Insomnia... is it really a symptom or is it the root cause?

[politicat]

One of my big issues is insomnia, which I've pretty much always had - I can remember being in kindergarten and not being able to sleep on a school night. As I've aged, of course, it's gotten worse, but the fact that I didn't sleep much and didn't need a lot of sleep sure helped me get through the Master's program.

While I'm on medical leave, though, I've been re-organizing client files and re-reading them with an eye to write a study on early childhood eating practices as correlated to later unhealthy eating patterns and the thing I keep coming across is insomnia as a precursor to a depression/dysthymia diagnosis. In 80% of the cases, I'm seeing insomnia before any other clinical diagnosis in the medical records.

Which is giving me a lovely chicken and the egg problem. Since we know that getting enough sleep on a proper schedule is necessary for weight maintenance, blood pressure regulation, neurotransmitter balance, and about a hundred other things (sleep apnea studies are proving that), it makes me wonder if depression and anxiety are not caused by insomnia, rather than insomnia being an effect of the disorder. So I'm thinking a couple of things - either insomnia and lack of adequate sleep are early warnings of neurochemical imbalances, or insomnia and lack of adequate sleep cause neurochemical imbalances that present as anxiety and depression, or both.

Any comments?

[DemExpat]

1. Certainly a chicken and egg issue here.

In my life I would say that my major periods of insomnia were caused by anxiety and depression, although sometimes lack of sleep would also bring up emotional imbalances including anxiety and depression, so they are definitly closely related and interrelated. I personally do not think that a simple correlation or cause and effect relationship exists which fits everybody as we are so all very unique...:-)

I think after all of my years of experience I choose to see it as a Yin Yang type of process - one contrasting state flowing into the other, one instigating the other,....and the trick, or key is to try and keep a good balance - by sensitively and carefully monitoring one's own feelings and state of health and bodily/emotional clues (hunger, sleepiness, need for exercise and movement, need for intimacy or fun,etc.) - something we tend to have been taught to totally "forget" throughout childhood - at least in my case!

So I would say that not listening to ouselves and not taking good care of ourselves - our feelings and bodies - is what causes MUCH dis-ease and ill health, etc.
It is IMO the Listening and taking action on what you hear that will bring balance into the interrelated processes.

DemEx

[mrgorth]

2. Chicken and egg

I slept quite well before my depression kicked in. That said, throughout my life, I've never been a tremendous sleeper which I think indicates a predisposition towards depression.

[mopinko]

3. sleep is an egg!!!

i have seen several examples in my family of sleep disorders that had physical roots, and they caused all manner of mental/emotional dysfunction. when the underlying causes were dealt with, all was better. i find it quite appalling that this is not more widely understood, and utilized. m.d.s dissed it, and shrinks never considered it. if i ever get that magic wand i keep wishing for, all psych inpatients will have their sleep monitored, and anyone presenting in a sleep deprived state will get that caught up before anything else is done. at the very least, they could have some better sleep hygiene. it ain't rocket science.

[Maraya1969]

4. Insomniac for my entire life here - and bp. I HAVE to get sleep or

else I'll end up with mania so if my medications don't work I have a second round of other stuff.

The one thing that is hard to realize about bp is you can't let yourself get too happy either. I bet that is the only illness in the world with that symptom.

[varkam]

5. I watch people sleep for a living.

I work at a sleep lab, and of course one of the big complaints that we get from our patients is insomnia. From what I understand about insomnia, it is generally viewed as a symptom in and of itself and not a disease. There are two different flavors (which is important to note in getting to the bottom of the issue) - transient and chronic. The transient insomnia usually lasts for anywhere from a few days to a couple of weeks and can be kicked off by some external stressor (e.g. work-related stress). The chronic type lasts for longer than a month and can become habitual. From what I've read and seen (and I'm no expert), it's more typical to see something like a general medical condition, mental illness, medication interactions, or all co-exist with chronic insomnia as opposed to external stressors.

But it's definitely a problem, regardless of whether or not one views it as a disease or a symptom. Sleep does have a tremendous impact on our lives, and not getting it can really affect everything that you do in the daytime due to sleepiness.

[RedOnce]

6. I did some research on insomnia...

for a bipolar relative a few years ago. Some of it was quite interesting. It seems that you can treat the circadian problem with enforced darkness (lights out at 10 pm, but you listen to the stereo if you want) and over time both the insomnia and the mood swings improved. Also you could treat the mood swings with mood stabilizers and the insomnia also improved.

It seems like a good idea to treat both, of course, neither is as easy or as simple as it sounds.

[varkam]

7. FYI...

here's a few ways to help with insomnia...

Practice good sleep hygiene - Try to go to bed at the same time and rise at the same time. Don't have too many distractions (e.g. computer, TV, etc.) in the bedroom. Don't use the bed except for sleeping and sex.

