Insomnia

A comprehensive but non-technical guide to the very common and distressing problem of sleepless nights followed by tired days

Second Edition, November 2012

by Dr Gordon Coates

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Disclaimer

Nothing in this article is intended as medical advice or as a basis for the specific treatment of any particular person. The article is provided for educational purposes only.

Cautions

Various physical and mental illnesses can either cause insomnia or make it worse. Also, in many cases, the normal emotional responses to the stress and grief which are, from time to time, an unavoidable part of everyday life may be the underlying cause of insomnia and may not resolve without expert advice and help. Therefore, depending on the severity of the insomnia, professional advice should either precede the use of self-help techniques, or be sought promptly if they do not provide relief after a reasonable trial. (The role of specific medical or psychological interventions is discussed briefly under Professional Therapy later in this article.)

Introduction

"I can't get to sleep. I can't stay asleep. I don't sleep deeply. I don't sleep well. I wake up early. I wake up still tired. I wake up feeling anxious. I wake up feeling depressed." The list goes on...

How often have you heard, or thought, one or more of the above? There are so many things that can interfere with sleep, that I sometimes wonder how we ever get any at all! Occasional sleep problems are perfectly normal, of course, but insomnia can be a terrible ordeal if it is frequent or severe.

What exactly is Insomnia?

Insomnia is usually defined as the subjective complaint of an insufficient amount or quality of sleep. It is the commonest significant sleep disorder, and is in fact very common indeed, being reported by about a third of those surveyed in some studies. (E.g. Ohayon M, "Epidemiology of insomnia: what we know and what we still need to learn", Sleep Medicine Reviews 2002; 6:97-111; and Grunstein R et al. 2004. Improving Knowledge about Sleep and Sleepiness in Young Drivers. Sydney: NSW Motor Accidents Authority.)

Note that other sleep disorders, such as obstructive sleep apnoea, restless legs syndrome and sleepwalking, are not covered in this article. Most large cities have at least one medical facility dedicated purely to severe sleep disorders – and severe sleep disorders should always be managed by a sleep specialist if at all possible.

Insomnia itself is usually subdivided into difficulties falling asleep, mid-sleep waking, early-morning waking and unrefreshing sleep. In practice, there is quite a lot of overlap between these various categories of insomnia. In fact, some people have all of them at once! Insomnia may also be described as transient (a few days) short-term (a few weeks) or chronic (months or years).

Most of the simple remedies described in this article can be applied to any type of insomnia. However, insomnia sometimes has a very specific underlying cause, which may need to be treated before simple remedies can help very much. There are many possible underlying causes for insomnia. Some of them are psychological in nature, which is hardly surprising. However, various physical illnesses can also cause insomnia.

I will not discuss any specific underlying causes of insomnia in this article, but the fact of their existence means that medical assessment is necessary if significant insomnia fails to respond to simple measures. I will comment very briefly on that situation under the next heading. After that, I will describe some simple and effective approaches to insomnia which might be tried before seeking medical advice, and which can also be used if a specific underlying cause for insomnia cannot be completely cured by medical treatment.

Medical Assessment of Insomnia

Medical assessment of insomnia can be important for two reasons. Firstly, if insomnia is due to a medical condition, whether physical or mental, it may be difficult or impossible to relieve it until that condition has been treated. Secondly, if the underlying condition is a serious one, failure to diagnose it in good time might result in a worse, or in some cases even a fatal, outcome.

Unfortunately, as discussed at the end of this article, medical assessment of insomnia quite often leads to a prescription for a "hypnotic" (sleep inducing) drug either before an underlying medical condition has been excluded or before non-drug management has been attempted. (The diagnosis or exclusion of an underlying medical condition is done by taking a medical history, performing a physical examination, ordering appropriate investigations and evaluating the information so collected. If necessary, one or more specialist referrals may then be made. This process is the basis of all modern evidence-based medicine. If it has not been properly completed, an underlying medical condition has not been excluded!)

