Articles written by me on Self-care and Palliative Medicine
On Self-Care & Palliative Medicine

Summoning Mr. Sandman

“A dream is a wish your heart makes, when you’re fast asleep”Cinderella, Walt Disney

Occasional insomnia, or inability to sleep, has plagued almost everyone. When our noses are blocked with a cold, when our arms and legs ache from touch football or too much yard work, or when worries overwhelm us, we toss and turn until the alarm clock signals another day. However, a substantial portion of the American population suffer from a more chronic form of insomnia, and health effects can be significant with prolonged sleep deprivation.

It’s estimated that up to one third of patients have occasional insomnia, and 10% of adults who seek primary care in this country have persistent insomnia. The prevalence of sleep disorders increases with age–in large measure because other medical conditions such as painful arthritis also increase. Women outnumber men 2:1 with insomnia; certainly, estrogen crashes with attendant hot flashes contribute to this ratio! Since sleep requirements differ widely between people (with 4 hours being sufficient for some and 9 hours being a bare minimum for others), criteria for insomnia depend more on how well a person sleeps than on how long they sleep. If you’re one of the estimated 40–50 million in this country who toss and turn with regularity, know there is help.

Why is insomnia important? Well besides its prevalence, even in short term or occasional frequency, it can increase our susceptibility to illness and jeopardize our physical and cognitive proficiencies; people fall asleep at the wheel, and sometimes people die. Insufficient, poor quality sleep promotes the “blues”. One of the most serious consequences of insomnia is its deleterious effect on our emotions.

Short term, it diminishes our coping mechanisms–generating short tempers and moodiness. As a consequence, others consider us grumpy and out-of-sorts! Long term, insomnia truly jeopardizes mental health in a fundamental way. In Chinese medicine, insomnia is considered to be a disturbance of shen, or spirit. Emotional disturbances can both be the cause and result of chronic insomnia. Macbeth astutely mused,

“Sleep that knits up the ravell’d sleave of care,
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great Nature’s second course,
Chief nourisher in life’s feast.” Shakespeare
So it’s common, and it can have serious, even deadly consequences. What’s an insomniac to do? Perhaps you can improve your sleeping significantly simply by changing some basic behaviors. Since nicotine, caffeine, and cold/sinus medications can all keep you awake, if you stop smoking, limit your coffee, colas, and chocolate (especially in the evenings), and avoid decongestants late in the day, you may find it much easier to commune with Mr. Sandman.

And, although evening alcohol consumption can indeed make you sleepy, it may have you awake again within several hours and unable to sleep afterwards. Hot chocolate and hot toddies are frequently touted as nightcaps, but in reality they’ll most likely have you making grocery lists or early New Year’s Resolutions as you count the shadows on the ceiling. Many prescription medications can also affect sleep, so read the information sheets carefully and take them early in the day, if you won’t jeopardize the therapeutic benefit in the process.

Although regular exercise often promotes better sleep habits, if you exercise within 3 hours of bedtime, you will probably make it harder to go to sleep. Too, believe it or not, regular sleeping schedules with fairly constant rising times and bedtimes (YES, on the weekends TOO!) will promote better overall sleep habits. Since all of you understand Circadian Rhythm after reading the 9-11-2000 Insight, you know that disrupting your body’s natural clock can have adverse health effects in many areas. . . and generating insomnia is one of them.

Barking dogs, raucous teenager music, and snoring or restless bedmates can also disrupt our sleep. But these are all remedial etiologies. After all, that’s why God made ear plugs and double beds! And, if it’s clear you’re not going to sleep on a particular night, don’t lie in bed; your mind and body need to associate the bed with sleep not restlessness.

On that subjct, Behavioral Modifications–including 1) Sleep Restriction Therapy to improve sleep efficiency, 2) Stimulus Control Therapy to reassociate bed and bedroom with rapid onset of sleep, and 3) Cognitive Therapy to change dysfunctional beliefs can all be quite helpful in the right patients. Pharmacologic Therapyincludes various hypnotics, some antidepressants (especially for maintenance therapy), occasional antihistamines, and various herbal and homeopathic remedies. Melatonin, in particular, has gotten much publicity. While it seems to be helpful for insomnia related to shift work and jet lag, the use of melatonin (especially longterm) remains controversial. Inverted yoga postures, acupuncture, meditation, and relaxation breathing techniques may also be useful.

And, remember, some medical illnesses create insomnia as a symptom. An overactive thyroid gland is a classic example, and bladder or prostate problems can keep both sexes trotting when they should be sleeping. Movement disorders, developing psychiatric illness, and even sleep apnea can be misinterpreted as a primary sleep disturbance when, in fact, they are generating secondary insomnia.

Don’t assume that your sleep problems are inevitable if insomnia plagues you. Please discuss your symptoms with health care professionals. Chronic insomnia is a serious medical problem and may not resolve without directed treatment. We all deserve a chance “To sleep–perchance to dream. . .” Hamlet

Stephen L. Hines, M.D.
November 2000

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