Wrapping things up and reflections.

In this blog, I have discussed many subjects related to insomnia.  I devoted an entire post to the most commonly prescribed sleeping medication in recent years and the dangers of this drug and its over-prescription by physicians.  I described in great detail a rather uncommon, but probably under-diagnosed, cause for insomnia.  I also explored the most common causes of insomnia, and the most effective treatments for these causes.  Now, I will present a few more opinions (of others, and my own) on the subject, and, finally, will reflect on my blogging experience.

There has been a great deal of media coverage of “driving while sleep deprived” in the past few years.  Many experts believe that driving while sleep deprived can be just as dangerous as driving while under the influence of alcohol, and some studies have supported this viewpoint.  As early as 1999, there were experiments comparing performance in simulated driving of intoxicated drivers and sleep-deprived drivers.  One such experiment found that both the sleep deprived and the alcohol groups exhibited a safety-critical decline in lane-keeping performance, and both groups exhibited alterations in primary task performance.  The findings of such research do not surprise me in the slightest.  The few times I have driven after a night in which insomnia kept me from sleeping, I have felt rather out of control behind the wheel.  This illustrates a way in which insomnia does not just affect its sufferers—it can affect everyone.

One subject that I did not really touch upon in my blog is natural treatments for insomnia.  In a journal called Healthy Solutions, I found an article which outlined several natural insomnia remedies.  The first several “treatments” the article listed were pretty obvious ones: getting more exercise during the day, avoiding alcohol and caffeine at night, going to bed at the same time every night, practicing good sleep hygiene, and trying a new mattress if your current one is old and/or uncomfortable.  The article went on to recommend melatonin and inosital, which is a member of the vitamin B family.

While I do believe melatonin can be an effective insomnia treatment for many people, I have always been bothered that it is touted as a “natural remedy”.  While melatonin is a naturally occurring hormone in the human body, the same can be said of insulin injections, birth control pills, many steroids, and thyroid medications.  They are all comprised of naturally occurring human hormones, but most people wouldn't put birth control pills in the “natural medicine” category.  One must remember that while melatonin is produced naturally by the human body, taking in extra melatonin isn’t really “natural”.  Nonetheless, it can help many people with their insomnia.  While I have read about several experiments evaluating the effectiveness of melatonin, I was unable to find any true scientific experiment that shows the efficacy of inosital.  I personally would never try a treatment based only on anecdotal evidence, as I could end up spending a lot of money on what is really a placebo.  Obviously, more sturdy scientific research needs to be done on the usefulness of various natural treatments of insomnia.

This blog has allowed me to not only share my personal experiences, but to learn more about a condition that has plagued me for years: insomnia.  My research led to many new discoveries for me, and it was quite an intellectual and emotional journey.  Using the blog format to present reviews of research was a new experience for me, and I think the format allowed me to express my opinions in a more natural way.  It also made the project much more of a personal odyssey than if I had just written traditional reviews of journal articles.  To be able to use visual rhetoric was also a plus, as it brought a new dimension to my discussions, and, in my opinion, made the postings much more engaging and easy for others to read and relate to.  I have thoroughly enjoyed this project, and I hope others have enjoyed reading my posts.

Bowden, J. (2008, May). Natural help for insomnia. Better Nutrition. Volume 70, Number 5. Retrieved on December 18, 2009, from EBSCOhost database.

Fairclough, S. H., Graham R.  (1999, March).  Impairment of Driving Performance Caused by Sleep Deprivation or Alcohol: A Comparative Study.  Human Factors: The Journal of the Human Factors and Ergonomics.  Volume 41, Number 1.  Retrieved on December 18, 2010, from Sage Premier database.

Imaged retrieved on December 19, 2010, from http://entrepreneurshipexpert.blogspot.com/2010/01/millionaire-mentor-importance-of-sleep.html

Image retrieved on December 19, 2010, from http://www.kalyx.com/store/images/images_misc/200399.jpg

Visual rhetoric.

 

The image above depicts how so many insomniacs feel; they feel as though some sort of malevolent force is keeping them awake.  Not to mention that chronic insomnia leads to an unstable mental state and this sort of frightening imagery is right up the alley of someone who is psychologically deteriorating as a result of continuing sleeplessness.  I would not be surprised if the artist of the image has suffered from insomnia him or herself. 

Pathos represents an appeal to the viewer’s emotions, and this image certainly does that.  It conveys the often frightening aspects of insomnia.  It also conveys the scary psychological state that someone who suffers from chronic insomnia can find themselves in.

