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Patient's insomnia is making her desperate

Case history

Louise is a 46-year-old accountant who has been having periodic problems with insomnia for years. For the last two months the problem has worsened and she cannot get to sleep until the early hours. She is getting tired and irritable and in desperation tried one of her friend's sleeping tablets, temazepam. She asks you for a prescription since it worked so well.

Dr Tanvir Jamil discusses.

How much of a problem is insomnia?

About 10-15 per cent of the population suffers from insomnia. It increases with age and women are twice as likely to suffer as men.

Only one in five people with this condition consult their doctor probably because they believe they will not be taken seriously, or that there is no effective remedy, or that they will be given potentially addictive 'sleeping tablets'.

Patients' definition of insomnia will vary but generally insomnia is not getting enough satisfying sleep.

Apart from tiredness, what are the other effects of insomnia?

Patients often complain of loss of concentration, poor memory, poor work performance, irritability and mood disturbance.

Anxiety and/or depression may also result from (as well as cause) insomnia. Physical symptoms include muscular aches and pains as well as tiredness all the time.

Interestingly few patients fall asleep during the day even though they may be tired. This is probably due to the presence of hyperarousal states such as anxiety.

What are the main causes of insomnia?

See box on opposite page. It's worth asking specifically about some of these in the history.

What self-help advice can I give the patient?

· Set a rigid sleep schedule: go to bed at the same time every evening, set a sleeping time of say midnight to 6am. When you are sleeping soundly through this six-hour period add 15 minutes each week to it. You will know when you are getting good sleep ­ you will wake up refreshed and energetic. Be sure to wake up at the appointed time. Do not lie in.

· Don't cat-nap during the day. This will stop you sleeping at the proper time.

· Don't waste time waiting to go to sleep: get up, read a book or magazine, watch TV, knit or listen to something soothing on the radio. When you feel drowsy, go back into bed again. If you can't fall asleep, repeat the procedure. But remember ­ always wake up at the same time every morning.

· Avoid coffee, colas and tea after 4pm. Avoid alcohol at dinner ­ a 'nightcap' will probably wake you up in the middle of the night. A glass of warm milk or a caffeine-free chocolate drink may help you relax.

· Avoid smoking: nicotine can cause shallow sleep and insomnia.

· Avoid strenuous exercise or emotional excitement immediately before you go to bed. Sex before bedtime, however, can help you sleep soundly.

· Exercise during the day or early evening. This will tire your muscles and help sleep.

· 'Quiet time' before going to bed: one or two hours before bedtime give yourself 10 minutes to think about the day's activities ­ including all the stresses, strains and problems. This will help clear your mind, ease anxiety and help you get off to sleep.

· Meditation: a few minutes before bedtime will help relaxation.

· Other useful tips: take a warm bath; change to a more comfortable bed; get dark curtains to block out the light; get rid of distracting clocks; wear loose-fitting clothes; keep the bedroom temperature comfortable; use earplugs to block out noisy neighbours/cars/snoring partners.

Do OTC/alternative remedies work?

Many patients try OTC diphenhydramine (Nytol) or promethazine (Phenergan) which are both sedating antihistamines and seem to work well for short-term insomnia.

The former seems to work faster and causes less daytime sedation. There is no evidence of dependence but patients should be advised to take them for no longer than two weeks continuously.

The herb valerian seems to work well for some people and is not addictive. Teas or infusions made from lavender, rosemary, passiflora or camomile may aid relaxation and reduce anxiety. Gentle massages with aromatic oils (jasmine, sandalwood) may help calm tense muscles and aid sleep. Meditation can work especially well for insomnia but needs daily practice.

Are there any logical ways to think about prescribing sleeping tablets?

Relatively newer drugs such as zopiclone (Zimovane) and zolpidem(Stilnoct) cause less daytime sedation than longer-acting benzodiazepines. They are not benzodiazepines themselves but act on the same receptors (or receptors sub-types).

They are not licensed for long-term use and there is evidence of dependence in a small number of patients. Since they are short-acting they are ideal for patients who have difficulty getting to sleep.

Temazepam (intermediate duration of action) may be better for a patient who has difficulty in maintaining sleep. A two-week course is useful for re-establishing a sleep pattern together with self-help advice. This can be repeated but patients should not be on sleeping tablets for longer than a month continuously because of the risk of dependence.

What is the role of sleep clinics?

Patients are referred to specialist sleep clinics when the cause of their insomnia is uncertain or if self-help and medication has not helped.

They can diagnose neurological causes and circadian rhythm disorders in addition to providing a variety of therapies including behavioural therapy, cognitive therapy, light therapy and chronotherapy (manipulation of sleep and waking times).

What is the latest research on insomnia?

The University of South Australia has found that body temperature is closely linked with sleep.

Apparently 60-90 minutes before falling asleep, the body starts to lose heat from its central core and that brings on increased feelings of tiredness in normal healthy adults.

People who have trouble getting to sleep probably have to wait longer for their body to lose heat.

It seems only to be a matter of a half to one degree, but that small temperature change may result in significant differences in arousal between insomniacs and people without sleeping problems.

This research might lead to alternative treatments for insomniacs by lowering their body temperature.

Main causes of insomnia

Short-term (up to three weeks)

·emotional events, eg bereavement, exams, family issues

·disruption of sleep-wake cycle, eg jetlag, shift work

·change in sleep environment, eg noise

·excessive caffeine/alcohol

Long-term

·anxiety, depression

·poor sleep environment, eg extraneous noise, snoring partner, uncomfortable bed

·neurological problems: dementia, restless legs syndrome

·non-neurological problems: chronic pain, asthma, prostatism, allergies

·drugs/medication

Tanvir Jamil is a GP in Burnham, Bucks

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