Treatment Strategies

Often the person with chronic insomnia has invariably tried multiple remedies from conventional to alternative medicine with temporary or no success and has the feeling of having “lost control over their sleep.” 

The aim of our treatment is to restore control over your sleep. The amount of work will vary from one person to another.

Management involved four broad areas:

  1. Management of primary sleep disorders if present including potential side effects of medications and other medical or psychiatric co-existing problems.
  2. Re-framing the problem of insomnia.
  3. Management of daytime issues.
  4. Management of bedtime and night time problems.

Do you have any of the following:

These are common conditions that can cause insomnia by fragmenting sleep.

  • Obstructive sleep apnea.
  • Restless leg and leg movements
  • Body clock problems
  • Medications you using
  • Excessive caffeinated beverages

Re-framing the problem of insomnia

The following is a simple way to proceed and can be modified if necessary.

Remember the following points:

  1. Insomnia is a symptom not a disease
  2. Insomnia is a symptom of 24 hour poor functioning, not just a bedtime/night time problem (fig 00). What the person does from 8.00am until 8.00pm is important to sleep as sleep is important to daytime function. What matters during the day is self, family and work environment relationships (see below).

  3. Understand the notion of “learned insomnia” (psycho-physiological insomnia).

  4. Be aware of insomnia with daytime sleepiness versus insomnia without daytime sleepiness and establish which group you belong to.

Daytime Issues

The way we function during the day is very important in order to have a good night’s sleep. Three main areas are relevant:

  • Self
  • Family/close friends
  • Working and social environment

Often the reason why we sleep poorly is found in events that occur during the day. Sometimes we are able to recognize precisely the day and even the time when difficulty initiating and maintaining sleep started. Other times it is more difficult. Insomnia seems to have started gradually over many months or years before the person seeks help.

It is important to think about events that may have triggered the symptom of insomnia. Typical cases to consider are death in the family, personal events such as separation or divorce, a change in job or career. A change in the working environment itself may have lead to an increased level of anxiety or stress which in turn leads to poor sleep. Poor sleep causes poor day functioning in what becomes a vicious circle.

Sometimes we feel that we have ‘come to terms’ with the stressful events. However, the emotional cost can take weeks, sometimes months to reveal itself and the only main manifestation of these unresolved feelings is often insomnia and a general un-wellness during the day.

Self and Family

Try to answer this question: do I feel “happy”? At the end of the day either at work or at home do we have a sense of fulfilment and satisfaction?

If this is missing try to explore the underlying reasons. Of course the most important issues are intimate relationships with our family, spouse, our children and our close friends. If there is any problem it is likely that it reflects at nighttime with difficulty with sleep and insomnia.

This is particularly the case when the person has to make a decision but is unable to make a final choice. For example the person may not be sure if to continue a relationship, or to quit a job or make a career change. Irrespective of the person being fully aware of these conflicts, these situations lead to an increase in the level of anxiety and insomnia is one of the symptoms.

Work and social environment

Another area of self reflection is the work environment. We spend 8 hours, sometime more, at work. Is the work place pleasant and friendly? Is there any bullying at work? These are important issues that affect the quality of sleep and the feeling of anxiety and depression during the day.

If the person is retired or not actively working, how is the person spending the day? What interests do they have? Loneliness can give rise to anxiety and depressed mood. Loneliness refers not so much to lack of social interaction per se, but rather to lack of social contact in someone who feels the need for it but who is unable to access social contact.

Sometimes the underlying problems can be addressed successfully, at other times they cannot be resolved. However just the awareness of a personal issue is the first step in treatment. You can do this kind of self-analysis by yourself or with the help of a health professional. The form in appendix 00 can be used to help you organize your thoughts and any issue can be discussed at follow up. Note that it is up to the person to find a solution to any of the daytime issues. The role of the health professional is to help in the process, not to offer a solutions to your problems.

Use of meditation/relaxation

Meditation and relaxation are very important techniques in managing chronic insomnia. Our life seems to be a continuous race from one activity to another. Often our mind is ‘bombarded’ continuously with tasks and we have no time off to let our mind rest. Some people use bedtime for reviewing what they have done during the day and often for planning the next day. This continuous mental activity is not conducive to sleep.

Meditation/relaxation techniques in whatever form, from guided meditation tape, imaging, yoga or any of its variants are one way to reduce the buzzing noise of our life.

However, these techniques are often used incorrectly. The most common mistake is to do relaxation/meditation at bedtime in order to fall asleep. We should take 10-20 minutes at least once a day, even better twice a day, in the morning or in the evening and usually away from bedtime. If we use the relaxation/meditation at bedtime in order to fall asleep we simply increase our anxiety and our expectation about sleep and often the techniques have a worsening effect.

Relaxation/meditation is a lifestyle decision, which is beneficial to sleep indirectly by reducing the level of stress.

The major difficulty in starting and continuing meditation/relaxation comes from our attitude. Often the person is not disciplined enough to allocate the 10-20 minutes necessary. The continuous compulsion to filling every minute of our life with activity is what predisposes the individual to insomnia and also prevents us to allocate a little of our time to rest our mind.

Awareness of this difficulty is important so that, when our daily planning is telling us that there is no time for the 10-20 minutes meditation, we are disciplined enough to persist with it. Virtually any form of meditation/relaxation is appropriate.

To summarize

The first part of treatment is to become aware of the importance of daytime personal problems to our disturbed sleep. We should self-reflect on important life issues that are relevant to all of us. Are we satisfied ourselves, with our personal relationships and with our environment? This self-reflection can give the opportunity to explore and clarify some of the issues. Understanding is more important than resolving personal conflict.

The relevance of daytime functioning needs to be addressed first. What can be done at bedtime and night time in order to improve the quality of sleep is explained next.