This image does not employ the strategy of logos, which would be written text or slogans that appeal to our intellect and reasoning.  This image really does the opposite of appealing to reason.  It evokes a pure emotional response.  The image also does not employ ethos; it has no details that appeal to our sense of trust and credulity.  Again, this image is more of a disturbing and surreal appeal to our emotions.

The image does, to an extent, appeal to us utilizing mythos, which are details that appeal to our beliefs in shared human values.  We all interpret the demon in the upper left as a frightening and threatening figure.  Demonic figures are a part of every religion and mythology that has existed in the history of the human race. 

Overall I think this is a very powerful image that appeals greatly to our emotions.  It really conveys the scary reality of insomnia by using a terrifying illustration which is not reality-based.

This editorial cartoon uses humor to illustrate the frustrations of a man with insomnia.  The practice of “counting sheep” is mostly found in popular culture, though the idea of this practice of a way to help one fall asleep has been around for ages and in many different cultures.  It’s rarely actually used as a treatment for insomnia, but it is an idea with which we are all very familiar.  In this cartoon, the man has obviously has been trying to fall asleep for a very long time, as he is close to counting is 2 millionth sheep.

This cartoon does imply the strategy of pathos, appealing mostly to the viewer’s sense of humor, but also the viewer feels sorry for the poor guy who obviously can’t sleep.  Though this cartoon is mostly meant to make people chuckle, we can all empathize with the cartoon man’s troubles, and the uselessness of this practice of counting sheep that is engrained in our culture.

This image does employ the use of logos, although it does so in a very simple manner.  The two numbers on the sheep, which are in the millions, convey to us just how long this cartoon figure has been counting these sheep.  Mostly the text is to further the humorous aspect of this image, but it does appeal to our sense of reason—if the man has counted this high, the practice of counting sheep is rather useless.

Since this is just a cartoon, and not a serious one at that, this image doesn’t really employ the use of ethos.  We aren’t meant to find this cartoon worthy of our trust or find it creditable; it is just a cartoon.

Lastly, this cartoon certainly employs the use of ethos.  It shows us a practice that is part of (most) of our shared culture.  While it doesn’t actually contain any presence of shared human values, it is something which we all can relate to.

Unlike the previous image, which was rather frightening, this image relies on humor to convey its point.  Nevertheless, it is a very effective image that is quite relatable.

Image retrieved on December 12, 2010, from http://ziofit.com/natural-health-remedies-the-best-solution-for-insomnia/

Singer, A.  (2006, January).  PoliticalCartoons.com. Retrieved on December 12, 2010 from http://www.politicalcartoons.com/cartoon/233c3507-84e2-4a3c-aede-1d9935e00047.html

Other causes of insomnia.

In my last post, I hypothesized that I suffer from non-24-hour circadian rhythm syndrome.  While this could explain why it is so difficult for me to keep a regular sleep schedule, it does not explain why I sometimes I cannot fall asleep at all, and why, without sleeping pills, I awaken every one to two hours throughout the night.  Also, very few people suffer from a non-24-hour circadian rhythm syndrome, so I have yet to explore the more common causes of insomnia.  In this post, I will investigate the more ordinary causes of insomnia.

One common cause of insomnia is sleep apnea, which is a fairly common disorder in which a person has one or more pauses in breathing or shallow breaths while he or she sleeps.  This condition is a chronic one, and the breathing pauses and/or shallow breathing often cause a person to move out of deep sleep and into light sleep, thus they are not getting restorative sleep much of the time.  This disorder is one of the most prevalent causes of insomnia and excessive daytime sleepiness.  Sleep apnea is caused by a blocked or narrowed airway while a person sleeps.  There are several reasons this can happen, including an individual’s throat muscles and tongue relaxing more than usual, oversized tonsils, being overweight (an excess of soft fat tissue can thicken the wall of the windpipe), or as a result of aging, because as a person gets older, the brain has a harder time signaling to keep his or her throat muscles stiff during sleep.  The best way to find out if you have sleep apnea is through a sleep study.  The treatments for sleep apnea include lifestyle changes, mouthpieces, breathing devices, and surgery.  Lifestyle changes include avoiding alcohol, quitting smoking, losing weight, and sleeping on your side instead of your back.  A mouthpiece can help people with mild sleep apnea, and is obtained through a dentist or orthodontist.  Breathing devices such as CPAP (continuous positive airway pressure) can help treat more severe sleep apnea.  A CPAP machine utilizes a mask that fits over someone’s mouth and nose, and gently blows air into their throat.  Lastly, surgery can be performed to widen breathing passages, shrink, stiffen, or remove excess tissue in the throat, or remove the tonsils if they are blocking the airway.  Luckily for me, I had sleep apnea ruled out with two overnight sleep studies.

