Sleep and wake are two sides of the same coin. Sleep affects daytime alertness and being awake in the day affects sleep at night. A basic concept of sleep-wake physiology is that there is a homeostatic mechanism at work, just like there is for hunger and eating. We get hungry so we eat, then get satiated and stop eating. If we don't eat we get hungry and want to eat. So too with sleep: We stay up all day and then get sleepy. We sleep and get less sleepy so we stop sleeping and are awake for a while.
This aspect of sleep is true, but it is not the whole story. Time-of-day (circadian) affects the likelihood of sleepiness or alertness for example. Also, the relationship breaks down in case of a disease or a sleep disorder. This is the topic for today: daytime sleepiness in people who have insomnia.
When we talk about insomnia, sometimes we might be talking about a symptom that happens once in a while, or we might be talking about a long-term condition itself, also called primary insomnia. This is the most common type of insomnia, the type that many people have even though they are not depressed and do not have another sleep disorder. Primary insomnia often begins with a stress of some kind, and over time becomes associated with anxiety and frustration in the night.
The interesting thing about people with primary insomnia is that even though they might only sleep 5 hours in the night, they usually cannot sleep during the day. This is a major difference from normal people, who if they have an occasional bad night are usually tired and sleepy the next day, and sleep more the next night. Again, for those people with primary insomnia, although they might be tired, exhausted, and can't function the next day, they usually cannot nap either. This is referred to as being "hyper-aroused." The usual homeostatic relationship between sleep and wake is altered, and there is less sleep in the night and less sleep in the day.
The lesson is this: If you have insomnia in the night lasting more than 3 months, AND if you are sleepy in the day, it is not likely that you have primary insomnia. It is more likely that you a sleep disorder causing the awakenings at night and you are trying to catch up in the day. This pattern of insomnia needs to be evaluated by a doctor and perhaps a sleep study to rule out sleep apnea or periodic limb movements. It should not be treated with sleeping pills until that time. Excessive daytime sleepiness, such as falling asleep when sedentary, is a symptom that needs evaluated no matter what.
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Getting off sleeping pills
A lot of people say, "I can't sleep without sleeping pills." I hear it as the main complaint from patients, and it is all over our insomnia forums and the "Can't sleep café." Today, I want to tell you how to get off sleeping pills.
Here is the short answer: You need to develop and practice techniques that help you sleep naturally. You need methods to help you cope when you don't get sleep. If you are sick or have depression or anxiety, they need to be treated. You need to get off the pills slowly, and lastly, your goals need to be realistic.
Let's start with realistic goals. There are some people who need sleeping pills, benefit from sleeping pills, and probably suffer no harm from sleeping pills. The modern sleeping pills are fantastic for their effectiveness, safety, and generally their non-addictive properties. People who seem to need are those with medical illness, mental illness, or those who have tried everything and still can't sleep or function. Like any medication, the risks and benefits must be weighed by you and your doctor.
The practices of cognitive behavioral therapy (CBT) include setting a regular wake up time, limiting time in bed, not being awake and frustrated in bed, and practicing some type of mental relaxation technique. Until you have such a routine as part of your life, you won't be able to get off sleeping pills. Getting off the sleeping pills is hard, and you will not sleep well for some time, so these techniques are to both help you sleep and to help you cope.
If you have a psychiatric or medical illness, beyond jus the stresses of life, you probably need to be on an antidepressant or other medication. CBT is not a cure for real depression, bipolar disease, or other serious problems.
SO: When you have been doing CBT techniques like those in our Can't Sleep Café or in other CBT programs for a few weeks, you can begin to get off the pills. This blog is not a detailed method, but in general, there are 3 ways to do this. First, you can stop them suddenly. This is not dangerous for Lunesta, Ambien, or Sonata in the recommended doses.
But if you are on an older pill like Valium or Halcion, or if the doses of the new pills are high, then you need specific advice from your doctor. Second, you can keep taking them nightly but trim the dose down, say cut it in half every week for 3 weeks to zero. Third, you can start skipping nights, and gradually get to where you only take a dose every 3rd night for a while. Some people can only go this far, but it is probably better than nightly use.
Here is the short answer: You need to develop and practice techniques that help you sleep naturally. You need methods to help you cope when you don't get sleep. If you are sick or have depression or anxiety, they need to be treated. You need to get off the pills slowly, and lastly, your goals need to be realistic.
