Insomnia Is Not a Trivial Concern

If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?” “My doctor says that’s self-inflicted. You just THINK you can’t sleep.” Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Talking about insomnia with friends.If you’ve struggled with chronic insomnia for years, even if you have some reliable management strategies, you may occasionally find yourself talking about insomnia with people whose looks and responses suggest it can’t be such a big deal.

“Aren’t there pills for that?”

“My doctor says that’s self-inflicted. You just THINK you can’t sleep.”

Here’s some new research that shows why persistent insomnia is a serious problem deserving of concern and treatment.

Benefits of Sleep

First, though, let’s review the central role sleep plays in maintaining well-being. In the past, people thought that nothing much happened during sleep and that the human brain essentially shut down at night. How wrong that notion was!

Many critical functions occur during sleep. Sleep enables the shoring up of the immune system and the repair of injuries. During sleep, memories are consolidated and brain waste is pruned. Negative emotion is processed during REM sleep. After a full night’s sleep you awaken in a more positive mood. During sleep energy is conserved. In the morning you awaken feeling rested and restored, and your brain is primed to learn and retain new information.

When sleep is disrupted, whatever the reason, the critical functions that take place during sleep may be compromised. In the case of chronic insomnia, common symptoms during the daytime—tiredness and lack of stamina; moodiness; and impaired attention, concentration, and memory—are suggestive of compromise. They cut down on the quality of our day-to-day lives.

Effects of Persistent Insomnia Over Time

Chronic insomnia also has several more insidious effects.

It increases the odds of our developing depression and anxiety. A new meta-analysis of studies on insomnia as predictor of mental illness has found that chronic insomnia makes us nearly 3 times as likely to develop major depressive disorder and over 3 times as likely to develop an anxiety disorder as people without insomnia.

Insomnia and Chronic Pain

Insomnia intensifies and increases susceptibility to pain. Past research has suggested that the relationship between insomnia and pain is bidirectional, with painful conditions interfering with sleep and sleep disturbances worsening painful conditions. But recent longitudinal studies (studies involving repeated observations over time) suggest that more often it’s insomnia symptoms that predispose us to chronic pain or to the worsening of painful conditions.

Insomnia and Heart Disease

Insomnia, especially when accompanied by objectively measured short sleep duration (less than 6 hours), makes us more susceptible to heart, or cardiovascular, disease (CVD). Meta-analyses have found that people with insomnia are between 33% and 45% more likely to develop and/or die of CVD than people without insomnia.

A new study of sleep duration and atherosclerosis (plaque formation in arteries) has found that short sleepers are 27% more susceptible to atherosclerosis than people who sleep 7 to 8 hours a night, and those whose sleep is highly fragmented are at even greater risk (34%) for plaque build-up.

A disorder that has so many negative effects on quality of life and long-term health cannot be dismissed as a minor annoyance. It’s important to get treatment for insomnia as soon as possible, with cognitive behavioral therapy or, in cases that don’t respond to CBT, medication.

Talking About Things We Know

Despite what you might infer from the fact that I blog about insomnia, I don’t go around seeking opportunities to talk about the problem in my everyday life. Sleep disorders now get quite a bit of attention in popular media, but most of us know the topic has the appeal of moldy leftovers for the good sleepers of the world — and they are in the majority.

Occasionally, though, conversations turn to talk about sleep, at a party or a meeting or anywhere in casual conversation. And who better than us to raise people’s awareness about the problem of insomnia since we’re the ones with all the experience?

If you’ve talked about insomnia with your family, friends, or acquaintances, what has been their reaction?

Sleep Restriction: New Thoughts on How It Works

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Sleep restriction therapy involves postponing bedtime

Sleep restriction therapy helped me a lot. In fact, even without the other insomnia treatments usually offered with it, sleep restriction alone (enhanced by daily exercise) would probably have turned my chronic insomnia around.

Sleep researchers at Oxford recently proposed a new model of how the therapy works. If you haven’t yet tried sleep restriction, here’s why you’ll want to check it out.

