Difficulties sleeping

*Severe sleeping problems, I can stay one week without sleeping at all (I feed physically and mentally exhausted but I can not disconnect my brain). problems at work and home as a result (not causing the stress). Can not drive.
* Problem started gradually 10 years ago (long nights studying at the University, with much coffee). After giving the exams...instead of being relaxed it took me at least two days to come down.
* tried everything !!(always with a dr. prescription, also yoga and meditation, nothing works).
* I get up in the morning tired, I go to bed more tired. After getting Imovane (prescribed by the Dr) I can sleep, but the quality of the sleep is very bad.
* before that I was prescribed Tolvon, and could not sleep and was very confused in the morning.
* Have put on weight in the last 5 years (28 kg!!), I could get riddd already 8 kg in the last 9 months with the help of a specialist.
* Hormonal profile, including cortisol (done in june 04) is OK.
* Never done a special study on sleeping.
* 30 minutes walk every day, controlled meals (low calories)
* Married and have a baby 20 months old. Full job at home and work (I am veterinarean working as a researcher). Don't have big worries.
* The more tired the more difficult to sleep (cycle); can not relax ( I think is organic)
* I want to know what is wrong with the sleeping (now is chronic and not related to daily life) and want to solve it, quality of life is very poor. I never have energy.

Relevante sykdommer/medisiner: * Diagnosed "Insulin resistance", not confirmed in Norway.
* Taking Imovane, 5 mg/night
* Taking reductil (1 tablet)
One year ago, had valium (low dose) for a short period. It worked (I could sleep) but I was tired in the morning.

Kvinne, 40 år

It is difficult to say anything absolute regarding the causes of your problems. Insomnia is commonly divided in primary and secondary. Secondary insomnia is caused by a physical condition (e.g. specific sleep disorder, a mental disorder or by substance use, while primary insomnia denotes an insomnia without such aetiology.

Primary insomnia may be caused by poor habits, a vicious learning process. Often there may be some personality tendencies, such as the tendency to worry that might, together with other factors, trigger insomnia.

When it comes to the vicious learning process most sleep experts argue that staying awake in bed over prolonged periods of time causes the bed and the bedroom to become associated with wakefulness. In addition, many insomniacs becomes so agitated, nervous and preoccupied by their sleeping problems that this causes them to expect sleeping problems at night - and this expectation obviously leads to activation and a state of arousal - incompatible with sleeping.

Primary insomnia is best dealt with by following some basic behavioral treatment programs, comprising of several specific elements, that I am referring to here:
SLEEP HYGIENE - consist of the most basic advices of how to obtain a good night sleep.
1) Stop intake of caffeine (coffee, tea, energy drinks, coke, chocolate) at 1200h as caffeine causes arousal and may have a biological effects for many hs after intake.
2) Do not smoke late at night, as nicotine also may cause activation.
3) Do not drink alcohol in order to sleep - alcohol do may your sleep worse.
4) Never sleep during the day - this make it difficult to initiate sleep in the evening and ofte make the nocturnal sleep poor.
5) Never sleep for longer periods than usual (e.g, 7 hs) in order to catch up for lost sleep. This only makes things worse in the long run and may cause disturbances in the circadian rhythm.
6) Do exercise every day (for about 30 minutes at least) but terminate training no later that 3-4 hs prior to bedtime
7) The last 3-4 hs before bedtime you should relax. If you do physical work or exercise, or work with mentally and intellectually stimulating tasks you will be aroused. Stop these kinds of activities no later than 3-4 hs before bedtime. Do not, if you can prevent it, expose yourself to emotionally upsetting stimulus (arguing etc) before bedtime. This point (no 7) is often ignored by many.
8) Take a warm bath for 30 minutes 2 hs before bedtime. The heating causes a compensatory fall of the core body temperature 2 hs later - research has shown that fall in the core body temperature makes us sleepy.
9) IMPORTANT: Get up the same time every morning, irrespective of hs sleept (e.g. 0700hs). Ideally, a maximum of hs should pass before going to sleep after waking up in the morning - studies show that in order to sleep well a build up of a sleep need is necessary (homeostatic sleep factor). That means that if you Sunday morning sleep until 1200h, it would become difficult to initiate sleep at 2300hs the same evening.
10) Another factor that governs sleep is the circadian. There is a biological clock, situated in the hypotahalmus. This clock governs the sleep-wake cycle and other prosecces in the human body (such as the core body temperature rhythm), The latter rhythm is normally synchronized with the sleep-wake rhythm in such a way that it is most easy to fall asleep when the core body temperature starts to fall (normally somewhere between 2200 h and 2400 h). The lowest point in the cory body temperature (nadir) usually is placed at 0500h, and one typically awakens spontaneously about 2-3 hours later. Sleeping problems may occur if the circadian rhythm is flattened (e.g. if one has worked and slept at irregular hours) or advanced or delayed. Delayed sleep phase is quite common and manifestations of this is difficulties initiating sleep and being very sleepy in the morning. Sunlight, or bright artificial light, comprise the best time givers (that corrects the period and amplitude of the inner biological clock). If you dont have a sleep wake rhythm that is advanced (typically falling asleep very early in the evening, and waking up in the night) I suggest that you expouse yourself for outdoor light for 30-45 min in the moring or morning bright light (10 000 lux) for 30-45 minutes in the morning (for example beteeen 0700hs and 0730 hs),
11) Do never have access to a bedroom clock. This only causes you to become preoccupied with time which is not conductive of getting relaxed.
12) Eat a light meal 1-2 h before going to bed. Hormones secreted from the gut following a meal probably have some sleep inducing properties. In addition, hunger disturbs sleep.
13) It should be as dark and quiet as possible in your bedroom. The temperature should be about 14-20 degrees Celsius. If it becomes to cold or hot this typically disturbs sleep (especially a sleep stage called rapid eye movement sleep, where the body temperature regulation system is inactive)

