Insomnia: Practice Essentials, Background, Anatomy

What causes primary insomnia?

Primary Insomnia – an overview

INSOMNIA AND USE OF HYPNOTIC AGENTS

Insomnia is the most common sleep-wake-related complaint, and sleeping pills are among the most commonly prescribed drugs in clinical practice at the primary health care level. Insomnia can be a symptom of an underlying condition, for which there are dozens of candidates, or it can be a primary disease. Many of the insomnia diagnoses are relatively new diagnostic entities, and there are few or no studies of their prevalence. We concentrate here on studies dealing with insomnia in general, its three main manifestations (i.e., trouble falling asleep, trouble staying asleep, and early morning awakening), and the use of hypnotic agents.

Table 52-1 presents studies on insomnia in general. The heterogeneity of the definitions and methods used is striking, but some clear trends can be seen.

First, insomnia increases with age. Approximately one third of subjects older than 65 years of age have more or less continuous insomnia, although at very old age, the levels may be lower. In Australia, insomnia was persistent in 16.2% of the community-dwelling population and 12.2% of institutional residents. Altogether, 14.5% of elderly subjects living in the community were using hypnotics regularly, whereas the corresponding figure was 39.7% among institutional residents.¹⁴ In a large U.S. population-based study,¹³ the prevalence of insomnia was 7.5%, and that of difficulty sleeping an additional 22.4%. In children and adolescents, the prevalence of frequent insomnia is quite variable; in several studies, it is higher than 10%. In middle-aged populations, the frequency of long-standing insomnia seems to be approximately 10%. Table 52-2 shows that trouble falling asleep seems to be the most common manifestation in younger age groups, whereas trouble staying asleep is the most frequent form of insomnia in middle-aged and elderly people.

Second, there is a clear sex difference, with insomnia occurring approximately 1.5 times more often in women than in men; this is especially true in menopausal and postmenopausal women compared with middle-aged men.

Third, seasonal differences, probably due to light exposure, can be seen, and the results are consistent in Nordic countries.¹⁵¹⁶ In northern Norway, 41.7% of women and 29.9% of men had occasional insomnia.¹⁵ As a whole, complaints of insomnia were more common during the dark period of year than during other times of the year. In the Tromsø study, occurrence of insomnia during the midnight sun period (summer insomnia) decreased with age, whereas the other seasonal types of insomnia increased with age.¹⁵

Fourth, the association of psychiatric disorders, especially depression, with insomnia is well known. Primary insomnia and insomnia related to mental disorders are the two most common DSM-IV insomnia diagnoses.¹⁷ The differential diagnosis may be difficult. In a large U.S. community survey by Weissman et al.,¹¹⁰ the prevalence of insomnia uncomplicated by psychiatric disorders was 4.9%. Among those with complicated insomnia in the past year, 25% had major depression, 19% abused alcohol, 12% had dysthymia, 9% had panic disorder, 8% abused drugs, 8% had schizophrenia, and 2% had somatization disorder. In a World Health Organization collaborative study, 25,916 primary health care attendees were evaluated.^17a Sleep problems were present in 27% of the patients. Of the patients with insomnia, 51% had a well-defined ICD-10 mental disorder, mainly depression or anxiety, or abused alcohol, or a combination. Use of alcohol and over-the-counter medications to control insomnia is common. Also, somatic and psychological complaints as well as psychological stress are associated with a higher prevalence of insomnia.

Fifth, social and occupational factors are important contributors to insomnia, as are medical illnesses. Being unemployed or unmarried is associated with a higher prevalence of insomnia complaints in Japan and other countries. Insomnia is a frequent complaint among patients with various respiratory symptoms. In a study by Dodge et al.,¹¹¹ the prevalence of insomnia was 31.8% to 52.4% among adults with cough, dyspnea, or wheezing; among adults without respiratory symptoms, the prevalence was 25.8% to 26.2%. In a questionnaire survey of 6268 adults in 40 different occupations, 18.9% of bus drivers complained of having some or very much difficulty falling asleep. Among male managers and male physicians, the respective percentages were 3.7% and 4.9%. Disturbed nocturnal sleep was complained of the most often by male laborers (28.1% waking up at least three times a night) and female cleaners (26.6%). Disturbed nocturnal sleep was rare among male physicians (1.6%), male managers (7.4%), female head nurses (8.9%), and female social workers (9.4%).¹⁸ Symptoms of work-related stress and mental exhaustion are associated with insomnia. Simple methods, such as the five-item version of the Mental Health Index and some other questions, may be used effectively to screen workers with mental health and sleep problems.¹⁹

