Sleep Soundly Every Night, Feel Fantastic Every Day (16 page)

1.
 
Progressive Muscle Relaxation.
See
chapter 3
.

2.
 
Guided Imagery.
The best way to begin this type of program is to listen to an audio induction that would help you relax while suggesting one imagery set for your focus. The mind is engaged in a pastoral scene, a walk on a mountain trail, or a slow swim through a warm pool.
Generally, these guided scripts last from 10 to 20 minutes, providing the space for the body and brain to relax. Such imagery sequences can also help you sleep better as part of your sleep hygiene changes.

There are several classes of medications available and approved by the FDA for the treatment of insomnia. I do not believe this is necessarily the best approach. However, I think it is important to understand how these medications work.

1.
 
Over-the-counter sleep aids for insomnia.
Most of these are antihistamines that block histamine, a stimulating wake-promoting neurotransmitter. Undesirable side effects include constipation, urinary retention, dry mouth, and daytime sedation. Most people become tolerant, meaning the drug loses its effectiveness in a short time.

2.
 
Melatonin supplements
tend to shorten the time to fall asleep and may be effective in certain circadian disorders, such as when you travel and experience jet lag or have delayed sleep difficulties. In addition, melatonin could be effective in the elderly who tend to produce less melatonin. Recent studies have demonstrated its effectiveness in patients on beta blockers. Doctors commonly prescribe these medications for hypertension, heart disease, migraines, and tremors. Beta blockers tend to block the production of melatonin by the pineal gland.

3.
 
Benzodiazepines
are the medications that target the GABA system (gamma-aminobutyric acid), the most potent sleep-promoting neurotransmitter in the brain. The following medications make this GABA neurotransmitter more potent:

    
1.
 
Temazepam (Restoril)

    
2.
 
Triazolam (Halcion)

    
3.
 
Flurazepam (Dalmane)

4.
 
The newer medications, such as zolpidem (Ambien) and eszopiclone (Lunesta), are
nonbenzodiazepines.
Like benzodiazepines, they target the GABA system, but they have a different chemical structure.

5.
 
Medications not developed for sleep, yet commonly used for sleep,
though the FDA has not approved them, include antidepressants such as

    
1.
 
Trazodone (Desyrel)

    
2.
 
Amitriptyline (Elavil)

    
3.
 
Mirtazapine (Remeron)

    
4.
 
Antipsychotic medication quetiapine (Seroquel)

If you suffer from chronic insomnia, do not ignore it. Do not wait until you develop a mood disorder. Seek out a sleep expert, who can offer a diagnosis based on your sleep history, medical history, and a possible sleep study if a primary sleep disorder like sleep apnea is considered.

If someone just writes a prescription for a sleep medication without taking the time to discuss your problem in depth, you are probably in the wrong place. Finally, there are practitioners skilled in both the pharmacologic and nonpharmacologic treatment of insomnia in most areas. An excellent resource is the American Academy of Sleep Medicine and the Society of Behavioral Sleep Medicine.

If you decide to see a doctor, pull together the following information:

1.
 
A sleep diary, at least one week's worth (Any patient coming to see me with a complaint of insomnia is provided with this at least a week in advance of our appointment.)

2.
 
A list of contributing insomnia factors as you see them

3.
 
A written review of your personal sleep history and habits

4.
 
A summary of how you function during the day

5.
 
A summary of how you cope emotionally and mentally (Are you moody, explosive, withdrawn? Is that emotional coping normal or not normal for you?)

6.
 
A list of what you have tried for sleeping and how you presently manage

Q.
 
I can fall asleep without a problem, but I wake up at least three times per night and cannot fall back to sleep for at least a half-hour each time. Would testing in a sleep lab be helpful?

A.
 
Sleep maintenance insomnia, which is an inability to stay asleep, may warrant a sleep study. What the sleep specialist will be looking for is a possible sleep disorder such as sleep apnea or periodic limb movement that may be causing you to wake up.

Q.
 
I have been having trouble falling and staying asleep for about four months. It does not happen every night, but about three to four times a week. Would this be considered insomnia?

A.
 
Yes, it's consistent with chronic insomnia. Chronic insomnia is difficulty falling asleep or staying asleep, as well as early morning awakenings at least three times per week and for greater than three months.

Q.
 
My husband returned from Afghanistan last year. He swears he sleeps no more than two hours a night. However, whenever I am awake, he seems to be asleep. I am sure he is sleeping much longer.

A.
 
Paradoxical sleep is very common in returning veterans. In fact, in one recent study, it comprised 15% of all
insomnias in vets. In the general population, it is less than 5%. Even though they are asleep, they do not perceive that they are sleeping, in part due to the hypervigilance and alertness they had to maintain day and night while they were on assignment.

Q.
 
My wife can drink coffee right up until bedtime and have no trouble falling asleep. If I consume anything with caffeine after 4:00 p.m., I have a hard time falling and staying asleep.

A.
 
Recent studies have shown that those who are sensitive to caffeine may have an inherited predisposition to its sleep-preventing properties. In some people, caffeine consumption disrupts the secretion of the sleep-promoting hormone melatonin, while in others it has little to no effect.

Q.
 
My husband sleeps only five hours a night. He claims it is all he needs. However, on the weekends he sleeps at least 12 to 13 hours. We do not have the family time I would like to see him spend with our children. What do you think?

A.
 
