Insomnia is “difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.” Both organic and non-organic insomnia without other cause constitute a sleep disorder, primary insomnia.
Based on the duration of symptoms, Insomnia may be divided into three classes:
• Transient insomnia: Insomnia lasting one week or less;
• Short-term insomnia or acute insomnia: Insomnia lasts more than one week but resolves in less than three weeks;
• Long-term or chronic insomnia: Insomnia lasts more than three weeks.
There is no doubt that those who have to suffer from this uncomfortable disease is really unhappy for their life. Due to sleeplessness, their health is difficultly recovered, and surely their brain is stressed the body and brain are not fully fit for the next day’s activity. The person feels very tired, fatigued, energy levels reduced and reflexes slowed. The sensitivity of the senses is blunted. Our mental functions like our ability to learn, remember and concentrate are affected by insomnia. The performance level in the workplace drops. The mind becomes sluggish and looses concentration. Lack of attention, dizzy spells and mood changes are other effects during the daytime caused by sleepless nights. Some people become very irritable and flare up for no reason. It may sometimes lead to emotional problems and depression. In chronic cases, when suffering from severe insomnia and sleepless nights continue for long time, people can even experience hallucinations.
If you suffer from insomnia, driving and operating machinery are very dangerous. Families and workplace colleagues find it very difficult to cope with someone who has not had a good night’s sleep.
2. Causes of Insomnia:
It is the fact that today more and more people, even young people tend to suffer from insomnia. It occurs in 30% to 50% of the general population. Approximately 10% of the population may suffer from chronic (long-standing) insomnia.
Based upon its causes, it can be classified as followings:
2.1) Due to short-term and transient factors:
Situational and stress factors:
• jet lag: medically referred to as “desynchronosis,” is a physiological condition which is a consequence of alterations to circadian rhythms; it is classified as one of the circadian rhythm sleep disorders. Jet lag results from rapid long-distance transmeridian (east-west or west-east) travel, as on a jet plane.
• physical discomfort: hot, cold, lighting, noise, unfamiliar surroundings.
• working different shifts: because of one’s work specific characteristics, he has to work at the different time divided into different shifts, which can make him find difficult to sleep.
• stressful life situations (divorce or separation, death of a loved one, losing a job, preparing for an examination),
• illicit drug use: Drug abuse, Drug addiction, Entheogenic, Performance-enhancing drug, Self medication.
• cigarette smoking: mostly for men.
• caffeine intake prior to going to bed,
• alcohol intoxication or withdrawal, or
• certain medications.
• when the underlying factors are removed or corrected, Insomnia may resolve.
2.2) Sleep hygiene
Sleep hygiene can play an important role in insomnia. Poor sleep hygiene includes physical factors such as:
• using the bedroom for things other than sleeping,
• eating or exercising prior to sleep,
• going to bed hungry,
• sleeping in a room with too much noise or lighting, or
• doing work in bed.
2.3) Medical and psychiatric conditions
Medical and psychiatric conditions may also contribute to insomnia.
• Some of these common medical conditions may include: breathing problems from chronic heart or lung disease (asthma, chronic obstructive pulmonary disease, congestive heart failure, obstructive sleep apnea, obesity, acid reflux, hyperthyroidism,
Otherwhile, Common psychiatric problems can be responsible for insomnia such as: depression, psychosis, mania, anxiety, posttraumatic stress disorder…Or some common physiologic conditions can lead to insomnia: menopause, menstrual cycle, pregnancy, fever, pain.
3. Signs and symptoms
The list of signs and symptoms mentioned in various sources for Insomnia includes the 20 symptoms listed below:
- Sleep problems
- Difficulty falling asleep
- Frequent night waking
- Difficulty returning to sleep
- Waking too early
- Unrefreshing sleep
- Racing mind
- Daytime tiredness
- Difficulty concentrating
- The history is the most important part of evaluating insomnia. It must include a complete sleep history, medical history, psychiatric history, social history, and careful medication review.
- Frequent or early morning awakening
- Problems in sleep onset
- Sleep disturbance varies from mild to severe.
- Insomnia may manifest as difficulty falling asleep or as frequent nocturnal awakenings.
- Mood alterations
4. Treatment for insomnia
Good sleep hygiene
Sleep hygiene aims to make you more aware of the different factors that may affect sleep.
We advise you to:
- establish fixed times for going to bed and waking up (and avoid sleeping in after a poor night’s sleep),
- try to relax before going to bed,
- maintain a comfortable sleeping environment (not too hot, cold, noisy or bright),
- avoid napping during the day,
- avoid caffeine, nicotine and alcohol within six hours of going to bed,
- avoid exercise within four hours of bedtime (although exercise earlier in the day is beneficial),
- avoid eating a heavy meal late at night,
- avoid watching or checking the clock throughout the night, and
- only use the bedroom for sleep and sex.
