August 19, 2001|By P. Elizabeth Anderson | P. Elizabeth Anderson,PROVIDENCE JOURNAL
You don't have a problem going to sleep. You sleep like a baby. Then your wife goes on a business trip, you become anxious about a meeting, or your mother is hospitalized. You try to sleep, but there you are -- wide awake, tossing and turning. Night after night, the same thing. The next day you feel awful, you can't think and everything is getting on your nerves.
What is the matter with you? It's insomnia.
In the middle of the night, it may feel as if you're the only person awake, but you're not. Last year, a whopping 51 percent of adult Americans reported in a National Sleep Foundation poll that they have insomnia a few nights a week or more. That's up from 27 percent reported in 1991.
"Insomnia runs across all groups of people," says Donn Posner, a behavior and insomnia consultant for the Sleep Disorders Center at Lifespan Hospitals in Rhode Island, and a clinical assistant professor at Brown University School of Medicine.
Yet people with insomnia share some characteristics. "There is a bit of a tendency to be internalizers of emotion, people who are very much interested in controlling their lives," Posner says. Sleep, however, is one of those things that you cannot force.
Most insomnia begins with a few fitful nights every now and then. These acute episodes are called transient or intermittent insomnia.
Stress is the main cause of short-term sleeping problems. Work or school pressures, family illnesses, and relationship problems create most of the stressful situations that kindle insomnia.
Environmental conditions such as noise, medications, changing work schedules and travel round out the other triggers for inability to sleep.
Medical conditions and mental disorders such as congestive heart failure, asthma and depression can cause or aggravate insomnia. Different life stages also pose sleep challenges. Older people, for example, frequently suffer insomnia.
Richard P. Millman, director of the Sleep Disorders Center, says that 40 percent of the patients he sees have an underlying condition, such as depression, anxiety or alcohol abuse, that may require concurrent treatment.
The rest have "psycho-physiological insomnia." They have simply learned how not to sleep. As a result, they have reset the internal body clock that regulates their body functions.
When transient and intermittent insomnia is not recognized and treated properly, chronic insomnia develops.
"Insomnia begets insomnia," Millman explains. "The less you sleep, the less you sleep." Even after the situation or condition that triggered the insomnia is gone, your clock is still off, and the insomnia remains.
"It only takes about three weeks to develop chronic insomnia," he adds.
Aggressive treatment of the occasional sleep problems with drugs can nip insomnia in the bud. "One of the clear indications for sleeping pills," Millman says, "is when someone acutely develops insomnia."
Neither Millman nor Posner recommends sleeping pills as a long-
term strategy, however, because they can be addicting.
Instead, they encourage good sleep hygiene (avoid exercise, alcohol and big meals before bed; abstain from naps; maintain sleep schedules even on weekends; and engage in relaxing activities before going to bed), and they coach their patients using behavioral therapy.
Ed Costa hadn't had a good night's sleep in almost 15 years, but before he could learn how to sleep, he had to learn to stay awake.
Costa, a retired education administrator who had been taking sleeping pills for about two years, was referred to Posner, who uses stimulus control and sleep restriction to coach his patients back to good sleep habits.
Stimulus control applies the notion that the bed should be for sleep and not for TV, reading or sex. With sleep restriction, you get out of bed if you lie awake for more than 15 minutes. You go back to bed when you're sleepy and repeat the sequence as much as needed.
"If someone goes to bed at 10 p.m. and gets up at 6 a.m., but only sleeps for four hours, you curtail their time in bed to four hours," Posner explains. "If they're only going to get four hours, get them solidly into bed for four hours to get that sleep."
When the person sleeps successfully during the assigned hours, bedtime is gradually pushed back. "This," Posner says, "retrains the body how to sleep when you're in bed."
Posner's success rate is in line with that of others doing similar work: 90 percent to 95 percent of the patients report that they sleep better.
"Half of our business is getting people off sleeping pills," he says.
The over-the-counter drug industry that has grown up around insomnia may be contributing to the sleep problem. "The huge [over-the-counter] treatments bypass the physician and often ... aren't really good, but people think they are safe and take them," Millman says.
He sees increases in sleep disorders in the younger population. "We don't know whether it's due to dual-career marriages or financial stresses of the '90s," he says, "but it is clearly rampant."