Another common cause of insomnia is a condition called Restless Leg Syndrome (RLS), which is characterized by an overwhelming urge to move one's limbs to stop uncomfortable or strange sensations.  The symptoms can include pricking, crawling, aching, burning, pulling, itching, and tingly sensations, which keep someone from falling asleep.  To receive a diagnosis of RLS, a person must meet four criteria: undesirable sensations in the leg that occur before sleep onset, an irresistible urge to move the limbs, partial or complete relief of the symptoms upon movement of the limbs, and return of the symptoms upon cessation of the movements.   Treatments for RLS include iron supplements, avoiding caffeine, alcohol, and nicotine, and drugs such as levodopa, ropinirole, and pramipexole.  My past sleep studies have also ruled out Restless Leg Syndrome as a cause for my insomnia.

Lastly, it is very common for insomnia to be caused by stress, anxiety, or depression.    Stress is often caused by ongoing stressful life events, which leaves a person feeling like he or she is not in control.  Stressed individuals will often feel like they just cannot turn off their brain when it is time to go to sleep.  Treatments for stress-induced insomnia include exercise, a healthy diet, relaxation techniques, and sedating medications or supplements.  Anxiety is characterized by a person’s inability to shake his or her concerns.  Individuals suffering from anxiety can experience exaggerated worry and tension, irritability, sweating, trembling, and a rapid heart rate.  Anxiety is commonly treated using anti-anxiety medications, such as benzodiazepines, or through cognitive-behavior therapy.  A major depressive episode is characterized by feeling helpless, hopeless, and worthless, and keeps an individual from functioning normally.  There are numerous possible causes of depression, including substance abuse, certain medications, a traumatic event, serious illness, or simply genetics.  Treatments for depression include psychotherapy, electric shock treatment, cognitive-behavioral therapy, and a variety of medications, such as selective serotonin reuptake inhibitors (SSRIs) like Prozac or Zoloft, serotonin and norepinephrine reuptake inhibitors (SNRIs) like Cymbalta or Effexor, tricyclic antidepressants like Elavil and Tofranil, and monoamine oxidase inhibitors (MAOIs) like Nardil and Parnate. 

I think that aside from the possible non-24-hour circadian rhythm syndrome, stress, anxiety, and depression all contribute to my insomnia.  To help combat these problems, I go to a therapist, and take Cymbalta in the morning and Xanax (a benzodiazepine) at night.  I hope that as the years go on, better sleeping pills and other insomnia treatments will be developed.

Depression:  Overview & Facts.  (2010).  WebMD.   Retrieved December 9, 2010, from http://www.webmd.com/depression/guide/depression-overview-facts

Generalized Anxiety Disorder.  (2010, December).  National Institute of Mental Health.  Retrieved December 9, 2010, from http://www.nimh.nih.gov/health/topics/generalized-anxiety-disorder-gad/index.shtml

Natarajan, R. (2010). Review of periodic limb movement and restless leg syndrome. Journal of Postgraduate Medicine.  Volume 56, Number 2.  Retrieved December 9, 2010, from Academic Search Complete database.

Sleep Apnea: What Is Sleep Apnea?  NHLBI: Health Information for the Public.  (2010, August). Retrieved December 8, 2010, from http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html

Image retrieved December 8, 2010, from http://www.accessrx.com/blog/files/media/image/Insomnia%20Collage.jpg

What planet am I from?

The vast majority of humans, as well as other animals, have a sleep-wake cycle that corresponds with the length of a day on Earth.  We all sleep, awaken, and engage in our daily activities in accordance with our circadian rhythm, which is the daily cycle of biological activity based on a 24-hour period and influenced by regular variations in the environment, such as the alternation of night and day.  Research has shown that the circadian rhythms of humans are actually slightly longer than 24 hours.  It is difficult to pinpoint our circadian rhythms exactly, because to do so would require deprivation of sunlight, of our awareness of time, and of a number of other cues that help to regular the sleep-wake cycle.  In everyday life, these cues are called zeitgebers, and daylight is the most influential.

Though I remember learning years ago in my introductory psychology class that the human circadian rhythm is approximately 25 hours, a study at Harvard University has shown that the normal human circadian rhythm may be much closer to 24 hours than scientists previously thought—approximately 24 hours and 11 minutes.  Thus, the average person should have little trouble conforming to a 24-hour sleep-wake cycle.  But what about the people who do not fall into the normal range?