Let's start with realistic goals. There are some people who need sleeping pills, benefit from sleeping pills, and probably suffer no harm from sleeping pills. The modern sleeping pills are fantastic for their effectiveness, safety, and generally their non-addictive properties. People who seem to need are those with medical illness, mental illness, or those who have tried everything and still can't sleep or function. Like any medication, the risks and benefits must be weighed by you and your doctor.
The practices of cognitive behavioral therapy (CBT) include setting a regular wake up time, limiting time in bed, not being awake and frustrated in bed, and practicing some type of mental relaxation technique. Until you have such a routine as part of your life, you won't be able to get off sleeping pills. Getting off the sleeping pills is hard, and you will not sleep well for some time, so these techniques are to both help you sleep and to help you cope.
If you have a psychiatric or medical illness, beyond jus the stresses of life, you probably need to be on an antidepressant or other medication. CBT is not a cure for real depression, bipolar disease, or other serious problems.
SO: When you have been doing CBT techniques like those in our Can't Sleep Café or in other CBT programs for a few weeks, you can begin to get off the pills. This blog is not a detailed method, but in general, there are 3 ways to do this. First, you can stop them suddenly. This is not dangerous for Lunesta, Ambien, or Sonata in the recommended doses.
But if you are on an older pill like Valium or Halcion, or if the doses of the new pills are high, then you need specific advice from your doctor. Second, you can keep taking them nightly but trim the dose down, say cut it in half every week for 3 weeks to zero. Third, you can start skipping nights, and gradually get to where you only take a dose every 3rd night for a while. Some people can only go this far, but it is probably better than nightly use.
Cell phones and insomnia
You probably saw the news: Radiation from cell phones can wreck your sleep.
The researchers say that they have a good study and a good conclusion; the cell phone manufacturers, who sponsored the study say that it is flawed and inconclusive. What's a sleep doctor to do?
The details of the study are not published, as far as I can tell. The study was conducted by researchers in Sweden and in Michigan. The study involved 35 men and 36 women aged 18 to 45. Before sleep they were exposed to radiation similar to that of a cell phone—but not an actual cell phone. Others in the group were treated in the same way but did not receive the radiation (sham radiation or control group). About one-half of the people considered themselves "electro-sensitive," but none of the participants could tell if they were receiving the real or the sham radiation.
Again, I was not able to find details today about the exact protocol used. Sleep was assessed with standard sleep studies as far as I can tell. Subjects who received the radiation took longer to reach sleep wave (deep) sleep, and had less of this deep stage of sleep. The researchers concluded that radiation from a cell phone adversely affects sleep.
I do not know if this is true—it is only one study and it should be considered preliminary. I am not sure if people who are "electrosensitive" are the same of normal people, for example. I will await the final report on this study, and another one before making recommendations.
Could radiation affect sleep? It is theoretically possible. We tested a radiation device from Symtonic a few years ago as a way to treat insomnia, but it did not help. Wikipedia has a good review of the possible health effects of radiation.
For now, it might make sense to use a "hands-free" approach, which places the radiation farther away from your brain, and has also been recommended as safer while driving.
The researchers say that they have a good study and a good conclusion; the cell phone manufacturers, who sponsored the study say that it is flawed and inconclusive. What's a sleep doctor to do?
The details of the study are not published, as far as I can tell. The study was conducted by researchers in Sweden and in Michigan. The study involved 35 men and 36 women aged 18 to 45. Before sleep they were exposed to radiation similar to that of a cell phone—but not an actual cell phone. Others in the group were treated in the same way but did not receive the radiation (sham radiation or control group). About one-half of the people considered themselves "electro-sensitive," but none of the participants could tell if they were receiving the real or the sham radiation.
Again, I was not able to find details today about the exact protocol used. Sleep was assessed with standard sleep studies as far as I can tell. Subjects who received the radiation took longer to reach sleep wave (deep) sleep, and had less of this deep stage of sleep. The researchers concluded that radiation from a cell phone adversely affects sleep.
I do not know if this is true—it is only one study and it should be considered preliminary. I am not sure if people who are "electrosensitive" are the same of normal people, for example. I will await the final report on this study, and another one before making recommendations.
Could radiation affect sleep? It is theoretically possible. We tested a radiation device from Symtonic a few years ago as a way to treat insomnia, but it did not help. Wikipedia has a good review of the possible health effects of radiation.
