A Family Doctor's Tale - INSOMNIA

DOC I HAVE INSOMNIA

Insomnia is a very common illness which is present in at least 1% of patients seen in a family practice.

However most of them are transient form of insomnia caused by emotional upheavals such as death of a family member or divorce, stress or change of shift duties.

In such cases a mild transquillizer or antidepressant will usually help.

Counseling especially by a psychiatrist will help in more severe cases of insomnia.


Insomnia is defined as a sleep disorder characterized by:
1.difficulty in falling and remaining asleep
2.Early morning final wakening
3.frequent awakenings during the night
4.lack of restful sleep
5.a combination of these.

Many of us have Insomnia at least once in our lifetime.
Insomnia can be classified as:
1.Transient Insomnia -usually difficulty to sleep properly or consistently for less than 1 week usually related to sudden stress, death in a family, emotional upset

2.Acute Insomnia - usually difficulty to sleep properly or consistently for less than 1 month also related to stress, emotional upset or change in sleep environment. Gradually the brain adapts to the environment or overcome the stress or emotion upset.

3.Chronic Insomnia - usually difficulty to sleep properly or consistently for more than 1 month :
Causes may be:
1.Anxiety

2.Depression

3.Use of stimulants such as caffeine, nicotine and other central nervous system stimulants

4.Shift duties affects the pattern of the sleep

5.Obstructive sleep apnea

6.Restless leg syndrome

7.Medical conditions which cause pain (arthritis, cancer,nerve pain)

8.Sleep habits such as sleeping after a heavy meal,alcohol,  coffee, strenuous activity before sleep

9.Jet lag, change of time zone

10.Menopause or hormonal changes

11.Trauma or injuries to the brain or body

12.Withdrawal of drugs, cigarettes or alcohol

Symptoms of Insomnia:
1.Difficulty falling asleep

2.Waking up in the morning and unable to get back to sleep

3.Restless disturbed sleep with frequent wakening

4.Associated other disturbances such as sleep walking or enuresis
(passing urine frequently at night)

5.Associated symptoms such as anxiety, depression, alcoholism, medicine abuse

Diagnosis is by:
1.Typical history of difficulty in sleeping

2.Electroencephalogram(EEG) for brain wave pattern

3.Sleep Laboratory Analysis

Treatment of Insomnia:
A.Non-medicine:
1.Avoid drinking alcohol, coffee, caffeinated drinks, and tea late at night

2.Avoid smoking

3.Avoid eating and exercising just before sleep

4.Avoid watching exciting television or reading exciting books before sleep

5.Behavior modifications through relaxation techniques, hypnosis, biofeedback techniques, psychological counseling

6.Treat obstructive sleep apnea with high pressure airflow device

B.Medicine
depends on the cause of insomnia:
1.Painkillers for those in pain

2.Antidepressant for those with depression

3.Tranquillizer for anxiety patients

4. Melatonin has been used for inducing sleep without affecting the sleep pattern and may be used in mild cases.

5.Antihistamines such as diphenhydramine and doxylamine have also been shown to induce sleep without dependence unlike hypnotics such as the benzodiazepine group. Another antihistamine cyproheptadine previously used as appetite stimulant has been found to improve sleep quality.

6.Hypnotic of the non-benzodiazepine group such as zolpidem or zopiclone may be given if the patient is still unable to sleep.

Benzodiazepines are to be avoided because of the danger of abuse and dependency.

Always start with short acting hypnotics and preferably for short
period because of danger of abuse by patients.

Prognosis depends on the cause of insomnia.
Psychoanalysis and discussion of the cause will help patient to
respond positively although rebound insomnia may recur.

Hypnotics should be withdrawn slowly to prevent rebound insomnia.