As hypnotic drugs sometimes do more harm than good, there is often much to be said for trying simple remedies first. These simple remedies are often referred to collectively as "sleep hygiene", so that is my next heading. However, as mentioned above under Cautions, depending on the severity of this (or any) problem, medical advice should either precede the use of self-help techniques, or be sought in good time if a reasonable trial of self-help techniques has failed to provide a satisfactory solution to the problem.

Sleep Hygiene

Sleep hygiene is so-called by analogy with ordinary hygiene. The principles are the same, only the details are different. Just as washing your hands helps to keep health-destroying germs out of your food at mealtimes, removing work or hobbies from your bedroom can help to keep sleep-destroying thoughts out of your mind at bedtime. And just as a thorough redesign of a village's water supply and sewerage system can have a tremendous influence on both length and quality of life, a thorough redesign of various aspects of daily life can have a tremendous influence on the length and quality of sleep.

In other words, sleep hygiene is very simple in concept – it just means avoiding things that make you less likely to have a good night's sleep, and doing things that make you more likely to sleep well. However, as with most things, the concept can be expanded, and the details can be important. Before going into these details, though, I will mention three simple tricks which sometimes make a more comprehensive approach to sleep hygiene unnecessary.

Three Simple Tricks

Firstly, the simplest treatment that could ever be devised for any condition (and one that is very dangerous for some conditions) is sometimes remarkably effective in the case of insomnia. What is that treatment? That treatment is simply to ignore it altogether! The less you worry about insomnia, the less it is likely to worry you. Although it may seem like trivialising a real problem, this approach actually works very well for some people. Just as an itch usually recovers sooner if you don't scratch it too much, and a worry usually subsides sooner if you don't chase it round in endless circles, insomnia often departs sooner if you don't treat it as a major disaster.

Secondly, it is sometimes possible to educate insomnia out of existence! As the amount of sleep needed by healthy people varies very widely (anywhere between four and nine hours per night) some people think they have insomnia, when they really just need less sleep than they are trying to get. This type of "insomnia" can be cured completely, simply by going to bed later or getting up earlier!

Thirdly, it is always a good idea to restrict your time in bed to the number of hours you have some chance of spending asleep. Otherwise, you may be tossing and turning in frustration, without gaining anything but that frustration. Sometimes, though, an even greater restriction of the time in bed is recommended, in order to make use of tiredness as a tool to establish better sleep habits. However, when that is done, great care must be taken to avoid accidents as a result of the deliberately induced tiredness.

Those are probably the three simplest things you can do for insomnia, and they are usually worth trying fairly early in the overall effort to improve matters. To recap them, you can ignore insomnia, you can redefine it, or you can make use of its inevitable effect, tiredness, as a tool with which to promote its cure.

If none of those simple tricks work, there are many more things that can be tried. I will consider a number of these things during the rest of this article. Sleep specialists have an even broader repertoire, but perhaps you will find an effective solution here.

Sleep hygiene can be conveniently divided into preparatory work, which addresses issues which may otherwise interfere with the transition to sleep, and techniques which you can employ while you are lying awake in bed. I will deal with the preparatory work, which sets the stage for a successful outcome, under the next heading, and then I will go on to describe some specific techniques for use when in bed. Later, I will list a few other helpful hints.

How to Set the Stage for Sleep

The daytime is the right time to address many issues which might otherwise reduce your chance of falling asleep quickly and sleeping well. These issues can conveniently be considered under the following four headings:

1. Specific problems which may be preventing sleep

2. Physical characteristics of the place where you sleep

3. Emotional associations of the place where you sleep

4. Personal factors which may be keeping you awake

I will therefore look at each of these headings in turn.

Specific Problems

The possibility of a medical condition acting as an underlying cause for insomnia has already been mentioned. Such a condition might be quite minor. For example, it could be something as simple as a bladder infection, causing frequent trips to the toilet. On the other hand, it could be something less obvious, such as an undiagnosed depressive illness, or a malfunctioning thyroid gland. That is why, as mentioned previously, professional advice should either precede the use of self-help techniques, or be sought promptly if they do not provide relief after a reasonable trial.

