The bedtime problem that can ruin your health

Chances are that you or someone you know suffers from sleeplessness. Furthermore, it’s a safe bet that many of your patients have dealt with this insidious issue. In the United States, about 40 million people suffer from chronic insomnia—a sleep disorder characterized by difficulty falling and/or staying asleep occurring at least 3 nights/week for at least 3 months (but often much longer).

In total, there are approximately 90 distinct sleep disorders, of which most are characterized by at least one of the following: excessive daytime sleepiness; difficulty initiating or maintaining sleep; or abnormal events occurring during sleep. Sleep loss and sleep disorders have been definitively linked to a gamut of harmful health consequences, based on decades of research.

Let’s take a closer look at not only the harmful effects of sleeplessness, but also other aspects of this condition.

Sleeplessness vs insomnia

To start off, it’s important to note the distinction between sleeplessness and insomnia.

“Both sleeplessness and insomnia refer to an inability to sleep. Insomnia is the original term used in medicine and research with specific criteria for diagnosing an insomnia disorder,” stated Donna Arand, PhD, clinical director, Kettering Sleep Centers, Dayton, OH, in an exclusive interview with MDLinx. “By comparison, sleeplessness is a new term commonly used in the press and public-oriented materials. Sleeplessness also refers to an inability to sleep but without the diagnostic association. The terms insomnia and sleeplessness are often used interchangeably now.”

Health detriments

The detrimental effects of insomnia manifest as systemic problems, which can gravely impact morbidity and mortality.

“Poor or inadequate sleep undermines health and well-being,” Brandon Peters, MD, sleep physician, Virginia Mason Medical Center, Seattle, WA, told MDLinx. “It is associated with mood disorders such as anxiety and depression, concentration and memory problems, chronic pain, and compromised work performance. Sleep deprivation may increase the risks of weight gain, hypertension, diabetes, cardiovascular disease, certain cancers, and immune system dysfunction.”

Pathology

Insomnia mediates detrimental health effects via several pathological processes.

“Sleeplessness has a direct effect on many chronic health conditions, including diabetes, obesity, hypertension, and cardiovascular disease,” said Dr. Arand. “It has been shown that insomnia impacts appetite-related hormones such that the appetite-suppressing hormone leptin is reduced while the appetite-stimulating peptide ghrelin is increased, leading to overeating.”

She added: “Insomnia has also been shown to increase the risk of diabetes due to impaired glucose tolerance. The impact on glucose is quick and very direct, as a study in healthy volunteers showed that glucose tolerance was impaired in just 6 nights of sleep reduced to 4 hours. Insomnia has also been shown to increase blood pressure after just 1 night of 3.6 hours of sleep, thereby suggesting a causal link to hypertension and cardiovascular disease.”

Dr. Arand also pointed out the effect of impaired homeostasis secondary to insomnia: “Sleep plays an important role as a modulator of metabolic homeostasis. When insomnia is present, this balance is disrupted. Difficulty falling asleep and non-restorative sleep were predicators of developing metabolic syndrome.”

Dr. Peters noted the dynamic nature of insomnia’s effects on health.

“A loss of sleep may have a bidirectional relationship with other medical conditions,” he said. “Poor sleep may worsen mood and mood disorders may worsen sleep, for example. When sleep deprivation leads to weight gain through hormonal changes, the increased weight may lead to sleep apnea that further worsens sleep. Sleep is a pillar of health, just like diet and exercise, and its health impacts should not be minimized.”

Psychiatric health

Insomnia can set the stage for a vicious cycle of psychiatric symptoms, according to Dr. Arand.

“It is estimated that 40% of all insomnia patients have a coexisting psychiatric condition, most notably depression and anxiety,” she said. “Insomnia is associated with a disruption in the brain neurotransmitters serotonin, dopamine, and norepinephrine. These chemicals also regulate mood, and a deficiency in these chemicals causes depression. Consequently, disruptions in these neurotransmitters due to insomnia can lead to depression or vice versa. This can set up a vicious cycle such that insomnia triggers depression and depression triggers and aggravates insomnia. The more severe the insomnia becomes, the more severe the depression.”

