For primary sleep disorders that have no identifiable cause, therapy is typically based on three pillars: behavioral or sleep therapy, improving sleep hygiene, and medication. In some cases, alternative methods such as hypnosis or acupuncture also help to improve the quality of sleep. Secondary sleep disorders have a cause. So there is an additional possibility here to eliminate the cause or at least to reduce its negative influence on sleep. Thus, depending on the circumstances, treatment will focus on several of the following objectives:
- Containing or eliminating the cause: If, for example, diseases lead to the sleep disorder, appropriate and consistent treatment should take place. Psychotherapy, medication, or both can help with depression. When faced with stress, stress management strategies and relaxation techniques can be useful. Treatment options depend on the cause.
- Learning Specific Beneficial Behaviors: In behavioral or sleep therapy, patients learn specific techniques designed to help them fall asleep better. They include behaviors that reduce anxiety about sleeping, for example, as well as those that improve sleep hygiene. They often also include relaxation techniques.
- Improving sleep hygiene, including the sleeping environment: Sleep hygiene is a term used by experts to describe behavior that promotes good sleep. These include regularity, physical activity and relaxation before going to bed. The sleeping environment is about avoiding potentially disruptive circumstances such as mattresses that are too hard or stuffy air in the bedroom. In most cases, those affected can do a lot themselves to improve their sleep hygiene. However, without proper information or guidance, there is also a risk of developing a detrimental sleep pattern. Therefore, those affected usually take part in sleep training or sleep counseling.
- Medication to improve sleep quality: Sleeping pills are helpful for many sleep disorders, especially when the cause cannot be improved or as support for a causal therapy. However, sleeping pills can also cause problems sleeping through the night. Experts estimate that 1 in 20 problems sleeping through the night is due to misuse of sleeping pills. You should definitely seek professional advice on suitable remedies and the frequency of their use. In any case, it is advisable to use sleeping pills sparingly and never to take them with alcohol.
Diagnosis of sleep disorders
Because the treatment differs depending on the cause of the sleep disorder, it is essential to clarify its origin or to find out whether a cause can be found. If so, treatment should definitely aim to contain or eliminate the cause.
First, patients have to answer a few questions about their symptoms, illnesses, medication, their alcohol consumption and other circumstances. The survey is often quite detailed because many sleep disorders are triggered by psychological factors such as stress and in principle there are many possible causes.
A sleep diary can be very useful in diagnosis. In it, those affected write down some information about their condition, their behavior, the sleeping times and their sleep problems in the morning and in the evening. You keep the sleep diary for several days or better weeks. Then it can provide information on how severe a sleep disorder is, where its origin may lie and later whether ongoing treatment is successful. Interested parties can usually get templates for the diary from their doctor.
Depending on requirements, further examinations take place, for example with devices that record certain sleep values. Some patients come to the sleep laboratory. There, experts can read the sleep progress, the sleep depth and other quality features from measured values.
Behavior and sleep therapy
Therapies or at least instructions on how to improve sleeping behavior are almost always useful - often even if sleep disorders have a specific cause. Without professional guidance, attempts to change one's own behavior in such a way that the quality of sleep improves can have exactly the opposite effect. Behavioral and sleep therapies take into account the individual characteristics of those affected. They go beyond just improving sleep hygiene. They also explain how patients can help themselves. The techniques that are often part of the therapies include:
- Sleep restriction: Patients are allowed to spend less time in bed. As a result, they become more tired when they go to bed and sleep better through the night.
- Cognitive Therapy: Patients learn to replace negative thoughts with those that promote sleep. Distraction techniques can stop nighttime rumination. Managing problems and making decisions during the day keeps you from struggling with them at night.
- Stimulus control: Those affected and therapists optimize sleep hygiene, for example by detecting and stopping unfavorable behavior, practicing useful behavior and improving the sleeping environment.
Improving sleep hygiene
With poor sleep hygiene, unfavorable behaviors contribute to disrupted sleep. Sometimes such habits only develop when the quality of sleep has already deteriorated. It is common, for example, that people who sleep poorly take naps during the day. Then, late in the evening, they are often not tired enough to fall asleep or sleep through the night. A cycle of sleep disorders can develop, leading to bad habits that in turn increase or at least promote sleep disorders. Good sleep hygiene includes some useful behaviors that patients can learn from sleep counseling or sleep education.
- Regular times for sleeping and getting up: Body and mind adjust to a daily rhythm. You get used to periods of activity and inactivity. That is why it is often an advantage for insomniacs to always go to bed and get up at a certain time. If you have trouble staying asleep, it can sometimes be helpful to delay the time you fall asleep. One then goes to bed so late that the problem-free length of sleep lasts without waking up until the usual time for waking up. If this works, the time to go to bed can slowly be pushed back. It is sometimes possible to improve sleep duration and sleep quality.
