From the Guidelines
To address hypervigilance at bedtime, cognitive behavioral therapy for insomnia (CBT-I) is highly effective, as evidenced by the 2021 study published in the Journal of Clinical Sleep Medicine 1. This approach helps individuals identify and change negative thoughts and behaviors that contribute to hypervigilance and insomnia. Some key strategies for managing hypervigilance at bedtime include:
- Establishing a consistent sleep routine beginning 30-60 minutes before bed with relaxing activities like reading or gentle stretching
- Avoiding screens, caffeine, and alcohol in the hours before sleep
- Practicing relaxation techniques such as deep breathing, progressive muscle relaxation, or guided meditation
- Creating a sleep-conducive environment that's cool, dark, and quiet
- Trying a "worry journal" to write down concerns before bed
- Considering non-habit forming supplements like melatonin (0.5-5mg taken 30-60 minutes before bed) or magnesium glycinate (200-400mg) for temporary relief
- Exploring prescription options like trazodone (25-100mg) or low-dose doxepin (3-6mg) under medical supervision for short-term use. According to the 2020 study published in the Annals of Internal Medicine 1, CBT-I has been shown to be effective in treating chronic insomnia, and the 2016 study published in the Annals of Internal Medicine 1 also supports the use of CBT-I as a first-line treatment for insomnia. Additionally, the 2008 study published in the Journal of Clinical Sleep Medicine 1 provides guidance on the evaluation and management of chronic insomnia in adults, including the use of CBT-I and other behavioral therapies. It's essential to consult with a healthcare professional to determine the best course of treatment for individual cases of hypervigilance and insomnia.
From the Research
Hypervigilance at Bedtime
Hypervigilance at bedtime can be a symptom of insomnia, which is a common type of sleep disorder defined by an ongoing difficulty initiating or maintaining sleep or nonrestorative sleep with subsequent daytime impairment 2.
Causes and Effects
The sleep disturbances in insomnia usually manifest as difficulty in falling asleep, maintaining the continuity of sleep, or waking up too early in the morning well before the desired time, irrespective of the adequate circumstances to sleep every night 2. Insomnia can significantly impact daytime functioning resulting in decreased workplace productivity, proneness to errors and accidents, inability to concentrate, frequent daytime naps, and poor quality of life 2, 3.
Treatment Options
The treatment of insomnia should involve a multi-disciplinary approach, focusing on implementing behavioral interventions, improving sleep hygiene, managing psychological stressors, hypnotic treatment, and pharmacological therapy 2, 3. Non-benzodiazepine hypnotics such as zolpidem, eszopiclone, zaleplon are the most used as adjunctive treatment 2. Cognitive behavioral therapy for insomnia (CBT-I) is also a primary treatment modality, but it is associated with difficulties with access and higher cost as well as poor response in some patients 3.
Pharmacological Management
Pharmacotherapy for insomnia is common and hypnotic agents are among the most frequently prescribed medications in the United States 3. The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations 3.
- Some key points to consider:
- Zolpidem has been associated with an increased risk of falls in hospitalized patients and hip fractures 2.
- Zolpidem has a wide variety of adverse effects, including CNS-related effects such as confusion, dizziness, and daytime sleepiness 2.
- The addition of extended CBT did not alter the long-term outcome over improvements obtained during the initial 6-week CBT 4.
- Participants receiving CBT with zolpidem taper in the extended treatment phase had significantly better results than those receiving CBT with continued zolpidem as needed 4.
- Benzodiazepines are used for those struggling with sleep, anxiety, spasticity due to CNS pathology, muscle relaxation, and epilepsy, but they have an addictive potential and can cause severe, harmful psychological and physical dependence 5.