Cognitive and behavioural treatments
Cognitive and behavioural treatments aim to change unhelpful thoughts and behaviours that may be contributing to your insomnia.
Your doctor may recommend any of the following for you:
- Stimulus-control therapy, which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern.
- Sleep restriction therapy, where you limit the amount of time spent in bed to the actual amount of time spent asleep, creating mild sleep deprivation. Sleep time is then increased as your sleeping improves.
- Relaxation training, which aims to reduce tension or minimise intrusive thoughts that may interfere with sleep.
- Paradoxical intention, which means you try to stay awake and avoid any intention to fall asleep. It is only used if you have trouble getting to sleep, but not maintaining sleep.
- Biofeedback, where sensors connected to a machine are placed on your body to measure body responses like muscle tension or heart rate. The machine then produces pictures or sounds to help you control your breathing and body responses.
- Cognitive behavioural therapy (CBT), which aims to examine and change your beliefs and attitudes about insomnia (see What does CBT for insomnia involve?).
These techniques may be carried out by a specially trained GP, although you may be referred to a clinical psychologist for CBT.
Sleeping tablets (hypnotics) are medictions that encourage sleep. They may be considered:
- if your symptoms are particularly severe,
- to ease short-term insomnia, or
- if the non-drug treatments mentioned above have failed to have an effect.
However, doctors are usually reluctant to prescribe this type of medication as they relieve symptoms but do not treat the cause of your insomnia. If you experience long-term insomnia, sleeping tablets are unlikely to help and your doctor may consider referring you to a clinical psychologist to discuss other approaches to treatment.
Sleeping tablets should only be used when the expected period of treatment will be short; for example, during an illness, for an overnight stay in a busy hospital ward, or because of jet lag.
You should be given the smallest effective dose possible for the shortest length of time necessary (for no longer than a week). In some cases, your doctor may advise that you only take the medication two or three nights a week, rather than every night.
These hypnotic medicines cause the following side effects:
- a feeling that you are hungover, and
- drowsiness during the day.
It is best to take the medicines at night, before you go to bed. In some people, especially older people, the hangover effects may last into the next day, so you should be cautious if you are likely to be driving the next day.
It is very easy to become dependent on these medicines, even after a short-term course. You should take note of any possible side effects before starting treatment. If you start treatment in hospital during a short stay, you should not automatically continue it when you leave.
If you are regularly taking sleeping tablets every night, you should consider reducing or stopping them. Do not stop taking the medicine suddenly, as withdrawal symptoms can include panic attacks, shaking and rebound insomnia. Speak to your doctor for advice.
Short-acting benzodiazepines or the newer ‘Z medicines’ (see below) are the preferred medicines for insomnia and are only available on prescription.
Benzodiazepines are tranquillisers designed to reduce anxiety and promote calmness, relaxation and sleep.
These medicines should only be considered if your insomnia is severe or causing you extreme distress. All benzodiazepines make you feel sleepy and can lead to a dependency. If they are needed to treat insomnia, then only the short-acting benzodiazepines (with short-lasting effects) should be prescribed, such as:
- loprazolam, and
Z medicines are a newer type of sleeping tablet that work in a similar way to benzodiazepines. They are also short-acting medicines and include:
- zolpidem, and
There is little difference between the benzodiazepines and Z medicines, so if one does not work, it is unlikely that swapping to another will have a different effect.
For more information, read Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (2004 guidelines from the National Institute for Health and Clinical Excellence).
Medicines containing melatonin have been shown to be effective in providing short-term relief for insomnia. Melatonin is a naturally occurring hormone that helps regulate the sleep cycle (known as the circadian rhythm).
At present, the only licensed medicine for the treatment of insomnia that contains melatonin is called Circadin. Circadin is only available on prescription for people who are 55 or over.
Circadin is designed as a short-term treatment for insomnia and should not be taken for more than three weeks. It is not recommended for people with a history of kidney or liver disease.
As yet, there is not enough evidence to say whether it is safe to take Circadin during pregnancy or when breastfeeding, so its use is not recommended in these circumstances.
As Circadin can make you feel drowsy, you should not drive or operate heavy machinery after taking the medicine at night, or if you still feel drowsy the next morning.
Side effects of Circadin are uncommon but include:
- stomach pain, and
- weight gain.
If you find these side effects troubling, you should stop taking Circadin and contact your GP.