Benefits of Sleep Restriction Therapy

Why would a person with insomnia even consider undergoing sleep restriction therapy (SRT), when what we want is to get more sleep and not less? Well, consider first the benefits. After 4 to 6 weeks of SRT, people typically

  • spend considerably less time in bed awake (a boon to sleep onset and sleep maintenance insomniacs alike)
  • fall asleep about a half hour sooner (particularly helpful for sleep onset insomniacs)

A few studies suggest that by the end of treatment, sleep timing is less variable than before treatment began. Total sleep time may be slightly longer, especially in the young and middle-aged.

If these benefits pale compared with what we really want (one to two hours more sleep, thank you very much!), consider next this new theory of how SRT works.

The Triple-R Model of Sleep Restriction Therapy

Chronic insomnia develops from a mix of physiological, psychological, and behavioral factors, and SRT, the Oxford researchers say, influences all of these factors at once. In effect, SRT walks us back to a time when sleep was less of a problem by doing three main things. It

  1. Restricts time spent awake in bed
  2. Regularizes the timing of sleep and wake
  3. Reconditions the association between bedroom factors and sleep

All together, the Triple-R process produces physiological and cognitive-behavioral alterations which in turn lead to better, healthier sleep.

This new model of SRT is theoretical, describing mechanisms the authors would like to see put to the test. It caught my attention because it pretty well describes what I saw happening when I went through SRT.

Restricting Time in Bed

The concept of restricting time in bed is foreign to many of us with insomnia. To get more sleep, it’s reasonable to think we need to spend more time in bed.

But the minute we find ourselves lying awake in bed for any length of time, we’re on a slippery slope. Lying awake in the darkness, our stamina low and our defenses down, we’re probably not fantasizing about a trip to Hawaii. We’re worrying instead about car payments or a mortgage, we’re obsessing over the latest political crisis. We’re anxious about sleeplessness itself and how it’s going to drag us down the next day.

Thoughts like these trigger physiological arousal—the heart beats faster, the body gets warmer—in turn feeding the mental anxiety, in turn arousing the body still more. Several nights like this can condition bodies and brains to associate the bed not with sleep but rather with wakefulness.

Then we’re cooked: Learned associations like this are hard to unlearn. I tried and failed for over 20 years.

Restricting Time Awake

When I considered sleep restriction, I assumed it would curtail the amount of time I slept. Some curtailment of sleep did occur during the first week of therapy, and that was rough.

But this early stage of SRT didn’t last long. Later the first week, the pressure to sleep increased to a point where by my prescribed bedtime I was falling asleep the minute my head touched the pillow and sleeping right through the night. With improved sleep efficiency, the sleep restriction protocol allowed me to increase my time in bed. So that by the end of therapy what I’d done was not decrease my total sleep time (in fact, I gained about half an hour) but rather decreased my time awake in bed.

What’s not to like about that?

Regularizing the Timing of Sleep and Wake

Regularity may sound boring but looking back, I think my insomnia was one of many signs my body actually craved it. And SRT delivered on that score. Starting from the first week of treatment I had to adhere to the same sleep schedule for one entire week. I made small adjustments on a weekly basis only, according to the protocol, adding time in bed as my sleep became more robust.

Why was regularity so important? Sleep and wake are controlled by two internal forces, the circadian pacemaker (the body clock) and the homeostatic pressure to sleep. Together, they dictate when we feel sleepy and when we feel alert. An erratic sleep schedule will tend to push these forces out of alignment, setting up the conditions for persistent insomnia.

A regular sleep schedule helps these forces remain in sync, in turn promoting better sleep. In myself, what I’ve observed is that regularity in almost everything I experience on a daily basis, including meals, exercise, light exposure, and even socializing, seems to benefit my sleep.

Reconditioning Myself for Sleep

Once sleep became more predictable, and once I was mainly sleeping when I was in bed (rather than lying in bed awake), my anxieties about sleep began to fade. Fear of sleeplessness wasn’t so quick to ambush me en route to the bedroom or when I glimpsed the clock at 2 a.m.

This last step in process — replacing my expectation that I’d be wakeful in bed with the expectation that I would sleep — came about gradually. During a couple of insomnia flare-ups, I needed to restrict my sleep again to keep my recovery on course.

