Treating insomnia, stop ear ringing after shooting gun - For You

Understanding insomnia and how it can most effectively be treated continues to challenge psychiatrists and other clinicians. This column provides information on how and why insomnia develops, as well as on its treatment, focusing primarily on behavioral interventions.
Behavioral treatments for insomnia can be very effective for many patients, but there are substantial challenges to clinicians desiring to use these treatments. Age is a factor in development of insomnia, but not because we need less sleep as we age or even that sleep drive and sleep depth are reduced with age. Personality traits may also play a significant contributory role in the development of insomnia, based on this model.
A wide range of events and stimuli may precipitate an insomnia episode in susceptible individuals.
As a consequence of the development of insomnia, patients may make various changes in their habits and routines to try to compensate for their sleep loss and greater difficulties falling asleep. Understanding how insomnia develops may provide opportunities to treat insomnia at early stages and prevent progression to chronic insomnia. Understanding how insomnia develops is also important when insomnia has become established as a chronic condition. Various behavioral therapies have demonstrated efficacy in the treatment of chronic insomnia.9 Research supports the hypothesis that non-pharmacologic therapies can be very effective in the treatment of insomnia, and an effort should be made to include behavioral therapies in the treatment of every patient with insomnia. Operationally, sleep restriction involves an initial limitation of time in bed to an amount close to the number of hours that the insomnia patient reports having slept. Stimulus control therapy (SCT), originally described by Bootzin and colleagues,11 has become so widely utilized in the behavioral treatment of insomnia that many practitioners do not appreciate that it defines a specific and universal approach to the treatment of insomnia. CBT, demonstrated to be effective in the treatment of depression, has also demonstrated efficacy in multiple research studies as a treatment for insomnia.12-14 Typically, CBT attempts to address maladaptive behaviors and thought patterns that plague insomniac patients.
The supplements L-tryptophan and 5-hydroxytryptophan can be useful for insomnia, a chemical that promotes relaxation.
Acupuncture might have an almost 90 percent success rate for insomnia, according to some reports. Patient information: See related handout on insomnia, written by the authors of this article.


Insomnia may be acute or chronic, but the majority of patients presenting for evaluation to treating physicians complain of chronic insomnia. The origins of chronic insomnia are usually much more complex, with contributions from predisposing, precipitating, and perpetuating factors. It also recognizes that chronic insomnia is maintained (unintentionally) by maladaptive coping strategies (perpetuating factors).
The presence of concomitant medical illnesses is the largest contributing factor to increased rates of insomnia seen with increased age. Insomnia patients are often anxious, and may develop fixations about the amount and quality of sleep that they obtain and the impact they believe it will have on daytime function. For example, using the Spielman model,2-4 if physicians and therapists recognize that premorbid traits predisposing to development of insomnia exist, they may be more aggressive in treating stress and instructing patients on avoidance of key stressors capable of provoking insomnia.
Identification of elements that have contributed to the development of insomnia, and educating the patient about the roles that behavior and conditioning have played in this process, should help physicians and patients understand that behavioral therapies combined with pharmacologic interventions are useful treatment options. Some of the elements from these specific therapies may also be incorporated in a more global approach to the treatment of insomnia using cognitive-behavioral therapy (CBT).
This restriction is based on assumption that most insomnia patients underestimate the amount of sleep that they have obtained. These disturbances develop over long periods of time, become an entrenched part of the insomniac’s thought and behavior patterns, and exacerbate insomnia severity. Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. An approach to the evaluation and treatment of the patient with insomnia is shown in Figure 1. Most insomnia can be related, at least in part, to comorbid medical and psychiatric conditions, which may play a role in any of these three contributory realms.
Thus, a person may be prone to insomnia due to trait characteristics, may experience a trenchant or short-term insomnia as a consequence of precipitating stresses, and may develop a persistent and chronic insomnia as a consequence of pathologic coping strategies and poor sleep hygiene.
Thought processes of this sort clearly contribute to the development of insomnia, and are excellent targets for cognitive therapy as part of an overall treatment program.
Parental demands, care-giving for a spouse or parent, or arousal related to a bed-partner’s sleep tendencies, schedule, or habits may all contribute to increased risk of developing insomnia.

Examples of disorders that could precipitate insomnia include arthritis flares, angina, prostatism, hyperthyroidism, and irritable bowel syndrome. If stressors are neutralized or insomnia symptoms are quickly and effectively treated, patients may revert to their pre-morbid, non-insomniac state. These disturbances tend to develop no matter how the insomnia originally developed, and include behavioral and cognitive elements that interfere with the patient’s ability to relax and fall asleep.
Another common habit exhibited by insomniacs is a tendency to look at clocks when they have trouble sleeping.
Long-term effectiveness of a short-term cognitive-behavioral group treatment for primary insomnia. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. If interventions are not made until perpetuating elements have developed, the insomnia condition is more likely to become chronic. Insomniacs will attempt to process the information provided by the clock in the middle of the night; this is always a negative phenomenon. A more comprehensive evaluation should be pursued with nonresponders or if a comorbid condition is present or suspected.The evaluation of chronic insomnia should involve a detailed history and examination to detect any coexisting medical or psychiatric illness and may include an interview with a partner or caregiver. The Insomnia Answer: A Personalized Program for Identifying and Overcoming the Three Types of Insomnia. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia.

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