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When You Can’t Sleep

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The advice always sounds so easy.  Establish regular sleep times. Don’t nap after 3 p.m. Get exercise. Use the bedroom for sleep and sex only. And no late-day “emergency” stops at Starbucks. (OK, maybe that’s not so easy.)

But as anyone with insomnia can tell you, getting a good night’s rest is a lot more complicated than that—largely because the reasons behind it are complicated.

“Unraveling why a patient has insomnia is like unraveling the skin of an onion,” says Lydia Wytrzes, M.D., a neurologist, sleep specialist and director of the Sutter Sleep Disorders Center in Sacramento. “But that’s what you need to do to come up with a treatment plan that’s helpful.”

Tossing and turning now and then is one thing. But chronic insomnia, defined as poor sleep every night or most nights for more than six months, has the debilitating power to negatively impact every aspect of a person’s life—and millions are caught in its grip. The American Insomnia Association reports that more than 1 in 10 American adults suffer from chronic insomnia, leading one to wonder, “Doesn’t anybody sleep anymore?”  Well, maybe babies do. But adults are another story.

Desperately Seeking Slumber

For Kelly Jones (not her real name), every night is like Groundhog Day, with the same question buzzing around her brain: Will she get any sleep? A 33-year-old wife, mom and full-time nurse at a local hospital, Jones first had trouble in her 20s, when a turbulent marriage led to turbulent tossing and turning.

Divorce, she hoped, would cure her insomnia.

It didn’t. 

“I’m now happily remarried, I love my job, love my co-workers, and love my kids,” says Jones. “So it’s not about stress.”

She’s tried counseling, biofeedback, darkening the shades in her bedroom. Sleep aids such as Sonata and Lunesta worked for a while. But after six years of regular use, she’s developed a tolerance that resists even the three-drug cocktail she’s concocted with the help of a sleep specialist.

Three hours of sleep a night, she says, just doesn’t cut it. (Experts say the average adult needs about 7.5 hours.)

“Without enough sleep, I cannot function,” she says. “My coping skills go way down. Little things will set me off. I cry easily. It affects my memory. It’s hard to focus.”

But what to do? That is the question.  “I think my doctor has done for me all she can,” says Jones. “I wish there were some kind of program, like sleep rehab, where I could go into a safe environment and get off meds and finally get so tired that I could go to sleep on my own.”

Maybe, she says, she should go to the Mayo Clinic or something, because she doesn’t know what else to do.

The Insomnia Picture

Stories like Jones’ don’t paint a pretty picture for patients with insomnia. Critics are quick to point out that insomnia research receives little federal funding, and that most of the research is focused on treatments instead of looking for the cause.

But maybe it depends on whether you’re looking at the glass half empty or half full. In 2005, the National Institutes of Health issued a “wake-up call” on insomnia, calling for increased research to learn more about not only treatment but also the causes and consequences of the disorder, which has been linked to everything from auto accidents (drowsy drivers cause more than 100,000 in the United States each year) to obesity (yes, people with insomnia are fatter) to depression.

Depression is not the only health problem associated with insomnia. But it’s a big one, says psychologist Debra Moore, Ph.D., director of Fall Creek Counseling Associates in Roseville and Carmichael.

“The classic sign of depression is early awakening at 3 or 4 a.m., when serotonin levels are low,” says Moore. The good news, she says, is that the medications commonly used to treat depression and anxiety, SSRIs (selective serotonin reuptake inhibitors), will often cure the sleep issue because they help regulate serotonin, a neurotransmitter known to affect mood.

Whether the depression or anxiety is causing the insomnia, or vice versa, is a chicken-egg question that can be hard to sort out, says Moore. Either way, addressing the sleep issue is always her first order of business, because effective treatment can take place when someone is sleep-deprived.

“All the talking in the world doesn’t do anything to help when our bodies are in disarray from sleep deprivation,” says Moore. The first step, she says, is to “put out the fires—stop the bleeding. And not getting enough sleep is bleeding. It’s a basic biological need.”