But by the end of the first year post-SRT, my anxieties about sleep were pretty much a thing of the past. And that is truer now than it was 10 years ago. I’ve stuck with the habits I developed in SRT, and my sleep is much more robust as a result.

SRT is not a magic bullet, but by my lights it’s the most effective insomnia treatment available today. Anyone with chronic insomnia will want to check it out.

Stay Healthy Over the Holidays Despite Insomnia

When my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Insomnia compromises immunityWhen my family gathers for a few days over the holidays, usually someone brings along a sore throat or a cough. Try though that unlucky person may to keep the germs from spreading, they almost inevitably do.

I catch colds fairly easily, and I’ve often wondered if insomnia has a part in that. A new study suggests that chronic insomnia does—at a minimum—increase our susceptibility to influenza. Here’s more about the study and precautions poor sleepers can take to stay healthy over the holidays.

Sleep and the Immune System

A robust immune system confers protection from colds and flu. In order to stay robust, the immune system needs ongoing attention, and it’s during sleep when the body’s metabolic resources are freed up to do this maintenance work. During sleep antibodies are created to fight invading viruses. Short sleepers develop fewer antibodies, past research has shown, and this puts them at higher risk for developing infections.

Insomnia Compromises Immunity

Chronic insomnia—trouble sleeping and daytime impairment—may also compromise the immune system, according to new research published in Behavioral Sleep Medicine. Participants in this study were 133 healthy college students, half meeting diagnostic criteria for insomnia and the other half experiencing no insomnia.

Via blood draws, the students’ influenza antibody levels were assessed twice: once before, and once 4 weeks after, they received flu shots (containing influenza vaccine). The expectation was that 4 weeks after receiving the flu shots, participants in the Insomnia group would have lower levels of influenza antibodies than participants in the No Insomnia group.

What the researchers found was telling. Both groups showed increases in antibody levels from pre- to postvaccine. But not only did the Insomnia group have lower antibody levels than the No Insomnia group 4 weeks after receiving the flu shots. The Insomnia group also had lower antibody levels to begin with.

Researchers can only speculate about why. But the result lends support to something I’ve thought (and sleep researchers have suspected) for a long while: chronic insomnia dysregulates the immune system, making insomniacs less able to fight off colds and flu.

Recipe for a Healthy Holiday Season

So if you’ve got persistent insomnia it’s wise to take extra precautions around the holidays. Here are suggestions for how to avoid colds and flu:

If you’re traveling: People with insomnia are said to sleep better away from home. Not me—I’m susceptible to sleep onset insomnia wherever I go. If you’re going away for the holidays, pack along all the accoutrements you need for a comfortable night’s sleep at home: ear plugs, eye mask, pillows, white noise machine, etc. I take a foam rubber futon for use in case the sleeping accommodations aren’t quite right.

Travel by plane: Airplanes are virus magnets. Pack along a couple face masks for use if nearby passengers are coughing or sneezing. Use antibacterial wipes on seatbelt buckles, tray tables, overhead air vents, and bathroom fixtures before touching them.

Avoid airborne viruses: Viruses are mostly spread through the air via coughing and sneezing and then inhaled. Steer clear of Uncle Dalbert if he has the bad manners to come down to Happy Hour hacking away. A hug for a sister who’s obviously contagious can wait for another day.

Hard surfaces that harbor viruses: Touching doorknobs, light switches, faucets and then absentmindedly touching your face is another way infection spreads. To lower your risk of infection, wash your hands with soap and water frequently (take along hand cream so your hands don’t dry out). Better yet, avoid use of your hands altogether. To open doors and turn on lights and faucets, use your arms instead. (It’s amazing what dexterous forearms and elbows I’ve developed since I set my mind to it.)

Pass on communal towels: Avoid sharing them—or give the sick one a towel of their own.

Passing dishes at the table: Leave the sick one out of the loop.

When you’re out and about: Carry a small bottle of hand sanitizer in your pocket or purse and use it often, especially after handling money, signing for credit card purchases, and pumping gas.

A final suggestion: I have a brother who swears that daily nasal irrigation (with dilute salt water or a commercial sinus rinse) keeps him from coming down with colds. I don’t have enough discipline to incorporate this habit into my daily ablutions. But I use a sinus rinse when I’m bothered by allergies or feel a sinus infection coming on, and it helps.