Underlying problems in the area of general health and lifestyle also need careful consideration. For example, excess food and drink, lack of exercise, or the use of unnecessary and/or dangerous drugs can easily cause various sleep disturbances, including insomnia. In addition, some things which are such a routine part of everyday life that we rarely think much about them can also be very important. Coffee, tea, caffeinated soft drinks and chocolate, especially after about midday, can wreak havoc with your sleep. Healthy activities such as physical or mental exercise can also interfere with sleep if they are undertaken too close to bedtime.

Unresolved worries, such as important decisions which need to be made, are another common source of trouble. In order to resolve worries, it often helps to write down the options, add a list of pros and cons, and discuss them with whoever is affected by the decision, as well as with one or more other people, unless the matter is private. This simple approach to problem solving can be expanded to so-called "mind mapping", using a very large sheet of paper (or one of many available software programs) to show the many related ideas, subjective responses and "lateral" thoughts you may have about any difficult issue. Adding to such a map over time will not only show how complicated the problem is (which should be reassuring, seeing that you couldn't solve it quickly) but will often lead, eventually, to a good decision. Always remember that your decision does not have to be the only decision, or even the best one. It just has to be your current choice – until or unless you decide to revise it.

Even when there are no major unresolved problems, most of us carry some background stress and grief "in the back of the mind" most of the time. An overall approach to the problems of stress and grief is discussed at great length in my first eBook, "Wanterfall", which provides a simple but comprehensive model for the understanding of human emotions and outlines a practical self-help approach to dealing with them. Professional therapies may sometimes also be necessary, as discussed briefly later in this article.

Physical Environment

The place where you sleep can often benefit from some attention. Is it noisy? Is it too hot or too cold? Does it smell of mould, mothballs, or the dustbins outside the window? Is it illuminated by nearby streetlights – or worse, by flashing lights? Are buzzing flies or whining mosquitoes disturbing your peace? Is the bed too hard, too soft, sagging, or sloping? Are your bedclothes and sleepwear less comfortable than they might be?

Many of these physical aspects of the place where you sleep can easily be improved, once you think of them. For example, external noise can be reduced by earplugs. Light from outside can be reduced by opaque curtains, but an eye mask (also called a sleep mask) is sometimes simpler and more effective. With a little imagination and common sense, you can do a great deal to make your bedroom an easier and more pleasant place to sleep in.

Emotional Associations

If your bedroom is a multipurpose room, being in it will have associations which may not be at all conducive to sleep! Instead, the bedroom may be strongly associated, in your mind, with the other activities it is used for.

Perhaps your computer is a few feet away from your pillow, with the hard copy of a current assignment sitting next to it. A half-completed jigsaw puzzle might be waiting impatiently on its other side… or perhaps a neglected DIY project languishes on the same table.

For reasons such as these, it is often better if your work and hobbies take place in rooms other than the bedroom. Indeed, it is often stated axiomatically, by sleep specialists, that a bedroom should be used only for sleep and sex – though presumably not simultaneously.

Despite this widely held view, there is scope for quite a lot of individual variation in the use of the bedroom. Many people are able to read a book in bed, and still sleep soundly thereafter – though horror stories might not be the best choice! Soothing music should not cause any problems, either, but loud or exciting music often does.

Incidentally, if tinnitus (a noise in the head or a ringing in the ears) keeps you awake, a recording of a waterfall or a babbling brook, played continuously through the night by setting the player to repeat, and just loud enough to mask the unwanted noise, can be helpful.

Using a bedroom for audio-visual entertainment such as television is sometimes more of a problem than playing music or reading, as it tends to capture more attention, and thus induce higher levels of alertness. However, some people sleep soundly without even turning the television off! The important thing, of course is the effect it has on you, and that can really only be discovered by experiment.

