Sleeplessness (Insomnia), is a disorder in which there is an inability to fall asleep or to stay asleep as long as desired. 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), which 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 an 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.symptoms:
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of depression.
Major depression leads to alterations in the function of the hypothalamic-pituitary-adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.[21]
They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study.
Studies of brain metabolism using positron emission tomography (PET) scans indicate that people with insomnia have higher metabolic rates by night and by day. The question remains whether these changes are the causes or consequences of long-term insomnia.
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.
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.
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).
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), which 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 an 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.symptoms:
- Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
- Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
- Early-morning awakening with inability to return to sleep.
- The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
- The sleep difficulty occurs at least 3 nights per week.
- The sleep difficulty is present for at least 3 months.
- The sleep difficulty occurs despite adequate opportunity for sleep.
- The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).
- The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
- Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.
Types of insomnia
Insomnia can be classified as Transient, Acute, or Chronic.- Transient insomnia lasts for less than a week. It can be caused by another disorder, by changes in the sleep environment, by the timing of sleep, severe depression, or by stress. Its consequences – sleepiness and impaired psychomotor performance – are similar to those of sleep deprivation.
- Acute insomnia is the inability to consistently sleep well for a period of less than a month. Insomnia is present when there is difficulty initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality. These problems occur despite adequate opportunity and circumstances for sleep and they must result in problems with daytime function. Acute insomnia is also known as short term insomnia or stress related insomnia.[15]
- Chronic insomnia lasts for longer than a month. It can be caused by another disorder, or it can be a primary disorder. People with high levels of stress hormones or shifts in the levels of cytokines are more likely to have chronic insomnia. Its effects can vary according to its causes. They might include muscular fatigue, hallucinations, and/or mental fatigue. Chronic insomnia can cause double vision.
Early morning awakening is an awakening occurring earlier (more than 30 minutes) than desired with an inability to go back to sleep, and before total sleep time reaches 6.5 hours. Early morning awakening is often a characteristic of depression.
Poor sleep quality
Poor sleep quality can occur as a result of, for example, restless legs, sleep apnea or major depression. Poor sleep quality is caused by the individual not reaching stage 3 or delta sleep which has restorative properties.Major depression leads to alterations in the function of the hypothalamic-pituitary-adrenal axis, causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria, excessive nighttime urination, can be very disturbing to sleep.[21]
Causes
Symptoms of insomnia can be caused by or be co-morbid with:- Use of stimulants, including certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA, modafinil, or excessive alcohol intake.
- Withdrawal from anti-anxiety drugs such as benzodiazepines or pain-relievers such as opioids.
- Use of fluoroquinolone antibiotic drugs is associated with more severe and chronic types of insomnia.
- Restless legs syndrome, which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations.
- Periodic limb movement disorder (PLMD), which occurs during sleep and can cause arousals of which the sleeper is unaware.
- Pain An injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep, and can in addition cause awakening.
- Hormone shifts such as those that precede menstruation and those during menopause.
- Life events such as fear, stress, anxiety, emotional or mental tension, work problems, financial stress, birth of a child and bereavement.
- Gastrointestinal issues such as heartburn or constipation.
- Mental disorders such as bipolar disorder, clinical depression, generalized anxiety disorder, post traumatic stress disorder, schizophrenia, obsessive compulsive disorder, and dementia.
- Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic circadian rhythm disorders are characterized by similar symptoms.
- Certain neurological disorders, brain lesions, or a history of traumatic brain injury.
- Medical conditions such as hyperthyroidism and rheumatoid arthritis.
- Abuse of over-the counter or prescription sleep aids (sedative or depressant drugs) can produce rebound insomnia.
- Poor sleep hygiene, e.g., noise or over consumption of caffeine
- A rare genetic condition can cause a prion-based, permanent and eventually fatal form of insomnia called fatal familial insomnia.
- Physical exercise. Exercise-induced insomnia is common in athletes in the form of prolonged sleep onset latency.
They also have an elevated metabolic rate, which does not occur in people who do not have insomnia but whose sleep is intentionally disrupted during a sleep study.
Studies of brain metabolism using positron emission tomography (PET) scans indicate that people with insomnia have higher metabolic rates by night and by day. The question remains whether these changes are the causes or consequences of long-term insomnia.
Risk factors
Insomnia affects people of all age groups but people in the following groups have a higher chance of acquiring insomnia.- Individuals older than 60
- History of mental health disorder including depression, etc.
- Emotional stress
- Working late night shifts
- Travelling through different time zones
Diagnosis
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 circadian rhythm disorder is a 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.
Treatment
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.
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).
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