Insomnia

Insomnia is the disturbance of a normal sleep pattern. For example, when you cannot get to sleep or you wake up after only a few hours sleep.

Sleep is a state of unconsciousness which gives your body and brain time to rest. While you are asleep, your body goes through different stages, at approximately 90 minute cycles. These include light sleep, deep sleep and dreaming, also known as rapid eye movement (REM) sleep.
Difficulties with sleep can appear in a variety of ways:

Difficulty getting to sleep (initial insomnia). This is most common in young people and in adults who are anxious.
Waking in the night (frequent nocturnal awakening). This is most common in older people and is associated with several physical problems.
Waking early in the morning - the least common type of sleep disturbance and classically associated with depressive illness.
Not feeling refreshed after sleep. You may have trouble functioning normally during the day, feeling irritable, tired, and finding it difficult to concentrate.
Waking when you have been disturbed from sleep by pain or noise.

Insomnia can last for days, months or even years and can be split into three categories:

Transient insomnia, which lasts for 2-3 days.
Short-term insomnia which lasts for more than a few days, but less than three weeks.
Chronic insomnia, which can be defined as insomnia most nights for three weeks or longer. Chronic insomnia can lead to mental health problems such as depression, misuse of alcohol or other medicines in order to gain sleep.

Everyone is different, so it is hard to define what normal sleep requirements are for an individual, but age is probably the most important determining factor. Newborn babies can sleep for 16 hours a day, while children of school age need an average of 10 hours. Adults usually need, on average, seven to nine hours sleep a night. As we get older, it's normal to need less sleep. Most people over 70 need less than six hours sleep per night, and tend to be light sleepers.
Nearly everyone has problems sleeping at some time or other and it is thought that a third of people in the UK have bouts of insomnia. If you have insomnia, it may have implications for driving. See the DVLA publication http://www.dft.gov.uk/dvla/medical/ataglance.aspx

Symptoms of insomnia

Depending on the type of sleeping problem, symptoms can include:

Lying awake for a long time at night before getting to sleep
Waking up several times in the middle of the night
Waking up early in the morning (and not being able to get back to sleep)
Feeling tired and not refreshed by sleep
Inability to function properly during the day, especially having difficulty concentrating
Irritability due to lack of sleep

Causes of insomnia

The common underlying causes of insomnia can be split into a number of categories.

Physical

Insomnia can be caused by an underlying physical condition causing involuntary movement, pain or discomfort. Examples include:

restless leg syndrome
nocturia –getting up in the night to pass urine. Very common in older men with prostate problems and in undiagnosed diabetes, and a number of other rarer conditions
coughing
arthritis, headaches and back pain
hot flushes (due to the menopause)
head injury
gastrointestinal disorders, e.g. GORD (gastro-oesophageal reflux disease -often called gastric reflux or just reflux for short) and ulcers
pruritus (excessive itching), and
Parkinson's disease

Physiological

Disruptions within the sleeping environment or to bedtime routines can cause insomnia. Factors include:

noise
light
snoring
partner moving about
jet lag
activities before bedtime, like reading or exercise

If you are a night or shift worker, your job can disturb your ability to sleep properly as your natural body clock will be affected. This is because of daily variations in hormone levels in a 24-hour cycle, corresponding to the usual daylight and night-time periods.

Psychological

Loss or worry can make sleeping difficult, caused by events such as:

bereavement
relationship problems
exam stress
work worries, and
anxieties about being unable to sleep

Psychiatric

Underlying mental health problems can affect your sleeping patterns. These include:

depression
dementia
anxiety

Pharmacological

Insomnia can be caused by drugs. Withdrawal from certain medicines such as hypnotics (prescribed for short-term insomnia) may cause re-bound insomnia, which means if you stop taking them, the sleeping problems recur.
Taking other medicines can produce side effects that reduce the quality of sleep, for example:

alcohol
antidepressants
appetite suppressants
decongestants
over treatment with thyroxine
beta-blockers and
corticosteroids

Sleep disorders

Sleep disorders are a specialized group of conditions. They are diagnoses in their own right and need their own treatments.

Narcolepsy - this causes very sudden, extreme tiredness, causing the sufferer to fall asleep at any time of the day without being able to control it.
Sleepwalking - getting out of bed and moving around during sleep, for example walking, opening doors and climbing up and down stairs.
Obstructive sleep apnoea - irregular and obstructed breathing at night causing drops in blood oxygen levels during sleep, and extreme daytime sleepiness.
Sleep starts (hypnagogic myoclonic jerks) - muscle jerks or a sensation of falling when you are just going off to sleep.

Diagnosing the cause of insomnia

Your GP will ask about sleeping routines, how much alcohol and caffeine you drink each day and your general lifestyle habits, such as diet and exercise.
The GP will check your medical history for any illnesses or medications that may be contributing to the insomnia. Your GP will ask if you are taking any other substances. For example, drugs. In many cases, a cause of insomnia can be identified through these simple measures.
If the cause is not immediately obvious, your GP may suggest you keep a sleep diary to show when you went to sleep, how long for and whether you were disturbed in the night.
A polysomnography is a physical test for identifying sleeping problems, although this is mainly used to diagnose sleep apnoea. Sensor leads (electrodes) are placed on various places on your body, including the torso and head. While you are asleep, the test will record:

electrical activity in the brain
eye and jaw muscle movement
leg muscle movement
airflow
respiratory effort (chest and abdominal movement during breathing)
heart activity (using an electrocardiogram or ECG), and
oxygen saturation (amount of oxygen being absorbed by the lungs)

If carried out in a sleep research centre (rather than your home), you may also be videotaped during the test, to compare the electronic readings with what was happening in the room.

