Can't fall asleep? You don't want to read this then.

This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American

The last post I put up was on narcolepsy and of course the opposite of a condition where you fall asleep all the time is a disease where you cant seem to fall asleep at all, insomnia.

Unlike narcolepsy, which has been shown to have genetic and environmental triggers insomnia seems to have no genetic component. The closest thing to a genetic insomnia is the ominously named fatal familial insomnia, which my old friend Thomas wrote about here.

A diagnosis of insomnia relies on the way the following questions are answered, "Do you experience difficulty sleeping?” or "Do you have difficulty falling or staying asleep?” You answer yes to either of those and you have insomnia.

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There are three types of insomnia called transient insomnia, acute insomnia and chronic insomnia. Also there is one other 'almost type' of insomnia called subjective insomnia or sleep state misperception but in essence they are all about how frequently you sufferer from sleeplessness. Transient insomnia referrers to attacks of a week or less and are brought by stress generally but depression or changes in your ‘sleep environment’ can also induce sleeplessness. Acute insomnia lasts for a month or less and is simply characterised as an inability to sleep well. All the same risk factors apply as for transient insomnia all that changes is the time frame but then we have chronic insomnia.

Chronic insomnia lasts for longer than a month and is typically seen as a result of other disorders but results in some pretty important symtoms in the patient. Chronic insomniacs will experience muscle and mental fatigue, often hallucinate, experience the world around them with a level of disassociation and often in slow motion and even double vision.

Typically with insomniacs it is the psychological effects that are the most wearing.

To prevent insomnia the most common suggestion is to kick the stimulants and live a healthier life. Diet and exercise help to establish our diurnal rhythms and so can fix insomnia on its own. The stimulant thing is just common sense, cant sleep after your third coffee of the night? Drink less coffee.

Outside of generally improving your health other non-pharma solutions include therapy to associate the patient’s bed and sleep with positive emotions. Another option is bright light therapy, which involves using very bright lights in the morning to help reset the body’s internal clock.

Another interesting option called paradoxical intention attempts to shift the focus of a patient to distract them. Rather than trying to fall asleep and becoming more anxious the longer you stay awake this therapy involves the patient doing everything they can to stay awake. It is widely considered to be one of the most effective techniques and ticks all the key indicators for treating insomnia.

These therapies are often combined with cognitive behavior therapies to reinforce positive association with sleep and remove misconceptions and negative or unrealistic associations. These techniques have bee shown time and again to be far more effective than pharmaceutical approaches due to the development of drug tolerance.

Alongside the issues of tolerance many drugs, such as the benzodiazepines, also result is dependence, which while effective in the short term often find that their effects are often reversed when the drugs are removed due to withdrawal.

Home remedies for insomnia also exist. I know on more than one occasion I have fallen asleep after drinking and surprise surprise… alcohol tops the list as most popular home remedy. Whilst its acts as a generalised depressant, long term alcohol use will, over time, actually reduce NREM sleep and REM sleep which will actually induce insomnia. Plus there are also all those other problems with long-term alcohol abuse thrown in.

What I use personally are drowsy formula anti-histamines. I suffer full-on allergies during spring and summer and find that the onset of allergies coincides with insomnia. My drug of choice (called Phenergan in Australia and is often recommended when benzodiazepines are not appropriate) contains the drug promethazine hydrochloride which is primarily an anti-mimetic and anti-histamine.

Most anti-histamines that act as sleep inducers block the H₁ histamine receptor. This receptor acts to reclaim histamine after it is released during nerve activity and is primarily found on nerve cells in the hypothalamus. The anti-histamines block this receptor and as a result lower nerve activity which artificially mirrors the change in activity in these nerves during time when you are awake (very active) and when you are asleep (no activity at all).

As opposed to narcolepsy which results in a tendency to fall asleep, has very few sufferers and requires drugs for effective control, insomnia or an inability to fall asleep easily is experienced by many people transiently throughout their lives and is most effectively treated by improving your general health. Maybe these diseases are opposites after all.

References

Reiner PB, & Kamondi A (1994). Mechanisms of antihistamine-induced sedation in the human brain: H1 receptor activation reduces a background leakage potassium current. Neuroscience, 59 (3), 579-88 PMID: 8008209

Roth T, & Roehrs T (2003). Insomnia: epidemiology, characteristics, and consequences. Clinical cornerstone, 5 (3), 5-15 PMID: 14626537

Rosenberg RP (2006). Sleep maintenance insomnia: strengths and weaknesses of current pharmacologic therapies. Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists, 18 (1), 49-56 PMID: 16517453

Jacobs GD, Pace-Schott EF, Stickgold R, & Otto MW (2004). Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Archives of internal medicine, 164 (17), 1888-96 PMID: 15451764