Insomnia

Insomnia, or sleeplessness, is a sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired. Although the term is sometimes used to describe a disorder demonstrated by polysomnographic or actigraphic evidence of disturbed sleep, this sleep disorder is often practically defined as a positive response to either of two questions:

“Do you experience difficulty sleeping?” or “Do you have difficulty falling or staying asleep?”

Insomnia is most often thought of as both a medical sign and a symptom that can accompany several sleep, medical, and psychiatric disorders characterized by a persistent difficulty falling asleep and/or staying asleep or sleep of poor quality. Insomnia is typically followed by functional impairment while awake. Insomnia can occur at any age, but it is particularly common in the elderly.

Insomnia can be short term (up to three weeks) or long term (above 3–4 weeks); it can lead to memory problems, depression, irritability and an increased risk of heart disease and automobile related accidents.

Those who are having trouble sleeping sometimes turn to sleeping pills, which can help when used occasionally but may lead to substance dependency or addiction if used regularly for an extended period.

Insomnia can be grouped into primary and secondary, or comorbid, insomnia.

Primary insomnia is a sleep disorder not attributable to a medical, psychiatric, or environmental cause. It is described as a complaint of prolonged sleep onset latency, disturbance of sleep maintenance, or the experience of non-refreshing sleep. A complete diagnosis will differentiate between free-standing primary insomnia, insomnia as secondary to another condition, and primary insomnia co-morbid with one or more conditions.

Insomnia Diagnosis

In medicine, insomnia is widely measured using the Athens insomnia scale. It is measured using eight different parameters related to sleep, finally it is represented as an overall scale which assess an individual’s sleep pattern

A qualified sleep specialist should be consulted in the diagnosis of any sleep disorder so the appropriate measures can be taken. Past medical history and a physical examination need to be done to eliminate other conditions that could be the cause of the insomnia.

After all other conditions are ruled out a comprehensive sleep history should be taken. The sleep history should include sleep habits, medications (prescription and non-prescription), alcohol consumption, nicotine and caffeine intake, co-morbid illnesses, and sleep environment. A sleep diary can be used to keep track of the individual’s sleep patterns. The diary should include time to bed, total sleep time, time to sleep onset, number of awakenings, use of medications, time of awakening and subjective feelings in the morning.

Workers who complain of insomnia should not routinely have polysomnography to screen for sleep disorders. This test may be indicated for patients with symptoms in addition to insomnia, including sleep apnea, obesity, a risky neck diameter, or risky fullness of the flesh in the oropharynx. Usually, the test is not needed to make a diagnosis, and insomnia especially for working people can often be treated by changing a job schedule to make time for sufficient sleep and by improving sleep hygiene.

Some patients may need to do a sleep study to determine if insomnia is present. The sleep study will involve the assessment tools of a polysomnogram and the multiple sleep latency test and will be conducted in a sleep center or a designated hotel. Specialists in sleep medicine are qualified to diagnose the many different sleep disorders. Patients with various disorders, including delayed sleep phase syndrome, are often mis-diagnosed with primary insomnia. When a person has trouble getting to sleep, but has a normal sleep pattern once asleep, a delayed circadian rhythm is the likely cause.

In many cases, insomnia is co-morbid with another disease, side-effects from medications, or a psychological problem. Approximately half of all diagnosed insomnia is related to psychiatric disorders. In depression in many cases “insomnia should be regarded as a co-morbid condition, rather than as a secondary one;” insomnia typically predates psychiatric symptoms. “In fact, it is possible that insomnia represents a significant risk for the development of a subsequent psychiatric disorder.”

Knowledge of causation is not necessary for a diagnosis.

Treatments

It is important to identify or rule out medical and psychological causes before deciding on the treatment for insomnia. Cognitive behavioral therapy (CBT):

has been found to be as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”

Pharmacological treatments have been used mainly to reduce symptoms in acute insomnia; their role in the management of chronic insomnia remains unclear. Several different types of medications are also effective for treating insomnia. However, many doctors do not recommend relying on prescription sleeping pills for long-term use. It is also important to identify and treat other medical conditions that may be contributing to insomnia, such as depression, breathing problems, and chronic pain.

Non-pharmacological

Non-pharmacological strategies have comparable efficacy to hypnotic medication for insomnia and they may have longer lasting effects. Hypnotic medication is only recommended for short-term use because dependence with rebound withdrawal effects upon discontinuation or tolerance can develop.

