Having sufficient restful sleep is a critical human requirement. It is vital to emotional and physical well being. Most adults sleep between 6 and 8 hours per day, without interruption. A few nights of poor sleep do no harm, but prolonged sleep disturbances can have serious consequences.
The Physiology of Sleep
People function according to a natural cycle that repeats itself about every 24 hours. This is known as the circadian rhythm, and it governs our sleep-wake cycles. As it gets dark, the cells in the retina of the eye send a message directly to a part of the brain called the hypothalamus, which then signals the pineal gland located in the hypothalamus to produce the hormone melatonin, which causes a drop in body temperature and sleepiness. At the same time there is a reduction in the chemicals responsible for arousal, like histamine, noradrenalin, and serotonin. In a normal person, this sequence brings on sleep. There are two types of sleep: rapid eye movement (REM) and nonrapid eye movement (NREM). NREM has four stages, with stage 1 being transitional sleep, stage 2 light sleep and stages 3 and 4 deep (delta) sleep. Delta sleep is the most restful kind. During NREM sleep, brain activity and body functions slow. During REM there is increased activity – body functions speed up and a person dreams. A person moves from one phase of sleep to another during the night.
What is Insomnia?
Insomnia is a sleeping problem in which there is either inadequate sleeping time, or poor quality sleep, occurring on a regular or frequent basis, often for no apparent reason. A person with insomnia may have difficulty falling asleep, may wake up too early, wake up intermittently during the night, or may wake feeling unrefreshed.
During the day a person with insomnia may suffer from general tiredness, lack of energy, difficulty concentrating, and irritability. Sleep deprivation also impairs memory, reaction time and alertness. Tired people are less productive at work, less patient with others, and less interactive in relationships. Sleep deprivation can also be dangerous for people who have to drive. When people are deprived of sleep over long periods, the body’s immune system becomes depressed, lowering resistance to disease and infections.
Insomnia is very common – between 20% and 30% of adults suffer insomnia to some degree, and about 10% to 15% of people have insomnia which is chronic or severe. Insomnia is more of a problem in the elderly, and is more common in women. Sleeping pills are amongst the most prescribed medicines in the world.
Types of Insomnia
Transient insomnia is a temporary disturbance of the normal sleep pattern. It generally lasts no more than several nights, and usually disappears on returning to a regular sleep pattern. Travel or relocation may cause it.
Short-term insomnia lasts for 2 – 3 weeks and can accompany worry or stress. It often disappears if the cause is resolved.
Chronic insomnia disrupts sleep for extended periods of time – sleeping problems occur for at least 3 nights a week for one month or more. It is a complicated disorder with potentially serious effects.
What causes Insomnia?
Insomnia is usually the result of an underlying condition. Discovering the cause is the most important step in relieving insomnia.
Lifestyle factors are common causes of insomnia, particularly transient or short term insomnia. These include factors like high stress or anxiety, an uncomfortable sleeping environment, eating a heavy meal or drinking alcohol or caffeine-containing drinks before bedtime, exercising just before bedtime and cigarette smoking.
Medical conditions may cause chronic insomnia. These include chronic illnesses like kidney disease, heart failure or asthma, painful illnesses like arthritis or cancer, and hormone imbalances like hyperthyroidism, menopause or pregnancy.
Psychiatric conditions like depression, anxiety disorders or schizophrenia may be associated with chronic insomnia.
Medications are a common cause of insomnia. Some antidepressants, high blood pressure and steroid medications can interfere with sleep. Many painkillers, decongestants and weight loss products contain caffeine and other stimulants which will keep a person awake. Reducing or stopping your regular dose of sleeping pills may also cause insomnia.
Certain sleep disorders may result in insomnia. Restless leg syndrome is a condition where a person experiences unpleasant sensations in the legs or feet, preventing sleep. Periodic limb movement disorder is where uncontrollable twitching of the legs or arms prevent refreshing sleep. Obstructive sleep apnoea is a condition in which people intermittently stop breathing for short periods during sleep, causing them to wake frequently. Circadian rhythm disorders develop due to time zone changes (jet lag), or in people who do shift work.
Psycho Physiological Insomnia is one of the commonest causes of insomnia affecting about 5% of people. It develops when a person experiences a poor night’s sleep and then has increased anxiety the next night, which again prevents him from falling asleep. This “vicious cycle” is repeated night after night, leading to chronic insomnia.
How Is Insomnia Diagnosed?
The many potential causes of insomnia mentioned above can be determined by assessing lifestyle factors, by reviewing physical or psychiatric symptoms and by performing a physical examination. Certain laboratory tests and special investigations may be necessary. A sleep diary, which provides a record of how long and when you sleep, may also be helpful. In some patients an assessment at a sleep clinic may be necessary.