Since I was a child, I have noticed that my pattern of sleeping and waking seems to constantly advance by an hour or two every night.  This anomaly is very apparent during vacations from work and school.  Without an alarm clock and daily obligations, I naturally fall asleep a little later each night, and get up a little later each morning.  If my vacation is long enough, this continues until my sleep schedule is completely reversed, and I end up having to stay awake for 24 hours or so in order to reset my biological clock.  I have often wondered if this problem of mine may be a real disorder with a biological basis.  After doing some research, I have found that the answer is yes—I may suffer from non-24-hour sleep-wake syndrome.

Non-24-hour sleep-wake syndrome, also known as free running syndrome, is defined as a chronic steady pattern comprising of one- or two-hour delays in sleep onset and wake times in an individual living in society.  In people with this disorder, the body basically insists that the day is longer than 24 hours and refuses to adjust to the external light/dark cycle.  If left untreated, a person with non-24-hour sleep wake syndrome will have a sleep-wake cycle that changes every day.  This is most commonly seen with blind individuals (nearly half of blind patients suffer from this condition), and it has also been observed in individuals who have sustained some sort of head injury.  There have also been some studies of “normal” people who seem to have the syndrome.  In one study, a subject with non-24-hour sleep-wake syndrome “appeared to be sub-sensitive to bright light,” which means that a possible cause for this disorder among sighted individuals could be that the body does not react to sunlight as it should.

The only way to know for sure if I have non-24-hour sleep-wake syndrome would be for me to be put away in a room for several days without sunlight, knowledge of time, or any other zeitgebers.  Obviously, this would be impossible unless I am part of a clinical study, so I will have to assume that I may have this disorder.  So, then what—what is the treatment?  Experts say that the best a person with non-24-hour sleep-wake syndrome can do is to get plenty of sunlight in the morning and throughout the day, and take melatonin supplements or sleeping pills if needed at night, to allow one to conform to the 24-hour day. 

Unfortunately for people like me, the Earth takes only 24 hours to spin once on its axis, and I have to somehow force my body to conform to that schedule.  Perhaps if humans ever colonize Mars, I might be better off; a day on Mars lasts 24 hours and 40 minutes.

Boivin D. et. al. (2003, June 10).  Non-24-hour sleep-wake syndrome following a car accident. Neurology.   Volume 60, Number 11. Retrieved November 22, 2010, from PubMed Database.

Circadian rhythm sleep disorders. (2008). American Academy of Sleep Medicine. Retrieved November 22, 2010, from http://www.aasmnet.org/resources/factsheets/crsd.pdf

Cromie, W.J. (1999, July 15). Human biological clock set back an hour. Harvard Gazette. Retrieved November 22, 2010, from http://www.news.harvard.edu/gazette/1999/07.15/bioclock24.html.

McArthur, A. et. al. (1996).  Non-24-hour sleep-wake syndrome in a sighted man: circadian rhythm studies and efficacy of melatonin treatment. Sleep.  Volume 19, Number 7.  Retrieved November 22, 2010, from PubMed Database.

The international classification of sleep disorders: diagnostic & coding manual. (2005).  American Academy of Sleep Medicine. Retrieved November 22, 2010, from http://www.esst.org/adds/ICSD.pdf

Image retrieved November 22, 2005, from http://en.wikipedia.org/wiki/Mars.

The Ambien Alibi

Remedies for insomnia have been around as long as civilization. The Chinese used acupuncture, the Greeks and Egyptians used opium, and Europeans used plants such as mandrake. Many cultures used chamomile and valerian to make sleep-inducing teas.

With the late 19th century came the widespread use, and abuse, of choral hydrate, one of the first mass-produced pharmaceuticals to treat insomnia. In the early 20th century, barbiturates such as pentobarbital and phenobarbital became the insomnia drugs of choice. The 1960s saw the introduction of benzodiazepines, such as valium, and by the end of the decade it seemed that everyone was popping the “little yellow pill,” immortalized in The Rolling Stones’ 1966 song “Mother’s Little Helper.”

Fast forward to the 1990s, when a new drug, zolpidem, was introduced under the brand name Ambien. It falls into a class of non-benzodiazepine “hypnotic” sleep aids. Ambien quickly became the first course treatment for insomnia, prescribed not only by psychiatrists, but internists, pediatricians, and physicians in practically every medical specialty. Touted as a safe, non-addictive sleep aid, doctors thought nothing of prescribing it to patients with mild insomnia, many of whom had never taken a sleep aid before.

