEY STOP BREATHING.

HE SAYS OFTENTIMES, PEOPLE MAY NOT EVEN KNOW THEY HAVE IT, AND THAT THEY’RE USUALLY TOLD BY THEIR SLEEP PARTNER THAT THEY EITHER STOP BREATHING OR SNORE LOUDLY.

DR. BAE SAYS ONCE SLEEP APNEA IS DIAGNOSED, TREATMENT USUALLY INVOLVES A CONTINUOUS POSITIVE AIRWAY PRESSURE, OR CPAP MACHINE.

Dr. Charles Bae says, “Depending on how serious the sleep apnea is that would determine when you need the machine, but it really, oftentimes, doesn’t matter. Someone with severe sleep apnea may not be sleepy, but they definitely need the machine. Someone with mild sleep apnea may be super sleepy, so certainly, that would be the time to consider it.”

DR. BAE ALSO SAYS IF YOU’RE GETTING 8 HOURS OF SLEEP, BUT STILL FEEL TIRED, OR ARE WAKING UP FOR UNKNOWN REASONS, TALK TO YOUR DOCTOR.  For more information, visit: www.clevelandclinic.org

English: The Cycle of Obstructive Sleep Apnea ...
English: The Cycle of Obstructive Sleep Apnea – OSA (Photo credit: Wikipedia)

NEW TREATMENTS FOR SLEEP APNEA

The Center for Minimally Invasive and Robotic Surgery at The Mount Sinai Medical Center—a pioneer in robotic surgery—now offers a procedure to patients with sleep apnea, whose obstructive breathing prevents them from sleeping normally.

Mount Sinai is one of only a few programs in the world to use transoral robotic surgery (TORS) to remove excess tissue or fix a collapsed airway that causes sleep apnea.

Through the robotic procedure, a laser removes the extra tissue in the throat that contributes to the airway obstruction in sleep apnea patients.

Patients typically return home the next day, and are back to work in 10 days, sleeping and breathing normally.

During sleep apnea, a person’s breathing is blocked and then restored when the brain sends a signal that awakens the patient to a lighter level of sleep.

This process can happen hundreds of times each night, leaving the patient exhausted during the day and at risk for many health complications, including cardiovascular disease and hypertension.

Many patients opt for a treatment called continuous positive airway pressure (CPAP), delivered through a mask that the patient wears at night to force his or her airway open for the duration of sleep.

However, some feel the mask hinders their quality of life, and look for better options.

“Over time many patients grow frustrated with CPAP or stop using the device, causing their sleep apnea to return and leaving them anxious for a better solution,” said Fred Lin, MD, Assistant Professor of Otolaryngology and Director of the Mount Sinai Sleep Surgery Center.

 “In the past, surgery had been a last resort. Now, using robotic surgery, we can remove the tissue that contributes to the airway blockage in a brief procedure with no external incisions and have patients home the next day, sleeping healthfully.”

During the robotic procedure, a surgeon sits at a console directly controlling a robotic arm that extends a small surgical instrument through the patient’s mouth. Using a high-powered 3-D camera, he or she has a clear view of the surgical field.

The previous surgical technique was less precise and potentially less effective because the surgeon was only able to use one hand, and had limited maneuverability.

“Mount Sinai is one of the original adopters of robotic surgery and we have seen first-hand the dramatic quality of life improvements it provides our head and neck cancer patients,” said Eric Genden, MD, Professor and Chair of Otolaryngology, Mount Sinai School of Medicine.

Causes

There are three types of respiratory events:

  • Obstructive apnea—caused by a temporary, partial, or complete blockage of the airway
  • Central apnea—caused by a temporary failure to make an effort to breathe
  • Mixed apnea—combination of the first two types

Risk Factors

These factors increase your chance of developing sleep apnea. Tell your doctor if you have any of these risk factors:

  • Sex: male
  • Overweight
  • Large neck circumference
  • Age: middle to older age
  • Family history of apnea
  • Structural abnormalities of the nose, throat, or other part of the respiratory tract. Examples include:
  • Hypothyroidism
  • Medicines: sedatives and sleeping aids
  • Alcohol consumption
  • Smoking

Symptoms

Symptoms include:

  • Fatigue and sleepiness during waking hours
  • Loud snoring
  • Breathing that stops during the night (noticed by the partner)
  • Repeated waking at night
  • Unrefreshing sleep
  • Morning headaches
  • Poor concentration or problems with memory
  • Irritability or short temper

People with chronic untreated sleep apnea may be at risk for:

Diagnosis

An overnight sleep study is used to help diagnose sleep apnea.

