Many people think of insomnia as one specific problem with one treatment. However, just as any type of pain can represent different causes in different people, insomnia has different causes in different people.
First of all, insomnia is often a symptom of some other disorder. Insomnia is defined as any one of 4 basic symptoms – difficulty falling asleep, waking up during the night and having difficulty getting back to sleep, early morning awakening insomnia and nonrestorative sleep insomnia. People can experience more than one of these symptoms.
Insomnia can occur for many reasons. It is often due to another undiagnosed sleep disorder, such as a circadian rhythm disorder (sleeping on a different clock, such as shift work or being on call or circadian rhythm delayed sleep phase, being a natural night owl), sleep apnea/sleep disordered breathing, periodic limb movement disorder but can also be due to mood disorders (it can herald the onset of depression or anxiety disorder or a substance abuse disorder) or be a residual effect of a previous episode of a mood disorder. It can be due to medications or pain issues as well. Unlike other fields of medicine, patients with sleep disorders often have more than one underlying sleep disorder, and all of them need to be treated.
In order to clearly understand insomnia, we need to take a very thorough history of the predisposing factors (“Why me?”) such as genetic insomnia tendency or mood disorders, the precipitating factors (“What got it started?”) such as abuse issues leading to hypervigilance, transitions including parenthood, stressors, shift work in the past, etc., and the perpetuating factors (“Why is insomnia STILL happening?”).
Our goal during our consultation is to isolate all of the possible perpetuating factors and put together a plan to diagnose and treat these factors. This may involve further testing or other treatment protocols that we approach and apply in a systematic manner.
Once the above has been addressed, many patients have a conditioned insomnia, in which the brain has been conditioned to have awakenings or arousals. The brain then needs to be retrained on how to sleep again because the coping mechanisms that people adopt for insomnia usually worsen the insomnia – for example, sleeping late because they “did not get a wink all night”, getting up to do relaxing activities or work during the night, “because since I can’t sleep, I might as well do something”, etc.
Many patients ask about using sleeping pills. There are no medical studies that show that the use of long term sleeping pills are either recommended or helpful in insomnia except in certain rare cases, such as after severe traumatic brain injury or other similar conditions. However, sleeping pills may be considered for brief periods if indicated due to particular stressors. The chronic use of sleeping pills is associated with multiple risks, including dementia and fall risks. Some sleeping pills can also be addictive and can cause a rebound insomnia, which can cause a more severe insomnia if the pills are discontinued.
More importantly, sleeping pills do not actually cure insomnia. A person can take sleeping pills for decades, and at the end of it, they will still have insomnia. The pills have only masked the insomnia. Masking the insomnia problem with pills is not the same as curing the insomnia. Proper treatment of insomnia requires thorough consultation and treatment of all perpetuating causes as well as more detailed treatments such as Cognitive Behavioral Therapy for Insomnia (CBTI).
Insomnia treatment can be challenging. A nice introduction to insomnia treatment that we sometimes recommend is a book called "Say Goodnight to Insomnia" which outlines some of the strategies that are used in Cognitive Behavioral Therapy for Insomnia.
For a thorough evaluation for your sleep problems, we recommend that you contact us at our Portland or Astoria location and schedule a consultation.