- Addressing worries, stress, fears and other psychological problems: Inner restlessness for many reasons is a common trigger for sleep disorders. Those affected should try to find out what the reason for their anxiety is. Afterwards it often makes sense to talk about it with people you trust (e.g. partner, relatives, friends) and/or other people involved (e.g. colleagues). If this is not possible or if the situation does not improve as a result, professional help (e.g. from suitable counseling centres, psychotherapists) can be considered. Relaxation techniques can help.
- Relaxation exercises and techniques: If your thoughts are spinning in circles or if you can't find inner peace in bed, relaxation can help. However, one should also try to eliminate the cause of the inner tension. Many sufferers fall asleep better after waking up if they try to think of nice things. These can be past or planned vacations, the idea of winning the lottery and other pleasant thoughts. Relaxation techniques such as progressive muscle relaxation according to Jacobson, autogenic training and meditation should be learned under professional guidance. After that, it's good to practice the techniques several times a week, preferably daily.
- Rituals to get you in the mood: Activities and an environment that do you good particularly promote falling asleep. Performing proper bedtime rituals can be beneficial. This can include relaxation exercises and pleasant thoughts. There are many ways to create a relaxing mood - candlelight, soothing music, audio books, a warm drink (decaffeinated!) and the like. Each person has to find out for themselves what calms them down and makes them sleepy. Corresponding rituals are particularly suitable if you have trouble falling asleep, but sometimes also if you have trouble sleeping through the night.
- Physical activity, sport: Regular sport adapted to personal fitness promotes sleep and general health. However, sport should never take place just before going to bed and it should also not be too stressful. Both can reduce sleep quality. Exercising to exhaustion is not a good sleep recipe. Too little physical activity can also lead to sleep problems because the body is not fully utilized, i.e. not tired.
- Avoid lying awake in bed: People with insomnia should only go to sleep when they are really tired. They should also get out of bed if they wake up and cannot fall asleep. Otherwise there is a risk that they will lie awake for a long time, get angry and develop a bad feeling about the bedroom and bed. This negative attitude can develop to such an extent that those affected can no longer sleep in the bedroom or in bed, but only somewhere else, for example on the couch in the living room. That too is unfavorable.
- Only use the bedroom for sleeping: In principle, no stimulating or exciting activities should take place in the bedroom or bed - e.g. no arguments, no professional work. Even exciting thrillers can be annoying. However, sex is allowed as an exception. In essence, it is about the time in bed corresponding as closely as possible to the time spent asleep. There is a special technique for this, the sleep restriction.
- Don't look at the clock: If you have trouble sleeping through the night, looking at the clock usually means "Now I've been lying awake for so long and can't go back to sleep". This puts those affected under pressure. With the desire to sleep at all costs, the tension grows. At the same time, the chance of falling asleep decreases. Without looking at the clock, the time pressure decreases or disappears.
- Avoid stimulants: Caffeine, nicotine, and alcohol can worsen sleep quality. Caffeine, foods containing caffeine (e.g. cola, tea) and medications containing caffeine are more likely to impede falling asleep. However, high caffeine consumption during the day can also disrupt sleep at night due to withdrawal symptoms. It's the same with nicotine. Former smokers who have overcome withdrawal fall asleep and stay asleep better. Alcohol has a depressant effect and can make it easier to fall asleep. On the other hand, drunk people wake up more often and often prematurely.
- Light diet: There are no rules that apply to everyone. However, many people sleep better when the last meal of the day was light and at least two to three hours before bed. Late night eating that is heavy and greasy can cause digestive problems that lead to waking up at night. But that doesn't bother other people. In some cultures it is even customary to wait until late in the evening to eat a large meal.
- Avoid excessive fluid intake: People who tend to have trouble sleeping through the night should try to only drink enough in the evening so that they don't have to go to the toilet at night.
- End the day: Instead of being woken up by thoughts like "Tomorrow I absolutely have to remember that..." or others, it's better to write down a note. The same applies to unfinished or half-finished work. Notes about the state of affairs can be reassuring.
- Stay calm: everyone has a bad night's sleep. This is no reason to get angry and tense up. When you're stressed, it's even harder to get a good night's sleep.
- Adjust room temperature: The air in the sleeping area should be neither too warm nor too cold. Most people sleep better when the temperature is slightly cooler. Many experts recommend 18 to 20°C.
- Good air quality: The air at the sleeping place should not be stuffy. Before going to bed, it is advisable to air the bedroom well or leave a window open overnight.
- Avoid being disturbed by noise: The ears cannot be switched off. Accordingly, nocturnal noises can be stressful, even if you don't find them disturbing at all as long as you are awake. You sleep less deeply and wake up more easily. There are several ways to reduce noise pollution. These include earplugs and soundproof windows. As a last resort, a change of residence is an option. If your partner disturbs your sleep, for example by snoring, you should consider whether you should spend the nights in separate rooms at times.
- Darkness: Light can disturb sleep. The bedroom should be dark and have as few light sources as possible at night.
