Insomnia
Sleep is one of the most important human behaviour which occupies 1/3 time of the total human life span. Thus, if we survive till the age of 80, more than 25 years of our life would be spent in sleeping collectively.
The most common sleep related complaint is that of insomnia. After pain, insomnia is the 2nd most common complaint among all the complaints overall reported by patients in primary care settings.
Famous personalities with insomnia
Winston Churchill, Charles Dickens, Napoleon Bonaparte, Benjamin Franklin, and Alexander Dumas: Apart from the common factor of being famous, all these personalities shared the common factor of insomnia.
How do you know you have Insomnia?
Despite having adequate opportunities for sleep, presence of one or more of the following determines insomnia:
- Difficulty in initiating sleep.
- Difficulty in maintaining sleep.
- Waking up too early.
- Non-refreshing and poor quality sleep.
Insomnia is also determined with one or more below mentioned complaints which lead to daytime impairment:
- Fatigue, lack of energy.
- Lack of motivation or initiative.
- Difficulty in attention and concentration.
- Impaired performance at job/work place.
- Mood disturbances and easy irritability.
- Worries regarding sleep.
- Physical symptoms like headache, body ache due to lack of sleep.
Thus, insomnia has two main components:
(1)Poor quality sleep at night
(2)Disturbances during daytime/wakefulness.
Prevalence of insomnia
- Insomnia is more common in elderly population and more common in women than in men. Insomnia is also common in patients who are suffering from anxiety, depression, chronic physical illness, excessive occupational stress, alcohol abuse etc.
- Studies suggest that overall 25% to 33% adult population all across the world suffers from some degree of insomnia each year.
- At the age of 30, about 5% to 8% of males and 14% to 18% of females have insomnia.
- After the age of 65, insomnia symptoms are reported by more than 30% of the population.
- Insomnia is responsible for: decreased work efficiency, increased accidents and errors at workplace and while driving, poor interpersonal relationships, and an overall reduced quality of life.
History
Ancient Greeks relate sleep to God Hypnos (FYI: Hypnotic = a drug that reduces consciousness and causes sleep.)
Initial report of insomnia dates from the writings of Aristotle and the Greek physician Heraclites. Heraclites suggested opium for insomnia treatment. Various other modalities were also used for the treatment of insomnia.
Insomnia (primary) according to DSM-IV-TR “is a difficulty in initiating or maintaining sleep, or a non-restrictive sleep, which causes significant distress or impairment in social, occupational and other important areas of functioning for at least 1 month.”
Insomnia is called primary when it is not due to some other medical or physical condition.
According to the classification system of ICD (International Classification of Disease) by WHO, “insomnia is a difficulty in initiating or maintaining sleep, or a non-restorative sleep, leading to social and occupational impairment and sleep disturbances at least 3 nights per week, for a month.”
Difference between short sleepers and insomniacs
- It is clear that insomnia is not determined by sleep duration but by quality of sleep sufficient for refreshment.
- So a person doesn’t have insomnia even with a sleep of as less as 4 to 5 hours, as far as that sleep is refreshing and it doesn’t impair his daily routines.
- On the other hand, a person has insomnia even with 8 hours of sleep if the sleep is non-refreshing and impairs his next day routine.
- Short sleepers are persons who sleep less than the average sleep duration of the population, and yet they function normally with a fresh feeling in the morning.
Insomnia patterns and associated common causes
With regard to the part of sleep that is affected, insomnia can be separated into the following three types:
1. Early insomnia or sleep-onset insomnia
- Early insomnia is also known as sleep-onset insomnia.
- It is characterized by difficulty in falling asleep with associated high level of arousal.
- Sleep-onset is delayed for more than 30 minutes.
- It is the most common pattern of insomnia and commonly seen in primary insomnia.
- Early insomnia is more common in women and elderly.
- Common causes for early insomnia are poor sleep hygiene, poor sleep environment, anxiety, depression and other psychological factors.
2. Middle insomnia or sleep maintenance insomnia
- Middle insomnia is also known as sleep maintenance insomnia.
- In this type of insomnia, sleep-onset may occur normally, but intermittent awakening occurs during nights which may or may not be followed by normal sleep.
- Middle insomnia is commonly seen in conditions associated with pain and medical conditions like Asthma and renal disorder.
- Alcohol intake is also a common cause of middle insomnia.
3. Terminal insomnia
- Terminal insomnia is also known as early awakening.
- It is common in elderly as well as in depression and bipolar mood disorders.