Non pharmacological strategies provide long lasting improvements to insomnia and are recommended as a first line and long term strategy of management. The strategies include attention to sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, paradoxical intention, patient education and relaxation therapy.

Reducing the temperature of blood flowing to the brain slows the brain’s metabolic rate thereby reducing insomnia. Some examples are keeping a journal, restricting the time spending awake in bed, practicing relaxation techniques, and maintaining a regular sleep schedule and a wake-up time.

Behavioral therapy can assist a patient in developing new sleep behaviors to improve sleep quality and consolidation. Behavioral therapy may include, learning healthy sleep habits to promote sleep relaxation, undergoing light therapy to help with worry-reduction strategies and regulating the circadian clock.

EEG biofeedback has demonstrated effectiveness in the treatment of insomnia with improvements in duration as well as quality of sleep.

Sleep hygiene is a common term for all of the behaviors which relate to the promotion of good sleep. These behaviors are used as the basis of sleep interventions and are the primary focus of sleep education programs.

Behaviors include the use of caffeine, nicotine and alcohol consumption, maximizing the regularity and efficiency of sleep episodes, minimizing medication usage and daytime napping, the promotion of regular exercise, and the facilitation of a positive sleep environment.

Exercise can be helpful when establishing a routine for sleep but should not be done close to the time that you are planning on going to sleep. The creation of a positive sleep environment may also be helpful in reducing the symptoms of insomnia. In order to create a positive sleep environment one should remove objects that can cause worry or distressful thoughts from view.

Stimulus control therapy is a treatment for patients who have conditioned themselves to associate the bed, or sleep in general, with a negative response. As stimulus control therapy involves taking steps to control the sleep environment, it is sometimes referred interchangeably with the concept of sleep hygiene.

Examples of such environmental modifications include using the bed for sleep or sex only, not for activities such as reading or watching television; waking up at the same time every morning, including on weekends; going to bed only when sleepy and when there is a high likelihood that sleep will occur; leaving the bed and beginning an activity in another location if sleep does not result in a reasonably brief period of time after getting into bed (commonly ~20 min); reducing the subjective effort and energy expended trying to fall asleep; avoiding exposure to bright light during nighttime hours, and eliminating daytime naps.

A component of stimulus control therapy is sleep restriction, a technique that aims to match the time spent in bed with actual time spent asleep. This technique involves maintaining a strict sleep-wake schedule, sleeping only at certain times of the day and for specific amounts of time to induce mild sleep deprivation.

Complete treatment usually lasts up to 3 weeks and involves making oneself sleep for only a minimum amount of time that they are actually capable of on average, and then, if capable (i.e. when sleep efficiency improves), slowly increasing this amount (~15 min) by going to bed earlier as the body attempts to reset its internal sleep clock. Bright light therapy, which is often used to help early morning wakers reset their natural sleep cycle, can also be used with sleep restriction therapy to reinforce a new wake schedule. Although applying this technique with consistency is difficult, it can have a positive effect on insomnia in motivated patients.

Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). One theory that may explain the effectiveness of this method is that by not voluntarily making oneself go to sleep, it relieves the performance anxiety that arises from the need or requirement to fall asleep, which is meant to be a passive act. This technique has been shown to reduce sleep effort and performance anxiety and also lower subjective assessment of sleep-onset latency and overestimation of the sleep deficit (a quality found in many insomniacs).

Meditation has been recommended for the treatment of insomnia. The meditation teacher Siddhārtha Gautama, ‘The Buddha’, is recorded as having recommended the practice of ‘loving-kindness’ meditation, or mettā bhāvanā as a way to produce relaxation and thereby, sound sleep – putting it first in a list of the benefits of that meditation.

More recently, studies have concluded that: a mindfulness practice reduced mental and bodily restlessness before sleep and the subjective symptoms of insomnia; and that mindfulness-based cognitive behavioural therapy reduced restlessness, sleep effort and dysfunctional sleep-related thoughts including worry.

Cognitive Behavioral Therapy

There is some evidence that cognitive behavioural therapy for insomnia is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.