Dr. Peters explained that adverse psychiatric effects stem from cognitive changes.

“The frontal lobe of the brain is important for mood regulation and higher-level cognitive functions. Sleep loss compromises the ability of the brain to function normally,” he said. “As a result, poor sleep may lead to irritability, anxiety, or depression. It affects concentration, attention, and short-term memory. It may negatively affect social interactions and work performance.”

Sleep apnea

At least 25 million Americans have sleep apnea. Sleeplessness and sleep apnea can overlap.

“Sleep apnea is often associated with snoring, witnessed pauses in breathing while asleep, sleepiness, frequent urination at night, teeth grinding, morning headaches, and other symptoms,” said Dr. Peters. “These symptoms may be unrecognized or overlooked by the affected person and their bed partner. Therefore, testing is often needed to sort out if sleep apnea is contributing to frequent awakenings at night and poor sleep.”

The good news is that treating sleep apnea often alleviates sleeplessness.

“If sleep apnea is present with insomnia, the effects of sleep apnea can generally be removed by treating the sleep apnea, typically with CPAP, continuous positive airway pressure. Most symptoms and effects of sleep apnea are reversed with treatment in a short period of time,” said Dr. Arand. “Any symptoms and problems that remain are likely the result of another disorder. In the case of comorbid insomnia, if insomnia remains following effective treatment of sleep apnea, then separate treatment needs to be initiated.

Quality of life

Dr. Arand stressed that insomnia takes a giant toll on quality of life, which should come as no surprise.

“Sleeplessness adversely affects quality of life in numerous ways. It can stress relationships, produce moodiness, decrease enjoyment of activities, reduce social interactions, decrease health perception, and increase bodily pain,” she said.

“A dose-response relationship has even been reported with greater sleeplessness being associated with greater impairments in daytime functioning and enjoyment of relationships,” she added. “Individuals with severe insomnia also report lower quality of life on all domains, including pain and physical health, as measured by the Medical Outcomes Study Short Form (SF-36), with ratings similar to patients with congestive heart failure and depression. Thus, sleeplessness indirectly impacts the chronic illness by making symptoms such as pain and bodily impairment seem worse.”

Getting help

With the repercussions of insomnia so great, the threshold to seek help from a sleep specialist is lower.

“Sleeplessness is a common response to acute stressful events,” explained Dr. Arand. “It is important to avoid bad sleep habits such as lying in bed awake, using alcohol, not waking at the same time, or taking naps when dealing with a stressful event. As the stress resolves, the sleep problem should also resolve unless bad habits have developed to perpetuate the insomnia.”

She added: “If the sleeplessness remains after the stress has dissipated, then cognitive behavioral therapy for insomnia (CBT-I) may be needed from a clinician certified in CBT-I. If insomnia is a chronic problem, make sure that you follow standard sleep hygiene rules, including standardized wake time, having a bedtime routine, eliminating caffeine and alcohol, not laying in bed awake, going to bed when sleepy, and having a bedroom conducive to sleep.”

If the sleeplessness persists, other treatment options include using guided imagery, progressive relaxation, or writing in a “worry journal” before bed.

• Guided imagery. “Guided imagery is helpful for those who can’t turn off their mind and have random unwanted thoughts intruding while trying to fall asleep,” Dr. Arand said. “Guided imagery involves focusing on a pleasant unending activity to prevent unwanted thoughts, such as imagining that you are floating along a beautiful endless coastline or gently skiing down an endless ski slope.”
  
  
• Progressive relaxation. “This involves tensing muscles in each limb for 10 seconds and then releasing before moving to another muscle group,” she explained.
  
  
• Journaling. “For those who lie in bed and worry, writing down problems or concerns with possible solutions (even if unlikely or impractical) before bedtime will reduce the anxiety associated with the thoughts if they occur again after going to bed,” Dr. Arand said.

In some cases, chronic insomnia will require cognitive behavioral therapy from a certified CBT-I practitioner, she noted.

Dr. Peters added: “If symptoms persist, a consultation with a board-certified sleep medicine physician may lead to further testing and treatments that can resolve the condition.”