Personal Factors

This aspect of sleep hygiene relates to how you think, feel and act in relation to sleep, and how those things influence the ease, quality and duration of your sleep. This can all add up to quite a large number of influences on your sleep! They can all have delayed effects, too, so it is not just a matter of how you think, feel and act while in bed.

How you think, feel and act during the evening is particularly important. Your general physical and emotional health, and indeed your overall lifestyle, also has important effects on sleep. In other words, this third aspect of sleep hygiene, which I have simply called "personal factors", is a very, very broad one! I think the best way to optimise this aspect is to practise "mindfulness", which is outside the scope of this article, but has been well described elsewhere.

(The best description of mindfulness I know of is in Kabat-Zinn, J. 1990. Full Catastrophe Living. New York: Bantam Dell (ISBN 978-0-385-30312-5). For comprehensive information about current courses and self-help materials, see University of Massachusetts Medical School | Center for Mindfulness in Medicine, Health Care, and Society at http://www.umassmed.edu/cfm/home/index.aspx)

What to Do when Lying in Bed Awake

Perhaps the most important thing to remember when lying in bed awake – and indeed, perhaps the most important thing about sleep hygiene altogether – is this: Never try to go to sleep. Just let sleep come to you. Trying to go to sleep is a sure way of staying awake!

Does "not trying to go to sleep" mean there is nothing you can do to promote sleep, or reduce the delay before you drift off? Certainly not! It simply means that the large number of things, which you can effectively do, does not include that one perfectly understandable but entirely counterproductive thing. And whatever you do with a view to facilitating sleep, the final step is always letting go and allowing sleep to occur of itself – now that you have stopped driving it away!

Under the previous heading, I talked about various things which are preparatory in nature, in that they are done before you go to bed with a view to setting the stage for sleep. Well, in a sense, the things which you can do when you are in bed are also preparatory. They also set the stage for sleep. Some of them are very powerful in their effects. Nevertheless, setting the stage in preparation for sleep is still all that they can do – nothing can ever directly force sleep to occur.

In fact, when it comes to sleep, you are not the actor – sleep is. And sleep always makes its entrance in its own time, never at your command. It is a bit like photographing a bird – the more patiently and quietly you wait, the sooner you will be successful. To recap, the act of trying to go to sleep just keeps you awake, so it is completely counterproductive. In fact, I strongly suggest that you don't even think about going to sleep while you are lying in bed!

Actually, in a very real sense, the phrase "going to sleep" is a prime example of an "oxymoron". In other words, it contradicts itself! You cannot possibly "go" to sleep. You don't even know where it is! Nobody ever "went" to sleep. Sleep comes to you. (Of course, we frequently talk about "going to sleep". As a figure of speech, there is nothing wrong with it at all. However, it is absolutely essential to remember that it is always a passive process, never an active one.)

Now, apart from this crucial realisation, that sleep is always yours to accept, but never to command, what else is helpful, when you are lying in bed awake? The answer is that you can do a great deal to facilitate the onset of sleep, while you lie in bed awake. Here are some of the things that you can usefully do.

First of all, when you get into bed, get comfortable. Some aspects of comfort in bed have already been considered, under Physical Environment, but once you get into bed you will soon discover any problems which were not solved in advance. Simply do whatever is necessary to optimise your comfort, as soon as you get into bed.

When you are as comfortable as possible, take a few deep, slow breaths. Check that your abdomen is moving as you breathe, as well as (or sometimes instead of) your chest. If not, "let go of" your tummy muscles and give your diaphragm room to move! Once that is achieved, just let your breathing do whatever it will – take no further part in it at all. (If you know a relaxing breathing exercise, you could do it for a while – but let it go, too, as soon as it has done its job.)

