Definition
Insomnia is the feeling of inadequate or poor-quality sleep because of one or more of the following: trouble falling asleep (Initial Insomnia); trouble remaining asleep through the night (Middle Insomnia); waking up too early (Terminal Insomnia); or unrefreshing sleep. These can all lead to daytime drowsiness, poor concentration and the inability to feel refreshed and rested upon awakening.
Insomnia is not defined by the hours of sleep a person gets or how long it takes to fall asleep. Individuals vary normally in their need for, and their satisfaction with, sleep. Insomnia may cause problems during the day, such as tiredness, difficulty concentrating and irritability.
Insomnia can be classified as transient, intermittent and chronic. Insomnia lasting from a single night to a few weeks is referred to as transient. If episodes of transient insomnia occur from time to time, the insomnia is said to be intermittent. Insomnia (or Primary Insomnia) is considered to be chronic if it occurs on most nights and lasts a month or more.
Women, the elderly and individuals with a history of depression are more likely to experience insomnia. Factors such as stress, anxiety, a medical problem or the use of certain medications make the chance of insomnia more likely.
Symptoms
People will be unable to carry out their daily responsibilities either because they are too tired or because they have trouble concentrating due to lack of restful sleep.
Insomnia may cause a reduced energy level, irritability, disorientation, dark circles under the eyes, posture changes and fatigue.
Patients with insomnia are evaluated by a medical history and a sleep history. The sleep history may be obtained from a sleep diary filled out by the patient or by an interview with the patient’s bed partner concerning the quantity and quality of the patient’s sleep. Specialized sleep studies may be recommended, but only if there is suspicion that the patient may have a primary sleep disorder such as sleep apnea or narcolepsy.
Diagnostic criteria of primary insomnia:
* The predominant complaint is difficulty falling or staying sleep, or nonrestorative sleep, for at least one month.
* The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
* The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder or a parasomnia.
* The disturbance does not occur exclusively during the course of another mental disorder (such as major depressive disorder, generalized anxiety disorder, a delirium).
* The disturbance is not due to the direct physiological effects of a substance (such as a drug abuse, a medication) or a medical condition.
Causes
Certain conditions seem to make individuals more likely to experience insomnia. Examples of these conditions include:
* Advanced age (insomnia occurs more frequently in those over age 60)
* Female gender
* A history of depression
There are a number of possible causes of insomnia:
* Jet lag
* Shift work
* Wake-sleep pattern disturbances
* Grief
* Depression or major depression
* Stress
* Anxiety
* Exhilaration or excitement
* Bed or bedroom not conducive to sleep
* Nicotine, alcohol, caffeine, food, or stimulants at bedtime
* Aging
* Excessive sleep during the day
* Excessive physical or intellectual stimulation at bedtime
* Overactive thyroid
* Taking a new drug
* Alcoholism
* Inadequate bright-light exposure during waking hours
* Abruptly stopping a medication
* Medications or illicit drugs
* Withdrawal of medications
* Interference with sleep by various diseases
* Restless leg syndrome
Transient and intermittent insomnia generally occur in people who are temporarily experiencing one or more of the following:
* Stress
* Environmental noise
* Extreme temperatures
* Change in the surrounding environment
* Sleep/wake schedule problems such as those due to jet lag
* Medication side effects
Chronic insomnia is more complex and often results from a combination of factors, including underlying physical or mental disorders. One of the most common causes of chronic insomnia is depression. Other underlying causes include arthritis, kidney disease, heart failure, asthma, sleep apnea, narcolepsy, restless legs syndrome, Parkinson’s disease and hyperthyroidism. However, chronic insomnia may also be due to behavioral factors, including the misuse of caffeine, alcohol or other substances; disrupted sleep/wake cycles that may occur with shift work or other nighttime lifestyles; and chronic stress.
Some behaviors may prolong existing insomnia, and they can also be responsible for causing the sleeping problem in the first place:
* Worrying about the upcoming difficulty sleeping
* Ingesting excessive amounts of caffeine
* Drinking alcohol before bedtime
* Smoking cigarettes before bedtime
* Excessive napping in the afternoon or evening
* Irregular or continually disrupted sleep/wake schedules
Stopping these behaviors may eliminate the insomnia.
Treatment
Transient and intermittent insomnia may not require treatment since episodes last only a few days at a time. For example, if insomnia is due to a temporary change in schedule, as with jet lag, the person’s biological clock will often get back to normal on its own. However, for some people who experience daytime sleepiness and impaired performance as a result of Transient Insomnia, the use of short-acting sleeping pills may improve sleep and next-day alertness. As with all drugs, there are potential side effects. The use of over-the-counter sleep medicines is not usually recommended for the treatment of insomnia.