Table 52-3 lists some studies on the use of hypnotic agents. In a nationally representative probability sample survey of noninstitutionalized adults, 3161 people 18 to 79 years of age were surveyed.²⁰ Insomnia affected 35% of all adults during the course of 1 year. During the year before the survey, 2.6% of adults had used a medically prescribed hypnotic agent; 0.3% of all adults and 11% of all users of hypnotic agents reported using the medication regularly for 1 year or longer. When anxiolytic and antidepressant agents were excluded, 4.3% of adults had used a medically prescribed hypnotic for sleep and 3.1% had used an over-the-counter sleeping pill. Since that time, the use of hypnotic agents has continued to increase.²¹

In Sweden, 10,216 members of the Swedish Pensioners’ Association were surveyed.²² Hypnotic agents were used by 13.5% of the men and 22.3% of the women. Of the men younger than 70 years of age, 7.9% were receiving such treatment; of those 70 to 80 years of age, 14.4% were using hypnotic agents; and of those 80 years of age or older, 21.8% were taking hypnotic agents (P < .0001). The corresponding frequencies among women were 15.0%, 23.0%, and 34.9%, respectively (P < .0001). Hypnotic agents are used by many institutionalized elderly subjects even without insomnia. This is problematic, and it raises an ethical question because the chronic use of hypnotic agents is associated with excessive mortality rates.²³

An excellent way of tracking the use of hypnotic medication of a population is to count unit defined daily doses (DDD) from the sales statistics of pharmacies and hospitals. When one knows the assumed average dose per day for each drug, sales per year, and population of the country, one can calculate DDDs per 1000 inhabitants per day. In Finland, for all hypnotic agents, the rate in 1994 was 38 DDD/1000 inhabitants/day. In 2002 the rate had increased to 53.4 DDD/1000 inhabitants/day. Benzodiazepines are available in all Scandinavian countries, and in 2001, the consumption of benzodiazepines (in DDD/1000 inhabitants/day) was 14.9 in Denmark, 21.5 in Finland, 20.8 in Iceland, 13.1 in Norway, and 11.7 in Sweden.²¹ Respectively, the consumption of cyclopyrrolones was 17.7 in Denmark, 29.5 in Finland, 34.5 in Iceland, 20.9 in Norway, and 24.3 in Sweden.²¹

Insomnia | MedlinePlus

What is insomnia?

Insomnia is a common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up.

What are the types of insomnia?

Insomnia can be acute (short-term) or chronic (ongoing). Acute insomnia is common. Common causes include stress at work, family pressures, or a traumatic event. It usually lasts for days or weeks.

Chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary. This means they are the symptom or side effect of some other problem, such as certain medical conditions, medicines, and other sleep disorders. Substances such as caffeine, tobacco, and alcohol can also be a cause.

Sometimes chronic insomnia is the primary problem. This means that it is not caused by something else. Its cause is not well understood, but long-lasting stress, emotional upset, travel and shift work can be factors. Primary insomnia usually lasts more than one month.

Who is at risk for insomnia?

Insomnia is common. It affects women more often than men. You can get it at any age, but older adults are more likely to have it. You are also at higher risk of insomnia if you:

• Have a lot of stress
• Are depressed or have other emotional distress, such as divorce or death of a spouse
• Have a lower income
• Work at night or have frequent major shifts in your work hours
• Travel long distances with time changes
• Have an inactive lifestyle
• Are African American; research shows that African Americans take longer to fall asleep, don’t sleep as well, and have more sleep-related breathing problems than whites.

What are the symptoms of insomnia?

Symptoms of insomnia include:

• Lying awake for a long time before you fall asleep
• Sleeping for only short periods
• Being awake for much of the night
• Feeling as if you haven’t slept at all
• Waking up too early

What other problems can insomnia cause?

Insomnia can cause daytime sleepiness and a lack of energy. It also can make you feel anxious, depressed, or irritable. You may have trouble focusing on tasks, paying attention, learning, and remembering. Insomnia also can cause other serious problems. For example, it could make you may feel drowsy while driving. This could cause you get into a car accident.

How is insomnia diagnosed?

To diagnose insomnia, your health care provider:

• Takes your medical history
• Asks for your sleep history. Your provider will ask you for details about your sleep habits.
• Does a physical exam, to rule out other medical problems that might cause insomnia
• May recommend a sleep study. A sleep study measures how well you sleep and how your body responds to sleep problems.

What are the treatments for insomnia?