For now, it might make sense to use a "hands-free" approach, which places the radiation farther away from your brain, and has also been recommended as safer while driving.
Sleep, insomnia, and meditation
The most commonly asked question on the Sleep Forums is probably "what can I do to sleep better?" People usually mean that they have trouble getting to sleep or staying asleep, or waking up too early. Usually they ask because they don't want to take a sleeping pill such as Ambien. Often the questioner wants a non drug therapy or a natural supplement.
Most of us answer that the best method for improving sleep is "cognitive behavioral therapy," or CBT. CBT can be accomplished with a one-on-one therapist or through an on-line site called cbtforinsomnia.com. You can read about it on the Revolution Health pages and try some of the advice on your own.
CBT has several components, but one of them is some sort of relaxation practice or meditation practice. Today, I want to talk about these a little bit, and give some links to CD's that teach meditation, relaxation, or mindfulness techniques.
Regular practice of a relaxation technique is one way to reduce the body's response to stressful life events. A lot of people seem to think that it is a method to get you back to sleep, but this is not really true. Practicing regularly during the daytime can prevent some of the physical changes in the nervous system that perpetuate stress-related conditions such as insomnia and headaches. It might seem strange, but spending 20 minutes relaxing in the morning or during work can help your sleep at night.
A lot of people with insomnia are more fearful of the fear of not sleeping than they are about not sleeping itself. Some people just really hate being awake at night, but accepting this and realizing that it is normal to be awake at night to some degree is essential to long-term improvement of insomnia. For those people who become impatient, frustrated, anxious, or even angry about insomnia, a mental relaxation technique during the night can fill the time and prevent undue bodily responses that make getting back to sleep impossible.
Most of us answer that the best method for improving sleep is "cognitive behavioral therapy," or CBT. CBT can be accomplished with a one-on-one therapist or through an on-line site called cbtforinsomnia.com. You can read about it on the Revolution Health pages and try some of the advice on your own.
CBT has several components, but one of them is some sort of relaxation practice or meditation practice. Today, I want to talk about these a little bit, and give some links to CD's that teach meditation, relaxation, or mindfulness techniques.
Regular practice of a relaxation technique is one way to reduce the body's response to stressful life events. A lot of people seem to think that it is a method to get you back to sleep, but this is not really true. Practicing regularly during the daytime can prevent some of the physical changes in the nervous system that perpetuate stress-related conditions such as insomnia and headaches. It might seem strange, but spending 20 minutes relaxing in the morning or during work can help your sleep at night.
A lot of people with insomnia are more fearful of the fear of not sleeping than they are about not sleeping itself. Some people just really hate being awake at night, but accepting this and realizing that it is normal to be awake at night to some degree is essential to long-term improvement of insomnia. For those people who become impatient, frustrated, anxious, or even angry about insomnia, a mental relaxation technique during the night can fill the time and prevent undue bodily responses that make getting back to sleep impossible.
Safer use of sleeping pills
The recent FDA request for stronger warnings about sleeping pills makes one wonder how safe these medications are. Should I take them at all? How often? What should I watch out for if I do take them?
Until very recently no sleeping pill was approved for long-term use due to fears of impairment and addition. Recently Ambien CR and Lunesta have been approved for long-term use and at the same time prescriptions for sleeping pills have increased tremendously. Some of this is due to direct to consumer advertising. I believe that the large numbers of people taking these agents is the reason that these relatively rare side effects have emerged. Generally they are probably safe. However, for all the hype about how great sleeping pills are, few people really look at the down side. If you want a different perspective, see HERE.
In general, almost all sleep specialists believe that nightly use of any sleeping pill is a last resort. It should only come after trials on other medications, patient education, cognitive therapy, and intermittent sleeping pill use. At that point, nightly use might be appropriate with close monitoring from a physician, understanding that there are risks.
If you are taking or are considering taking a sleeping pill, here are some suggestions to make it safer:
1. When starting a sleeping pill always take the lowest dose at home, preferably with someone present. Do not take it for the first time in a hotel, at a friend’s house, or on a plane. (Next blog: The Ambien traveller arrested for bizarre behavior, a true story.)
2. Do not combine any sleeping pill with other sedative medications including certain antidepressants and certainly alcohol.
