CBT-I, if professionally delivered by a very experienced clinician, can be administered for insomnia in almost every circumstance you can think of. Thus, it's a powerful way to move forward as an initial therapy. The question about medication is much trickier, because it's well known CBT-I does not work as well in some hypnotic dependent patients. For these individuals, there is a goal to try to help them taper off the medication first. Nevertheless, it is entirely possible to combine the two steps into a parallel program of CBT-I while tapering off drugs, all simultaneously. In my experience, most insomniacs suffer an underlying physiological component to their sleeplessness, such as sleep breathing disorders, leg movement disorders, chronic pain or other physical things. I like to see these patients aggressively attempt to resolve, if possible, the physiological disruption before ever considering tapering off sleeping pills, because tapering off pills is sometimes very psychologically painful for someone who has used them for a long time.
Much has been written about caffeine impact on insomnia, and there's no question the later you drink or take caffeine, then your susceptibility for insomnia is higher. But, it also depends on whether you have risks for insomnia. For example, someone with anxiety will have more trouble with caffeine in the afternoon than someone with no anxiety. One interesting biologic point is that caffeine reduces your adenosine levels or blocks adenosine action in the body so you no longer feel as tired. That's why it's so "addictive" because it really does work biologically to boost energy. Thus, the big question is why is the person tired and can they find another way to improve fatigue without caffeine. In mild fatigue, most people really do benefit from increased activity. For a tired person who wants to nap, he or she may discover a 30 min walk at a reasonable pace eliminates the drowsiness. The bigger problem is for someone with greater fatigue where the focus should instead be on trying to solve this low energy state not just treating the symptom. In these cases, two of the most common underlying conditions would be an underlying sleep disorder like OSA or UARS or an underlying mental health issue like depression.
A great paradox about PAP therapy is that it could either cure insomnia or cause and aggravate insomnia. If an individual has fallen in love with their PAP device, which is the goal I suggest to everyone who attempts PAP, then it's very likely the PAP will reduce some or all of the breathing related awakenings. If however through no fault of the patient the PAP device becomes an irritant, then things like masks, chinstraps, mouth breathing and so on can all lead to new or continued insomnia episodes
There are numerous subtypes of insomnia, and it seems researchers spend a lot of time creating more and more categories, although it's not clear to me these distinctions bear out when treatment is applied. Clearly, the psychological aspects of chronic insomnia are well described and almost always include the problem of being unable to turn off the mind. Racing thoughts in fact are the single most common cause of insomnia when you ask patients to describe the problem. What worsens insomnia on the psychological front is the problem of losing sleep over losing sleep. If the individual becomes obsessed and frustrated with the lost sleep, then this obsession will lead to worse insomnia. On the physiological side, those with sleep-disordered breathing or leg jerks frequently suffer from co-occurring insomnia problems. In sum, it's always worthwhile to figure out what caused initially or what continues to cause insomnia, after which applying treatment becomes more targeted or as I like to say, "personally tailored."
Regarding clinical standard, insomnia is generally thought to be a disorder if a person reports difficulty falling asleep or staying asleep two or three times per week, feels impaired during the daytime from this lack of sleep, and the process has been occurring for 3 to 6 months.
Planning on running a whole thread on Nightmares in the coming months. For now, I would point out it's a fairly complex topic, because there are many different causes as well as many different treatments for nightmares. That said, there's two basic issues to look at when first attempting to deal with nightmare-induced insomnia. Initially, you must decide if you want to treat the nightmares, hoping that would resolve the insomnia (which it only does sometimes). Or, you can look at nightmares as a cause similar to typical insomnia patterns that we call "learned" insomnia. For example, if you continue to have nightmares, your mind-body would eventually tell you, "why am I going to sleep? I'm just going to have another nightmare." And so this person "learns" to have insomnia to prevent the nightmares.
If we are talking about hypnotic dependency, then the immediate question is why is the pill not working to solve the insomnia? Only a small proportion of patients obtain fantastic results with prescription sleeping pills, which is why so many try them out and then quit for lack of good or consistent results. Unfortunately, some individuals continue taking the sleeping pills because they don't appear to be given other options. The general rule in the field of sleep medicine is that if the individual wants to get off of sleeping pills, they can usually do so successfully with cognitive-behavioral therapy or CBT-I. Nonetheless, this process may take several months and occasionally as much as a year if the individual has been on medication for a long time.