Overnight Sleep Study (Polysomnography)

This testhelps detect the presence and severity of sleep apnea. During sleep, it measures your:

  • Eye and muscle movements
  • Brain activity ( electroencephalogram)
  • Heart rate
  • Breathing (pattern and depth)
  • Percent saturation of your red blood cells with oxygen

Other Studies

In addition to sleep studies, your doctor may order:

Treatment

There are a number of treatment options for sleep apnea, including:

Behavioral Therapy

  • Lose weight if you are overweight.
  • Avoid using sedatives, sleeping pills, alcohol, and nicotine, which tend to make the condition worse.
  • Try sleeping on your side instead of your back.
  • Place pillows strategically so you are as comfortable as possible.
  • For daytime sleepiness, practice safety measures, such as avoiding driving or operating potentially hazardous equipment.

Mechanical Therapy

Continuous positive airway pressure (CPAP) entails wearing a mask over your nose and/or mouth during sleep. An air blower forces enough constant and continuous air through your air passages to prevent the tissues from collapsing and blocking the airway. In some cases, dental appliances that help keep the tongue or jaw in a more forward position may help.

Surgery

In some cases, surgery may be recommended. It is most often beneficial in pediatric patients.

Types of surgery that may be done to treat severe cases of sleep apnea include:

  • Uvulopalatopharyngoplasty—The doctor removes excess soft tissue from the nose and/or throat.
  • Maxillomandibular advancement—The jawbone is repositioned forward.
  • Tracheotomy—For life-threatening cases of sleep apnea, an opening is made in the windpipe to allow for normal breathing.

Bariatric surgery may help with weight loss in some people who are obese. This surgery may reduce many of the complications that are related to obesity, including sleep apnea.

Medications

Only used in central apnea, acetazolamide (Diamox) may help improve the ability to regulate breathing. Overall, there is not a lot of evidence to support the use of medicines to treat sleep apnea.

Supplemental oxygen may be given if blood levels of oxygen fall too low during sleep, even after opening the airway.

Prevention

You may be able to prevent the onset of sleep apnea by maintaining a healthy weight . Avoid alcohol, nicotine, and sedatives, which may contribute to airway obstruction.

RESOURCES:

American Academy of Sleep Medicine

http://www.sleepeducation.com/

American Sleep Apnea Association

http://www.sleepapnea.org/

National Sleep Foundation

http://www.sleepfoundation.org/

CANADIAN RESOURCES:

Canadian Lung Association

http://www.lung.ca/home-accueil_e.php

Canadian Sleep Society

http://www.css.to/

References:

American Academy of Sleep Medicine. The International Classification of Sleep Disorders. 2nd ed. Westchester, IL; American Academy of Sleep Medicine; 2005.

American Sleep Apnea Association website. Available at: http://www.sleepapnea.org. Accessed July 9, 2009.

Smith I, Lasserson TJ, Wright J. Drug therapy for obstructive sleep apnea. Cochrane Database Syst Rev. 2006;19:CD003002.

Obstructive sleep apnea. DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Accessed October 22, 2007.

Kushida CA, Littner MR, Hirshkowitz M, et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adults with sleep-related breathing disorders. Sleep. 2006;29:375-380.

Littner MR, Kushida C, Wise M, et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep. 2005;28:113-121.

Morgenthaler TI, Kapen S, Lee-Chiong T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006;29:1031-1035.

Pack AI, Maislin G. Who should get treated for sleep apnea? Ann Intern Med. 2001;134:1065-1067.

Sleep apnea: treatment and drugs. Mayo Clinic website. Available at: http://www.mayoclinic.com/health/sleep-apnea/DS00148/DSECTION=treatments-and-drugs. Updated June 29, 2010. Accessed April 4, 2011.