Got any tips for staying healthy during flu season? Please share them in a comment below!

Sleep (Re)Training for Insomnia

What does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Insomnia sufferers relearn the feeling of falling asleepWhat does falling asleep feel like? Good sleepers may never bother with the question. One minute they’re conscious and the next minute they’re out. But if you have chronic insomnia, falling asleep (or back to sleep) can feel like a tiresome slog.

Insomnia sufferers may actually lose touch with the feeling of falling asleep, some have claimed. So Sleep Technologist Michael Schwartz created a smartphone app to put people back in touch and increase their confidence and ease in falling asleep.

Racing Thoughts and Brain Activity at Night

An independent study has found the smartphone app, called Sleep On Cue, to be accurate at detecting the start, or onset, of sleep. But let’s step back, for a moment, and imagine a typical insomniac night.

It’s after midnight and you’re obsessing about your deadlines tomorrow. Or you’re thinking about how to fight your way out from under all your student loans. The next thing you know the clock on your bedside table says it’s 2 a.m. In desperation, you stare at the clock face, willing time to stop. By 3 a.m. you’re still awake and hopping mad about it!

Maybe you have spent the last 4 hours with your entire brain spinning along in problem-solving mode. Chances are, though, that if on such a night you were undergoing a sleep study, your brain waves would tell a somewhat different story. Beta waves, fast wave activity commonly observed in people who are are thinking and solving problems, might be mixed in with alpha waves (slower waves linked to more relaxed states) and even slower theta waves, heralding the start of Stage 1 sleep.

Detecting the Lighter Stages of Sleep

But would it feel like you were actually sleeping? Research has shown that people woken up in Stage 1 sleep are often unaware that they’ve been asleep. In this liminal state, people can drift back and forth between sleep and wakefulness for quite some time before descending further into more sustained sleep, which is called Stage 2.

Stage 2 sleep is characterized by a predominance of theta waves and by features called sleep spindles and K complexes. Awoken in Stage 2 sleep, people are somewhat more likely to be able to sense that they were asleep.

But people with insomnia may not be as apt to report they were sleeping. Investigators have speculated that with all the nighttime baggage accompanying chronic insomnia—anxiety about sleep loss, lack of confidence in sleep ability, negative beliefs about sleep, increased beta wave activity during sleep—some insomniacs may simply lose touch with the feeling of falling asleep.

A Sleep Training Smartphone App

When a call went out for an inexpensive way to detect the start of sleep at home, Schwartz developed Sleep On Cue. A recent study comparing it to polysomnography (the test used in overnight sleep studies) found that Sleep On Cue was accurate at predicting the onset of Stage 2 sleep.

Why is this important? For one thing, the app (which costs $4.99) may prove to be useful in helping to administer intensive sleep retraining—an insomnia treatment developed in Australia—inexpensively in people’s homes.

But for readers of this blog, the immediate value of this app may lie in its potential to train or retrain insomnia sufferers to recognize what falling asleep feels like. This could alleviate some of the worry and anxiety about sleep and insomnia and thus make it easier to fall asleep and fall back to sleep.

Here’s How the App Works

Sleep On Cue works best, Schwartz says, if you conduct your training sessions when the pressure to sleep is high: late in the afternoon or early in the evening after a poor night’s sleep.

  1. Lie down and relax in bed, holding your smartphone in one hand. The phone will periodically emit a soft tone. Every time you hear the tone, give the phone a slight shake.
  2. When the app no longer detects movement, it assumes you’re asleep. Then, the phone vibrates to wake you up.
  3. The screen then displays this message: “Do you think you fell asleep?” Press “yes” or “no.”
  4. Next, you’re instructed to leave the bed for a few minutes. The phone will then vibrate to let you know when to return to bed for the next sleep trial. In this way, you begin to relearn what falling asleep feels like and gain confidence in your ability to do it.
  5. You decide when to end each training session. The screen then displays a graph with feedback about your sleep ability and your awareness of your sleep.

Here’s a link to the Sleep On Cue website. At $4.99, it’s not much of an investment and the payoff could be great.

If you’ve tried Sleep On Cue, did it improve your sleep and, if so, how?

