Let’s talk about insomnia. For the past several weeks, I’ve been coping (with varying degrees of success) with insomnia. This is not uncommon in cancer patients and seems to be linked to cancer-related fatigue, as well. I hate taking any kind of drug that fuddles my mind, so I avoid my sleeping pills as much as I can. I decided to go to PubMed (1) to see if I could find a magic wand.
Yes; I want a magic wand. I deserve a magic wand! Give me my magic wand!
The first thing I discovered is that I am not alone. I had that sense from the people in my support groups and the wonderful on-line breast cancer community, but having a scientific bent, I mistrust purely anecdotal evidence. One abstract I read is written in straightforward language and reinforced my sense that this is a common issue for us:
“Insomnia affects up to 50% of patients with cancer, but has received little attention from the oncology community compared with other symptoms such as pain and fatigue. Insomnia and subsequent sleep disturbances can lead to fatigue, mood disturbances, and contribute to immunosuppression, which can have a profound impact on quality of life and perhaps affect the course of disease. Insomnia in cancer patients must be distinguished from cancer-related fatigue. Although they are 2 distinct conditions, insomnia and fatigue are interrelated. Insomnia often leads to daytime fatigue that interferes with normal functioning. Conversely, daytime fatigue can lead to behaviors such as napping, which result in insomnia.” (2)
A slightly more technical article is directed specifically at physicians who treat insomnia in cancer patients. It also discusses the interrelatedness of cancer-related fatigue and insomnia, and the fact that insomnia is undertreated by oncologists. The author writes, “Evidence suggests that management of insomnia through a combination of pharmacologic and nonpharmacologic means can have a positive impact not only on insomnia but also on related symptoms and, consequently, on overall health and quality of life,” and suggests that “[p]hysicians should use hypnotic agents appropriately and be aware of the reduced potential for producing tolerance and dependence with the nonbenzodiazepine hypnotic agents. The management of insomnia in cancer patients should include a global treatment plan designed to address not only the underlying sleep disturbance but also the related symptoms that may contribute to insomnia or occur as a result of it.” (3)
So the first thing I learned is that it’s not all in my head; it’s a real issue. This is important because whenever I have a symptom of any kind my first reaction is that I’m imagining it or exaggerating it or acting like a drama queen. (I won’t subject you to the roots of my psychological problems. Nothing to see here. Let’s move on.)
Finding that there is actually medical literature on the subject and that I am in very good company, with up to half of all cancer patients experiencing insomnia, was not only affirming, but also helped to reduce the anxiety that is related to the insomnia.
I recently noticed that the longer I have been suffering from insomnia, the greater my anxiety just before going to bed. This is independent of any other anxiety I may be experiencing, like that related to the cancer itself or to work or family matters. Getting ready for bed is no longer a time of progressively “powering down” from the day, slowing down, divesting myself of the cares of the day, relaxing, settling. It has become a tense, anxious time. “Will I get any sleep? Should I take something? I don’t want to become dependent. What if I’m up all night though? Do I have morning commitments? Why is this so hard?” If I’m not careful, I can escalate and end up becoming quite anxious indeed.
I need to calm myself. I reassure myself with the same things I used to tell my patients. Insomnia is self-limiting. It won’t kill you. You will eventually sleep. And I make the same snarky replies to myself that some of my patients made to me. Okay, we tried that. Next?
I listen to a pleasant book or quiet music for eight to fifteen minutes and then put on some ambient sounds like ocean waves or birds in the forest or rainfall. I adjust my breathing, gently slowing it down, and then I begin progressive relaxation. I may take myself on a guided meditation.
On occasion, this works. More and more these days, it does not. I should probably stop trying to juggle the meds I have and instead talk frankly with my physican about the problem. The thing is, I feel like a wimp if I bring it up, which brings us full circle back to my psychological issues. I guess I’m going to have to get over myself, though, and just do it.
Before I take the radical step of actually consulting with my doctor, I think I’ll try one more remedy: synthetic melatonin. Many people I know who travel quite a bit use it to combat jet lag. Melatonin is a hormone produced by the pineal gland, and its production is related to the daylight we are exposed to. I don’t get outside every day and there is little natural light in my house. (My Vitamin D level is very, very low as a consequence.) I will try being more conscious about being outside in the sunshine for a while each day, and I will also get hold of some melatonin and see if it helps me sleep.
No magic wand to be found, so I’ll just keep trudging along until I find something acceptable that works.
Since this is such a common issue for people who have cancer, I thought I’d finish off with a link to Living Beyond Breast Cancer’s informative page on sleeping problems (insomnia and fatigue).
1. PubMed is a free online resource that provides access to professional medical literature. From the homepage: “PubMed comprises more than 23 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites.”
2. JF O’Donnel, Insomnia in cancer patients. Clin Cornerstone. 2004; 6 Suppl 1D:S6-14.
3. DE Theobald, Cancer pain, fatigue, distress, and insomnia in cancer patients. Clin Cornerstone. 2004; 6 Suppl 1D:S15-21.