Plagued by Insomnia

One in three people report episodes of sleep disturbance or insomnia, which are usually mild and transient.

Problems with sleep are not trivial. If insomnia becomes chronic – in an estimated one in ten adults – it significantly impairs health and quality of life. Persistent sleep disturbance may have many causes from underlying neurological disorders to pain to worries about the problems of daily life.

A range of treatment options exist and it is tailored to the individual. With proper treatment, considerable improvement is achieved in terms of wellbeing.

Defining Insomnia

Two aspects to chronic insomnia present: one is difficulty in falling asleep and the other problems with maintaining sleep. Most brief episodes of insomnia have identifiable triggers, such as situational crises, schedule changes, acute health problems, and medication. If it persists for at least 1 month and becomes chronic then more detrimental learned behaviours can develop that exacerbate the problem.

Primary insomnia is an independent disorder with no concomitant disorders. Comorbid insomnia typically coexists with neurological disorders such as depression, fibromylagia, substance abuse or obstructive sleep apnea.

Adjustment insomnia occurs in temporal relationship with an identifiable stressor and lasts less than 3 months. Sleep usually improves with the removal of the stressor. In some cases, adjustment insomnia evolves into a more persistent form.

People with psychophysiological insomnia have a conditioned feeling of wakefulness associated with the bed, bedroom, and bedtime routines. Learned sleep-avoidance behaviours make the sleep difficulty worse.

Paradoxical insomnia occurs when the patient’s description of their sleep problem does not correlate with objective evidence of what appears to be enough sleep.

Idiopathic insomnia is persistent insomnia that starts in children with no identifiable trigger and persists chronically into adulthood.

Inadequate sleep hygiene occurs with behaviors that interfere with normal sleep. These detrimental behaviors include: having an abnormal sleep-cycle, use of sleep-disrupting substances – eg caffeine – and having evening routines or a bedroom environment not conducive to sleep.

Behavioral insomnia of childhood is the sleep difficulty a child has when they are unable to fall asleep in their own bed or routinely fail when they try to fall asleep.

Consequences of Chronic Insomnia

Chronic insomniacs wake up too early, and often don’t feel refreshed after sleeping.  Breaking the cycle of disrupted sleep is difficult.

Chronic insomnia often involves hyperarousal, as the brain sleep cycle is disrupted, and symptoms present during the day as well as at night. Common daytime consequences include increased fatigue, poor performance and poor concentration. But other symptoms present, for example, low mood and irritability, poor motivation and low energy, and making errors. Not sleeping causes considerable stress and may trigger depression and anxiety.

Untreated chronic sleep disturbance may lead to considerable negative health outcomes and co-morbidity. For this reason, treatment of insomnia is comparable to other lifestyle interventions in health promotion and prevention of disease.

Some people adopt maladaptive behaviours, such as increased coffee drinking during the day, drinking alcohol at bedtime, and spending excessive time in bed. They may develop a psychologically conditioned arousal – that perpetuates the insomnia – associated with the bedroom and around bedtime routines.

Good Sleep Practice

Adopting a general healthy lifestyle will help resolve sleep problems and increase overall wellness. A plan for good health practices for every healthy person, such as diet and exercise, should focus on sleep patterns and trying to adopt a sleep routine.

Some practical strategies to prevent chronic insomnia include:

• Establish a routine before going to bed.
• Avoid stimulating activities such as watching TV or videogames before bed.
• Avoid nicotine, coffee or alcohol in the evenings.
• Do regular exercise, but making sure you finish at least 3 hours before bed.
• Avoid taking naps in the evening.
• Spend sufficient time in bed, but avoiding the frustration from lying awake and worry.
• Make sure the bedroom is not too warm, better to be cool or neutral temperature.
• Use psychological treatments – eg cognitive behaviour therapy – as it is effective in some patients.

Treating Insomnia Co-morbidity

Treating any co-existing conditions, such as pain, neurological disorder or sleep apnoea improves sleep. So making a diagnosis is valuable when evaluating insomnia symptoms. Sleep laboratory studies are not routine, but will help identify co-morbid sleep disorders. Sleep logs and diaries help evaluate patients.

Sleep apnea is a common sleep disturbance. Asking a bed partner about symptoms displayed at night often helps, such as snoring, breathing irregularity, or sleep related movements. Diagnosing sleep apnoea and starting CPAP may improve things.  Treating with CPAP treatment or even just making a diagnosis often alleviates sleep disturbance.

Medications used for pain or neurological disorders – eg anxiety, depression, seizures or Parkinson’s symptoms – are all likely to improve sleep patterns.

Psychological Treatments

Cognitive behaviour therapy is the only psychological treatment with proven effectiveness for treating chronic insomnia. It focuses on the sleep cycle and cognitive distortions, and aims to improve sleep habits and dispel negative thoughts and anxieties about sleep. Some of the problems to tackle include:

• Unrealistic expectations about the amount of sleep needed to function;
• Misconceived ideas about the cause of insomnia;
• Excessive worry and negative thoughts about functioning during daily life;
• Performance anxiety.

For some patients CBT is superior to medication. Some of the techniques used in CBT for insomnia are:

• Sleep restriction therapy – spend only the time in bed that is estimated to be the time spent asleep each night. No waking time is spent in bed. The aim is to condition the mind that bed is for sleep alone.
• Stimulus control therapy – go to bed only when sleepy and then spend 10 minutes in bed. Get up again if fail to fall asleep.  Also stay up longer when awake during the night.
• Paradoxical intention – go to bed at normal time, but plan to stay awake. This aims to reduce the worry associated with sleep.
• Changing the sleeping environment to make it more conducive to sleep.
• Using relaxation techniques.

Medical Treatments

Three medicines are most commonly used to treat chronic insomnia: GABA modulating agents, antihistamines and melatonin receptor agonists.

Modulation of the GABA response improves insomnia and sedatives, such as benzodiazemine, are the most commonly prescribed medications. Benzodiazemines have a widespread brain effect, but also target the ventral posterior nucleus, which is the sleep-wake regulatory area of the hypothalamus. Depending on the dose and the elimination half life of the specific medicine, patients can feel groggy even after sleeping and sleepy throughout the day. Benzodiazepines are, however, addictive medicines and dependence can develop with long-term treatment .

Low doses of the tricyclic antidepressant doxepin may help in sleep maintenance. It is a H1 receptor antagonist, and decreases histamine levels and promotes sedation. Higher doses of tricyclics are not recommended long term because of the limited evidence of benefit and side-effects.

Many people take over the counter antihistamines to self-treat insomnia despite limited evidence of their effectiveness. If used in too high doses they may have anticholinergic side-effects. Tolerance may also develop.

Melatonin receptor agonists decrease the amount of melatonin secreted in the second half of the day. Melatonin levels in the hippocampal suprachiasmatic nucleus – the area that controls our daily circadian rhythm – drop and this makes sleep easier at bed time and helps maintain a sleep cycle. Melatonin supplements can help in circadian rhythm disorders

Alcohol has a sedative effect, but sleep is not good quality and it has a negative net effect on sleep balance.

No proven benefit – despite widespread use for treating insomnia – exists for using valerian, chamomile, passionflower or hops. Kava kava is liver toxic and should not be taken.