- Very less percentage of patients with terminal insomnia as sole complaints visits clinics as compared to early & middle insomnia.
- As persons with terminal insomnia have at least few hours of good sleep, they are more comfortable with insomnia as compared to persons with early and middle insomnia
Insomnia: Transient and Chronic
Transient Insomnia
- When Insomnia lasts for less than 3 weeks it is termed as transient insomnia.
- Transient insomnia is more common as compared to chronic insomnia.
- It is mainly a result of stress and anxiety in patients caused by some adverse psychological or social events, which the patients are not able to cope with.
- Transient insomnia when once cured & reappears with intermittent improvement in between, it becomes recurrent insomnia.
- Recurrent insomnia is commonly seen in relapse of some psychiatric disorders like depression or bipolar mood disorders or alcohol abuse.
In fact, insomnia is a warning sign in many psychiatric disorders.
Chronic insomnia
- It is less common but the most disturbing variant of insomnia. Patients may become adapted with chronic insomnia because of its continuity; however, it causes significant distress in the life of the patient suffering from it. Treatment of chronic insomnia is quite difficult as many psychological factors are incorporated.
Chronic insomnia treatment will be discussed later on.
Sleep functions
As stated earlier, sleep is one of the most important human behaviors and it is as necessary as food and sex.
According to evolution theories, sleep is seen as a protective mechanism to keep the animal out of danger during the inactive states.
- Sleep conserves energy, restores energy & regulates temperature. Also, from the psychological point of view, sleep is important. Dreams take place during sleep, which plays a major role in the resolution of intra-psychic conflicts as explained by Sigmund Freud in his “Interpretation of dreams”.
-Sleep deprivation causes a number of disturbances in the body & it ultimately leads to the death of a person.
Insomnia symptoms / Insomnia effects
As such, insomnia itself is viewed as a symptom by many. There are several other symptoms associated with insomnia.
Common symptoms associated with insomnia are;
- Fatigue
- Lethargy
- Poor concentration
- Irritability
- Heaviness in head
- Apprehensions
Insomnia is associated with hyper-arousal state, whether as a cause or as an effect is still unclear. Insomnia may be associated with chronic sympathetic hyperactivity & decreased parasympathetic activity.
Sympathetic hyperactivity leads to increase in heart rate & increase in blood pressure with an overall increase in the cardiac workload. Thus, increased sympathetic activity may cause physical symptoms like muscle tension, uneasiness, restlessness, etc.
Insomnia related psychological disturbances induce mood & cognitive changes. Insomnia leads to difficulty in concentration & poor attention.
It may lead to impaired memory (short term type mainly), easy irritability, lack of interest and low mood.
Anxiety & depression are commonly associated with chronic insomnia.
In fact, insomnia fuels a vicious cycle of stress-anxiety-insomnia-fatigue. Patients with prolonged insomnia develop excessive worries about poor sleep. Due to subsequent failed attempts at good sleep, these people try even harder to go to sleep, which results in a worse condition than before.
They become more watchful & vigilant for sleep. They are kept awake by their fear & apprehension of the next day being spoilt if they don’t get enough sleep in the night. Attention deficits created by insomnia make the person prone to errors.
Treatment and management of insomnia
There are a number of factors affecting sleep. Thus, for the treatment of insomnia, a multidimensional approach would be the most effective.
Let’s have an overview of insomnia treatment first.
Insomnia treatment can be discussed under two headings:
1. Non-pharmacological treatment
2.Pharmacological treatment
Non pharmacological treatment of insomnia
These are the insomnia treatment approaches in which drugs are not used.
These are
- Sleep hygiene
- Sleep restriction therapy
- Sleep stimulus control therapy
- Cognitive behavior therapy for insomnia
- Relaxation therapy
- Yoga and meditation
- Photo therapy or light therapy
- Natural remedies for insomnia
Pharmacological therapy for insomnia
It includes allopathic drug therapy, which are mainly psychoactive agents used in insomnia treatment.
1st line agents:
zolpidem or eszopiclone- for onset of sleep and maintenance
Zolpidem, zoleplone, rameltelon- for onset of sleep
2nd line agents:
These are the main benzodiazepines used in insomnia treatment.
