Transcript of "Insomnia Recognition and Intervention" Podcast

Samantha Reeves: Hello and welcome to the National Jewish Health Podcast Series. My name is Samantha Reeves and I'm here with Dr. Sheila Tsai a Sleep Medicine specialist at National Jewish Health. We're here today to discuss Insomnia Recognition and Intervention. In this podcast we will be addressing some of the questions people may have about insomnia, so let's start with the basics.

Dr. Tsai, can you tell me, what is insomnia?

Sheila Tsai, MD: Thank you Samantha. Insomnia is characterized by disturbed sleep, despite the presence of adequate opportunity and circumstances for sleep. This sleep disruption causes problems in daytime functioning. Usually in insomnia patients, sleep is very light and easily disrupted. Insomnia also has at least one of the four defining clinical features which are: difficulty in getting to sleep; difficulty in staying asleep; waking up too early; or nonrestorative or poor quality sleep.

SR: Are there varying degrees or different types of insomnia?

ST: Insomnia may be categorized into two groups: acute and chronic. Acute insomnia is temporary and may last a few days to a few weeks. Acute insomnia is typically not associated with any major long-term effects. However, with chronic insomnia, inadequate sleep may last for several months or more. If your symptoms persist for more than 90 days, it's likely that you have chronic insomnia. Chronic insomnia may be categorized into two groups, primary and secondary insomnia. Primary insomnia cannot be directly related to an underlying diagnosable condition. Secondary, or comorbid insomnia, exists if you have an underlying illness or take a specific medication that plays a considerable role in causing or maintaining the insomnia.

SR: How many people suffer from insomnia?
ST: An estimated 25 - 35% of adults will experience insomnia at some time in their life. Many patients with insomnia have had the disorder for at least a year, and approximately 40% have suffered with the problem for five years or more. Secondary insomnia accounts for 80-85% of chronic insomnias. Even children can suffer from insomnia since they will often delay bedtime for a variety of reasons. Some children may be afraid of the dark, or afraid to be left alone, or may have to take several trips to the restroom during the night causing frequent sleep disturbances.

SR: Thank you Dr. Tsai. What are some of the causes of insomnia?

ST: The causes of insomnia are wide-ranging. Precipitating life stressors, such as major life events like the loss of a loved one, a job change, marriage, or divorce can cause acute insomnia. Even sleeping in an unfamiliar location like a hotel or hospital room, can cause temporary or acute insomnia. Certain environmental factors like loud noises, harsh odors, bright lights and extremely warm room temperatures can also disturb sleep, causing acute insomnia. If your sleep partner snores, or you have an uncomfortable bed, you may have restless nights. Consuming caffeine and alcohol too close to your bedtime as well as vigorous exercising less than three hours before your scheduled bedtime can also lead to poor sleep.
Secondary insomnia is more than likely caused by a medical condition such as obstructive sleep apnea where the airway collapses at night and disrupts sleep. Secondary insomnia can also be caused by neurological or psychiatric conditions such as anxiety or depression. People with secondary insomnia may have higher metabolic rates, increased body temperature, increased heart rate, and muscle tension these also could be signs of a hyperactive thyroid.

Certain medications that have a stimulating effect may also cause insomnia, especially when taken too close to your bedtime.
There are also several sleep disorders and behaviors which can cause insomnia. Many sleep disorders may start in early childhood and are displayed by an inability to fall asleep without certain conditions or dependence on something. For example, a child may need a specific blanket, or toy to aid them in falling asleep. This can go into adulthood and a person may depend on the television or music to assist them in falling asleep. An insomniac may also try too hard to fall asleep and focus on their inability to fall asleep which can cause anxiety and tension about not being able to sleep.

SR: And, if a person believes they have insomnia, how can they discuss it with their doctor?