A Different Pathway to Chronic Insomnia

Let’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

Stress and poor sleep can lead to chronic insomnniaLet’s say you grow up in a family of champion sleepers, yourself included. At college, you sail through rowdy dormitory life sleeping like a log. Job interviews, stressful to some, don’t faze you. By 27, you’ve landed a good job and in a few years earned enough for a down payment on a house. Sleep is still dependable and stays that way for a decade.

Then, coinciding with a move and the birth of a second child, you find yourself wide awake at your normal bedtime, staring at walls. Soon this becomes the rule rather than the exception. Before you know it you’ve developed chronic insomnia. How can sleep go from good to bad so quickly?

How Insomnia Develops

For decades sleep scientists have been trying to work out how chronic insomnia develops. The main model they’ve proposed looks something like this:

  1. Predisposing factors are presumed to exist in everyone who develops chronic insomnia. They include such observable factors as (a) parental history of insomnia, (b) high sleep reactivity (a tendency to sleep poorly before and after stressful events such as giving a speech or having an argument; and to be highly reactive to caffeine, jet lag, and interpersonal stressors), and (c) poor health—all associated with biological challenges to sleep.
  2. Precipitating factors come next: major life stressors that often trigger an episode of insomnia such as a job loss, marriage, or relocation to a different town.
  3. Perpetuating factors are the habits some people then adopt for insomnia relief—taking naps, going to bed early, sleeping in on weekends—that actually make their sleep worse.
  4. Conditioned arousal of the cerebral cortex is the final step in in the process. Lying awake for long stretches of the night opens the door to worry and rumination. This brain activity can spill over into sleep and keep insomnia going indefinitely.

This may be how chronic insomnia develops in some people. There may also be alternative pathways to insomnia. A large community-based study (Evolution of Pathways to Insomnia Cohort) was recently conducted to figure out what those alternative pathways might be. Working with data from that study, Michigan researchers have concluded that even people who have no evident predisposition to insomnia may develop chronic insomnia through a process involving sleep system sensitization. Here’s more on what they found.

From Normal Sleep to Insomnia in Just One Year

In this prospective study, thousands of participants filled out a series of questionnaires at the start of the study and one and two years later. The Michigan researchers looked at the 262 participants who did not have insomnia at the start of the study but who, by year 1, had developed it.

These participants might be expected to have characteristics predisposing poor sleep from the start (a mother with insomnia, for example, or high sleep reactivity). But not all of them did. A total of 60 participants tested low for sleep reactivity at the start of the study (on the Ford Insomnia Response to Stress Test, or FIRST). But by year 1, these 60 people had jumped an average of 4 points on the FIRST, indicating a significant increase in sleep reactivity. Over two-thirds went from low sleep reactivity to very high sleep reactivity following major life stress and the onset of insomnia in the space of just one year. At year 2, the high sleep reactivity persisted regardless of whether their insomnia was chronic or not.

A Different Path to Chronic Insomnia

In a nutshell, here’s the take-away:

  • People with apparently low vulnerability to insomnia (like the person described at the beginning of this blog post) can develop high sleep reactivity in conjunction with major life stress and an episode of insomnia.
  • Stress exposure leading up to insomnia appears to sensitize the sleep system. This lends support to the idea that insomnia itself may be a perpetuating factor in chronic insomnia. Every episode may trigger neurobiological changes that increase the risk of subsequent bouts of insomnia, just as every experience of depression increases the risk of future depression.
  • High sleep reactivity, once it develops, is persistent.

No matter how or why your insomnia develops, don’t wait to look for help. Take action right away.

Insomnia and Your Genes

If you suspect there’s a biological component to your insomnia, you’re probably right. Although talk about insomnia is mostly confined to situational triggers as well as habits and attitudes that keep insomnia alive, all models of chronic insomnia assume the existence of predisposing factors. Some of these factors may be inherited at birth.

What evidence is there for genetic involvement in insomnia, and where might it lead? A review published recently in Brain Sciences brings us up to date.