Treatments include lifestyle changes, counseling, and medicines:

• Lifestyle changes, including good sleep habits, often help relieve acute (short-term) insomnia. These changes might make it easier for you to fall asleep and stay asleep.
• A type of counseling called cognitive-behavioral therapy (CBT) can help relieve the anxiety linked to chronic (ongoing) insomnia
• Several medicines also can help relieve your insomnia and allow you to re-establish a regular sleep schedule

If your insomnia is the symptom or side effect of another problem, it’s important to treat that problem (if possible).

NIH: National Heart, Lung, and Blood Institute

Diagnosis and treatment of chronic insomnia

Definition of chronic insomnia

Although there are various definitions of chronic insomnia, the most widely accepted[16] is the one that defines it to be a condition characterized by “inadequate quantity or quality of sleep characterized by a subjective report of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment and has persisted for at least one month”. The causes of this are many, the most important of which are medications, drug or alcohol abuse, psychiatric disorders like depression or anxiety, medical disorders (such as arthritis, asthma, Parkinson’s disease, hyperthyroidism, prostate hypertrophy, degenerative neurological disorders, renal disorders, heart failure, rhinitis), poor sleep hygiene, and other disorders like sleep apnea, periodic limb movements, conditioned insomnia (behavioral conditioning), restless legs syndrome, circadian rhythm disorder or advanced/delayed sleep-phase syndrome. Neurological causes such as fibromyalgia and Morvan’s syndrome, medical causes such as gastroesophageal reflux disease, and in children, sleep-onset association disorder and limit-setting sleep disorder also need to be identified and addressed since these can commonly present as chronic insomnia.

Difficulty in falling asleep may be primarily due to behavioral and cognitive factors such as worrying in bed or having unreasonable expectations of sleep duration.[17] Gillin[18] believes that this excessive worry about sleep loss eventually becomes persistent and “provides an automatic nocturnal trigger for anxiety and arousal.” Further, unsuccessful attempts to control thoughts, images, and emotions only worsen the situation. After such a cycle is established, “insomnia becomes a self-fulfilling prophecy that can persist indefinitely.” Other behaviors in bed or in the bedroom that are incompatible with sleep may include talking on the telephone at night, watching television, using computers, exercising, eating, smoking, or “clock watching.”

Evaluation of a patient with insomnia

As insomnia is both a symptom and a disorder in itself, detailed evaluation of the problem is imperative before reaching a clinical diagnosis. The treating clinician should have a high index of suspicion of insomnia or sleep difficulty when patients present with the following symptoms:[19] fatigue, excessive daytime sleepiness, major and/or minor depressive episode, generalized anxiety disorder, memory/concentration complaints, pain.

The mandatory assessment of insomnia includes the following.

Sleep history

Sleep history is the first step in evaluation of primary insomnia, which provides the clinician with a structured approach to a diagnosis. It requires a general description of the disorder, i.e., its duration, severity, variation, and daytime consequences. The NHLBI Working Group has devised the following approach which may be followed [].[20]

Table 1

Use of prescription drugs

Various prescription drugs may be responsible for chronic insomnia. Such a use should be asked for specifically and ruled out. The drugs may include anticonvulsants such as phenytoin and lamotrigine, beta-blockers like acebutolol, atenolol, metoprolol, oxprenolol, propranolol, and sotalol, antipsychotics like sulpiride, antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) or Monoamine oxidase inhibitors (MAOIs) and non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, diclofenac, naproxen, and sulindac.

Sleep diary or sleep log

A sleep diary helps in specifically estimating the severity of the problem, the night to night variability, and presence of maladaptive habits such as taking naps or spending excessive time in bed (more than 8 hours). Sleep diary also keeps track of compliance with behavioral interventions and response to treatment.

Sleep and psychological rating scale

Epworth Sleepiness Scale (ESS) rates the chance of dozing in the following situations[21] which may be during sitting and reading, watching television, sitting inactively in a public place, being a passenger in a car for an hour without a break, during lying down to rest in the afternoon, sitting and talking to someone, sitting quietly after lunch without alcohol or while waiting at a traffic signal in a car.

The ESS is rated on a 4-point scale for each of the above factors based on the following scores:

• 0 – no chances of dozing;

• 1 – slight chances of dozing;

• 2 – moderate chances of dozing; and

• 3 – high chances of dozing.

A score of more than 16 indicates daytime somnolence, while a cutoff of 11 is often employed to indicate a possible disorder associated with excessive sleepiness.