Sleep restriction - Allot a certain amount of time per night for time spent in bed, regardless of how much you actually sleep. For instance, lay down at 12 and get up at 6 even if you don't fall asleep until 4.

Avoid daytime naps.

If you're laying in bed for twenty minutes and have trouble achieving sleep onset, try getting out of bed and going into another room and doing something quiet and boring (e.g. reading a dry book) until you feel tired again. Then go back to bed and lay down, repeat as needed.

Short term use of hypnotics - there are some OTC meds that are pretty good at Txing transient insomnia (such as Tylenol PM, benadryl), but should only be used for a max of a week or so as they do carry a risk of psychological dependence (anything that can induce sleep carries that risk)

Do not drink alcohol to fall asleep - This one is a big one, as lots of people do it - and it's one of the worst things you can do for your sleep. Alcohol might help you reach sleep onset, but as your body metabolizes the toxic component of alcohol, portions of your CNS become aroused and it leads to sleep fragmentation. In addition, Alcohol is a depressant and relaxes your muscles and (in larger doses) your respiratory drive. If you already have risk factors for obstructive sleep apnea (obese, smoker, middle-aged, Hx of snoring, often wake with a dry mouth / headache, etc.), then throwing alcohol on top of that is likely to make it worse.

CBT / biofeedback - studies show that for certain individuals with chronic insomnia, cognitive-behavioral therapy and biofeedback can do more than medication alone.

Circadian Rhythm entrainment / light therapy - I find this one especially helpful myself, as I'm a shift worker - which can lead to a circadian rhythm disorder. Bright light acts as a "time-giver" for our body. It tells us what time it is. If I have trouble getting to sleep at night because of shift work, then what I do is sit in front of a bright light for an hour in the morning and an hour at around noon - works like a charm for me.

<on edit> Exercise - Try to work some exercise into your routine. It's a simple thing, and for someone of the patients I've worked with it's done wonders. But don't do it right before bed.

Hope some of that helps someone.

[DemExpat]

8. A friend of mine recently went to a sleep clinic in a hospital here

and the "prescription" she received was just that:

"Go to bed every night at midnight, rise and 6:30" - she seems to need less sleep than I do, for I feel best at 7 1/2 hours or more of good sleep.
Seems like such simple advice, after all of the extensive testing....:eyes:

Daily long walks are great too in my experience.

DemEx

[varkam]

9. Sometimes the best treatment...

is just that. Behavioral treatment of insomnia is often overlooked, especially in our society which tends to be a bit pill-happy. The hypnotics which are used to treat insomnia are pretty good, especially the newer non-benzodiazipines that still act to modulate GABA like ambien and lunesta - but the results tend to be a bit mixed for treating chronic insomnia.

And you're quite right about some people needing less sleep than others. There's no one recommendation about how much sleep we should all get because it's different for each person. I'm like you, I need about 7 hours to feel like my head is screwed on straight, but my girlfriend needs about 9 hours - so go figure.

[depakid]

10. Welp, when you're hypomanic

it's a symptom.

Most bipolars have trouble with sleeping patterns- and good hygeine is important. One poster mentioned light affecting circadian rhythms- and that seems to happen every spring to many of the folks on another website/support group I help run. Typically it's reduced sleep- 2-4 hours a night for days or weeks at a time (depending on how one cycles) but there are people who go through periods of 30-60+ hours without sleep.

Most people have some sleep aids that work for them- seroquel, ativan, maybe lunestra (though that hasn't been out long enough- or tested thoroughly). Zyprexa also seems to work for some people. However, there are others for whom nothing really works.

They just end up having to grit it out.

[varkam]

11. On sleep meds

Here's some of my experiences with the newer meds out on the market:

Ambien - Tried and true. Usually works to achieve a fast sleep onset in most people. It's the #1 Rxed sleep aid in the United States. Studies on it's efficacy are pretty solid and show that the differences in sleep architecture (e.g. how much time you spend in each stage of sleep) isn't statistically different from placebo.

Ambien CR - Essentially the same thing as ambien except one half of it has an enteric coating that slows absorption into the bloodstream while the other half is the immediate release form (it's supposed to get you to sleep quick and keep you there). My personal experience with it has been mixed.

Lunesta - The first non-BZD sleep aid to be approved for long-term use, which is good for chronic insomniacs. However the dosages are pretty low, so the effect might be negligible if you happen to metabolize the drug too quickly.

Sonata - The sleep aid of choice for elderly (65+) patients. It has a faster half-life, so it's out of your system by morning (no hangover effect). This is especially useful in the elderly as they tend to metabolize drugs much more slowly (they stay in the system longer), and studies have shown that there is a significantly increased risk of injuries (such as slipping and falling) due to a lack of motor coordination with an elderly population taking benzos.

