Psychiatric News December 7, 2001
Volume 36 Number 23
© 2001 American Psychiatric Association
p. 10
Sleepless in America: Terrorist Attacks Boost Insomnia, Nightmares
Lynne Lamberg
A recent rise in prescriptions for hypnotics and other psychoactive drugs points to increased anxiety and depression.
Poor sleep and bad dreams are good barometers of the nation’s heightened anxiety and grief since the attacks on the World Trade Center and Pentagon on September 11. Continuing threats from anthrax and worries about further terrorist acts have made many Americans hypervigilant and hyperaroused, sleep experts say.
New prescriptions for all medications used to treat insomnia increased about 10 percent to 12 percent across the nation in the month following the attacks, according to data compiled by NDCHealth, an Atlanta-based health care information services company. "The data indicate that physicians, in general, recognize that use of hypnotics for insomnia associated with acute stress is often appropriate," said James Walsh, Ph.D., president of the Washington, D.C.-based National Sleep Foundation, and director of the sleep disorders center at St. Luke’s Hospital in St. Louis, Mo.
People are not jamming sleep center phone lines. "Everybody knows what’s going on. People turn to sleep centers when they don’t know what’s going on," said Neil Kavey, M.D., director of the sleep disorders center and a clinical professor of psychiatry at Columbia Presbyterian Medical Center in New York City.
Many patients whose insomnia had been under control before September 11, however, have had recurrences, Kavey said. Sleep specialists outside of New York and the Washington, D.C., area report similar observations. "Patients with chronic insomnia point to September 11 and to lingering fears of anthrax and whatever else might happen as a source of stress and a trigger for their troubled sleep," said David Neubauer, M.D., associate director of the sleep disorders center and an assistant professor of psychiatry at the Johns Hopkins Medical Institutions in Baltimore.
Some patients at sleep centers in New York canceled scheduled appointments. "Many said they’d be uncomfortable sleeping away from home," said Joyce Walsleben, Ph.D., director of New York University’s sleep disorders center.
Even people who still sleep reasonably well, Kavey pointed out, lose sleep if children or other members of their household have trouble settling down, sleep fitfully, or awaken from bad dreams in need of comforting.
‘Idling at a Higher Speed’
"Since September 11 we’ve all been living at a different level of arousal," Kavey said. "We’re idling at a higher speed. It’s harder to wind down and to maintain sleep through the night." A depressed mood further complicates this situation, he said, probably by altering both the alerting mechanism and the neurochemistry of sleep.
The resulting sleep deprivation likely is having numerous subtle yet powerful effects, he said. People feel tired and distracted. They’re more apt to have driving mishaps. Their productivity at work has fallen. They’re more irritable.
In New York, Kavey noted, the mayor has urged people to try to resume their normal routines. But New Yorkers can’t avoid seeing the altered skyline. Many neighborhoods still display posters of the missing. Having the New York Yankees in the World Series provided some respite, said Kavey, and the team’s dramatic wins boosted the city’s mood, despite their final loss to the Arizona Diamondbacks.
Sleep Improves Over Time
Studies following earthquakes, floods, and other natural disasters show sleep usually improves over time. Studies of sleep in wartime, such as those of Israelis living under the threat of Scud missiles, show that initial complaints of difficulty falling and staying asleep fade quickly in most people. Peretz Lavie, Ph.D., and colleagues at the Technion-Israel Institute of Technology in Haifa recorded sleep in both subjects’ homes and in their sleep laboratory during the Persian Gulf War in 1991. Despite having increased anxiety at bedtime, Lavie said, most people objectively slept as well as usual.
"The situation may be different here," Kavey said. "Israel was born in conflict," he noted. "Up until now, we have lived with an enormous sense of security."
Many mentally healthy people are having sleep problems now, Kavey said. And some who aren’t worry that sleeping well implies a lack of sensitivity on their part. "This crisis is hitting people in different ways," he said, "reflecting both individual variability and proximity to the traumatic events."
Good sleep hygiene, such as sticking to regular bedtimes and waketimes to program the body’s biological clock for sleep, is especially important now, sleep experts maintain. They advise people to skip coffee at dinner and not to consume alcohol, watch news on television, read the newspaper, or discuss worries near bedtime. "Many people need a larger window of relaxation before bedtime," Kavey said, "and greater attention to behavior that didn’t bother their sleep before." Walsleben suggests people spend more time with their families and get extra sleep if they can. Children may need more evening quiet time and more time for bedtime stories and other sleep rituals.
Some people will need to talk to their primary care physician, and some will benefit from taking hypnotics, Neubauer said. It’s important to remind patients, he added, that a bad night’s sleep will not help them process this disaster. People will function better in all ways if they are sleeping better, he said, noting that newer hypnotics, such as zolpidem (Ambien) and zaleplon (Sonata) are unlikely to impair daytime functioning. 
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