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People with insomnia the inability to sleep may be plagued by trouble falling asleep, unwelcome awakenings during the night, and fitful sleep. They may experience daytime drowsiness yet still be unable to nap, and are often anxious, irritable, and unable to concentrate. Insomnia is one of the most common types of sleep disturbance, at least occasionally affecting about one in three Americans. Epidemiologic studies suggest that 9% to 15% of Americans experience problems functioning in the daytime as a result of insomnia. Because insomnia often occurs in conjunction with a psychiatric disorder, insomnia may affect as many as 50% to 80% of patients in a typical mental health practice. Sleep problems are particularly common in patients with anxiety, depression, bipolar disorder, and attention deficit hyperactivity disorder (ADHD).
Types of insomnia
One of the most common ways to classify insomnia is in terms of duration of symptoms. Insomnia is considered transient if it lasts less than a month, short-term if it continues for one to six months, and chronic if the problem persists longer than six months. The causes of transient or short-term insomnia are usually apparent to the individual affected. Typical circumstances include the death of a loved one, nervousness about an upcoming event, jet lag, or discomfort from an illness or injury. Chronic insomnia, on the other hand, is most often learned through conditioning. After experiencing a few sleepless nights, some people learn to associate the bedroom with being awake. Taking steps to cope with sleep deprivation napping, drinking coffee, having a nightcap, or forgoing exercise only worsens the problem. As insomnia persists, anxiety regarding the insomnia may grow more intense, leading to a vicious cycle in which fears about sleeplessness and its consequences become the primary cause of the insomnia. Treatment becomes necessary once insomnia impairs sleep quality to the degree that it adversely affects a person's health or ability to function during the day.
the patient learns to fall asleep quickly and sleep soundly, the time in bed is slowly extended until it provides a full night's sleep. Some sleep experts suggest starting with six hours at first, or whatever amount of time the patient typically sleeps at night. Setting a rigid early morning waking time often works best. If the alarm is set for 7 a.m., a six-hour restriction means staying awake until 1 a.m., no matter how sleepy. Once the patient is sleeping well during the allotted six hours, he or she can add another 15 or 30 minutes until attaining a healthy amount of sleep. Reconditioning. This technique reconditions people with insomnia to associate the bedroom with sleep instead of sleeplessness and frustration. It incorporates elements of stimulus control and sleep hygiene education by suggesting strategies such as these:
Use the bed only for sleeping or sex. Go to bed only when sleepy. If unable to sleep, move to another room and do something relaxing. Stay up until feeling sleepy, then return to bed. If sleep does not follow quickly, repeat. During the reconditioning process, get up at the same time every day and do not nap.
Relaxation techniques. For some people with insomnia, a racing or worried mind is the enemy of sleep. In others, physical tension is to blame. A variety of techniques such as meditation, breathing exercises, progressive muscle relaxation, and visualization of peaceful settings can calm the mind and relax the body enough to foster sleep.
The effect of antidepressants on sleep quality varies; in general, they reduce REM (dreaming) sleep but have little impact on deep sleep. Common side effects include dizziness, dry mouth, upset stomach, weight gain, and sexual dysfunction. These drugs also can increase leg movements during sleep. Some people find certain antidepressants make them feel nervous or restless, so the medication can actually exacerbate insomnia. It's not clear if these medications lead to tolerance or rebound insomnia. Melatonin. The hormone melatonin helps control the circadian cycle of sleep and wakefulness. The brain's production of melatonin peaks in the late evening, in conjunction with the onset of sleep. Drugs or supplements that act on melatonin try to take advantage of this natural sleep aid by boosting levels of this chemical before bedtime. Ramelteon (Rozerem) triggers melatonin receptors and is approved to treat insomnia for people who have trouble falling asleep at bedtime. Because people produce less melatonin as they age, theoretically this drug may be more likely to benefit older rather than younger people. In reality, however, most older people with insomnia tend to have problems with nighttime awakenings, not with falling asleep suggesting that ramelteon should be prescribed on the basis of symptoms rather than age. Ramelteon's most common side effect is dizziness, and it may also worsen symptoms of depression. To avoid a drug interaction that elevates blood levels of ramelteon, people who use the antidepressant fluvoxamine (Luvox) shouldn't take it. People with severe liver damage should also avoid taking ramelteon. Another option is synthetic melatonin, sold as a supplement. Despite some initial enthusiasm for this approach, however, most subsequent research has been disappointing, finding either minimal benefits or none at all. The most commonly reported side effects of melatonin supplements are nausea, headache, and dizziness.