Flurazepam
Temazepam
Estazolam
Triazolam
Quazepam
Trazodone
Not recommended but commonly used:
Alprazolam
Lorazepam
Diazepam
Other drugs are quetiapine, melatonin, diaphenhydramine
Insomnia treatment and sleep hygiene
The most important cause of insomnia is poor sleep hygiene. Our daily routine affects the duration and the quality of sleep. Whether having sleep disturbances or not, sleep hygiene is underestimated by most of the persons. Sleep hygiene is aimed at making persons aware by explaining the nature of sleep, the factors affecting sleep, how life style changes with sleep, and the environmental changes (including bedroom changes) to improve and stabilize sleep pattern. Sleep hygiene is a good advice for everyone, even for those who don’t have insomnia or other sleep disorders
If you are searching for help for beating insomnia, you must have heard about good sleep hygiene, may have already tried it. You may argue that it’s worthless and you failed at it. But before refusing it, you should ask yourself:
1. Did you try it everyday for a sufficient period?
2. Did you do everything that you are supposed to do?
3. Did you try it wholeheartedly?
Most probably, the answer would be “no”. So it becomes more likely that you didn’t get the total benefit from it.
Sleep hygiene
Avoid CNS stimulants
The commonest CNS stimulants are caffeine, alcohol, and nicotine. They should be avoided for at least 6 hours before going to bed.
Caffeine
The most important among those listed above is caffeine. It maintains wakefulness.
It is found not only in a cup of coffee but also in other stuffs like cocoa, chocolate, and carbohydrate drinks like cola. It’s advisable to check labels of the products which patient may consume.
Nicotine
Nicotine is also a CNS stimulus found in cigarettes and other tobacco products. Smoking is injurious not only to health, but also hinders sleep. Sleep disturbed due to excessive smoking can be managed by de-addiction.
Alcohol
In contrast to caffeine and nicotine, alcohol is a CNS depressant, so theoretically it should induce sleep. But alcohol disrupts sleep architecture and causes increased night wakefulness and restlessness, leading to disturbed sleep. It also causes increased urination and thereby increased thirst and disturbed sleep.
Optimize your biological clock for sleep
Fix a time to go to bed and also fix awareness time. Avoid drifting during bed time and awakening time. Follow it regularly.
Avoid day time naps
It will be easier to get a good sleep at night if day time naps are avoided. Short naps in the afternoon are recommended by many but they are probably not appropriate for people with insomnia. If it becomes necessary then it should be less than 30 minutes.
Don’t bring your worries to bed
It is difficult to stop worries or control it at one’s wish, but you can postpone it for daytime. Give some time during the day to think on your worries; don’t stress your mind on what to do tomorrow or planning about future activities. Make a habit of finishing it before going to bed.
Don’t use your bed for any other purpose except for sleep or sex (as sex relaxes and induces sleep)
Avoid watching television in bed as most of the people do. Avoid talking on phone, discussing, reading or working.
Don’t go to bed until you are sleepy
Get up if you don’t get sleep in 15 to 20 minutes.
Follow this rule everyday. If you don’t feel sleepy repeatedly after going to bed, then repeat this procedure until you finally go to sleep.
Reading a book or doing a work that you don’t like will bring sleep much easily.
Avoid strenuous exercise at night
Regular exercise is recommended as it improves sleep and overall health as well. But it should be in the morning or in the afternoon. Strenuous exercise after dark will activate the brain and maintain wakefulness, making sleep difficult to initiate.
Avoid heavy meal at night .
Avoid spicy food if you are suffering from heartburn.Snack before sleep helps in initiating sleep.
Sleep stimulus control
According to sleep stimulus control therapy, insomnia is seen as a result of maladaptation, in which temporal stimulus (time to go to bed) and environmental stimuli that were previously inducing sleep are in balance to be associated with wakefulness, frustration and arousal. Thus, in sleep stimulus control therapy, the main therapeutic objective is to rebalance the control between sleep and the environment which promotes sleep.
Sleep stimulus control therapy breaks the negative association of being in bed and being unable to sleep. It is especially helpful for individuals with sleep onset insomnia and prolonged awakening. Most procedures mentioned below are already covered under sleep hygiene.
-Go to bed only when sleepy.
-Use bed only for sleep and sex.
-Avoid watching television, eating, working etc.
-Arise from the bed at the same time in the morning, and go to bed same time everyday.
-If you don’t get sleep in 30 minutes, get up and engage yourself in some activities till you feel sleepy.
Sleep restriction therapy
Sleep restriction therapy is based on observation of patients with insomnia limiting the time spent in bed awake is an effort to provide more opportunity for sleep. This strategy is more likely to result in fragmented sleep.
Sleep restriction therapy is aimed at limiting the amount of time spent in bed to the actual sleep time.
Sleep diary is helpful for the determination of actual sleep time & time spent awake in bed.
Read more about this and other treatment modalities in the next post...