Genetic variants may be an underlying factor in insomniaIf you suspect there’s a biological component to your insomnia, you’re probably right. Although talk about insomnia is mostly confined to situational triggers as well as habits and attitudes that keep insomnia alive, all models of chronic insomnia assume the existence of predisposing factors. Some of these factors may be inherited at birth.

What evidence is there for genetic involvement in insomnia, and where might it lead? A review published recently in Brain Sciences brings us up to date.

Family and Twin Studies

The number of family studies is small—five—and one reason may be that in family studies it’s hard to tease apart genetic effects from the effects due to shared environment. But overall these studies suggest that insomnia tends to run in families. A recent study found that the children of parents with high levels of stress related insomnia were more likely to experience higher cognitive–emotional hyperarousal.

Twin studies are more numerous (20). By comparing correlations between identical twins (who share 100% of their genes) and fraternal twins (who share 50% of their genes on average) who are raised together, researchers can more easily sort out which effects are genetic and which are due to a shared environment. Based on twin studies, insomnia heritability estimates range from 22% to 59% in adults, depending on the type of study and which sleep variable was assessed (sleep duration? trouble falling asleep at the beginning of the night? subjective sleep quality?).

Recently, a large twin study by Lind and colleagues provided new evidence that

  • there is a larger genetic contribution to insomnia in women (59%) than in men (38%), and
  • in adults, insomnia heritability is stable across time.

Researchers assessed the heritability of insomnia through childhood and adolescence in another twin study. In youth, too, they found that genetic influences on insomnia are stable across time.

Studies of Candidate Genes

The one drawback of twin studies is that they don’t point to which genes confer vulnerability to (or protection from) insomnia. But based on knowledge of specific genes that figure in other disorders (notably psychiatric disorders and other sleep disorders), scientists can guess which genes might be involved in insomnia and then conduct candidate gene studies on them. The aim of such studies is to compare variation in a gene suspected of causing insomnia in people with and without insomnia.

One gene that figures in the transport of serotonin (5-HTTLPR) has been studied for its relevance to depression and to insomnia. Huang and colleagues found that variation in this gene

  • significantly affected people’s vulnerability to insomnia, and
  • significantly predicted people’s reactivity to job-related stress.

Other candidate genes have been studied, including some that increase the risk of insomnia and others that protect against it. But few genes have been studied in detail and replication studies are still lacking.

Genome Wide Association Studies (GWAS)

GWAS allow scientists to examine millions of variants across the genome at the same time. Only four GWAS of genes potentially involved in insomnia have been conducted so far. But now that genotyping has become less expensive and management of data is easier, GWAS are the wave of the future.

One GWAS of interest was conducted by Australian researchers looking at insomnia and several aspects of sleep in a sample of twins. They found no genome-wide variants of significance.

But the most prominent finding was that a variant of CACNA1C, a gene associated with bipolar disorder, was also associated with sleep quality and sleep latency (the amount of time it takes to fall asleep). The relationship between CACNA1C and sleep quality was later replicated in a British study, suggesting that this gene may indeed be involved in insomnia.

CACNA1C codes for a mechanism that excites neurons and leads to the release of neurotransmitters. If this excitation occurs in neurons that promote wakefulness or neurons that inhibit sleep, this could lead to hyperarousal and trouble sleeping, in turn increasing a person’s risk of developing insomnia.

Why This Is Important

There hasn’t been much discussion of the factors that predispose us to insomnia—at least not in the popular press—and this is partly because not a lot is known about them. And at present little can be done to alter genetic traits.

But knowledge of the genetic underpinnings of insomnia will be increasingly important to the prevention and treatment of insomnia in the future. It could enable doctors to know which insomniacs will likely respond to treatment with cognitive behavioral therapy and which ones will not, or which medications will likely be effective and which will not.

Early intervention and prevention may also be possible once the risk and protective genes for insomnia are known. Further down the line, it may be possible to alter the expression of risk genes (with drugs that target gene regulation) or use gene therapy to replace defective genes.

All this may not help us manage insomnia now. But it’s heartening to know that scientists are pursuing knowledge that could take some of the guesswork out of treatment for insomnia and eventually render the treatments available today—imperfect as they all are—obsolete.

Comments, anyone?

