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BVHS Weekend Column: Troubled Sleep and Insomnia

by Erika Manis, MD

Do you frequently have trouble falling or staying asleep? Taking longer than 30 minutes to fall asleep or
being awake for more than 30 minutes after falling asleep may be abnormal when persistent and
associated with daytime impairment such as fatigue.

A discussion with a healthcare professional can help first assess for frequent comorbid sleep or
psychiatric disorders such as obstructive sleep apnea, depression, anxiety, or substance use that could
be causative or contributory. Other known risk factors for insomnia are female gender and family
history.

Evaluation may include a sleep study depending on information revealed from a detailed history,
including a review of medication and a physical exam. You will likely be asked to keep a sleep diary
and/or wear an actigraph (if available), which is similar to a wearable fitness tracker. This is used, in part,
to look for sleep patterns that may represent a circadian rhythm disorder that would be approached
differently.

Both behavioral and pharmacologic (medication) treatment options are available for insomnia. Cognitive
Behavioral Therapy for Insomnia (CBT-I) is preferred to hypnotics due to safety and efficacy. There are
fewer side effects and longer-lasting results once discontinued. It is typically six to eight one-hour
weekly sessions, although a brief intervention may be accomplished in as few as three to four sessions.

This is done with a sleep psychologist who focuses not only on sleep hygiene (sleep habits) but, perhaps
more importantly, on sleep restriction (intentional mild sleep deprivation to increase sleep drive) and
stimulus control (getting out of bed when unable to sleep to build a positive relationship with the bed
and bedroom) as well as some shared techniques of relaxation (progressive muscle relaxation, guided
imagery, and diaphragmatic breathing), and cognitive restructuring (addressing unhelpful thoughts).

Group formats, telemedicine, and computerized programs have increased access to care for this
preferred treatment modality. A sleep aid, however, may ultimately be indicated after a thorough risk-
benefit discussion with a prescribing provider. New medication classes are available that may be safer
due to reduced risk for daytime sedation and dependence.

Erika Manis, MD                                               Sleep Medicine                                              Daniel J. and Maria H. Sak Sleep Wellness Center

 

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