Last reviewed September 2011 by Marjorie Bunch, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

Copyright © 2012 EBSCO Publishing. All rights reserved.

 “This minimally invasive procedure has the potential to fundamentally change the treatment paradigm for people battling sleep apnea.”

For more information, visit http://www.mountsinai.org/.

Find Mount Sinai on:
Facebook: http://www.facebook.com/mountsinainyc
Twitter: @mountsinainyc
YouTube: http://www.youtube.com/mountsinainy

Related articles

Sleep Paralysis: Can’t Scream or Move Nightmare

Cope with Sleep Paralysis

Sleep paralysis is a condition where people are paralyzed at the onset of sleep or upon waking. It is a disorienting condition that may also proffer vivid and terrifying hallucinations. Here are some steps to help you identify and cope with sleep paralysis.

Recognize the Symptoms

  1.  

    Learn to recognize the symptoms. Sleep paralysis can affect you in many different ways. There are, however, some commonalities that people experience, including[1]:

      
     
     
    An inability to move the trunk or limbs at the beginning of sleep or upon awakening 
    • Brief episodes of partial or complete skeletal muscleparalysis
       
    • Visual and auditory hallucinations(people often sense an evil presence, or feel a phantom touch, or hear an unidentifiable noise in the room)
       
    • A sense of breathlessness (or chest pressure)
       
    • Confusion
       
    • Helplessness
       
    • Fear
       
     

What to Do During Sleep Paralysis

  1.  

    Focus on body movement. You may find that you are able to move a part of your body (often your toes, fingers, or tongue) to force yourself to a fully waking state. [2]

      
     
  2.  

    Focus on eye movement. Your ability to open your eyes and look around is generally not hindered by sleep paralysis. Some people recommend rapidly moving their eyes back and forth to break the paralyzed state.[2]

     
      
     
  3.  

    Focus on breathing. Controlled breathing can be an excellent relaxation technique. Knowing some breathing techniques in advance may help you regain control during a sleep paralysis episode.

     

     
     
  4.  

    Imagine yourself moving. Some people intentionally induce a sleep-paralysis state to induce what they believe to be out-of-body experiences. Imagining oneself moving effortlessly from the body may be a pleasant alternative to sleep paralysis.[2]

     
     
     
     
     

Treating the Symptoms

  1.  

    Sleep regularly. Sleep paralysis is thought to happen when the sleeper enters the REM-sleep state prematurely.[2] Since this is more likely to occur when a person is sleep-deprived, maintaining a regular healthy sleep pattern and getting enough sleep can significantly reduce the likelihood of sleep paralysis episodes.[3] If you suffer from insomnia, train yourself to fall asleep more easily.

     
     
     
     
     
     
  2. “Sleeping on my side worked for me.” -Maria

    Sleep on your side. About 60% of sleep paralysis episodes reportedly occur when the sleeper lies on his or her back; to break this habit, sew a pocket or pin a sock to the back of your nightshirt and insert a tennis ball or two.[2]

     

     
     
  3.  

    Exercise regularly.[3] You don’t have to go to the gym. Simply introduce a low-impact exercise regimen to your day. Taking a walk in the morning, for example, is a good idea.

     
     
      
     
  4.  

    Eat healthy. Nothing is more important than what you put inside your body. Cut out the things that will affect your sleep, such as caffeine, alcohol, and sweets.

     
     
     
  5.  

    Relax. Stress interrupts normal sleep cycles, which can greatly contribute to the likelihood of sleep paralysis.[2] There are many things you can do to help you calm down, such as meditating, listening to music, and playing with a pet. Decide what works best for you.

     
     
     
     
  6.  

    See a doctor. When episodes occur once a week for 6 months, it’s time to consult with your personal health care provider.

     
     
     

Further Preemptive Treatments

  1.  

    Talk about it with your friends. It’s much easier to deal with a medical condition when you know you’re not the only one. You might be surprised to learn that someone you know has gone through something similar.

     
     
     
     
     
     
  2.  

