

We hear the word INSOMNIA very often nowadays. So much that at times we misunderstand the word for its meaning. Insomnia is “frustration”, it is a consistent lack of quality sleep that is piled over months. We all have sleepless nights at times in our lives. But we tend to get over it with our body’s clock adjusting itself back to normal automatically. With insomnia, it’s not that easy, especially with the chronic type.



DSM-5 defines insomnia as dissatisfaction with sleep quantity or quality associated with one or more of the following symptoms: difficulty in initiating sleep, difficulty in maintaining sleep with frequent awakenings or problems returning to sleep, and early morning awakening with inability to return to sleep. Having said this, there can be other medical disorders that have to be ruled out before being diagnosed for Insomnia.

Have you found yourself staring at the walls or ceiling in your room while you’re trying to sleep? Is there worry about not being able to sleep, fatigue and lower output in academic or professional life? Do these worries run in your head constantly every night when you try to sleep? If the answer to these questions is yes, you might be suffering from “Insomnia”. Depending on the duration you might fall in the acute (sleep difficulty >3 months, at least 3 nights/week) or chronic (sleep difficulty < 3 months, at least 3 nights/week) category of Insomnia.



How is insomnia caused?

Acute insomnia can be because of a physical ailment or persistent or transient stressor/s or anxiety, ex. An upcoming examination or evaluation at the workplace. Our body on its own normally fights back acute insomnia in most cases, In some cases medical intervention becomes imminent. Prolonged sleep deprivation for more than 3 months leads to a daily struggle in concentration/focus and other cognitive functioning. This impairment is paired with fatigue and low energy which normally adds up to anxiety/depression and or physiological problems.



What should be treated first, the symptoms or the causes of Insomnia?

Both the symptoms and the causes of Insomnia have to be addressed together in the most efficient way by a clinical practitioner. Insomnia can lead to developing anxiety/depression or vise verse. Treatment should include a modality which encompasses all the factors leading to impairment or deficit in daily functioning and treat them accordingly.



Treating Insomnia

The next step after being diagnosed with insomnia would be to effectively deal with it. There are a couple of ways this can be achieved and your therapist can develop a combination of treatment as per your requirements and with your consent.



Melatonin vs prescription drugs

Melatonin supplements work well in case of acute sleep-onset insomnia, shift workers also in case of jet lag. The recommended dosage for an adult would be around 3-5mg half an hour before sleeping. Consumption of alcohol/anti-inflammatory drugs should be avoided while using melatonin supplementation as they might suppress the effects of melatonin. Melatonin supplement wouldn’t work in case of chronic insomnia, where combination prescription drugs would be administered to deal with the associated anxiety/depression or other medical conditions that would be affecting sleep quality.

Cognitive-Behavioral Therapy



Cognitive-behavioral therapy (CBT) as a treatment modality uses a combination of behavioral and cognitive techniques to overcome dysfunctional sleep behaviors, misperceptions, and distorted, disruptive thoughts related to sleep. Studies repeatedly show significant, sustained improvement in sleep symptoms, including number and duration of awakening and sleep latency from CBT. Short-term benefits are similar to that of medication, but CBT tends to have lasting benefits even 36 months after treatment. With the cessation of the medication, insomnia frequently returns and is sometimes accompanied by rebound insomnia. CBT has not been shown to produce any adverse effects. https://www.tuck.com/cbt-insomnia/



Universal Sleep Hygiene

A common finding is that a patient’s lifestyle leads to sleep disturbance. This is usually phrased as inadequate sleep hygiene, referring to a problem in following generally accepted practices to aid sleep. Many behaviors can interfere with sleep and may do so by increasing nervous system arousal near bedtime or by altering circadian rhythms. https://www.sleepfoundation.org/articles/what-circadian-rhythm



The focus of universal sleep hygiene is on modifiable environmental and lifestyle components that may interfere with sleep, as well as behaviors that may improve sleep. Treatment should focus on one to three problem areas at a time. Especially because some of these behaviors are difficult to change, only one or two items that are collaboratively chosen by the patient and clinician should be addressed. A carefully explained program of sleep hygiene, with follow-up, represents a fairly inexpensive but effective intervention. Furthermore, improving sleep habits can enhance sleep even when the major cause of insomnia is physical.

Stimulus Control Therapy

It is a deconditioning paradigm developed by Richard Bootzin and colleagues at the University of Arizona. This treatment aims to break the cycle of problems commonly associated with difficulty initiating sleep. The first rule is, go to bed only when sleepy to maximize success. Second, use the bed only for sleeping. Do not watch television in bed, do not read, do not eat, and do not talk on the telephone while in bed. Third, do not lie in bed and become frustrated if unable to sleep. After a few minutes (do not watch the clock), get up, go to another room, and do something nonarousing until sleepiness returns. The goal is to associate the bed with rapid sleep onset. The fourth and final instruction attempts to enhance the mechanisms underlying the circadian and sleep-wake cycles-that is, awaken at the same time every morning (regardless of bedtime, total sleep time, or day of the week) and totally avoid napping. Stimulus control therapy does work; however, results might not be seen during the first few weeks or months. If continually practiced, the bouts of insomnia lessen in both frequency and severity. https://www.psychologytoday.com/us/blog/sleepless-in-america/200905/cognitive-behavioral-therapy-insomnia-part-2-stimulus-control

Sleep Restriction Therapy

Restricting time in bed can help to consolidate sleep. If the patient reports sleeping only 5 hours of scheduled 8-hour time in bed, reduce the time in bed. It is advised, however, not to reduce bedtime to less than 4 hours per night and to warn the patient about the hazards of daytime sleepiness. Sleep at other times during the day must be avoided, except in the elderly, who may take a 30-minute nap. The clinician then monitors sleep efficiency (time asleep as a percentage of the time in bed). When sleep efficiency reaches 85 percent (averaged over five nights), time in bed is increased by 15 minutes. Sleep restriction therapy produces a gradual and steady decline in nocturnal wakefulness.





Biofeedback

It provides stimulus cues for physiological markers of relaxation and can increase self-awareness. A machine is used to measure muscle tension in the forehead or finger temperature. Finger temperature rises when a person becomes more relaxed. Patients require careful and adequate training; simply giving them an instruction tape is not especially helpful. Techniques are ideally mastered during the day for several weeks before application to the sleep problem; this is best achieved

outside of the bed. By the time the techniques are applied in bed, the skill should be automatic. Relaxation techniques readily lend themselves to being combined with sleep hygiene and stimulus control therapies. Sometimes, they make good distractions from thinking about the inability to sleep. The ruminations fuel insomnia, and if the ruminator can be distracted, then the person may sleep better.

Conclusion

Understanding Insomnia as a psychophysiological hindrance to well being is quintessential. There is enough research evidence which points towards the far-reaching negative effects that Insomnia can have on our mental and physical health. But there is good news, insomnia can be treated with the right intervention plan. There have been cases in which insomnia has gone undiagnosed due to the presence of other disorders like depression/anxiety. The symptoms and causes of insomnia have to be addressed simultaneously for its treatment to be effective. Prescription drugs are effective in cases with chronic insomnia but have proven to be habit-forming and have a lot of side effects. Psychological therapies, on the other hand, have no side effects but take more time to show results. The client’s active commitment towards treatment also has a positive effect on the treatment of Insomnia. Maintaining sleep hygiene aids in the prevention of sleep-related problems but can’t cure chronic insomnia. Diagnosing insomnia promptly and choosing an appropriate treatment plan can help reduce the negative impact insomnia can have on our daily functioning and wellbeing.