Focused physical examination

A general physical examination may help assess certain organic pathologies such as chronic obstructive pulmonary diseases (COPD), asthma, or restless leg syndrome which may disturb sleep.

Blood tests

Blood tests may help to rule out subtle manifestations of thyroid diseases, iron deficiency anemia, and vitamin B12 deficiency (restless leg syndrome).

Polysomnography

It is considered the gold standard for measuring sleep. electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography (ECG), pulse oximetry, and air flow are used to reveal a variety of findings like periodic limb movement disorder, sleep apnea, and narcolepsy.[22]

Actigraphy

Actigraphy measures physical activity with a portable device (usually including an accelerometer) worn on the wrist. Data recorded can be stored for weeks and then downloaded into a computer. Sleep and wake time can be analyzed by analyzing the movement data. This approach to estimating sleep and wake time has been shown to correlate with polysomnographic measures in normal sleepers, with reduced values noted in patients with insomnia.[2,23]

Summary of investigations

Investigations do not always correlate well with the patient’s experience of insomnia and cannot replace a thorough clinical evaluation. Hence, it is important to recognize that insomnia is a subjective clinical diagnosis, and therefore, a patient’s subjective report of sleep difficulties should play the most important role in directing management in most cases. It is also important to ask questions about the range of symptoms experienced and changes over time. Because insomnia is a patient-reported symptom, rather than a polysomnographically defined disorder, referral to a sleep laboratory for polysomnographic diagnosis should be reserved for cases in which another primary sleep disorder, such as obstructive sleep apnea or periodic movement disorder, is suspected, because these may require greater expertise in sleep medicine.[24] Other measures that can be used are evaluation of mental status, subjective sleep quality, psychological assessment scales, daytime function, quality of life, and dysfunctional beliefs and attitudes.

Diagnosis

The DSM IV TR [][25] provides a list of diagnostic criteria for primary insomnia. The term “primary” indicates that the insomnia is independent of any known physical or mental condition.

Table 2

Diagnosis of primary insomnia

The International Classification of Sleep Disorders 2[26] codes insomnia under the broad heading of dyssomnias, either intrinsic or extrinsic sleep disorders. Based on the severity, it classifies insomnia into three types as follows.

1. Mild insomnia:This term describes an almost nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by little or no evidence of impairment of social or occupational functioning. Mild insomnia is often associated with feelings of restlessness, irritability, mild anxiety, daytime fatigue, and tiredness.

2. Moderate insomnia: This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by mild or moderate impairment of social or occupational functioning. Moderate insomnia is always associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.

3. Severe insomnia: This term describes a nightly complaint of an insufficient amount of sleep or not feeling rested after the habitual sleep episode. It is accompanied by severe impairment of social or occupational functioning. Severe insomnia is associated with feelings of restlessness, irritability, anxiety, daytime fatigue, and tiredness.

Treatment of Chronic Insomnia

The treatment of chronic insomnia consists of initially diagnosing and treating the underlying medical or psychological problems. The identification of behaviors that may worsen insomnia follows and stopping (or reducing) them would help eliminate insomnia. Next, a possible trial of pharmacology can be tried, although the long-term use of drugs for chronic insomnia is controversial. This is in spite of the fact that the US FDA has approved three medications for the treatment of insomnia with no limitation on the duration of their use. A trial of behavioral techniques to improve sleep, such as relaxation therapy, sleep restriction therapy, and reconditioning, is however useful. Behavioral intervention combined with pharmacologic agents may be more effective than either approach alone.

Non-pharmacologic management strategies

Non-pharmacologic interventions for insomnia consist primarily of short-term cognitive-behavioral therapies. These methods act primarily by reducing heightened autonomic and cognitive arousal, modifying self-perpetuating maladaptive sleep habits, altering dysfunctional beliefs and attitudes about sleep, and educating patients about healthier sleep practices.[27] The techniques include the following.

Stimulus control therapy

Stimulus control therapy is based on the premise that insomnia is a conditioned response to temporal (bedtime) and environmental (bed/bedroom) cues that are usually associated with sleep.[28] Accordingly, the main objective of stimulus control therapy is to train the patient to “re-associate the bed and bedroom with rapid sleep onset by curtailing sleep-incompatible activities (overt and covert) that serve as cues for staying awake and by enforcing a consistent sleep-wake schedule.” Stimulus control therapy consists of the following instructional procedures[29] consisting of going to bed only when feeling sleepy, using the bed and bedroom only for sleep and sex and nothing else like watching TV, getting out of bed and going into another room whenever unable to fall asleep or returning to sleep within 15–20 minutes and returning to bed only when sleepy again, maintaining a regular rising time in the morning regardless of sleep duration the previous night, and avoiding daytime napping.