    Keep a log. Track the details of the experience, the time, your sleep pattern, sleeping position, mental/emotional state before and after you were paralyzed, and if you were paralyzed while falling asleep or upon waking up. This can all be useful information, especially if you decide to a see a doctor about the condition.

     
     
     
     
     
     
  3.  

    Identify the triggers. Sleep paralysis can be triggered by a variety of situations. For example, some researchers have found that it can be caused by the position you fall asleep in. These researchers recommend sleeping in any position other than your back. It can also be caused by certain sedatives or pain medication. Switching medications can eliminate the problem.

     

     
     
  4.  

    Avoid the triggers. After identifying your personal triggers, do your best to avoid them. This will significantly reduce the chances of experiencing sleep paralysis.

     
     

    Tips

  • Avoid caffeine 5 hours before sleep.
  • Sleep paralysis can be terrifying but it isn’t dangerous or harmful.
  • Consider having your doctor administer a sleep study diagnosis. With proper treatment of a diagnosed sleep apnea condition, the sleep paralysis may subside and/or disappear.
  • If you feel an episode coming on at night, try sitting up and staring at a bright light for a minute or two.
  • If you experience disassociation (“out of body” feelings), try to “feel” the texture of your sheets, clothes, or furniture around you. It’s easier to wake up if you focus on one of your senses. Alternately, ignore the sense of paralysis, and allow yourself to follow the “out of body” feelings; you can turn an unpleasant surprise into an enjoyable lucid dream, which you may be able to control. Try visiting friends or pleasant spots you have visited. No harm can come to you, so don’t be afraid.
  • Sleep paralysis is a very common medical phenomenon. Do not worry about the supernatural or spiritual implications of such an episode.
  • You might find yourself still dreaming while experiencing paralysis. This is the time when sleep paralysis is most confusing. For example, you might awaken to see the outlines of your bedroom, but at the same time you might see an intruder in your dream. These sorts of dreams are common in conjunction with sleep paralysis, and they are known to be exceptionally frightening.
  • You might feel the urge to break free of the paralysis by trying to sit up or moving a lot. Doing this can often cause you to be paralyzed further and the pressure to increase. The best way is to simply relax and recognize that you are in no danger and the feeling will soon pass.

Sources and Citations

  1. Guardian article on sleep paralysis
  2. 2.0 2.1 2.2 2.3 2.4 2.5 University of Waterloo resources on sleep paralysis – this site also has an ongoing study on sleep paralysis where you can contribute your experiences
  3. 3.0 3.1 Sleep Paralysis Information Service
 

60

                                                                                                                              

60.  Minimum # of days it takes to change an unhealthy eating habit.

HOW TO CHANGE AN UNHEALTHY EATING HABIT TO A HEALTHY ONE:

1.  AWARENESS – Be mindful of the unhealthy eating habit.  Think of WHY you reach for certain unhealthy foods. Then, exchange it for something healthy.  See list below.

2.  PLAN MEALS – If you have no time for lunch and that is when you grab something unhealthy, prepare a healthy meal the night before and bring it to the office with you.  If you work from home, put it in the refrigerator for easy grabbing the next day.

3.  REDUCE STRESS – Meditate. Reducing stress will also improve your sleep.  Mediatating just twice a week can help with sleep problems.  Turn off all electronic equipment and find a quiet place with no distractions and simply breathe and stretch.  Nature is wonderful to quiet the noise.