3. Make your environment safe if you do try a sleeping pill. Be sure that you could not wander out of the house or even your room. (Don’t’ sleep on the top bunk.)
4. Be aware of what others notice, or be sensitive to possible signs that you were sleep walking. For example, early signs of a problem might include forgetting a conversation or forgetting that you walked to the kitchen. If there are such signs, reduce the dose.
5. Take the sleeping pills intermittently, such as 1 to 5 times per week. Everyone can stand a bad night of sleep—if you think you can’t you need cognitive therapy.
6. The older you are the lower dose you need. So if you’ve been on Ambien for 10 years, the level in your blood now is higher than when you began: Reduce the dose.
Until very recently no sleeping pill was approved for long-term use due to fears of impairment and addition. Recently Ambien CR and Lunesta have been approved for long-term use and at the same time prescriptions for sleeping pills have increased tremendously. Some of this is due to direct to consumer advertising. I believe that the large numbers of people taking these agents is the reason that these relatively rare side effects have emerged. Generally they are probably safe. However, for all the hype about how great sleeping pills are, few people really look at the down side. If you want a different perspective, see HERE.
In general, almost all sleep specialists believe that nightly use of any sleeping pill is a last resort. It should only come after trials on other medications, patient education, cognitive therapy, and intermittent sleeping pill use. At that point, nightly use might be appropriate with close monitoring from a physician, understanding that there are risks.
If you are taking or are considering taking a sleeping pill, here are some suggestions to make it safer:
1. When starting a sleeping pill always take the lowest dose at home, preferably with someone present. Do not take it for the first time in a hotel, at a friend’s house, or on a plane. (Next blog: The Ambien traveller arrested for bizarre behavior, a true story.)
2. Do not combine any sleeping pill with other sedative medications including certain antidepressants and certainly alcohol.
3. Make your environment safe if you do try a sleeping pill. Be sure that you could not wander out of the house or even your room. (Don’t’ sleep on the top bunk.)
4. Be aware of what others notice, or be sensitive to possible signs that you were sleep walking. For example, early signs of a problem might include forgetting a conversation or forgetting that you walked to the kitchen. If there are such signs, reduce the dose.
5. Take the sleeping pills intermittently, such as 1 to 5 times per week. Everyone can stand a bad night of sleep—if you think you can’t you need cognitive therapy.
6. The older you are the lower dose you need. So if you’ve been on Ambien for 10 years, the level in your blood now is higher than when you began: Reduce the dose.
Sleep walking and sleeping pills
Today the Food and Drug Administration will start requiring the manufacturers of several sleeping pills to list complications such as sleep walking in the information about the drug. As most people know, numerous reports of abnormal behavior such as eating or walking or driving occur after use of certain medications. This is especially clear for Ambien because it is the most prescribed agent, but can occur with many other medications such as Lunesta, triazolam, and temazepam.
I have personally had negative, embarrassing, and upsetting experiences with the problem of sleep walking after Ambien use, and I am happy to see a little backlash on what has been years of marketing and increased prescriptions. As the New York Times article from Stephanie Saul states, prescriptions are up 60 % in the last 6 years.
My first experience was presenting a case to colleagues. At our weekly conference I talked about a 55 year old woman whose family reported that she “sleep walked” after taking Ambien and would walk to the kitchen. Because they were still awake, they would lead her back to bed. Two of my senior colleagues in essence said that this was impossible and that the woman needed psychiatric help. This was back in 1995 when Ambien was fairly new but even at that time there were isolated case reports. In the next year, a physician friend told me that he ate a chicken one night during his sleep after taking Ambien and he stopped taking it
More recently, I had a tragic case of a woman who lived alone and got up in the night after taking Ambien and took a bath. She left the water running and totally flooded her condo and did not have flood insurance. She is probably losing her home. Another very nice lady aged 60, drove from San Diego to Temecula (about 50 miles) during a night after taking Ambien, parked her car in a closed bank, and then woke up near morning. She had no idea of how she got there. Obviously neither woman takes it anymore.
I have personally had negative, embarrassing, and upsetting experiences with the problem of sleep walking after Ambien use, and I am happy to see a little backlash on what has been years of marketing and increased prescriptions. As the New York Times article from Stephanie Saul states, prescriptions are up 60 % in the last 6 years.
