It is imperative to first understand the five stages of Basic Sleep Architecture so that it is easy to see how insomnia affects our minds and bodies.
Wakefulness- This is a gradual transition to sleep. Most people who say “I wasn’t sleeping” are in this cycle as it is easy to open your eyes and converse with others. It is possible to still hear and acknowledge what is going on around you while in this stage.
Stage 1- Eyes move slowly and little muscle activity occurs. This is very shallow and fragmented. Awakening is easy in this stage as well, but yields no refreshing feeling or restorative results.
Stage 2- For most people, this is the longest stage of sleep. Eye movements slow down, but it is still easy to wake up. People with chronic illnesses and the elderly may spend most of the night here.
Stage 3- Deeper stage of sleep results in difficulty to be aroused. Those who awaken may feel disoriented. Slow wave sleep. This is where the body’s repair processes occur.
Stage 4- Deepest stage of NREM sleep. Neurotransmitters and growth hormone are synthesized during this stage. It is the most prominent and intense during childhood, declines sharply from puberty through age 30. Those 30 and older experience a progressive decline. It may be completely absent in old age. It is in this stage that we are prone to twitch or move.
Stage 5- REM sleep and dreaming stage. Our eyes have activity but our bodies cannot. Muscle paralysis occurs in the extremities, to prevent us from getting up and acting out nightmares. Breathing becomes shallow, rapid and irregular, blood pressure and pulse rise, oxygen consumption increases as well as blood flow to the brain. We have longer periods of REM sleep between 4-8 am and the closer to morning, the easier it is to recall a dream.
Our sleep-wake cycles are regulated by a circadian process that is influenced by a balance of hormones and neurotransmitters. Those that help us sleep are GABA, melatonin, galanin and adenosine. Those that keep us awake are histamine, serotonin, norepinephrine and acetylcholine.
**Note: Going outside at noon when the sun is high, ‘time-stamps our brains’ and sends a message that sleep will be half a day away. In 12 hours our brains will give us a burst of melatonin to help us sleep at night. Insomnia is debilitating but the tendency to sleep in is the worse response. Get up on time and get bright sunlight! Napping is okay, but avoid sleeping more than 45 minutes or after 3pm.
As we age past 30, sleep changes with:
*Delayed sleep onset *Increased awakenings after falling asleep
*Altered perception of sleep depth/quality *Decreased sleep efficiency
*Less time spent in deep sleep *More time spent in light sleep
Insomnia is a sleep disorder characterized by problems falling asleep, staying asleep or having poor quality of sleep. There are primary and secondary insomnias. Idiopathic insomnias can start early in life and persist or can be associated with a stressful situation.
* Paradoxical insomnia is common, especially in an inpatient setting of a hospital. It is a sleep-state misperception; the patient’s report of sleeplessness does not correlate with sleep study findings.
Secondary insomnias are due to specific illness or conditions such as poor sleep habits, can be triggered by stress, medical conditions (pain, nocturia, or getting up to urinate, etc), psychiatric disorders (PTSD, anxiety, depression) or substance or drug use or withdrawal.
Transient insomnia lasts < 1 week Short term insomnia last 1-4 weeks
Chronic insomnia last > 1 month. Often affects women, the elderly, those with chronic illnesses
Like the chicken and the egg, it is unknown which comes first, insomnia, depression or anxiety.
*Those who are anxious usually cannot fall asleep (racing thoughts, etc)
*Those who are depressed may wake up prematurely and not be able to fall back to sleep
*Those who have insomnia are more likely to demonstrate depression or anxiety
People who are not sleeping well tend to focus on that fact. A perceived inability to sleep at night develops and insomnia evolves as a maladaptive conditional response.
Sleep study finding in common conditions:
Depression: Delayed sleep onset, fragmented sleep, early morning awakening, hypersomnia
Hypersomnia may develop in adolescents, people with bipolar or SAD
Mania/Hypomania: Longer to fall asleep=total sleep time reduced
Alcoholism: Less time in REM, frequent arousals during night. Abnormal pattern may persist for years after alcohol use stops
Schizophrenia: Day-night reversals, general insomnia, sleep fragmentation
Unhealthy habits affect sleep
*inactivity *overeating/indigestion *over stimulation *excessive worry
*erratic schedules *overextension *caffeine, nicotine *alcohol
*Temp too hot/cold *light *noise *clutter
*mattress/pillow condition *space *spouse *pets
There are more meds that you can think of that affect our sleep. Some may surprise you…
Antihistamines bronchodilators decongestants antihypertensives
Steroids thyroid meds antiepileptics antipsychotics
Antidepressants analgesics diuretics stimulants (ADHD meds)
Alzheimer meds chemotherapeutics anticholinesterase drugs
These meds are for medical reasons and those comorbid illnesses affect not only our sleep but our emotional health as well
52% of people with 1-3 co-morbid illnesses had a sleep disturbance
69% of people with 4 or more co-morbid illnesses had a sleeping problem
Disorders and medical conditions range from cardiovascular, respiratory, gastrointestinal, musculoskeletal, RLS, renal, dental, sleep apnea, the list goes on and on…
Again, what comes first, the chicken or the egg? The depression, anxiety or insomnia?
The worse your respiratory illness is, the less you sleep. The less you sleep,
the worse your respiratory illness becomes.
Sleep deprivation in diabetes often aggravates insulin resistance and
impairs glucose control.
Fibromyalgia and Chronic Fatigue Syndrome
Fibromyalgia: Widespread pain, at least 11 of 18 tender points on body, along with significant fatigue.
Chronic Fatigue Syndrome: Severe new onset of fatigue lasting at least 6 months, resulting in ≥50% reduction in previous level of physical functioning as well as social and professional functioning. 4 or more of these symptoms must be present: sore throat, tender lymph nodes, muscle pain, multiple joint pain (not arthritis), headache, un-refreshed sleep, malaise.
Patients that truly meet the diagnostic criteria for fibromyalgia or CFS almost always demonstrate signs and symptoms of a sleep disorder. The deeper stages of sleep are interrupted by a glitch that sends them back to lighter stage 1 throughout the night, thus resulting in un-restful sleep.
The single most effective therapy is to restore normal sleep architecture using a combo of mild exercise and low doses of non-benzo hypnotics (Ambien, Sonata).
Review of Sleep Meds
Not appropriate or not suggested: Effective with cautions:
Benzodiazepines (Ativan, Xanax) non-Benzo hypnotics (Ambien, Lunesta)