“To sleep, perchance to dream; aye, there’s the rub.” -from Hamlet by William Shakespeare (1564-1616)
Prince Hamlet was referring to death, but what if the rub refers to insomnia? What then to do?
insomnia n.: Prolonged or abnormal inability to sleep. -Taber’s Cyclopedic Medical Dictionary
So, insomnia comes in two forms. The first can be merely a prolonged inability to sleep, which per se may not be abnormal, dependent upon context. The second is abnormal, independent of context.
In the first case, the independent variable (controlling factor) is environmental. Some environmental stressor is eliciting a negative physiological response in the form of an inability to sleep, be it an inability to fall asleep, to stay asleep, or both.
Treatment? Simple! Remove the stressor, if possible, or at least try to diminish its potency.
How? There, too, lies a rub. The ability to meet that challenge is that which separates winners from losers in life — hugs, kisses, kind words, and other “warm fuzzies” notwithstanding.
Meanwhile, a simple set of procedures is available:
1) Use the bed only for sleeping or sexual activity. Do not lie awake in bed.
2) Avoid intake of stimulants such as caffeine with or after supper.
3) Avoid use of alcohol before bedtime, the rebound from which involves wakefulness.
4) Avoid stimulating activities directly before bedtime, including watching television; which, contrary to a widespread misconception, is not relaxing.
5) Practice meditation or Relaxation Procedure.
How detrimental is insomnia in healthy people? The answer remains unclear. Some claim that a lack of sleep per se never killed anyone — directly, that is; mishaps in the biological context of somnolence notwithstanding. In fact, forced wakefulness actually relieves depression, which does kill people. Two points: 1) worrying about insomnia promotes insomnia; and 2) best to avoid sleeping medications, if possible.
In the second case, the independent variable is biological. Some pathological condition is eliciting a negative physiological response in the form of an inability to sleep, be it an inability to fall asleep, to stay asleep, or both.
Treatment in this case depends upon the underlying diagnosis. What is the pathological condition? The answer may be complex if more than one condition is the cause.
In the elderly, for example, insomnia may herald the onset of dementia. Add to dementia delirium, and the combination can present a real medical challenge. By the way, delirium interfering with sleep may accompany dementia once manifest or other neurodegenerative diseases.
Regarding circadian rhythm, older insomniacs display advanced sleep-phase; whereas, young adults display delayed sleep-phase, often the consequence of simply remaining active past normal bedtime playing video-games. Treatment, especially for the elderly, may be use of a bright light possibly coupled with melatonin. Whatever the case, only a comprehensive medical evaluation by a competent physician can determine the underlying condition, if any.
That medical evaluation begins with a complete medical history, increasingly difficult to come by in this era of the Sovietization of American medicine when patients increasing are attended by “Doctor Nurse” instead of “Doctor Doctor” and even by the latter for diminishing periods of time. Often, the patient’s bed-partner provides the best information. Despite all the fancy and expensive technological innovations, 80% of medical diagnoses still are made by history, 10% by physical examination, and 5% by routine laboratory-tests.
Once diagnosed, the underlying condition can be treated as best as practicable. When such treatment proves inadequate, the physician can prescribe a pharmacological agent. Some newer agents are relatively safe even long term and maintain sleeping architecture; i.e., normal phases of the sleeping cycle. Avoid “over-the-counter drugs” because the benefit:risk ratio often is uncertain, at best.
Sleep is a natural function found in most vertebrates, if not all. It restores the neurochemical balance. Sweet dreams!
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