ST: Many people who suffer from insomnia will not think of it as a medical condition and may not mention it to their doctor for that reason. Be specific when explaining to your doctor how you're sleeping. Try to differentiate between normal, good, or bad nights of sleep. Tell your doctor if you experience sleepiness, fatigue, and low motivation and energy throughout the day. These daytime symptoms are required for an insomnia diagnosis. If you describe your sleep as being brief and insufficient, unrefreshing, easily disrupted, and of poor quality, your doctor may also give you a diagnosis of insomnia.
Your doctor may recommend you keep a sleep diary to help describe the nature and severity of your sleep disturbances. In addition to recording your sleeping patterns, you can also fill out questionnaires given by your doctor that assess sleep, sleepiness, anxiety, depression, and fatigue.

SR: Great! And so, what are some treatment options for someone who has insomnia and how can someone best manage their insomnia?

ST: If you are diagnosed with insomnia, additional history is required to evaluate the problem and determine the best treatment options. This evaluation is done by your doctor and includes a medical, psychiatric, family, and medication-use history as well as a physical examination. You may be referred to sleep specialists for objective testing, or various therapies. Sometimes, insomnia can be managed simply by the short-term use of sleep medication, or by applying basic sleep strategies. However, it's important to find out what's triggering your insomnia. Insomnia can be a lingering disorder that does not end even when the primary condition has improved. In many cases, treating insomnia in tandem with the primary condition may provide the best treatment method.

There are a variety of therapies used to treat insomnia. Nonpharmacologic therapy is done without medication and is commonly known as cognitive-behavioral therapy or CBT. This type of therapy is one of the most effective ways to deal with insomnia. Cognitive-behavioral therapy equips the patient with tools to deal with their insomnia and helps them re-associate the bed with sleep. It includes Relaxation techniques, where your doctor may have you meditate and think pleasant thoughts. Relaxation techniques are best used in combination with other cognitive-behavioral techniques.
CBT also involves Stimulus control therapy which helps to reinforce the connection of the bedroom with sleeping rather than with insomnia. With this type of therapy your doctor may advise you to avoid daytime naps, to go to bed only when you're sleepy, and to get out of bed if you're not asleep within 20 minutes and engage in relaxing activity away from the bedroom until you're sleepy again.

As part of CBT, Sleep restriction, may be recommended, this limits the total amount of time you may stay in bed. Sleep restriction is often delivered along with stimulus control therapy.

Light therapy may be used for some patients who suffer from awakening too early or those who have sleep-onset insomnia if their sleep issues are related to a circadian rhythm disorder or problem with the body's internal clock. Exposure to bright light produces a phase advance or delay in the sleep-wake cycle, core body temperature, and melatonin rhythms.

Pharmacologic therapy or medication therapy may be used for the short-term treatment of acute insomnia, some chronic insomnia cases, and those with primary insomnia who do not respond to behavioral treatment. Even patients who do not show improvement after treatment for an underlying condition may be given hypnotic, or sedating medications. A variety of medications are now available for the treatment of insomnia since they increase drowsiness and facilitate sleep. If your insomnia is more persistent or the level of distress is high, the temporary use of sleep-promoting medications may be considered by your doctor.

Benzodiazepines, such as lorazepam or temazepam for example, reduce the length of time it takes for you to fall asleep, increase total sleep time, and decrease the frequency of awakenings for patients with insomnia. There are adverse effects to taking Benzodiazepines, including rebound insomnia after discontinuation, especially following chronic use. To avoid this adverse reaction, you should only take the medication when absolutely needed with your doctor's permission, and wean yourself off the medication gradually when discontinuing. Benzodiazepines can also exacerbate underlying sleep apnea if it is present.

There are also Non-benzodiazepines which have similar hypnotizing and sedating effects as benzodiazepines, but are less likely to cause dependency.
The most frequently used treatments for insomnia are over-the-counter non-prescription medications. The most commonly used are diphenhydramine and other antihistamines. If you use an over-the-counter sleep medication for an extended period of time, you may also become dependent on it. After a while, your body may be less responsive to its sedating effect. If this happens, another method or medication may need to be used to promote your sleep.

To optimize management of your insomnia, you should have ongoing monitoring, support, and adjustments to your routine as necessary.

SR: Thank you so much for your time today Dr. Tsai.