Now, when you are in bed, you are obviously lying on a surface – usually a mattress. Imagine that you are sinking gradually into it – just far enough to feel fully supported by it, but not far enough to feel smothered by it. Alternatively, imagine that you are floating – maybe in water, maybe on a cloud. Every part of you is limp and heavy, and is fully supported, effortlessly. Just leave this idea and image in your mind in a lazy sort of way, without putting any effort into it at all.

Whenever you notice that you are thinking about something specific, very gently let it go – over and over again, if necessary. However, if it is something that you really don't want to forget, just switch on the light briefly and write yourself a reminder, so that you can safely leave it alone until tomorrow. (Getting up like that for a minute keeps you awake for a few minutes more – but staying in bed with a nagging thought in your mind might keep you awake all night, so it is sometimes very helpful to have pencil and paper at the bedside.)

If you still have difficulty letting go of your thoughts, you can try replacing the thoughts that are keeping you awake with a single, very boring thought. Here is one, often suggested by sleep specialists, which can be astoundingly effective if you just think it patiently and persistently:

the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the the…

Say this to yourself silently (your tongue can move if it wants to, but do not whisper or speak aloud). Say it to yourself at a steady, comfortable pace, and keep on saying it to yourself forever. (Of course, you will stop saying it as soon as sleep has made its stealthy entrance on the scene – but you won't know that, will you?)

If you lose patience with all those definite articles, here is something else that often helps. Have you noticed that, when you get very sleepy, your thoughts become disjointed and scattered? Imitating this phenomenon can sometimes induce sleep. Just let your mind flop around aimlessly from one thought or picture to another, perhaps starting with an episode from childhood. When things start to get a bit confused, be glad of it, for you will soon be sleeping peacefully!

Another trick, which suits some people better, is to count backwards silently from 3,000 in steps of 3 (3,000 – 2,997 – 2,994 – etc). This gives you something more specific to focus on, and it leaves relatively little unused "brain space" for your worries to play in. Again, you may find yourself getting a little muddled after a while. As always, that is a sign that sleep is not far away!

Yet another trick, which is actually a type of self hypnosis, is to say to yourself "I will fall asleep by the time I say the number 60"... and then begin counting to a hundred, all the while relaxing and breathing easily. To make it even more powerful, open your eyes on odd numbers, and close them on even numbers. You might also try thinking the even numbers more slowly than the odd numbers. Again, the onset of confusion is a sign that sleep is approaching!

However, there is no single method which can guarantee rapid success, and the way you deal with the temporary lack of success is another important aspect of sleep hygiene. If you don't mind lying comfortably in bed practising your favourite stage setting techniques, there is no need to get up (until morning). If, on the other hand, you have been lying in bed for about half an hour and you feel distressed about not being asleep, it is best to get up for a while.

If you do get up in this situation, avoid bright light, caffeine and any activities that might increase your alertness. Do something pleasant, but not energetic, in another room, until you begin to feel tired and/or sleepy. Then, simply return to bed and resume one of the techniques described above. Sooner or later, this approach will work.

Getting up for a while in this way prevents you from forming, or strengthening, an association between lying in bed and endless frustration. That would be counterproductive. The aim of sleep hygiene is to improve your chance of a good night's sleep – not to make yourself miserable in the attempt! On the other hand, as mentioned above, if you are quite content lying comfortably in bed, then there is no need to get up at all.

A Few Other Helpful Hints

There are many helpful hints, which are often recommended by sleep specialists, and which can contribute to improved sleep hygiene. I will list some of them here. (Some of these hints have already been mentioned in the text, but others have not.)