Insomnia during the 3rd trimester is usually thought to be related to various discomforts or symptoms, for example pain or trips to the bathroom, both of which may be common during the final stages of gestation. However, more recent research implicates sleep-disordered breathing as a cause of insomnia, because certain women are very susceptible to developing breathing disorders in the 3rd trimester. This breathing disruption leads to awakenings, and then the individual may discover it's difficult to fall back asleep. More OBs are now recognizing the need to put 3rd trimester women on PAP machines, which often leads to improved insomnia symptoms, not to mention less trips to the bathroom.
Can you offer any suggestions to those who are dealing with insomnia as a result of chronic nightmares? It has been my family’s experience that it is difficult/nearly impossible to find doctors who understand how chronic nightmares can cause severe insomnia, many docs don’t seem to view nightmares as a real problem. Thank you!
Planning on running a whole thread on Nightmares in the coming months. For now, I would point out it's a fairly complex topic, because there are many different causes as well as many different treatments for nightmares. That said, there's two basic issues to look at when first attempting to deal with nightmare-induced insomnia. Initially, you must decide if you want to treat the nightmares, hoping that would resolve the insomnia (which it only does sometimes). Or, you can look at nightmares as a cause similar to typical insomnia patterns that we call "learned" insomnia. For example, if you continue to have nightmares, your mind-body would eventually tell you, "why am I going to sleep? I'm just going to have another nightmare." And so this person "learns" to have insomnia to prevent the nightmares.
Thank you for your time!
Good night, sweet dreams
Looks like bedtime is approaching. I will leave you with this sweet song, and remember you can always skip the ad in 5 seconds:
https://www.youtube.com/watch?v=dkTkNVQwQDY
Is it typically best to initiate CBT-I before reducing sleep medication (with insomnia)?
CBT-I, if professionally delivered by a very experienced clinician, can be administered for insomnia in almost every circumstance you can think of. Thus, it's a powerful way to move forward as an initial therapy. The question about medication is much trickier, because it's well known CBT-I does not work as well in some hypnotic dependent patients. For these individuals, there is a goal to try to help them taper off the medication first. Nevertheless, it is entirely possible to combine the two steps into a parallel program of CBT-I while tapering off drugs, all simultaneously. In my experience, most insomniacs suffer an underlying physiological component to their sleeplessness, such as sleep breathing disorders, leg movement disorders, chronic pain or other physical things. I like to see these patients aggressively attempt to resolve, if possible, the physiological disruption before ever considering tapering off sleeping pills, because tapering off pills is sometimes very psychologically painful for someone who has used them for a long time.
even the insomniacs!
It's beginning to look like I've been successful in putting some people to sleep.
Is there a relation between too much caffeine intake and insomnia? How do you reduce your caffeine intake if you’re feeling exhausted by mid day.
Much has been written about caffeine impact on insomnia, and there's no question the later you drink or take caffeine, then your susceptibility for insomnia is higher. But, it also depends on whether you have risks for insomnia. For example, someone with anxiety will have more trouble with caffeine in the afternoon than someone with no anxiety. One interesting biologic point is that caffeine reduces your adenosine levels or blocks adenosine action in the body so you no longer feel as tired. That's why it's so "addictive" because it really does work biologically to boost energy. Thus, the big question is why is the person tired and can they find another way to improve fatigue without caffeine. In mild fatigue, most people really do benefit from increased activity. For a tired person who wants to nap, he or she may discover a 30 min walk at a reasonable pace eliminates the drowsiness. The bigger problem is for someone with greater fatigue where the focus should instead be on trying to solve this low energy state not just treating the symptom. In these cases, two of the most common underlying conditions would be an underlying sleep disorder like OSA or UARS or an underlying mental health issue like depression.
How much does sleep apnea and use of PAP play into insomnia?
A great paradox about PAP therapy is that it could either cure insomnia or cause and aggravate insomnia. If an individual has fallen in love with their PAP device, which is the goal I suggest to everyone who attempts PAP, then it's very likely the PAP will reduce some or all of the breathing related awakenings. If however through no fault of the patient the PAP device becomes an irritant, then things like masks, chinstraps, mouth breathing and so on can all lead to new or continued insomnia episodes
What's the clicnical standard for being insomniac? Are there subcategories, perhaps relating to different causes?