In this therapy, patients are taught improved sleep habits and relieved of counter-productive assumptions about sleep. Common misconceptions and expectations that can be modified include:

(1) unrealistic sleep expectations (e.g., I need to have 8 hours of sleep each night)

(2) misconceptions about insomnia causes (e.g., I have a chemical imbalance causing my insomnia)

(3) amplifying the consequences of insomnia (e.g., I cannot do anything after a bad night’s sleep)

(4) performance anxiety after trying for so long to have a good night’s sleep by controlling the sleep process.

Numerous studies have reported positive outcomes of combining cognitive behavioral therapy for insomnia treatment with treatments such as stimulus control and the relaxation therapies. Hypnotic medications are equally effective in the short-term treatment of insomnia but their effects wear off over time due to tolerance. The effects of CBT-I have sustained and lasting effects on treating insomnia long after therapy has been discontinued.

The addition of hypnotic medications with CBT-I adds no benefit in insomnia. The long lasting benefits of a course of CBT-I shows superiority over pharmacological hypnotic drugs. Even in the short term when compared to short-term hypnotic medication such as zolpidem (Ambien), CBT-I still shows significant superiority. Thus CBT-I is recommended as a first line treatment for insomnia. Metacognition is also a recent trend in approach to behaviour therapy of insomnia.

Effects

Aside from the annoyance that insomnia can cause to its sufferers, this sleep disorder causes those afflicted to lose enthusiasm and energy, acquire memory and concentration problems, feel lethargic, frustrated, and of course sleepy. Worse cases that may be induced by insomnia is one’s being prone to accidents, reduced work productivity and the aggravation of psychological and medical conditions.

So what exactly are the culprits that make insomnia one menacing sleeping problem?

1. Emotional Distress

More particularly when it is from internalized anxiety or anger, emotional problems can easily trigger this sleep disorder.

2. Substance Abuse

Drinking too much coffee, colas or other “energy-upper drinks” is known to cause insomnia. Caffeine from these drinks is the main reason. Chain smokers can also be easy victims of insomnia because of the nicotine that cigarettes contain. Herbal remedies, alcohol and other medications can also make one prone to becoming an insomniac. Some may think that alcohol, when consumed, can make one feel drowsy. But little did they know that in the long run, when the alcohol gets metabolized, sudden wakefulness will follow.

3. Biological Clock Disturbance.

Also known as circadian rhythm, one’s body clock, when altered, can damage the amount of sleep one can peacefully enjoy. This body clock disturbance can be caused by an irregular slumber schedule because of too much siesta or partying too late at night. It can also be jetlag or body clock disturbance due to traveling by plane to some place where there is a different time zone. Other causes may be the grave yard schedules of workers and cramming review season for students induced by exams.

4. Environmental Factors

Extreme temperatures can disrupt one’s sleeping patterns. Noise and bright lights can have the same effect too. Homesickness or when one is forced to sleep in an unfamiliar place is also one reason behind getting into the habit of not having enough sleep.

5. Health Problems

Health disorders such as diabetes, heart failure, hyperthyroidism, ulcers, and Parkinson’s disease can also induce insomnia. Asthma may also be one health problem that makes one prone to insomnia because of an asthmatic’s shortness of breath. Frequent urination, heartburn, and chronic pain from leg cramps, tooth ache and arthritis can also cause insomnia.

Psychiatric conditions such as schizophrenia and depression are also possible culprits for insomnia. Snoring with prolonged pauses in breathing while at sleep, also known as sleep apnea can also cause insomnia. Periodic arm and leg movements during sleep causing the muscles to twitch excessively is one underlying cause of this sleep disorder. Another cause is narcolepsy or one’s lack of control on whether to stay awake or to fall asleep, is another cause of this sleep disorder.

6. Pre-bedtime Activities

Engaging to vigorous activities such as exercise just right before bedtime can deprive one of a good night’s sleep. Consuming large meals when one is just about to sleep can also make one experience this sleeping disorder. This is because when metabolism is at its most active thus the body prompts one to stay awake.

Further Reading:

Morin, Charles (2003). Insomnia: A Clinical Guide to Assessment and Treatment. New York, New York: Kluwer Academic/Plenum Publishers.

Summers-Bremner, Eluned (2010). Insomnia: A Cultural History. London: Reaktion.

Michael L. Perlis, Carla Jungquist, Michael T. Smith, Donn Posner (2008) Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide Springer

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