Rozerem - Works on the melatonin receptors as opposed to modulating the effects of GABA (which is primarily what the others do). I'm not really aware of any efficacy studies done on it, but my experiences with it (and those of three friends) have been horrible. When I took it, it took me a long time to go to sleep, my sleep was extremely fragmented, and I slept about 12 hours. The experiences of my friends were very similar.

[depakid]

12. Ambien is tricky

Most pdocs don't like their patients taking it because of drug interactions and some nasty side effects associated with unipolar depression and bipolar cycling. And if you're going to take ambien, you might as well take a benzo like ativan or klonopin- which are safer.

Haven't heard about Rozerem. I'll have to look into that. Some people seem to respond well enough to melatonin- especially for jet lag type things- but it won't do jack for racing thoughts. Benadryl also works for some people- but again, it's no match for hypomania. Chamomile tea? LOL- it tastes nice, but it's not going to knock an insomiac out.

As to lunestra (what a marketing name, eh?) It hasn't been around long enough to know what sort of things might crop up. A lot of "on the ball" pdoc's don't trust the FDA's approval system anymore (with good reason). Personally, I'd be very wary of using it for any length of time.

[RedOnce]

13. Some people report some pretty strange behavior on Ambien...

it seems that they walk around in a stupor doing things that they wouldn't normally do. They talk about taping their door knobs so they can't leave the room and taping their phones so they can't make calls. They don't realize what they were doing until the next day.

Of course, others think Ambien is the best sleep med out there.

Due to Sonata's short half-life it is often suggested for use you when you wake up in the middle of the night and still need to go back to sleep.

[varkam]

14. Ambien does have it's drawbacks, for sure..

I once had a patient who was taking Klonopin when she came into the lab and couldn't fall asleep, so we gave her 10mg of Ambien. She woke up in the middle of the night and started talking into her bottle of water as if it was a phone. Then of course she took a drink out of it, so I'm really not sure if it was legit or not.

But with agonistic drug interactions, people who are poor metabolizers of the drug, or people who are taking any substance that suppresses the enzyme family responsible for breakdown can have adverse reactions to the drug like those mentioned (e.g. having no memory of things done in the morning, walking around in a stupor, etc.).

Also, yes, Sonata is also good for people with terminal insomnia (waking in the middle of the night and unable to fall back asleep), but from my experience terminal insomnia is usually a definite symptom of an underlying cause - usually obstructive sleep apnea (though certainly not always).

[mrgorth]

15. I'm on restoril.

Seems to help me stay asleep better than ambien.

[Digit]

16. I have problems with anxiety

I have always been a light sleeper and lately, could not sleep more than 5-6 hours at a time.
I had heard of GABA, and purchased a product called "True Calm" last week from my local GNC. It is manufactured by NOW and cost 14.95 for 90 capsules.
The ingredients are listed as follows:
Niacin 45 mg
Vitamin B6 8 mg
Magnesium 13 mg
GABA 200mg
Glycine 200 mg
Taurine 200 mg
Inositol 100 mg
Valerian 25 mg

I started with one in the morning, and one before bed and my sleep level is deeper than it has ever been. I am not sure if this is a good thing or bad thing. It is just so "different" to sleep so soundly and not wake up several times a night. I wonder if it is TOO deep. I am considering cutting down to one capsule per day.
My anxiety level may be slightly lower, but not by much.
The dosage states to take 1-3 capsules daily on an empty stomach.


Is anyone familiar with this product?

[hedgehog]

19. Valerian is an herb that causes sedation.

I had to warn my daughter not to use it. She thought it would make nice tea from the smeell, but when we looked it up it can be rather strong sedative. Check with your doctor or pharmacist for interactions with anything else you may be taking.

[zanne]

17. Lots of sunlight.

My GP recommended that I get my internal clock back on track by getting outside and getting as much sun as possible. Granted, I don't have a really serious insomnia problem, but it works for me.

[politicat]

18. Good way to get really sick....

At least for me. I have almost no melanin; I burn in 10 minutes without sunscreen. I use sunscreen, obviously, but that's an interesting point. I go back to work on Tuesday so I may use this to encourage clients.

[hedgehog]

20. Root cause and a symptom.

So much brain function seems tied into various feed back loops that it all depends on the exact situation. When my depressive cycles peak (trough?) I can sleep 14 hours a day and still be drowsy.

[stepnw1f]

21. I Have Had Bad Sleeping Habits

due to anxiety/obsessive worrying. The everyday would just drag, eventually making me feel tired ALL the Time, and extremely touchy towards any criticism. Once I got a bunch of sleep I felt better. This sounds like a Chicken and Egg situation.

I was prescribed Trazadone for a while, until my sleeping habits improved.