where to get help with insomnia

Medication
Numerous medications are associated with insomnia. Stimulants such as coffee, tea and chocolate, nicotine, and amphetamines cause insomnia. Certain psychiatric medications are associated with insomnia.

Medical conditions
Any disease that is associated with chronic pain may result in insomnia. Heart-lung conditions that cause orthopnoea (difficulty breathing) cause insomnia. Urinary frequency and diuretic medication can also lead to insomnia.

Sleepapnoea. This condition is associated with ear-nose-and-throat obstruction. The obstruction takes place during sleep and results in a reduction of oxygen supply to a tissue below physiological levels, until eventually the level of blood oxygen drops to such an extent that the individual wakes up.

Circadianrhythm. Humans have an internal biologic clock that determines their sleep-wake cycle. Any disturbance of this cycle will result in insomnia. Crossing time zones results in jetlag that is often associated with insomnia during the night and somnolence (sleepiness or unnatural drowsiness) during the day.

Environmental changes. Changes in sleep environment; such as going on vacation or sleeping in different quarters when on call, can result in insomnia.

Nocturnal myoclonus or restlesslegssyndrome. Nocturnal myoclonus consists of jerky leg movements at night. “Restless legs” is a feeling that the legs should constantly be moving during the night.

Treatment
Many insomniacs attempt to treat themselves through various methods ranging from alcohol use to over-the-counter medications and prescriptions. However, effective behavioural and medicational treatments are available and often a combination of the two help in the treatment of insomnia.

Medications. The most common medications that are used in the treatment of insomnia are hypnotics, these are drugs that induce sleep and are primarily used for the short-term management of insomnia. Benzodiazepinereceptorantagonists are the most commonly prescribed hypnotic agents for insomnia. Antidepressants can be used to not only address the sleep symptoms of depression but have also been found to have sleep-improving properties.

Behavioural treatments. Psychological interventions seek to change maladaptive sleep habits and dysfunctional beliefs that may exacerbate insomnia and reduce involuntary arousal. These treatments produce reliable and durable benefits for many insomnia patients and avoid the undesirable consequences of many medications.

Stimulus control is a technique in which the patient is trained to re-associate the bed and bedroom with rapid sleep onset.

Sleep restriction is a technique whereby the amount of time in bed is shortened to match the subjective amount of time asleep.

Progressive muscle relaxation is a technique in which patients are instructed to tense and relax different muscle groups throughout the body to reduce the muscle tension that is often observed among insomniacs at night and during the day.

Biofeedback involves providing visual or auditory feedback to insomniacs to help them control certain physiological factors, such as muscle tension, ultimately reducing somatic arousal.

Imagery training is a visualisation used to focus on pleasant or neutral thoughts in order to diminish cognitive arousal.

Paradoxical intervention is a technique in which patients are persuaded to stay awake. This method is based on the principle that performance anxiety about falling asleep contributes to anxiety and arousal that ultimately exacerbates insomnia.

Natural substances Trytophan-containing foods, such as milk, turkey and potato induce sleep. Melatonin tablets and valerian root tablets may also induce sleep.

Sleep hygiene education a technique used to help patients identify lifestyle and environmental factors that may make it difficult to achieve or maintain sleep.

• Avoid stimulants such as caffeine and nicotine before bedtime.
• Do not use alcohol as a sleep aid and avoid alcohol before bedtime.
• Exercise regularly but not within 3 hours to bedtime.
• Minimise light, noise, and extreme temperatures during sleep.
• Eat only a light snack before bedtime, if hungry.
• Do not watch the clock after going to bed.
• Do something relaxing before bedtime, e.g. having a hot bath.
• Use the bed only for sleeping
• Do not nap during the day (except in the elderly).
• Get up at the same time each day, even when tired.
• If not asleep within 20 minutes of going to bed, do a low energy activity (e.g. reading) in another room until tired. Return to bed.

Cognitive therapy is a useful technique for sufferers that often display unrealistic sleep expectations. This leads to performance anxiety due to excessive effort at trying to control the amount and quality of sleep. Cognitive therapy identifies and modifies dysfunctional beliefs about sleep by replacing them with more adaptive beliefs and shifting of attention.

Summary
Insomnia disturbs the normal restorative functions of sleep and results in diminished daytime alertness. This is associated with an increased risk of involvement in accidents. Psychiatric, medical and substance use disorders are associated with insomnia. Non-pharmacologic treatment options on their own or with a short (two weeks) prescription of a hypnotic, resolve most cases of insomnia.

Further references/resources
 EEG and Sleep Laboratory
031 309-5059 / PO Box 47251 Greyville 4023 / Fax: 031 309-5060

Sleep Laboratory, Rosepark Hospital
051 505-5111, Jaco Smit / 083-262-2517
Sleep Laboratory, Pretoria Academic Hospital
Mrs. Janse van Rensburg, 012 354-2282
Prof. P Bartel, 012 354-2120
Dr. C Schutte, 012 354-1643

Sleep Laboratory, 021 404-4360
Department of Neurology & Respiratory Medicine
Groote Schuur Hospital, Main Road, Observatory 7925

For more information please contact the Mental Health Information Centre
tel: 021 938-9229.