4.  TAKE IT SLOW SO YOU DON’T CRASH – Slow-and-Steady is best.

 20 SMALL CHANGES YOU CAN MAKE THAT ADD UP in 60 DAYS:

  1. Start each day with a nutritious breakfast.
  2. Get at least 8 hours of sleep because lack of sleep can cause you to overeat.
  3. Drink more water instead of sugary drinks, sodas, soft drinks or energy drinks.
  4. Don’t eat meals on the run.
  5. Eat when you’re really hungry.  Stop when you’re comfortably full.
  6. Say no to second helpings.
  7. Eat healthy snacks every few  hours: fruits, veggies, almonds, walnuts.
  8. If you eat dairy, switch to soy or lower-fat dairy products.
  9. If  you eat white bread, switch to whole-grain bread.
  10. Use mustard instead of  mayo.
  11. Instead of sauces, flavor your foods with herbs, vinegars, mustards, or lemon.
  12. If you drink coffee, switch to cafe au lait, using strong coffee and hot skim milk instead of cream.
  13. Limit alchohol to 1 or 2 drinks a day.
  14. Eat larger portions of water-rich foods and less of calorie-dense foods.
  15. If you never exercise –start with walking each day.  Stretch and walk.
  16. Replace unhealthy snacking foods in your house with healthy ones. 
  17. Replace ice cream with  yogurts.
  18. Replace salty pretzels and chips with cereals, almonds, walnuts or popcorn.
  19. Stock your refrigerator with fresh fruits & veggies for snacking.
  20. Make your goal feeling healthy,  rather than a certain weight.

60 DAYS.   TWO MONTHS.  LONGTERM CHANGE.  BE PATIENT.

Treatment of Insomnia in Anxiety Disorders

by Gregory M. Asnis, MD, Elishka Caneva, MD, and Margaret A. Henderson, MD
Insomnia is highly prevalent in psychiatric disorders, and it has significant implications.

This review focuses on insomnia in the context of anxiety disorders. The prevalence of comorbid insomnia in anxiety disorders is addressed and the clinical implications associated with insomnia are discussed as well as when and how to treat this important comorbidity.

Just how specifically insomnia relates to and possibly affects anxiety disorders is highlighted by the fact that insomnia is one of the defining criteria in a number of the DSM-IV-TR anxiety disorders.

For example, difficulty in falling or staying asleep is a criterion for PTSD, acute stress disorder, and generalized anxiety disorder (GAD).

The relationship of insomnia to anxiety disorders is also influenced by comorbid major depression. The severity of insomnia is increased when an anxiety disorder is comorbid with a major depressive disorder (MDD).1 This is highly relevant because 58% of MDD patients have a lifetime anxiety disorder.2

The presence of insomnia has a deleterious effect on daytime functioning and negative effects on quality of life, including social and work relationships.3

Insomnia (1997 film)
Image via Wikipedia

Also, there is clear evidence that the presence of insomnia in anxiety disorders is associated with increased morbidity.

For example, in patients with PTSD, insomnia is associated with an increased likelihood of suicidal behavior, depression, and substance abuse as well as nonresponsiveness to treatment.4-6

In addition, insomnia as an early symptom in traumatized patients increases the risk of the development of PTSD 1 year later.7

Early assessment

It is important to carefully assess for insomnia early in the evaluation of patients with anxiety disorders and to aggressively treat this complicating comorbidity.

Insomnia is an underrecognized and undertreated problem. Patients rarely report their symptoms of insomnia spontaneously to their doctor. Adding to the problem of detecting insomnia is the finding that doctors rarely inquire about insomnia in their patients.3,8,9

 Thus, a carefully taken history is an important first step in the assessment of insomnia.

Self-rating sleep questionnaires and direct clinical interviews are used to obtain a history of potential sleep disorders (eg, insomnia). A number of well-validated sleep questionnaires have been widely used.

The most widely used and validated questionnaire is the 19-question Pittsburg Sleep Quality Index. The questions cover sleep quality, sleep problems, sleep medications, and so on, within the past month.10

Another widely used questionnaire is the Leeds Sleep Evaluation Questionnaire (LSEQ). The LSEQ consists of 10 self-rating questions that cover sleep and aberrant sleep behaviors.11

Besides self-rating questionnaires that depend on memory of sleep disturbances, a sleep log or diary can confirm questionable sleep disturbances prospectively.

The use of a sleep log allows for an analysis of day-to-day sleep patterns, such as the time that the patient went to bed, sleep latency, and nighttime awakenings.8,9 The log is filled out by the patient shortly after awakening in the morning (see Morin9(p38) for an example of a sleep log). If at all possible, monitoring for up to 2 weeks is highly recommended because it allows for sleep abnormalities that might show marked day-to-day variability and would more likely be detected by extensive monitoring.12,13

What is already known about insomnia
in patients with anxiety disorder?
No Me Mireis!

■ Anxiety disorders frequently coexist with insomnia. The latter is believed to be part and parcel of various anxiety disorders and is one of the defining criteria of a number of them.

