Insomnia

Insomnia is the most common sleep disorder that remains a life-long issue for many people. For a minority (<90%), insomnia results entirely from a lifetime history of being a “light sleeper”. For the vast majority, there are also coexisting issues with an underlying medical/pain condition or mood disorder. If not properly addressed, these issues can significantly disrupt sleep. Further, the effects of centrally acting medications or substances, or their withdrawal, cannot be overemphasized. Unfortunately, the very struggles people can have with initiating or maintaining sleep can create and reinforce unhealthy relationships with the bedroom environment making it even more difficult for them to find restorative sleep.

I like to think of insomnia as being about the "3 P's". They are:

• Predisposing factors

• Precipitating factors

• Perpetuating factors

Predisposing means personal factors or traits that make you more likely to have sleep difficulties. If you are higher strung during the daytime, you might find it more difficult to settle yourself at night. Precipitating factors means life events, health conditions, etc., that disrupt your sleep. The easiest example for me at this time of life is raising a young family with the disruptions that regularly occur with feedings, diapers, and the like. However, the death of a loved, perhaps a chronic pain issue, would also all apply. These life events act as catalysts for poor sleep. Perpetuating factors means changes to our behaviours that actually promote disrupted sleep well after the precipitating factors have resolved. As an example, people who clock watch develop increased anxiety that only makes falling asleep more challenging. Those that nap during the day after a poor night's rest reduce their sleep drive for the night that follows. Those that "sleep in" to catch up on a difficult night destabilize their circadian rhythms.

Treating insomnia means addressing all of the P's. If you focus on sleep hygiene, but do not address your chronic pain issue, then sleep will continue to suffer. If your kids have grown up, but you have not addressed issues of anxiety that prevent you from putting your mind to rest, then sleep will continue to suffer. If you have managed your individual characteristics, treated or survived the precipitating factors, but still go to bed at random times and like to sleep in, well... you get the point. Also consider this, as we age, the amount of N3 and REM sleep we get diminishes, our sleep becomes more fragmented and we are likely to develop more of those issues that can precipitate poor sleep.

So, what's the role of medications for chronic treatment. Well, fairly limited and for obvious reasons. The only role I can imagine for sleeping medications is for short term treatment when someone is dealing with a precipitating situation so that they do not develop perpetuating behaviours. For chronic issues, there is no real role because they do nothing to address what is at the root for poor sleep. Basically, medications have limited use, can have unwanted side effects and tend to demonstrate only modest benefits. For many, the benefits diminish over time while unwanted side effects persist.

The first step in insomnia treatment involves addressing any contributing conditions and optimizing sleep hygiene. Non-pharmacologic treatment comes in the form of Cognitive Behavioral Therapy for Insomnia (CBT-I). This form of therapy is typically provided by those trained in psychotherapy and have experience with the unique challenges of sleep disorders.

Although CBT-I is considered a first line treatment for insomnia and has been consistently validated in studies, access remains a problem. Many psychotherapists are not trained or familiar with the specific approaches used in CBT-I. Those that do, typically provide services that are not insured through the Medical Services Plan (MSP), which can make treatment costly in the absence of extended insurance. Fortunately, many people find help through books and interactive online programs. For books, the following should be considered a non-exhaustive list, written by reputable authors who are experts in the field of sleep medicine. Browsing these books online (for example on Amazon) or at a Chapters might help you identify one that will work the best for you.

• The Insomnia Workbook: A Comprehensive Guide to Getting the Sleep You Need by Stephanie Silberman

• Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety or Chronic Pain by Colleen Carney

• No More Sleepless Nights by Peter Hauri

There are also interactive online programs that have been validated as an effective means of providing CBT-I. Most have some cost associated and so it is generally advised to get a sense of them before paying. Free trial periods, online reviews and money back guarantees can help you identify a program that will work the best for you and minimize your costs if it does not.

"Slumber Pro" is an online self-help program that has been quite reasonably priced in the past (previously about $39). More information can be found at http://www.sleeptherapy.com.au/. A more complicated and sophisticated online program is “Sleepio” which can be found at http://www.sleepio.com/. This online program is considered one of the more established treatments. Yet another option is “Somryst” at https://www.somryst.com.

Ultimately, you are the best person to identify what kind of treatment will work best for you! For more additional information on insomnia, please also consider visiting HealthLinkBC’s website at:

http://www.healthlinkbc.ca/healthtopics/content.asp?hwid=uh1001#uh1002