The New Thinking

Hand-wringing worrywarts are more inclined to insomnia than are their calmer counterparts, and women are particularly vulnerable. Menopausal women have more complaints about sleep loss than at any time in their lives, says Wytrzes, because they are battling hormonal hell alongside other life stressors such as aging parents and kids moving out. The simple act of getting older makes sleeping harder, too. “Your sleep clock becomes less efficient as you age, just like all your other bodily functions,” explains Wytrzes. Retired people run into trouble when their bed and rise times become irregular, throwing the sleep cycle out of whack.

But we’ve known all of this for a while. What’s new is the idea that insomnia needs to be treated not like Cinderella’s ugly stepsister but as a disease in its own right.

“Historically, we thought of insomnia as a complaint, not a disease,” says Wytrzes. “But now we’re starting to acknowledge that many of these sleeping problems are biochemical in nature, just as depression or other diseases are. We’re focusing on sleep as an issue in itself—an issue that needs to be addressed independently.”

And while drug therapy is still a cornerstone of treatment—for some people, says Wytrzes, it’s the only thing that works—that, too, may be changing.

More and more, sleep experts are focusing on getting to the root cause “instead of just grabbing a medicine off the shelf,” says Alan Shatzel, D.O., a neurologist and sleep disorders specialist for Mercy Medical Group in Sacramento.

An old-fashioned sleep log is still one of the best investigational tools, he says. When patients record the details of their sleep for two to four weeks, some very revealing facts pop out.

People who report that they awaken frequently for no apparent reason are often found to have a sleep breathing disorder, such as apnea. Other times, the logs reveal something almost laughable—like patients who sleep with pets who wake them up several times a night.

“I put that in the category of a kind of environmental sleep disorder,” Shatzel says.

Underrecognized and Underreported

Problem is, most patients (nearly 70 percent) don’t report their sleep issues to their doctors and don’t receive proper treatment. Not everyone needs a sleep specialist. But because poor sleep is linked to so many other health issues—and can also erode relationships, negatively affect job performance and even endanger society (you wouldn’t want to be on a plane operated by a sleep-deprived pilot, would you?)—sweeping it under the carpet is definitely not the answer.

Self-treatment is not always the best way to go, either, says Shatzel.

“People think they can handle it themselves, and I’m not so sure that’s true,” he says. Maybe, he says, people don’t recognize insomnia as a medical condition and therefore never think to tell their doctor about it.

One of the biggest treatment challenges, experts agree, is helping patients to break the vicious cycle of going to bed, night after night, and psyching themselves right out of sleep.

“They go to bed with the attitude that they’re not going to sleep,” says Nour Karzoun, M.D., a pulmonary, internal medicine and sleep medicine specialist for Kaiser Permanente in Sacramento and Roseville. Relaxation therapy, over time, can help them to break the cycle, he says.

As difficult as proper diagnosis and treatment of chronic insomnia can be, Karzoun stresses that it is “not insolvable.” He prefers a nonpharmacological approach, with an emphasis on “stimulus control therapy”—i.e., don’t read, eat or watch television in bed, don’t watch the clock, that sort of thing.

“Patients often come to me and say, ‘I know you cannot help me, but I want to give it a shot,’” says Karzoun. “That kind of desperation is common in insomniacs.”

Six months to a year of therapy is what Karzoun usually asks of his patients. But some insomniacs may find instant relief in one simple step: Stop sleeping with your partner.

“Studies show that people who are not sharing a bed are better sleepers,” says psychologist Moore. “Sleeping separately has been a very quick cure for a lot of couples.”


Insomnia Facts

• More than one-third of American adults experience occasional insomnia.
• Chronic insomnia affects more than 1 in 10.
  
  Source: American Insomnia Association

A 2008 “Sleep in America” poll by the National Sleep Foundation found that:

• Nearly a third (32 percent) reported getting a good night’s sleep only a few nights per month
• 10 percent of respondents said they use sleep aids: 7 percent over-the-counter and 3 percent prescribed by a doctor
• Nearly half of those polled (49 percent) said they wake up feeling unrefreshed in the morning or were awake a lot during the night (42 percent) at least a few nights each week

According to the American Academy of Sleep Medicine:

• Insomnia is considered a disorder only when it causes a significant amount of distress or anxiety—or when it results in daytime impairment.