Your husband is showing signs of chronic sleep deprivation. One of the major clues as to whether you are getting enough sleep is the “sleep debt.” Your total sleep time per night should not vary much on weekends or vacations. The fact that he is sleeping so long on the weekends indicates insufficient sleeping on the weekdays.

Q.
 
My wife is unable to sleep more than five hours a night. She claims the problem is stress. We are both retired and pretty much have the same routine. Why is it that I have no trouble sleeping and she does?

A.
 
One explanation that stands out is a breakdown of coping skills. In a recent study in the journal
Psychosomatic Medicine,
people with insomnia were compared to a group that slept well. The frequency of minor stressors in their lives was not different between the two groups. However, the group with insomnia perceived their lives as more stressful and relied on “emotion-focused coping strategies.” The insomnia patients tended to focus on the underlying negative emotions and took this to bed with them. This resulted in increased anxiety and disturbed sleep. Actual stress events can be the same with you, but how you perceive and deal with it is the difference. Counseling and behavioral therapy may be beneficial to those who suffer with insomnia.

Q.
 
My wife sleeps only a few hours each night. She smokes right up until bedtime and then again when she wakes up. I keep telling her that the smoking is not helping her sleep. Her answer is, “It relaxes me.” What do you think?

A.
 
Nicotine initially causes relaxation in some. However, within a short period of time it binds to areas of the brain that release a chemical called acetylcholine. This is a wake-promoting neurotransmitter and definitely will interfere with sleep. I would tell your wife to taper down her smoking, especially around bedtime. Even better, she should quit altogether.

Q.
 
My husband has severe insomnia. It takes him hours to fall asleep. He refuses to speak to our health care provider about this. His memory does not seem to be as sharp as it once was. I'm wondering if his lack of sleep could be the cause.

A.
 
It is hard to say, but lack of sleep could be a factor. Most insomniacs lack delta sleep or what is often called deep or slow wave sleep. This period of sleep is very important to memory, especially the memorization of facts. Although there may be other causes, your husband's lack of sleep could be playing a part. He really should discuss this with his health care provider.

Q.
 
I have had insomnia for 10 years. I average about 5 hours of sleep a night. I have tried and failed to improve with medications, hypnosis, meditation, and various behavioral techniques. Is there anything new out there that is safe and effective?

A.
 
The answer is yes, maybe. There is a new type of medication now being tested. It blocks the actions of the major wake-promoting neurotransmitter in the brain called orexin. Several recently published trials have been very impressive, both as to its effects and as to safety. It has not yet been released and is in the process of undergoing further clinical trials.

Q.
 
I have had trouble sleeping for many years. I get only five hours of sleep out of the eight I spend in bed. I have tried several over-the-counter sleep aids without success. Do you have any ideas?

A.
 
Yes, first you are spending too much time in bed. The more time you spend in bed trying to make yourself fall asleep, the less likely you are going to fall asleep. A behavioral technique called Sleep Restriction Therapy may work for you. Maintain your same wake time but decrease your time in bed to five and one-half hours for the first week. No napping during the day.
Monitor your time asleep versus your time in bed. After a week, if it exceeds 85%, go to bed 15 minutes earlier. If not, do not change your sleep time. Every week that you sleep on average 85% or more of the time in bed you can advance your sleep time by 15 minutes. This is one of the most successful behavioral techniques for insomnia.

Q.
 
My 72-year-old husband has trouble falling asleep. Most nights it takes him hours to get to sleep. He has a couple of cups of strong coffee during the day, but always before noon. Our health care provider is advising him to stop consuming coffee completely. I read somewhere that caffeine is metabolized in four to six hours, so how will giving up coffee help?

A.
 
Actually, those studies were done on younger people with the majority being under 30. Studies that are more recent have shown that in the elderly population it may take 16 to 20 hours to metabolize caffeine. Therefore, I agree with your health care provider. Eliminating the caffeine for a while to see what effect it has on your husband's sleep seems to be reasonable.

Q.
 
I acquired a Valium from my friend for one night when over-the-counter sleep inducers weren't helping. I took half of the pill and it helped me go to sleep better than Unisom ever has, and with fewer side effects such as palpitations. How can I talk to my primary care physician about this?

A.
 
Valium is a very poor choice as a sleep aid. First, the FDA does not approve it for sleep and it has a very long duration of action—as much as 40 hours. If you are chronically in need of a sleep aid, you should talk to your primary physician about this. There are excellent nonpharmacological treatments available. However, if you need a prescription medication, there are many with far fewer potential side effects and with FDA approval for sleep.

Q.
 
I have allergies and asthma and the past six months have been particularly difficult. My doctor started me on Singulair, which took care of my symptoms and really improved my lung capacity. However, soon after starting it, I began having many dreams at night and ultimately I stopped the drug because the dreams were becoming more intense. Several times, I woke in the early morning in a state of panic. In addition, I noticed a wobbly, unbalanced feeling in my legs during waking hours. I know there are other meds delivered by nasal spray and inhaler that do the same thing that Singulair does. If I try those, would I experience the same side effects? I will be seeing my doctor again soon to discuss this and to also inquire about starting the Allergy Easy drops.

A.
 
It is highly unlikely that you will have the same side effects. Singulair (montelukast) has been associated, although rarely, with nightmares and insomnia. It is in a class of medications called leukotriene inhibitors. Most other medications for allergy and asthma are not in this class, and have not been associated with this side effect.