Besides this basic rules that you might already conform to, I strongly suggest that you adhere to the principles of sleep restriction and stimulus control. It is of the utmost importance that you understand the rational for these interventions in order to be motivated to adhere to them. Sleep restriction and stimulus control were techniques developed in the US in the 1970s. The researchers that developed these techniques observed that many insomniacs typically just stayed in bed when awake, and some even increased time spent in bed in order to compensate for their poor sleep. What happens, as I mentioned earlier, when you spent excessive amounts of time awake in bed is that you automatically associates your bed and bedroom with wakefulness. Hence a vicious circle develops. It is important to realize that this &#34learning process&#34 is not governed by any voluntary acts, but comes in to place againts our own will (like classical conditiong - jfr the dogs of Pavlov).

Therefore, in order to break the negative association with bed/bedroom and wakefullness, and to relearn that the bed/bedrom shoud trigger the sleep response you should adhere to the following rules:
1) Curtail time spent in bed (e.g .from 2400 to 0700hs). Never stay in bed outside this time window. The magnitude of this window might of course be adjusted according the individual sleep need - this vary from person to person.
2) Never go to bed unless you are sleepy. There is a great and important difference between being tired and sleepy. You can be tired (but have quite a high arousal). When you are really sleepy you have problems keeping your eyes open. If you go to bed when you are not sleepy you will associate you bed with wakefulness and not sleepiness.
3) If you cannot initiate sleep in 15-30 minutes go out of the bed and into another room. Stay there (make it comfortable for you) until you are sleepy again. Then you can go to bed again and try to sleep.
4) Repeat rule 3 as many times as necessary during the night. This also pertains to nocturnal awakenings and when you wake early in the morning without being able to return to sleep. Remember - the overall principle is that you stay as much time in bed as possible asleep, and so little time in bed as possible awake.
5) The only activity that should take place in your bed is sex and sleep. Never eat, watch TV, argue, read etc in bed. The bed and bedroom should be associated with sleep, not with activities one perform when awake.
6) Never sleep during the day.

An important aspect about this procedure is that you have to be motivated in order to follow it. It do not work if you sometimes follow it and sometimes don&#39t. It is also of paramount importance that you understand that sleep will not improve in an day or so using this procedure. You should stick consistently to this procedure for at least 2-4 weeks before significant improvement may be expected.

Try also to change the way to think about your sleeping problems, at least on a day to day basis. It is not a catastrophe if you don&#39t sleep one night or two. As long as you don&#39t stay awake in bed you should try to focus on the fact that you actually do something that is meant to improve your sleep in the long run.

If you like perform yoga or some other relaxation techniques in the evening in order to calm down - feel free to do so.

If you follow through with the recommendations given here, and to not obtain a significant improvement in 4-6 weeks you should take some further steps to assess your sleep. Ask your GP for a referral to a polysomnographic evaluation. This is done in over a night in a hospital, where brain activity, eye movements, muscle tension, respiration, and leg movements are being registered. This procedure will identify potential sleep disorders (such as sleep apnea (overweight is quite common in patients with this disorder) or periodic limb movements during sleep) that may case your problems. Other common causes of secondary insomnia are depression and anxiety as well as physical disorders (metabolic disorders, pain, cardiovascular disease). Some drugs as well as medications, such as Reductil, may also be a cause of insomnia.

Ståle Pallesen, søvnspesialist

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