“Sleep Was Easier to Give Up Than the Job”

Several people I interviewed for The Savvy Insomniac blamed their insomnia on stress at work. A trial lawyer attributed his nighttime wake-ups to “mostly job related stress.” A 52-year-old woman on Social Security disability saw her insomnia as resulting from 14 years of shift work as a dispatcher with emergency services.

Work can interfere with sleep in many ways, including shortening sleep duration. The CDC has just released a report on the categories of work most likely to shorten people’s sleep. Here’s what they are and how they may relate to chronic insomnia.

Persistent trouble sleeping can develop from years of shift workSeveral people I interviewed for The Savvy Insomniac blamed their insomnia on stress at work. A trial lawyer attributed his nighttime wake-ups to “mostly job related stress.” A 52-year-old woman on Social Security disability saw her insomnia as resulting from 14 years of shift work as a dispatcher with emergency services.

Work can interfere with sleep in many ways, including shortening sleep duration. The CDC has just released a report on the categories of work most likely to shorten people’s sleep. Here’s what they are and how they may relate to chronic insomnia.

Occupations Associated With Short Sleep

The findings are based on surveys conducted on working adults in 2013 and 2014. By telephone, workers answered questions about the kind of work they did and how much sleep they normally got in 24-hour period. In all, the CDC analyzed the responses of nearly 180,000 people. The data show a high percentage of workers in these five broad categories typically slept less than 7 hours a night:

  1. Production (printing workers, plant and system operators, supervisors, and production workers), about 43%
  2. Healthcare Support (nursing, psychiatric, and home health aides), about 40%
  3. Healthcare Practitioners and Technical (health technologists and technicians, health diagnosing and treating practitioners), about 40%
  4. Food Preparation and Food-Related (supervisors, food preparation and serving workers, cooks), about 40%
  5. Protective Service (fire fighting and prevention workers, law enforcement officers), about 39%

Occupations Involving Shift Work

The jobs in all five categories often involve shift work. Round-the-clock operations in hospitals, factories, restaurants, and police and fire departments make it necessary for some employees to work at times when we’re normally at rest. In other work situations employees regularly rotate from one shift to the next.

Shift work is known to interfere with sleep, contributing to shortened sleep and excessive sleepiness. It disrupts circadian rhythms and has a negative effect on health, contributing to a rise in certain cancers, obesity, and impaired glucose tolerance. It also increases the risk of injury.

Could Shift Work or Work-Related Short Sleep Lead to Chronic Insomnia?

Lynda, the retired dispatcher on disability, felt there was a direct link between her insomnia and her work in emergency services. Day jobs she’d held previously gave her “no trouble sleeping at night.” But the dispatch job was different:

I really do believe that the shift work was a major contribution to my sleeping problems. I base this on comparisons with my coworkers. I don’t know any policeman, fireman, or dispatcher who didn’t have trouble sleeping while swinging shifts on a regular basis. I loved this line of work because it was always rewarding to be able to help someone, or be responsible for saving someone’s life. Sometimes, depending on the size of the catastrophe, it could be very intense. You could feel the adrenaline pumping. . . . It just gave you a great feeling knowing that YOU were the one who made a difference. I guess that would explain why I couldn’t sleep after coming off of working something major. Sleep was easier to give up than the job.

How It Could Happen

The neurocognitive model of insomnia suggests how chronic insomnia might develop from work-related stress and short sleep. In fact any stressful situation can trigger acute (or temporary) insomnia, including stress at work. But acute insomnia does not necessarily become chronic. Sleep can—and, in many people, does—return to normal once the situational triggers for insomnia get resolved.

But in the five categories of jobs identified by the CDC, less-than-perfect conditions of employment may be a given when you accept the job. Want to work in emergency services? Fine. You’ll work rotating shifts.

If you find this situation stressful because it interferes with your sleep, you may be tempted to resort to measures that often make sleep worse—using alcohol to get to sleep, for example, or spending long stretches lying awake in bed.

Lying awake in bed often leads to worry and rumination, and to high-frequency brain activity during sleep onset and beyond. Eventually you wind up conditioning arousal in your body and brain. Et voilà, you’re saddled with chronic insomnia—all because you were a good citizen and willing to work around the clock.

