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INSOMNIA - a patient's guide
Editorial Team
Overview
Insomnia affects up to 95 percent of the population at
some time in their lives
Insomnia can take several different forms such as difficulty
falling asleep, non-refreshing sleep, or waking too early
in the morning
Causes of persisting insomnia include environmental noise,
shift work, stress and depression.
Behaviour therapy, relaxation, sleep restriction therapy
and various medications can be used in the treatment of
insomnia
The long-term use of sleeping pills (benzodiazepine class)
for insomnia should be avoided as they can be habit-forming.
What is it?
Insomnia is defined as inadequate or poor quality sleep
and includes problems with falling asleep, waking in the
middle of the night and not being able to go back to sleep,
or waking too early in the morning.
It is estimated insomnia affects up to 95 percent of the
population at some time in their lives. About 40 percent
of adults will experience some form of insomnia in any one
year, with up to 15 percent experiencing severe problems.
Insomnia is more likely in over 60 years olds, women,
and when there is a history of depression. The problem is
exacerbated when a person becomes anxious about sleep and
expects to have trouble sleeping.
The condition can lead to irritability during the day,
problems concentrating, fatigue and lack of energy.
There are several different types of insomnia. These include:
Acute insomnia
This is caused by emotional stress, environmental factors
(noise, heat), and jet lag. This type of insomnia lasts
between one night and a few weeks.
Chronic insomnia
This involves abnormal sleep-wake rhythms and often occurs
in relation with other health problems. With chronic insomnia
there is difficulty sleeping for at least three nights a
week for one month or more.
Insomnia associated with medical or psychiatric disorders
Mental health illness is a common cause of insomnia, with
mood and anxiety disorders the most likely to be related
to insomnia.
Health conditions such as asthma, gastroesophageal reflux,
pregnancy and menopause can also lead to problems with sleeping.
Insomnia associated with medications or drug abuse
Several prescription and non-prescription medicines can
cause insomnia. Drugs commonly associated with insomnia
include steroids, alcohol, nicotine, caffeine, and recreational
drugs such as amphetamines (speed).
Insomnia associated with sleep disorders
Some sleep disorders can cause insomnia and unrefreshing
sleep. These include:
Sleep apnoea - associated with excessive snoring and tiredness
during the day.
Circadian rhythm sleep disorders - these occur when the
body's natural sleeping pattern is interrupted such as with
shift work or when there is difficulty falling asleep at
the desired time and difficulty waking, or going to sleep
too early at night and waking too early.
Restless leg syndrome - this is associated with sensations
in the legs or feet and can be accompanied by periodic limb
movements and twitching.
Primary insomnia
This is diagnosed when other causes of insomnia have been
ruled out. It can be related to severe stress, poor sleeping
patterns and over stimulation.
How is insomnia diagnosed?
A sleep diary is useful for obtaining a history of a person's
sleeping patterns and what may contribute to the insomnia.
Occasionally, a sleep study in a sleeping laboratory is
required when sleep apnoea or narcolepsy (excessive sleeping)
is suspected.
What can be done to help?
Several behavioural possibilities to help improve sleep
should be tried before considering medication.
Behavioural therapy
This treatment aims to change bad sleeping habits and
alter an individual's beliefs and attitudes which may contribute
to insomnia.
Relaxation
This is based on the belief that insomniacs find it difficult
to properly relax both during the day and at night.
Relaxation therapy aims to teach relaxation techniques
that can be used before sleep. These may include breathing
techniques, muscle relaxation and meditation to help limit
racing thoughts.
Sleep Restriction Therapy
This involves restricting the amount of time spent in
bed to the amount of time spent asleep. Therefore, if a
person is only sleeping six hours a night, they are initially
required to just spend this amount of time in bed. The amount
of time spent in bed is increased by 20 to 30 minutes each
night until an acceptable level of sleep is achieved. It
is better to go to bed later and get up at the same time
in order to maintain normal sleeping rhythms. Do not spend
any less than five hours in bed.
Drug treatment
Hypnotic medications (sleeping pills) are used in the
short-term management of insomnia and may be combined with
other psychological therapy. The most commonly used medicines
are from the benzodiazepine class. In general, these medicines
are prescribed at the lowest dose possible to produce the
desired effect. Because of the risk of being habit forming,
these medications should not be taken for prolonged periods.
A few days is usually fine however.
These medicines should not be used by pregnant women,
those with untreated obstructive sleep apnoea and people
with a history of substance abuse.
It is common for antidepressants with a sedative action
to be used in a low dosage (less than a full antidepressant
dose) to help improve sleep, particularly early morning
waking.
If the insomnia is due to an underlying clinical depression,
treatment of this with full therapeutic doses of an antidepressant
can be helpful.
It is worth noting that antidepressants are not habit
forming and offer a safe option if medication is needed
for a while.
Over the counter sleeping aid products often include antihistamines
which have been shown to improve insomnia with short-term
treatment.
Melatonin has also been used in the treatment of insomnia.
A 5 mg dose of melatonin has been shown to help with sleep
in the elderly, shift workers and those with jet lag, however
no large studies have been undertaken. The long-term safety
of using melatonin has not been established.
Other drugs such as barbiturates and older drugs such
as chloral hydrate, methyprylon and meprobamate have been
used for insomnia in the past but they are no longer recommended
because of their potential for abuse and addiction.
Hints for getting a good sleep:
Go to bed at the same time each night and wake at the
same time
Do not drink coffee or caffeine drinks up to six hours
before bedtime
Do not smoke before bed or if you wake in the middle of
the night
Do not drink alcohol to try to get to sleep. It may cause
you to wake at night
Avoid heavy meals before bedtime
Avoid naps during the day
Avoid exercise up to four hours before bedtime. This can
cause over stimulation
If you can't fall asleep get up and do something else
and go back to bed once you feel sleepy
Make sure the bedroom is dark, silent, and a comfortable
temperature
Getting help
If you are experiencing persisting sleep problems, discuss
the problem with your doctor.
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