My first experience was presenting a case to colleagues. At our weekly conference I talked about a 55 year old woman whose family reported that she “sleep walked” after taking Ambien and would walk to the kitchen. Because they were still awake, they would lead her back to bed. Two of my senior colleagues in essence said that this was impossible and that the woman needed psychiatric help. This was back in 1995 when Ambien was fairly new but even at that time there were isolated case reports. In the next year, a physician friend told me that he ate a chicken one night during his sleep after taking Ambien and he stopped taking it
More recently, I had a tragic case of a woman who lived alone and got up in the night after taking Ambien and took a bath. She left the water running and totally flooded her condo and did not have flood insurance. She is probably losing her home. Another very nice lady aged 60, drove from San Diego to Temecula (about 50 miles) during a night after taking Ambien, parked her car in a closed bank, and then woke up near morning. She had no idea of how she got there. Obviously neither woman takes it anymore.
In The Habit Of Being Awake At Night
Most instances of long-term insomnia begin with a stressful life problem. In the case of a nice 50 year old woman I met yesterday, the problem began with her neighbors 3 years ago. She had always slept pretty well before then and she had no medical disease, major anxiety or depression. Then, her next door neighbor began to make a lot of noise at night.
Every night for a couple of months she was awakened by the noise of cars, music, talking, and general activity, usually between midnight and 2 am. This was very upsetting to her, partly because of having to get up at 530 am for work, and partly because her relationship with the neighbor became so unpleasant. A few times, she called the police.
After a little while, she asked her doctor for a sleeping pill. Eventually, she began taking clonazepam 1 mg and zolpidem 10 mg every night, which helped quite a bit. She found another house on a quiet street and moved. After a total of 6 months the noisy neighbor problem was history.
Unfortunately, the insomnia continued. If she didn't take the sleeping pills she would lie awake for hours and she couldn't stand the frustration of being awake at night. She worried about her job performance and her dependence on the sleeping pills. Even with the pills she was waking up in the night, and began to go to bed earlier so as to get extra chances at sleep.
Her type of insomnia is called by various names: primary insomnia, conditioned insomnia, or psychophysiologic insomnia. Once the brain is in the habit of being frustrated, awake, or upset while in bed trying to sleep, the habit can last forever. After all, the brain's main function is to learn, and her brain learned that the bed at night was an unpleasant place. Many sleep specialists believe that this negative conditioning process between the passive act of falling asleep and the bed environment is the cause of most insomnia.
Our nice lady needs to slowly discontinue the sleeping pills under a doctors direction, and re-train her brain to sleep. This is a long process for most people, involving sleep restriction, cognitive behavioral therapy, relaxation techniques, daytime bright light, and a healthy daytime lifestyle. Most people can get better sleep by using a combination of these therapies and a lot of encouragement and motivation.
Every night for a couple of months she was awakened by the noise of cars, music, talking, and general activity, usually between midnight and 2 am. This was very upsetting to her, partly because of having to get up at 530 am for work, and partly because her relationship with the neighbor became so unpleasant. A few times, she called the police.
After a little while, she asked her doctor for a sleeping pill. Eventually, she began taking clonazepam 1 mg and zolpidem 10 mg every night, which helped quite a bit. She found another house on a quiet street and moved. After a total of 6 months the noisy neighbor problem was history.
Unfortunately, the insomnia continued. If she didn't take the sleeping pills she would lie awake for hours and she couldn't stand the frustration of being awake at night. She worried about her job performance and her dependence on the sleeping pills. Even with the pills she was waking up in the night, and began to go to bed earlier so as to get extra chances at sleep.
Her type of insomnia is called by various names: primary insomnia, conditioned insomnia, or psychophysiologic insomnia. Once the brain is in the habit of being frustrated, awake, or upset while in bed trying to sleep, the habit can last forever. After all, the brain's main function is to learn, and her brain learned that the bed at night was an unpleasant place. Many sleep specialists believe that this negative conditioning process between the passive act of falling asleep and the bed environment is the cause of most insomnia.
Our nice lady needs to slowly discontinue the sleeping pills under a doctors direction, and re-train her brain to sleep. This is a long process for most people, involving sleep restriction, cognitive behavioral therapy, relaxation techniques, daytime bright light, and a healthy daytime lifestyle. Most people can get better sleep by using a combination of these therapies and a lot of encouragement and motivation.
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