Last summer, there was a brief article in Rolling Stone entitled “Welcome to the United States of Ambien” by Rob Sheffield. He addressed how Ambien has become a pop culture phenomenon. Though the medication has been around since the early 1990s, he writes that “only now has it reached its cultural saturation point.” He likens Ambien to LSD in 1969 and Ecstasy in 1989 in that it is “the drug that unlocks the fantasy of the moment.” He writes about many of the activities linked to Ambien, such as sleep-eating, sleep-driving, sleep-shopping, and sleep-blogging. He goes on to write that “every night, you can practically smell the Ambien fog settling over a nation of Zolpidem zombies” and that Ambien “gives you the hallucinatory urge to indulge your most moronic whims.”

I have experienced Ambien’s dangerous effects first hand. I was first prescribed the drug in early 2001, when I as only 15 years old. It was a small dose, and it worked satisfactorily for a while without incident. I was new to sleep aids, so my body responded quickly to the drug and it actually put me to sleep. A couple of years later, my doctor upped the dosage. It was soon after that that I first noticed Ambien’s other effects. By this point I had also tried many other sleep aids and my body didn’t react as quickly as it did when I was younger, so I would take the drug and often stay awake for a while. I started to do and say things with little or no recollection in the morning, and when I could remember what I had done, it was as if it had happened in a dream. Luckily I was safe in my parents’ house at that time, and whenever my mom noticed me acting strangely, she would make sure I promptly got into bed.

I stopped using Ambien sometime during my senior year of high school because it had lost its effectiveness to put me to sleep. When Ambien CR came out while I was in college, I decided to give it another go, in conjunction with another sleep aid, with the hope that it would keep me asleep longer. At first it worked well, but then I began to take the Ambien before I took my other sleep aid. The gap between the two grew wider as I noticed how happy I felt while on Ambien; it was like I was suddenly filled with warmth, all of my troubles melted away, and the universe seemed to open with possibilities. Trouble soon ensued as I would have phone conversations, write emails, and walk around campus while on Ambien. The situation would get worse when sometimes, in my altered state, I would decide to take a second pill. At this point I would no longer be making decisions with my right mind, and I would take yet another pill. Then I would essentially lose control, sometimes taking up to a dozen tablets without consciously knowing it. It was as if I was performing these actions in my sleep.

I could write a novella of my Ambien stories alone. I have done some very embarrassing things, with absolutely no recall for the even the next day. Once, while I was living at home, my mom video-taped my Ambien experience so I could see first-hand how it affected me. My speech was slurred, and though I could put full sentences together, nothing I said made sense in my current setting. I would think I was shopping at a clothing store, and then I would think I was at school, then outside. I was having complete hallucinations, and it was frightening so see it caught on tape as I typed on an invisible computer and used an invisible mouse.

So far, no proper scientific studies have shown a very high incidence of engagement in activities while on the drug with next-morning amnesia. Yet practically every day you can find a current news story about someone driving under the influence of Ambien, and TV networks are full of stories of Ambien-eating and other activities. A recent Taiwanese study showed that only 5.1% of participants had “amnesic sleep-related behavioral problems” while on the medication. Yet anecdotal evidence suggests that this percentage should be much higher. I have to wonder if drug-taking behavior is different in the context of a study. Perhaps participants are more likely to take the drug right before they get into bed—they might follow their instructions perfectly. That simply is not the case in the real world.

I look forward to new studies, perhaps ones that involve surveys administered to long-time Ambien users questioning them about their past experiences, to find the true proportion of people that experience Ambien’s undesirable side effects. It is my opinion that this is a dangerous drug, and I am certain that in coming years it will no longer be a first-course treatment for insomniacs, but rather a last resort.

Alternative insomnia treatments | Ancient sleep aids. (n. d.) Sleepdex - Resources for better sleep.  Retrieved  November 5, 2010, from http://www.sleepdex.org/alternative.htm.

Sheffield, R. (2009, June 11). Welcome to the United States of Ambien. Rolling Stone. Retrieved November 5, 2010, from Academic Search Complete Database.

Tsai, J.H., et. al. (2009, January). Zolpidem-induced amnesia and somnambulism: rare occurrences? European Neuropsychopharmacology. Volume 19, Number 3. Retrieved November 5, 2010, from Academic Search Complete Database.

Image retrieved on November 5, 2010, from http://onthevernalequinox.blogspot.com.

Introduction

My name is Lauren and I'm an insomniac. I've had problems with insomnia since I was a teenager. I've tried everything: practically every sleeping pill out there, herbal supplements, teas, meditation, yoga, psychotherapy, neurofeedback--you name it, I've tried it.

This blog with be an amalgam of the following: my insomnia experiences; reviews of treatments I have used; and research into causes and treatments for insomnia.

Image retrieved on November 5, 2009, from http://desdesants.blogspot.com/.