Treatment of Insomnia
Chronic or severe insomnia should be discussed with a doctor to rule out any medical or psychiatric condition.
Lifestyle changes: Regular moderate exercise, a balanced diet and avoiding excessive alcohol or caffeine will improve health and sleep. Reduce tension, promoting better sleep.
Behavioural therapies may also be used to treat some patients with insomnia. Relaxation therapy uses special techniques to calm the person and relax the muscles. Sleep restriction is a program that initially permits only a few hours of sleep per night, then gradually increases the nightly sleeping time. Reconditioning teaches the person to associate a bed with sleeping (and sexual activity), not daytime naps.
Drug treatment: If insomnia is transient or short-term, and sleep hygiene (see below) or non-medical treatments are not helpful, medication may be effective to prevent psycho physiological insomnia. In chronic insomnia, it is important to diagnose any underlying medical or psychiatric condition, and treat this effectively. Prolonged use of pills, without addressing the root cause may result in dependency. Hypnotic (sleep-inducing) medications, like the benzodiazepines, should be used for a few days at a time, to try to break a pattern of sleeplessness, while addressing any underlying problem. They should be used for short periods only, as they may become addictive. Antidepressants are effective in patients in whom depression has been diagnosed. Some Antihistamines have sedative effects and may be effective in the short-term. Melatonin may help insomnia by shifting the phases of the circadian rhythms, but is still undergoing further studies.
Sleep Hygiene is a holistic approach to sleeping. Good sleep hygiene prevents or relieves insomnia, and makes sleep more restful and pleasurable.
- Establish a regular time for going to bed and waking up.
- Use the bed for sleep or sexual activity only, not for reading, TV, or work.
- Avoid naps, especially in the evening.
- Exercise before dinner – exercising close to bedtime, however, may increase alertness.
- Take a hot bath about an hour and a half before bedtime.
- Do something relaxing in the half-hour before bed like reading or a walk.
- Keep the bedroom cool and ventilated.
- Do not look at the clock. Worrying about the time and “forcing” yourself to sleep makes it more difficult to sleep.
- A light snack before bed can help sleep. A large meal may do the opposite.
- Avoid fluids just before bedtime to reduce the need to urinate.
- Avoid caffeine in the hours before sleep.
- Quitting smoking eliminates the effects of nicotine on sleep loss.
- People who can’t sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until sleepy again.
- If a person with insomnia is distracted by a sleeping bed partner, a couple of nights apart may be useful.
Tips to beneficial sleep and feeling energized day after day: While many strategies are available, it is important to experiment and discover what works for you, what works for one person may not work for another!
- Take control of the stressors in your life.
- Focus on what’s really important in life.
- Make time for two or three quiet moments during the day and before retiring for the night.
- Fitness through exercising.
- Exercise will lower anxiety and tension.
- Heart and lung fitness, a direct result of exercise, promote healthy sleep.
- Easy stretching should precede all exercise.
- Exercises such as walking, dancing and aerobic work outs should be done in the late afternoon.
- Stay alert during the day.
- Keep yourself busy and involved during your daytime activities.
- Involvement with other people allows you to reduce stress by focusing on issues other than your own.
- Eat balanced meals.
- Make this part of the total, personal health plan.
- Strive for a balance between vegetables, protein and carbohydrates.
- Avoid a large meal within four hours of going to bed.
- Alcohol and bedtime do not mix.
- The effects of alcohol are greatly magnified by sleep deprivation.
- Sleep apnoea can be aggravated by drinking at bedtime.
- Avoid alcohol within three hours of bedtime.
- Develop a bedtime ritual.
- Read for pleasure.
- Gradually dim the lights.
- As your mind clears and you become drowsy, turn off the light.
- Cleanse the mind.
- Commit your worried thoughts to an index card on the night stand.
- Add some points about the potential solution.
- Leave the card there in case you awaken during the night.
- Relaxation at bedtime
- Play mind games with yourself.
- Mental imagery.
- Deep breathing.
- Time in bed: Only as long as is necessary
- You may go to bed earlier than usual due to stress and worries.
- Stay in bed only for the period that you usually need for sleep.
- Sleep until you are refreshed.
- Consult a sleep specialist if needed.
- Always share your sleep problems with your doctor.
- He/she may give you valuable advice or refer you to a sleep specialist.
- Awaking with shortness of breath or chest pain requires prompt attention.
- Your doctor must be told if you are falling asleep at inappropriate times.
Reference: Maas J.B. (1999): Power Sleep, New York: Harper Perennial p84-99
Courtesy of Medical Essentials, Health Information