I never had an easy time working split shifts and I avoided other jobs that might disrupt my sleep. People like Lynda are more adaptable. But . . . at what cost?

If you’ve had a job that shortened or otherwise interfered with your sleep, how did you manage the situation, and were their any long-term effects?

Sleeping Pills: New Prescribing Guidelines

Let’s say you go to the doctor hoping to get a prescription for sleeping pills to relieve your insomnia. You’ve been through cognitive behavioral therapy and it has helped. But there are nights when you’re wound up so tightly that nothing—push-ups, meditation, a hot bath—will calm you down enough so you can get a decent night’s sleep. What then?

The American Academy of Sleep Medicine recently released a clinical practice guideline for the medical treatment of chronic insomnia in adults. Here’s what the academy now recommends.

New guideline for sleeping pills may change doctors' prescribing habitsLet’s say you go to the doctor hoping to get a prescription for sleeping pills to relieve your insomnia. You’ve been through cognitive behavioral therapy and it has helped. But there are nights when you’re wound up so tightly that nothing—push-ups, meditation, a hot bath—will calm you down enough so you can get a decent night’s sleep. What then?

The American Academy of Sleep Medicine recently released a clinical practice guideline for the medical treatment of chronic insomnia in adults. Here’s what the academy now recommends.

Why the Need for a Clinical Practice Guideline?

Most experts in sleep medicine are well acquainted with the literature on sleeping pills and know how to diagnose and treat insomnia. When medication for insomnia is warranted, they know the best drug to prescribe based on your symptoms and medical history.

But most people with sleep complaints take them first to primary care providers. And when it comes to prescribing sleeping pills, not all doctors are on the same page. In fact, a new study from Harvard Medical School shows that, rather than prescribing based on individual patients’ symptoms and history, many doctors find one or two sleep medications they’re comfortable with and prescribe the same drug or drugs again and again.

The new clinical practice guideline contains recommendations that are evidence based. It has the potential to change physicians’ prescribing habits and thus to affect people with insomnia who use sleeping pills, now and in the future.

The Guidelines Are Based on Weak Evidence

The four sleep experts who created the guideline first conducted a literature review. They concluded that no sleeping pill or sleep aid on the market today has been tested in multiple clinical trials and found to be extremely effective and carry very few risks. So the evidence base for their recommendations is, they note, “weak.”

This doesn’t mean that a given medication would not be appropriate and effective for a particular individual with insomnia. It just means as a general treatment for everyone with chronic insomnia, no sleeping pill is backed up strongly by the evidence.

These Sleeping Pills Got a Thumbs-Up

Perhaps predictably, the medications judged to be appropriate—based on the quality of evidence, the balance of benefits and harms, and patient values and preferences—are medications approved by the FDA for the treatment of insomnia. The guideline does not suggest that one drug is better than another since so few studies comparing the efficacy of two or more sleeping pills have been conducted. So the medications listed here are in no particular order:

MEDICATION

SLEEP ONSET INSOMNIA

SLEEP MAINTENANCE INSOMNIA

suvorexant (Belsomra)  X
eszopiclone (Lunesta) X  X
zaleplon (Sonata) X
zolpidem (Ambien) X
triazolam (Halcion) X
temazepam (Restoril) X X
ramelteon (Rozerem) X
doxepin (Silenor) X

These Sleep Aids Were Not Recommended

The following medications and supplements are sometimes prescribed and used for chronic insomnia. Depending on an individual’s symptoms and history, they may help. But the published data on these substances is insufficient in quantity and/or quality to warrant a recommendation for general use as a treatment for chronic insomnia.

  • trazodone (a sedating antidepressant)
  • tiagabine (an anticonvulsant approved for the treatment of epilepsy and used off-label to treat anxiety and panic disorders)
  • diphenhydramine (the antihistamine found in most over-the-counter sleep aids, including ZzzQuil, Sominex, and Tylenol PM)
  • tryptophan (a supplement containing an amino acid found in milk and other sources of dietary protein)
  • melatonin (a supplement which is bio-identical to a hormone produced in the body, useful for jet lag and delayed sleep phase disorder)
  • valerian (a plant-based supplement)

If you’ve used any of these medications or supplements, how effective were they, and did you experience any side effects?