Treating insomnia

The first step is to diagnose any underlying causes and treat the condition. For example, if insomnia is being caused by depression; once the depression is treated, the insomnia will often disappear without further medical help.
Non-drug treatments are usually the preferred first course of action. These treatments can include:

Lifestyle advice on sleep hygiene. This includes restricting caffeine, nicotine, and alcohol; taking regular exercise; keeping regular times for sleeping and waking; maintaining a good sleeping environment.
Education about sleep and relaxation.
Counselling, if the insomnia is related to bereavement or stressful life events etc.
Problem-solving approaches that may help you feel in control (for example, keeping a sleep diary to identify patterns and causes).

Sleeping tablets (hypnotics)

Sleeping tablets 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

Doctors are cautious in prescribing this type of medication as they relieve symptoms but do not treat the cause of sleeplessness, unless a hypnotic helps to restore a lost sleep routine. If you experience long-term insomnia, sleeping tablets are unlikely to help and there is a risk of dependency with all hypnotics. The newer cyclopyrrolone hypnotics (eg zopiclone, zolpidem, zaleplon) are far less likely to cause this problem than the older benzodiazepine hypnotics (nitrazepam, diazepam) and produce a more natural and refreshing sleep with less hangover effect than the older drugs.

Melatonin

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 (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 aged 55 or over.
Circadin is only designed as a short-term treatment for insomnia and should not be taken for more than three weeks.

Circadin 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 your drowsy you should not drive or operate heavy machinery after taking the medicine at night, or if you still feel drowsy the next morning.

Other medicines

Antihistamines can be bought over the counter at pharmacies, and some are sold for their sedative properties, but their sedative effect does not last for more than a few nights in a row (due to the phenomenon of tolerance, where the body rapidly adjusts to a drug and its effect becomes diminished), and they tend to be associated with a morning hangover.
Certain herbal remedies such as chamomile and passionflower have had some reported positive effects but have not been thoroughly clinically investigated to support their use and long term safety

Preventing insomnia

Some simple measures can help:

Set a specific time for getting up each day. Stick to this time, seven days a week, even if you feel you haven't had enough sleep. This should help you sleep better at night.
Only ever go to bed when you are feeling tired and sleepy.
Try to create a bedtime routine, such as a warm bath and warm milky drink every night. These activities will then be associated with sleep and will cause drowsiness.
Do not take a nap during the day.
If the early morning sunlight or bright street lamps affect your sleep, use thick blinds or curtains, or wear an eye mask to create a dark environment.
If noise is a problem, wear ear plugs.
Do not use the bedroom for anything other than sleeping or sex. Do not watch television, make phone calls, eat, or work while you are in bed.
Rather than worrying about things while you are trying to get to sleep, write a list of your worries and any ideas you have to solve them; then forget about it until the morning.
Avoid or limit tea, coffee, chocolate and cold remedies containing caffeine.
Avoid drinking alcohol and smoking as these are also stimulants. Alcohol may make you sleepy at first but will wake you up when the effects have worn off.
Don't eat a big meal or spicy foods just before bedtime. A small snack that contains tryptophan (a natural sleep-promoting amino acid) may help, such as turkey, banana or fish.
Keeping fit will generally help you to have a good night's sleep. Take daily exercise at least 4 hours before you are planning to go to bed as this will give your body temperature a chance to cool down.
Make sure you have a comfortable mattress, a pillow you like, and adequate bed covers for the time of year. For example, a quilt for winter.
If it takes longer than 20 or 30 minutes to get to sleep, do not lie in bed becoming anxious about sleeping. Instead, get up and go to another room for a short period and do something else such as reading or watching television, then try again.
Don't watch the clock as this will only make you anxious. For example: ‘It's 2.30. I've got to be up at 6.30'.

Try these methods for at least 3 - 4 weeks so that you break your usual sleep patterns. Be aware that you may feel tired during this period so you must take extra care when you are driving or operating machinery etc.

Useful links

Sleep Council

www.sleepcouncil.com

The Sleep Council is a non-profit making generic organisation which aims to promote the importance of a good night's sleep to health and wellbeing.

Sleep Apnoea Trust

www.sleep-apnoea-trust.org

The Sleep Apnoea Trust is Britain's largest patient support group for sleep apnoea sufferers with some 1500 members from all over the country. The Sleep Apnoea Trust exists to improve the lives of sleep apnoea patients, their partners and their families.

Cry-sis

www.cry-sis.org.uk

Cry-sis was founded by a small group of parents who were experiencing problems with their crying and sleepless babies. The charity's aim is to be professional, efficient and effective in providing self-help, support and information to families with excessively crying, sleepless babies