What new information does this article provide?

■ Our article clarifies new approaches to considering insomnia in anxiety disorders. The presence of insomnia should be considered a comorbid illness and treated on its own. Pharmacotherapy, cognitive-behavioral therapy, and a combination of both are discussed.

Insomnia is an added pathology that brings increased morbidity to patients with anxiety disorders. Our review suggests that successful treatment of insomnia actually increases the responsiveness of anxiety disorders to many antianxiety treatments.

What are the implications for psychiatric practice?

■ When evaluating patients with anxiety disorders, psychiatrists should carefully evaluate for the presence of insomnia. Patients infrequently bring up this symptom on their own. If insomnia is present, aggressive treatment early in the course of therapy is highly suggested.

If the presence of insomnia is suspected, interviewing a spouse, a significant other, or a caregiver is helpful. Some patients who believe they have insomnia symptoms appear to have “sleep state misperception,” where their partners clearly state that their sleep is normal.14

These “others” can also report problems that are likely not obvious to the patient:

• Apnea spells or excessive snoring as seen in obstructive apnea

• Excessive body movements as seen in periodic leg movement disorder and restless legs syndrome

• Various sleep-related behaviors (sometimes violent and aggressive) as seen in rapid eye movement behavior disorder (RBD)

• Sleepwalking

Referral to a sleep specialist and sleep polysomnography has been recommended if pharmacological or nonpharmacological options are not working. Referral is also warranted for patients with insomnia in whom a specific sleep disorder, such as obstructive sleep apnea, periodic limb movements, narcolepsy, or RBD, is suspected.12,15

Even when a visit to a sleep laboratory is suggested, the cost of an overnight visit is often prohibitive—more than $1000 per night; usually 2 nights are required with the first being an adaptation night for the patient. Insurance frequently does not cover these costs.16

If it is found that the patient has sleep apnea, a sleep movement disorder, RBD, or a number of other sleep disorders, specific nonhypnotic treatments may be required (eg, continuous positive airway pressure for sleep apnea is the treatment of choice).

Before beginning treatment of anxiety disorder–associated insomnia symptoms, rule out any concurrent medical illness, medication treatment, or substance use that might be inducing or worsening insomnia. Many medical illnesses, such as cardiovascular disorders (eg, congestive heart failure), pulmonary disorders (eg, emphysema), endocrinopathies (eg, thyroid disorders), GI disorders (eg, acid reflux), and neurological disorders (eg, pain syndromes), are associated with insomnia.12

Carefully assess the use of medications for medical and psychiatric disorders that may be implicated in insomnia as well as caffeine(Drug information on caffeine) or alcohol(Drug information on alcohol) use. Even small amounts of the latter have been associated with increased nighttime awakenings.

Insomnia
Image by EasyPickle via Flickr

Before providing any significant intervention for insomnia, a careful evaluation regarding behaviors that might contribute to insomnia should be made.

Daytime naps, late nighttime snacks or meals, watching television in bed, nighttime exercise, or excessive light or loudness in the bedroom should be identified and modified. Eliminating these behaviors can lead to significant sleep improvements. A 13-item self-rating questionnaire by Mastin and colleagues17 can help elicit sleep hygiene information.

Pharmacological options

The treatment of insomnia in patients with anxiety disorders is, for the most part, the same as the treatment of insomnia per se: pharmacological, nonpharmacological, or a combination of the two.

The primary treatment of insomnia is pharmacological because of the rapid onset of action (eg, hypnotics are usually effective within days to 1 week of use). The most common nonpharmacotherapy, cognitive-behavioral therapy for insomnia (CBT-I) takes considerably longer.3,8,12 Currently, the FDA has 11 approved drugs for the treatment of insomnia:

• Nonbenzodiazepines: eszopiclone, zolpidem(Drug information on zolpidem), zolpidem ER, and zaleplon(Drug information on zaleplon)

• Benzodiazepines: estazolam, flurazepam(Drug information on flurazepam), quazepam, temazepam, and triazolam

