- The Washington Times - Sunday, April 15, 2001

3:15 Wake up.
3:17 Toss, turn.
3:25 Flip through the pages of a book.
4:13 Stress out about a long day at the office on too little sleep.

This is a typical night for someone suffering from insomnia. For John Wiedman, a mortgage banker from Memphis, Tenn., nights like this went on for years.
After a while, Mr. Wiedman grew accustomed to being up at night. He jokes that he is now an expert on the juicers and abdominal toners sold on late-night television.
That doesn't mean he grew any more comfortable with less sleep.
"The cycle got worse and worse until I was up until 4 or 5 a.m. four nights a week," says Mr. Wiedman, 51. "If I ever got six hours of sleep, it was like I had napped all day. It was horrible. I was usually grouchy all the time."
Mr. Wiedman eventually took control of his sleep by modifying his daytime and evening behavior. He chronicled his struggle in a book, "Desperately Seeking Snoozin': The Insomnia Cure From Awake to Zzzzz."
His case was severe, the kind of chronic insomnia that endures for decades. That type of insomniac could benefit, as Mr. Wiedman did, by seeing a sleep specialist, undergoing behavioral therapy and changing the sleep environment, says Dr. Richard Hoffman, a sleep medicine specialist at Inova Alexandria Hospital.
Other types of insomnia exist, too, and from time to time almost everyone will be afflicted.
"Technically, primary insomnia is defined as the inability to fall asleep after 20 minutes of lying in bed trying to," Dr. Hoffman says. "But really what characterizes it is a sense of distress about not being asleep."
Insomnia can be characterized as transient, which is temporary sleep trouble related to a definable event, such as a big work project, he says. Short-term insomnia is the type that may go on for a few weeks due to ongoing stress such as a family crisis.
Chronic insomnia often has underlying stress as a symptom, but a person should be evaluated for depression, anxiety, allergies and restless leg syndrome (a "It becomes a self-fulfilling prophecy," Dr. Hoffman says. "You develop habits that make it difficult to get to sleep."

How sleep works

"Sleep is a very complex thing," says Dr. Michael Twery, a program officer at the National Heart, Lung, and Blood Institute's National Center on Sleep Disorders Research. "There is a buildup of chemicals that drives sleepiness."
The coordinator of those chemicals is the hypothalamus, the part of the brain that drives the biological clock, setting the circadian rhythms that tell us when to be awake or sleepy. The biological clock and the circadian rhythms change through the years as humans age, Dr. Twery says.
During a normal night, humans pass through stages of sleep. Stage 1 is light sleep, the 10-minute transitional period between wakefulness and sleep. Stage 2 is deeper sleep, and after about 20 minutes, an individual enters Stages 3 and 4, which are similar and hard to differentiate. At Stages 3 and 4, a person experiences the deep sleep with restorative powers. This deep sleep is known as delta sleep from the delta waves the brain makes.
About 90 minutes later, rapid eye movement sleep, the deep sleep in which we dream and rapidly move our eyes, takes over.
Most people cycle back and forth through the stages of sleep several times throughout the night. Problems occur when the cycle is broken, such as when a person wakes up before falling into restorative sleep.
"As we mature from childhood, the pattern changes," Dr. Twery says.
That is why infants sleep most of the day and wake during the night, why teens can stay up late at night and why some elderly people fall asleep on the couch after dinner.
"Our sleep system deteriorates with age," says Dr. Peter Hauri, head of the insomnia program at the Mayo Clinic in Rochester, Minn. "It is normal not to sleep as soundly at 80 as you did at 20."
The elderly can be particularly prone to disruptions in the circadian rhythms, Dr. Hoffman says. He says he sees many patients who are sleepy during the day, who find it necessary to go to sleep early, but then wake up for the day at about 4 a.m.
"This is part of the normal aging pattern," he says. "The important thing is to not get upset about it. If you go to bed early and wake up early, do something when you get up, such as read a book or do a hobby. Don't stress out about being awake."
Dr. Hoffman also advises elderly patients to limit daytime naps to less than 20 minutes.
"If you nap for more than 20 minutes, you will go into deep sleep," he says. "That will affect your chances of getting a good night's sleep."
The hormonal disturbances of menopause can wreak havoc on older women's sleep patterns, Dr. Twery says. Hot flashes and depression can play a part in insomnia, he says. In men, weight gain can lead to sleep apnea, the interruptions in natural breathing that prevent the natural progression of sleep cycles, he says.

Those who cannot sleep

The United States is a nation of drowsy drivers, fatigued workers and sleepy students, according to the latest poll by the nonprofit National Sleep Foundation (NSF).
The NSF's 2001 Sleep in America poll, a survey of 1,004 adults, reported that 51 percent of respondents have had insomnia at least a few nights during the past year. Twenty-nine percent say they have trouble falling asleep nightly.
Forty percent of the respondents said sleepiness on the job interferes with their work. One-third of the respondents reported sleeping less than 6.5 hours a night.
Nearly 90 percent of the respondents said they spend the hour before bedtime watching television. Twenty-three percent said surfing the Internet is a part of their pre-sleep routine, while 21 percent said they catch up on work before going to bed.
Dr. Hoffman advises patients who cannot sleep to re-examine some of those bedtime activities.
"People used to leave work at 5 p.m., and they were done for the day," he says. "Now, with home equipment and telecommuting, there is the adverse consequence of taking away the sanctity of the home. In order to get to sleep, you should not use your bedroom as an office."

What to do about it?

Transient or short-term insomnia can usually be treated with changes in sleep hygiene which consist of behaviors that lead to healthier sleep, such as waking up at the same time daily or not falling asleep while watching television. Chronic insomnia can sometimes be treated with various behavioral treatments, Dr. Hauri says.
The simplest of those treatments would be relaxation training, such as meditation or listening to relaxation tapes.
"It doesn't matter which one you pick, as long as you do it well," Dr. Hauri says.
Sleep restriction therapy also can have an impact. Rather than lying in bed worrying about not sleeping, a person gradually cuts back on his time in bed until he is there and almost exhausted by the time he gets there about four or five hours a night, Dr. Hauri says.
"Once you have learned how to fall asleep when exhausted, you can increase the amount of time you spend in bed," he says.
Cognitive therapy, where a patient explores the reasons for insomnia, also can be effective, Dr. Hauri says.
"The patient and doctor discuss what sleep means to them," he says. "They talk about what ideas are keeping the patient from sleeping. Research has shown time and again that this is more effective than taking pills. Once you have learned what the problem is, it will get better. When you take pills, behaviors can get worse."
Dr. Hoffman says pills are an option for transient insomnia. Short-term or chronic problems, however, should be treated with behavioral therapy, changes in sleep habits or by treating the insomniac for the underlying problem, such as muscle pain or depression.
"Pills are a real no-no for chronic insomnia," Dr. Hoffman says, noting that some people develop a dependence on the medication, thereby creating another problem.
"Trying to wean off the pills adds another dimension to the problem," he says. "Taking pills for 10 days is fine. But for more time than that, it would not be good."

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