Treatment for diagnosed chronic insomnia includes identifying and stopping (or reducing) behaviors that may worsen the condition, possibly using sleeping pills (although the long-term use of sleeping pills for chronic insomnia is controversial and should be a last resort), trying behavioral techniques to improve sleep, such as relaxation therapy, sleep restriction therapy, and reconditioning.
Relaxation Therapy
There are specific and effective techniques that can reduce or eliminate anxiety and body tension. As a result, the person’s mind is able to stop racing, the muscles can relax and restful sleep can occur. It usually takes much practice to learn these techniques and to achieve effective relaxation.
Sleep Restriction
Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. They may benefit from a sleep restriction program that at first allows only a few hours of sleep during the night and gradually increases the time until the person achieves a normal night’s sleep.
Reconditioning
Another treatment that may help some people with insomnia is to recondition them to associate the bed and bedtime with sleep. For most people, this means not using their beds for any activities other than sleep and sex. As part of the reconditioning process, the person is usually advised to go to bed only when sleepy. If unable to fall asleep, the person is told to get up, stay up until sleepy and then return to bed. Throughout this process, the person should avoid naps and wake up and go to bed at the same time each day. Eventually the person’s body will be conditioned to associate the bed and bedtime with sleep.
Practice good sleep hygiene: Avoid using alcohol in the evening. Avoid caffeine for at least eight hours before bedtime. Quit smoking. Establish a regular bedtime, but don’t go to bed if you feel wide-awake. Avoid staying in bed for long periods of time while awake, or going to bed because of boredom. Exercise regularly, but not in the last two hours before going to bed. Sex can be a natural sleep inducer and helps some people. If these fail, you may want to ask you health care provider to recommend other options.
Tips for a Good Night’s Sleep:
Set a schedule:
Go to bed at a set time each night and get up at the same time each morning. Disrupting this schedule may lead to insomnia. Sleeping in on weekends also makes it harder to wake up early on Monday morning because it resets your sleep cycles for a later awakening.
Exercise:
Try to exercise 20 to 30 minutes a day. Daily exercise often helps people sleep, although a workout soon before bedtime may interfere with sleep. For maximum benefit, try to get your exercise about five to six hours before going to bed.
Avoid caffeine, nicotine, and alcohol:
Avoid drinks that contain caffeine, which acts as a stimulant and keeps people awake. Sources of caffeine include coffee, chocolate, soft drinks, non-herbal teas, diet drugs and some pain relievers. Smokers tend to sleep very lightly and often wake up in the early morning due to nicotine withdrawal. Alcohol robs people of deep sleep and REM sleep and keeps them in the lighter stages of sleep.
Relax before bed:
A warm bath, reading or another relaxing routine can make it easier to fall sleep. You can train yourself to associate certain restful activities with sleep and make them part of your bedtime ritual.
Sleep until sunlight:
If possible, wake up with the sun, or use very bright lights in the morning. Sunlight helps the body’s internal biological clock reset itself each day. Sleep experts recommend exposure to an hour of morning sunlight for people having problems falling asleep.
Don’t lie in bed awake:
If you can’t get to sleep, don’t just lie in bed. Do something else, like reading, watching television or listening to music, until you feel tired. The anxiety of being unable to fall asleep can actually contribute to insomnia.
Control your room temperature:
Maintain a comfortable temperature in the bedroom. Extreme temperatures may disrupt sleep or prevent you from falling asleep.
See a doctor if your sleeping problem continues:
If you have trouble falling asleep night after night, or if you always feel tired the next day, then you may have a sleep disorder and should see a physician. Your primary care physician may be able to help you; if not, you can probably find a sleep specialist at a major hospital near you. Most sleep disorders can be treated effectively.
Sleep research is expanding and attracting more and more attention. Researchers now know that sleep is an active and dynamic state that greatly influences our waking hours, and they realize that we must understand sleep to fully understand the brain. Innovative techniques, such as brain imaging, can now help researchers understand how different brain regions function during sleep and how different activities and disorders affect sleep. Understanding the factors that affect sleep in health and disease also may lead to revolutionary new therapies for sleep disorders and to ways of overcoming jet lag and the problems associated with shift work. We can expect these and many other benefits from research that will allow us to truly understand sleep’s impact on our lives.