There are numerous subtypes of insomnia, and it seems researchers spend a lot of time creating more and more categories, although it's not clear to me these distinctions bear out when treatment is applied. Clearly, the psychological aspects of chronic insomnia are well described and almost always include the problem of being unable to turn off the mind. Racing thoughts in fact are the single most common cause of insomnia when you ask patients to describe the problem. What worsens insomnia on the psychological front is the problem of losing sleep over losing sleep. If the individual becomes obsessed and frustrated with the lost sleep, then this obsession will lead to worse insomnia. On the physiological side, those with sleep-disordered breathing or leg jerks frequently suffer from co-occurring insomnia problems. In sum, it's always worthwhile to figure out what caused initially or what continues to cause insomnia, after which applying treatment becomes more targeted or as I like to say, "personally tailored."
Regarding clinical standard, insomnia is generally thought to be a disorder if a person reports difficulty falling asleep or staying asleep two or three times per week, feels impaired during the daytime from this lack of sleep, and the process has been occurring for 3 to 6 months.
Planning on running a whole thread on Nightmares in the coming months. For now, I would point out it's a fairly complex topic, because there are many different causes as well as many different treatments for nightmares. That said, there's two basic issues to look at when first attempting to deal with nightmare-induced insomnia. Initially, you must decide if you want to treat the nightmares, hoping that would resolve the insomnia (which it only does sometimes). Or, you can look at nightmares as a cause similar to typical insomnia patterns that we call "learned" insomnia. For example, if you continue to have nightmares, your mind-body would eventually tell you, "why am I going to sleep? I'm just going to have another nightmare." And so this person "learns" to have insomnia to prevent the nightmares.
Is it possible to overcome chronic insomnia while still being on sleep medication?
If we are talking about hypnotic dependency, then the immediate question is why is the pill not working to solve the insomnia? Only a small proportion of patients obtain fantastic results with prescription sleeping pills, which is why so many try them out and then quit for lack of good or consistent results. Unfortunately, some individuals continue taking the sleeping pills because they don't appear to be given other options. The general rule in the field of sleep medicine is that if the individual wants to get off of sleeping pills, they can usually do so successfully with cognitive-behavioral therapy or CBT-I. Nonetheless, this process may take several months and occasionally as much as a year if the individual has been on medication for a long time.
Can you make any recommendations for insomnia during the third trimester of pregnancy ?
Insomnia during the 3rd trimester is usually thought to be related to various discomforts or symptoms, for example pain or trips to the bathroom, both of which may be common during the final stages of gestation. However, more recent research implicates sleep-disordered breathing as a cause of insomnia, because certain women are very susceptible to developing breathing disorders in the 3rd trimester. This breathing disruption leads to awakenings, and then the individual may discover it's difficult to fall back asleep. More OBs are now recognizing the need to put 3rd trimester women on PAP machines, which often leads to improved insomnia symptoms, not to mention less trips to the bathroom.
Can you offer any suggestions to those who are dealing with insomnia as a result of chronic nightmares? It has been my family’s experience that it is difficult/nearly impossible to find doctors who understand how chronic nightmares can cause severe insomnia, many docs don’t seem to view nightmares as a real problem. Thank you!
Barry Krakow, MD8 min ago
Planning on running a whole thread on Nightmares in the coming months. For now, I would point out it's a fairly complex topic, because there are many different causes as well as many different treatments for nightmares. That said, there's two basic issues to look at when first attempting to deal with nightmare-induced insomnia. Initially, you must decide if you want to treat the nightmares, hoping that would resolve the insomnia (which it only does sometimes). Or, you can look at nightmares as a cause similar to typical insomnia patterns that we call "learned" insomnia. For example, if you continue to have nightmares, your mind-body would eventually tell you, "why am I going to sleep? I'm just going to have another nightmare." And so this person "learns" to have insomnia to prevent the nightmares.
Thanks Dr. Krakow! I’ll be looking forward to your future discussion on nightmares!
I forgot to mention we have resources on the main website including videos and workbooks on how to treat chronic nightmares.
https://barrykrakowmd.com/products-for-sleep-patients-and-sleep-professionals/
Yes, this is where I will attempt to put you to sleep and overcome insomnia
LOL. I am still getting used to the format. It took me a moment to find the discussion.
Hi. Am I in the right spot to tune in to the discussion on Chronic Insomnia?