Managing chronic hyperarousal insomnia: for many insomnia patients, lifestyle changes are needed to reduce symptoms

Journal of Family Practice, Sept, 2004 by Peter J. Hauri

A majority of patients with insomnia are chronically hyperaroused and, surprisingly, not only at night. This meal]s, among other things, that their metabolism is faster than that of good sleepers, their body temperature is slightly higher, their brain waves are faster, and they are thinking and speaking fast, highly aroused, as if anxious.

These speeded-up signs are not what one would expect if the insomnia were caused by a lack of sleep. When a normal sleeper is deprived of his customary rest for a few nights, his body functions slow down: His metabolism and brain waves are slower: his temperature is lower, and his thinking is sluggish. Yet this scenario is exactly the opposite of what happens in insomniacs.

To give a good sleeper the sense of being an insomniac, one would not just deprive him of sleep. Rather, one also would administer a chronic dose of a stimulant (such as methylphenidate) for a period of at least a few weeks. This would "speed up" the person, giving him a faster metabolism and higher body temperature, as found in insomnia patients. At the same time, having spent his waking hours on a high-energy plane and not having slept much because of the stimulant, the person would start to feel exhausted, depleted, and weak, as do insomniacs.

Nature or nurture?

Insomnia due to increased arousal is not yet a diagnostic entity. The unresolved issue is whether this high arousal occurs with most types of insomnia, regardless of the diagnosis, or whether it occurs only in a specific subset, which would merit a separate diagnosis.

The obvious questions are: What causes this 24-hour hyperarousal in insomniacs, and what can be done about it? In some patients, the hyperarousal is an innate trait; but in many more insonmiacs, their lifestyle causes or aggravates the hyperarousal.

One man's stress is another man's pleasure

Surprisingly, boredom can trigger severe chronic insomnia as can desperately trying not to get excited and "hyper." It seems that everyone has an optimal level of stimulation and excitement, and this level is individually determined. One person's exciting and satisfactory lifestyle may be another person's cause of severe insomnia.

Alternatively, what is stressful for one person may not be so for another. For example, I recently saw a patient from northern Minnesota who had developed severe insomnia after moving there to take a job as manager of a fishing camp. Although he was very successful and enjoyed his day-to-day work, he missed the big city lights, theater, and social life of his Minneapolis home. While his clients enjoyed the lack of stress in the big north woods, for him that lifestyle had become a source of stress.

An "acceptable" level of stress also varies with the life cycle. A lifestyle that is fun and exciting for a 30-year-old may well provide the added stress leading to insomnia in the same person in his or her 50s.

Help patients examine their lifestyles

Telling a person to change his/her lifestyle is about as useful as telling an anxious person not to worry. Instead, what is necessary is to examine the driving forces in the insomniac's lifestyle in a cognitive, therapeutic, and nonthreatening way. Often, I have found that going into specifics is important.

Cognitive psychotherapy takes considerable skill, time, and practice. It is often much more effective to refer patients to a cognitive therapist rather than to try to do this alone, but the following questions may be helpful in beginning a dialogue with a patient experiencing insomnia, seemingly due to external stresses:

* You talked about work stress. In your opinion, is this stress mainly because 'they' demand too much of you in this job? Have you felt such stresses at previous jobs?

* Have you ever wondered why you feel work stress in almost any job you do? How do you explain this to yourself?

* Might your need to impress yourself or others have something to do with it?

* If part of this stress is internally driven, what do you suppose could be done about it?

* If a friend of yours had this problem, how would you advise him?

* What do you suppose you are saying to yourself to create this exaggerated work stress? Is what you are telling yourself true?

* How much of this seems reasonable to you?

When the patient finally realizes that "to sleep better, I have to slow down," only half the work is done. Next, he himself must identify what he could specifically change in his life or even just what he can do tomorrow to start taking a breather (or, if he is understimulated, what will spark his interest). Only then are we making progress.

Not all insomnia patients need a detailed lifestyle analysis to start sleeping better. But for some, it is the only thing that will cure their insomnia permanently.

If you believe a patient's insomnia stems from lifestyle issues but you don't have the qualifications or time to address them, I suggest making a referral to a qualified psychotherapist who is experienced in managing insomnia.

FOR MORE INFORMATION

Bonnet MA, Arand DL. The consequences of a week of insomnia. Sleep. 1996;19(6): 453-461.