• A tricylic antidepressant: low-dose sinequan

• A melatonin(Drug information on melatonin) agonist: ramelteon

In recent years, nonbenzodiazepines have become the most recommended of the approved hypnotics. (There has been less and less reliance on benzodiazepines.) Not only are nonbenzodiazepines effective in treating insomnia (equivalent to the benzodiazepines), but there is a notion that they are safer than benzodiazepines.3,12

Both nonbenzodiazepines and benzodiazepines are associated with adverse effects that include fatigue, dizziness, ataxia, and the development of dependence and tolerance with long-term use. Although head-to-head studies comparing these classes of hypnotics have been minimal, a recent meta-analysis supports the finding of reduced adverse effects for the nonbenzodiazepines.18 The nonbenzodiazepines typically have a shorter half-life and are more selective at the γ-aminobutyric acid receptor, factors that are partially responsible for less residual daytime sedation and other adverse effects.

In the treatment of anxiety disorders with comorbid insomnia, the latter should be treated concurrently with, but independently of, the anxiety disorder per se. The idea that one should wait to see whether the insomnia resolves with only the treatment of the anxiety disorder is no longer valid. Clinical experience has shown that without targeted insomnia treatment, insomnia frequently persists.3,19

When adding a hypnotic to an antidepressant in the treatment of anxiety, the risk to benefit ratio must be considered. Pollack and colleagues20 looked at a large group of patients with GAD comorbid with insomnia (N = 595). The patients received either 10 mg of escitalopram(Drug information on escitalopram) coadministered with 3 mg of eszopiclone or the escitalopram with placebo. Those in the active hypnotic treatment group had a significant response in their insomnia by the first week. The combination of medications was well tolerated with no significant increase in adverse effects.

Most surprisingly, the anxiety scores for those patients who received the hypnotic significantly improved starting at week 4 even after removing insomnia symptoms from the anxiety assessment. The time to onset of the anxiolytic response was also reduced. In addition, the combination treatment led to a slightly better symptom response and remission rate for the anxiety disorder.

Similar results were reported in a 12-week open-label study (N = 27) undertaken by Gross and colleagues.21 The researchers evaluated ramelteon (8 mg/d), a melatonin agonist, in patients who had GAD comorbid with insomnia and whose condition was partially responsive to an SSRI or a serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitor. The hypnotic was well tolerated, effective for insomnia, and appeared to facilitate the treatment of GAD.

A double-blind placebo-controlled study by Fava and colleagues22 evaluated the efficacy and safety of zolpidem(Drug information on zolpidem) extended-release (12.5 mg/d) versus placebo in patients with comorbid GAD and insomnia who were being treated with escitalopram (10 mg/d). Sleep measures improved significantly by the end of week 1, and there was no added burden of adverse effects. Zolpidem did not show a beneficial anxiolytic effect.

Approximately 50% of patients with insomnia continue to have insomnia 3 years after initial diagnosis, and many patients require months to years of treatment. Nonbenzodiazepines for primary insomnia were found to have continued efficacy and to be well tolerated with no evidence of abuse or withdrawal symptoms on discontinuation of use after 12 months.23,24 Ramelteon was also found to be efficacious with no significant issues of abuse or tolerance in a 24-week open-label study.25 The literature for longer use of hypnotics is scarce.

Anxiety disorders are frequently comorbid with alcohol(Drug information on alcohol) or substance use disorders.4,26 Consider ramelteon or low-dose sinequan to avoid potential issues of abuse and addiction. Nonbenzodiazepines are preferred over benzodiazepines; there is evidence that the former have decreased potential for abuse and a better adverse-effect profile.

In some patients with insomnia, benzodiazepines are clearly necessary. The other hypnotics may not be as effective for some patients, and the anxiolytic properties of benzodiazepines may be helpful.

When hypnotics are used (particularly, benzodiazepines and nonbenzodiazepines), their use should be reassessed—every 3 to 4 weeks.3,12 Many patients with insomnia do not experience sleep disturbances nightly. Therefore, the use of hypnotics on an as-needed basis or a few times a week helps cut down on the amount and exposure to medication.27

Trazodone and mirtazapine(Drug information on mirtazapine) are also widely used for insomnia, as are atypical antipsychotics and herbal preparations. Unfortunately, these agents have not been rigorously studied for insomnia and thus their effectiveness and safety remain unclear.3

Nonpharmacological interventions

CBT-I is an important, widely accepted, multimodal treatment for insomnia and the best-studied of the nonpharmacological approaches for this disorder.