• Avoid alcohol, tea, coffee, caffeinated soft drinks, chocolate, nicotine, much food or much fluid at or near bedtime

• Avoid mentally stimulating activities at or near bedtime

• Avoid daytime naps, or sleeping late, if at all possible

• Set a regular bedtime, and try to stick to it

• Ideally, set bedtime sometime between 9 and 11 pm

• Set a regular alarm, allowing no more sleep than you need

• Turn your alarm clock around, so that you can't check the time during the night

• Exercise daily, but do so at least a few hours before bedtime

• Try allotting a specific "worry time", again at least a few hours before bedtime

• Get some exposure to bright light every day, especially in the mornings

• Develop a standard ritual of preparation for bed (e.g. brushing teeth and checking that appliances are turned off and doors and windows are locked)

• Try a warm milk drink or some camomile tea at bedtime

• Have a hot shower or bath before going to bed (this raises the body temperature slightly – sleep is induced as it falls again)

• Learn some simple stretching and breathing exercises which are suitable for bedtime use (some stretching and breathing exercises encourage sleep, while others have the opposite effect, so it might be worth considering a few yoga classes)

Professional Therapy

In some cases it may be necessary to supplement the various aspects of sleep hygiene discussed above with the assistance of a professional therapist. This may involve treatment of specific conditions, especially physical illnesses, anxiety disorders or depressive disorders, or it may focus on insomnia alone if this appears to be the only problem. Although such professional therapy is not the topic of this article, I will briefly mention a few examples.

In the case of physical illnesses or severe episodes of depression, medical treatment is the first essential, and is usually very effective. For anxiety disorders, and also as a general approach to dealing with life's inevitable problems, the Mindfulness-Based Stress Reduction program pioneered by Jon Kabat-Zinn is well validated and widely recommended. For the original description of this technique, see Kabat-Zinn, J. 1990. Full Catastrophe Living. New York: Bantam Dell (ISBN 978-0-385-30312-5). For comprehensive information about current courses and self-help materials, see University of Massachusetts Medical School | Center for Mindfulness in Medicine, Health Care, and Society at http://www.umassmed.edu/cfm/home/index.aspx

Therapist-led evidence-based therapies include Cognitive Behaviour(al) Therapy (including its various mindfulness-based derivatives), Acceptance and Commitment Therapy, and Interpersonal Psychotherapy. When considering these or other professional therapies, the choice of therapist is obviously very important. This choice may be facilitated by referral or personal recommendation, and reviewed in the light of personal experience.

Herbal Remedies

Various herbal remedies, such as valerian, camomile and California poppy, are often suggested for insomnia. However, in controlled trials, evidence for their efficacy is quite inconclusive. Of course, if taken with confidence, they are likely to have a beneficial placebo effect. It also seems probable that their adverse effects are likely to be less severe than those of the "sleeping tablets" discussed at the end of this article. However, it must always be remembered that natural remedies are not necessarily harmless. Indeed, some of the most potent poisons known occur in nature. It is also important to remember that "alternative" or "complementary" remedies often have potentially dangerous interactions with medically prescribed drugs, so they must always be brought to the attention of a person's doctor.

Melatonin

The natural hormone melatonin is known to play a role in the normal control of wakefulness and sleepiness, and both natural and synthetic forms have been available for some years. More recently, a prolonged-release preparation of synthetic melatonin (marketed as Circadin) has been formulated, with the aim of mimicking the natural production of melatonin by releasing it gradually over 8-10 hours. Other "melatonin receptor agonists" also exist, and one of them (ramelteon) is available in North America at the time of writing.

It seems reasonable to hope that melatonin receptor agonists may find a useful role in situations where various causative factors, such as shift work or jet lag, interfere with the way in which natural melatonin appears to facilitate the normal sleep-wake cycle. However, at the time of writing, this result is far from certain.

Not surprisingly, considering the size of the market, melatonin receptor agonists are also being enthusiastically marketed to the wider population as an alternative to the hypnotic drugs discussed under the next heading. At the time of writing, I think it is much too early to say whether they will prove to be either safe or effective in this more general role. However, they do not appear to cause impaired daytime alertness, severe withdrawal effects or dependence.

Sleeping Tablets

Perhaps you have been wondering why I have spent so much time writing about insomnia, without mentioning the wide variety of so-called hypnotic drugs which are commonly referred to as "sleeping tablets". Well, I have left sleeping tablets until last for one simple reason. Having practised medicine now for some forty years, I am absolutely convinced that sleeping tablets are the last thing that a person with insomnia should have on their list of possible remedies!