- Comfortable sleeping environment: The bed should support good quality sleep. Mattresses that are too soft or too hard, duvets that are too warm or covers that are too thin or uncomfortable, or pillows that are too high or slip easily can be a hindrance.
When medication can help
There are a number of medications that can help you sleep better. In the case of problems sleeping through the night, drugs with a comparatively long duration of action are available. After all, they still have to work after a few hours and into the early morning. With a short duration, users would wake up too early and probably lie awake. However, the effect must not last too long, otherwise sleeping pills can lead to impairments (hangover) the following day.
Short term use is often considered when sleep disturbances are acute but likely to resolve soon. This can be the case in a limited phase of high stress, for example for a few days before a professional presentation or exam. In some cases, sleeping pills can even prevent an acute sleep disorder from developing into a chronic one. Sleeping pills can also help temporarily while the root causes are treated. The funds reduce the level of suffering. This usually improves the motivation to carry out a causal therapy to the end. For the same reason, sleeping pills can be useful in the preparation and initiation of causal treatment.
Long-term use is an option if the cause cannot be treated or if other methods do not improve the sleep disorder. Long-term use should also be considered in patients with high levels of suffering. It can usually take place at least when there is no evidence that dose escalation habituation is developing.
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The different groups of sleeping pills
- Herbal sleep aids are calming and can help you fall asleep. Its effects come on slowly and are light. The remedies do not lead to hangover and do not lead to habituation. Side effects such as gastrointestinal complaints or skin reactions are also rare. In the case of problems sleeping through the night, however, their effect is rarely sufficient.
- Antihistamines are substances that reduce allergies. The older active ingredients from the first generation, such as diphenhydramine and doxylamine, also make you tired. They are suitable for the treatment of problems falling asleep and staying asleep, whereby the time of ingestion plays a role. If you have trouble staying asleep, take it right before you go to bed. The funds are available without a prescription. Doxylamine and diphenhydramine work for about three to six hours. Nevertheless, they can occasionally lead to a hangover, especially if used incorrectly. To reduce this risk, you should always take the medication before going to bed, plan a sleep time of eight hours and never swallow more tablets at night. After two to three days it is advisable to try to sleep without the remedies. They can lead to habituation after a few days and discontinuation insomnia after prolonged use. Antihistamines are considered to be well tolerated, but can cause side effects such as headaches and constipation. Some people should not take the medicines at all, e.g. people suffering from epilepsy, glaucoma or incomplete emptying of the bladder due to an enlarged prostate (benign prostatic hyperplasia).
- Benzodiazepines are one of the most commonly prescribed sleeping pills. They bind to a specific receptor on nerve cells (GABA or benzodiazepine receptor) and thus develop a calming, sleep-promoting effect. There are drugs with a medium to long-lasting effect (e.g. temazepam, flunitrazepam) that can be used to treat problems staying asleep if doctors deem it appropriate. Benzodiazepines can be addictive, even with small doses over a long period of time. They should only be used under professional guidance for a maximum of three to four weeks. However, it is better to try to do without the funds after two weeks. Habituation, weaning insomnia and hangover symptoms are also possible. Because benzodiazepines also relax muscles, they increase the risk of falling. Numerous other possible side effects are known, such as irritability, aggressiveness, drowsiness, blurred vision and digestive problems. Users should strictly follow the doctor's instructions regarding the dose, when to take it, and when to stop using it.
- Z-drugs are so named because the names of the active ingredients, such as zopiclone and zolpidem, all begin with the letter Z. They act like benzodiazepines, binding to the same receptor. Many doctors prefer to prescribe the drugs over benzodiazepines because they carry fewer risks of habituation, withdrawal insomnia, hangover, and fewer other side effects. The differences are small, however, as has been shown in the meantime. Zopiclone has a longer duration of action than zolpidem. The same precautions apply as with benzodiazepines. Users should strictly follow the doctor's instructions regarding the dose, when to take it, and when to stop using it.
- Some antidepressants also have a sleep-inducing effect. Here in Switzerland they are not approved for the treatment of sleep disorders. However, doctors sometimes prescribe them for this purpose in certain circumstances, such as coexisting depression or insomnia that is not relieved by other means. The corresponding antidepressants have little or no dependence potential. But they can cause many other, sometimes serious side effects. Therefore, in many circumstances, their application is not possible from the outset.
- Some neuroleptics have a sleep-inducing effect. In Switzerland, doctors sometimes prescribe the active substance quetiapine for sleep disorders, although it is not approved for this purpose. Older patients with chronic sleep disorders in particular often receive it.
- Melatonin is a natural hormone that is commonly made and secreted by a gland in the brain. The substance plays a major role in regulating the sleep-wake cycle. As a drug, melatonin is approved for sleep disorders in people aged 55 and over. The substance is particularly suitable if it is difficult to fall asleep because the sleep-wake cycle is disturbed, as is often the case with shift workers or with jet lag (circadian sleep-wake cycle disorders). Melatonin can cause some side effects.
There are other substances that have a sleep-inducing effect. But they are very rarely used.