It is a manualized treatment that focuses on various components of CBT (ie, cognitive restructuring and the use of psychological interventions, such as the practice of good sleep hygiene, stimulus control, sleep restriction, and relaxation therapy).

These methods address negative and distorted cognitions and behaviors that initiate and perpetuate insomnia.9,28 Treatment duration is relatively short. It is administered for 5 hours divided over 4 to 6 weeks and can subsequently be used as a maintenance treatment in monthly sessions. There are approximately 12 well-designed CBT-I trials that have clearly demonstrated that it is a highly effective intervention for insomnia for 1 year or longer.29,30

Studies that compared CBT-I with pharmacotherapy found equivalent efficacy.31 This has led the NIH Consensus and State of the Science Statement to conclude that CBT-I is “as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”3 In contrast to hypnotics, learned CBT-I skills may persist even when active treatment ends.9 Furthermore, some patients may prefer CBT-I over hypnotic drugs because of their possible adverse effects or because of concerns about drug interactions or taking a drug during pregnancy.9

In general, CBT-I is underutilized—only about 1% of patients with chronic insomnia receive this therapy.32 To increase the availability of CBT, it can be administered via self-help strategies (eg, educational books and materials) and in group formats. In addition, the use of the Internet to provide CBT has been shown to be effective. Nonetheless, patients frequently prefer face-to-face contact.33

Besides CBT-I, a number of other nonpharmacological therapies, such as bright light, physical exercise, acupuncture, tai chi, and yoga, have been used to treat insomnia. Unfortunately, the results have been inconsistent.32,34

Combination therapy

  • Is a combination of pharmacotherapy and nonpharmacotherapy more effective than either alone in the treatment of anxiety disorders with insomnia? Combination therapy has not been addressed in studies of this particular patient population. Furthermore, the question has been minimally addressed even in the treatment of insomnia per se.
    Study findings suggest only modest differences in outcomes with a combination of therapies. Similar results were seen in a study that compared CBT with CBT pluszolpidem(Drug information on zolpidem). The 6-week acute study demonstrated a 60% response rate and a 40% remission rate; the group with the combination treatment did have a significant increase in sleep time of 15 minutes, but the researchers question the clinical significance of this isolated finding.29

Summary

Anxiety disorders with comorbid insomnia are highly prevalent with potential negative consequences. Therefore, assess for insomnia with self-rating scales and careful clinical interviews. When appropriate, refer patients for polysomnography.

Insomnia should be treated aggressively with pharmacotherapy, nonpharmacotherapy (particularly CBT-I), or a combination. Some of the hypnotic treatments actually appear to facilitate successful therapy for the anxiety disorder.

Benzodiazepines and nonbenzodiazepines have a number of adverse effects and can lead to abuse and dependence. Patients with an anxiety disorder may be particularly vulnerable, especially those with a history of alcohol(Drug information on alcohol) and drug abuse. Treatment with benzodiazepine and nonbenzodiazepine hypnotics needs to be reassessed monthly. Alternatively, ramelteon, low-dose sinequan, and CBT-I should be considered because they have minimal adverse effects and no risk of abuse.

Successful treatment of insomnia is an important goal in patients with anxiety disorders. Both pharmacological and nonpharmacological interventions have response rates of approximately 60%.

ABOUT THE AUTHORS:  Dr Asnis is Professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine and Director of the Anxiety and Depression Clinic of Montefiore Medical Center, Bronx, NY; Dr Caneva is a Psychiatry Fellow at the Anxiety and Depression Clinic of Montefiore Medical Center; Dr Henderson is Research Coordina-tor at the Anxiety and Depression Clinic of Montefiore Medical Center. Dr Asnis is Consultant for Bristol-Myers Squibb and has received grants in the past year from Forest Pharmaceuticals, Lilly, Otsuka, and Pfizer. Drs Caneva and Henderson report no conflicts of interest concerning the subject matter of this article.