Of course, I do not mean that sleeping tablets should not be on the list. Of course they must be on the list – they can be very useful in a number of (very specific) situations. I simply mean that everything else should be tried first, and sleeping tablets can then be considered.

However, it is a bizarre and often sad irony that this last thing is sometimes the first thing suggested by a doctor, when a patient complains of insomnia. It is not uncommon for doctors to feel pressured (and indeed, they sometimes are) to provide a quick and easy solution to the common complaint of insomnia. Only the prescription pad can achieve such a quick fix, but the cost is sometimes much higher than either the doctor or the patient expects.

Of course, an important part of the art of medicine is to lead patients in the direction of the best solutions to their problems, which are quite often not the easiest ones. However, we doctors are just as susceptible to subconscious influences as anyone else, and it has been my experience that various non medical factors, including the advice, gifts and free samples received from "drug reps", the apparent desires and expectations of our patients, and the inevitable time constraints of a busy clinic, can all too easily have an adverse effect on medical decision making.

Well, be that as it may, perhaps you will one day find yourself taking sleeping tablets, and perhaps they will help you to sleep. However, it is important to remember that there is no such thing as a sleeping tablet that has no adverse effects or potentially dangerous interactions with other medications, alcohol or recreational drugs.

The possibility of such adverse effects or interactions persists for as long as the tablets are taken. However, the desired effect, which is usually very helpful at first, diminishes progressively, becoming very weak after about three months.

By that time, you may have developed great faith in the medication. In that case, it may appear to remain effective – such is the power of suggestion. If not, it is quite likely that you will be advised to increase the dose, or perhaps to change to "something stronger". The same problem may then recur, after about another three months; and again… and so on.

As the dose or strength of the tablets increases, the adverse effects can sometimes become very considerable – even though the desired effect is decreasing. However, the adverse effects may not be recognised as being due to the "safe and effective" sleeping tablets that you have been taking for some time...

Unfortunately, by the time these problems are recognised, you will probably have developed considerable physiological tolerance to the medication, so that it is not safe to withdraw it suddenly. In addition, psychological addiction can also occur in some cases.

At about the time that I graduated as a doctor, it was hoped that the transition from barbiturate sleeping tablets to benzodiazepines would solve most or all of these problems. Unfortunately, it did not. Instead, it simply modified them in various ways. In fact – and this will probably surprise you, but a little googling will soon confirm it – the "withdrawal syndrome" that occurs when a benzodiazepine sleeping tablet is stopped suddenly after long term use at fairly high dosage is actually more dangerous than sudden withdrawal from heroin!

In other words, if you received the same quality of care in each case, you would be more likely to die while withdrawing from the commonest sleeping tablets prescribed by doctors at the time of writing (November 2012) than if you were withdrawing from a serious heroin habit. Perhaps that is not a reason to avoid the use of sleeping tablets altogether, but I do think it is food for thought…

What about "the very latest and greatest" sleeping tablets? New sleeping tablets have been introduced from time to time, and while often better in some ways, they have usually brought new problems with them. For example, the relatively new non-benzodiazepine "z-drug" hypnotics (zolpidem, zopiclone and zaleplon) have been associated with reports of potentially dangerous phenomena such as sleep-walking, sleep-driving and hallucinations. In my experience, though, new sleep medications have always been presented (usually with considerable fanfare) as "safe and effective – at last"!

Declaration of Interest

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By the Same Author

For a discussion of the genesis of emotional distress in general, see "The Origin of Emotions" at www.wanterfall.com/Wf3Origin.htm

For a simple approach to self-help as an adjunct in the overall management of anxiety, grief or any other distressing emotional state, see "Emotional EEEEs" at www.wanterfall.com/Wf13EEEEs1.htm

For more free articles and ebooks, on a wide range of topics, visit http://www.wanterfall.com