Evidence suggests that stimulus control therapy is effective and well suited for the clinical management of insomnia in the elderly[30] with effect sizes ranging from 0.81 to 1.16 for sleep latency, 0.41 to 0.38 for total sleep time, and 0.70 for wake after sleep onset.[31,32]

Sleep restriction

Sleep restriction therapy consists of restricting the amount of time spent in bed to nearly match the subjective amount of time spent sleeping.[30] For example, if a person reports sleeping an average of 5 hours per night out of 8 hours spent in bed, the initial prescribed “sleep window” (i.e., from initial bedtime to final arising time) would be 5 hours. Subsequently, the allowable time in bed is increased by 15–20 minutes for a given week when sleep efficiency (defined as ratio of total sleep/time spent in bed × 100%) exceeds 90%, decreased by the same amount of time when sleep efficiency is lower than 80%, and kept stable when sleep efficiency falls between 80 and 90%. Periodic adjustments are made (usually on a weekly basis) until an optimal sleep duration is achieved. Sleep restriction therefore creates a mild state of sleep deprivation and is said to “promote a more rapid sleep onset, more efficient sleep, and less inter-night variability.” To prevent excessive daytime sleepiness, time spent in bed should not be less than 5 hours per night. Evidence suggests that sleep restriction therapy is moderately effective with effect sizes ranging from 0.85 to 0.98 for sleep latency, –1.06 to 0.37 for total sleep time and 0.76 for wake after sleep onset.[31,34]

Relaxation therapies

Relaxation-based interventions are based on the observation that insomnia patients often display high levels of arousal (physiological and cognitive), both at night and during daytime.[33] Relaxation methods are used to deactivate the heightened arousal system, and the selection of a specific technique varies depending on whether physiological or cognitive arousal is targeted for treatment. Progressive muscle relaxation and biofeedback techniques seek to reduce somatic arousal, whereas attention focusing procedures such as imagery training and thought stopping are intended to lower presleep cognitive arousal (e.g., intrusive thoughts, racing mind). Additional relaxation therapies (e.g., abdominal breathing, meditation, hypnosis) have also been advocated, but currently there is no evidence to support their use in the clinical management of insomnia with less than modest effect sizes ranging from 0.81 to 0.83 for sleep latency, 0.25 to 0.52 for total sleep time, and 0.06 for wake after sleep onset.[31,32] As is the premise for most self-management skills, all these relaxation techniques require regular practice over a period of several weeks, and professional guidance is often necessary in the initial stage of training.

Cognitive therapy

Cognitive therapy seeks to alter faulty beliefs and attitudes about sleep.[34] For example, insomniacs “often display a great deal of apprehension about bedtime and performance anxiety in their attempt to control the process of sleep onset; some even entertain catastrophic thinking about the potential consequences of insomnia, all of which may heighten their affective response to poor sleep.” The objective of cognitive therapy is to cut short the vicious cycle of insomnia, emotional distress, dysfunctional cognitions, and further sleep disturbances. Examples of treatment targets for cognitive therapy include having unrealistic sleep expectations (e.g., “I must get 8 hours of sleep every night”), misconceptions about the causes of insomnia (e.g., “my insomnia is entirely due to chemical imbalances in my body”), amplifications of its consequences (e.g., “I am going to fail after a poor night’s sleep”), and performance anxiety resulting from excessive attempts at controlling the sleep process.[35]

The advocates of cognitive therapy believe that “it consists of identifying patient-specific dysfunctional sleep cognitions, challenging their validity, and replacing them with more adaptive substitutes through the use of restructuring techniques such as reattribution training, decatastrophizing, hypothesis testing, reappraisal, and attention shifting.”[36] The evidence for this mode of intervention is the strongest with effect sizes ranging from 0.93 to 1.20 for sleep latency, 0.28 to 0.57 for total sleep time, and 0.28 for wake after sleep onset.[31,32]

Paradoxical intention

Paradoxical intention is a method that consists of persuading a patient to engage in his or her most feared behavior, i.e., staying awake.[37] The basic premise is that performance anxiety inhibits sleep onset. Thus, if a patient stops trying to sleep and contrarily attempts to stay awake, performance anxiety will be reduced and sleep may come more easily. This procedure may be conceptualized as a form of cognitive restructuring technique to alleviate performance anxiety. Effect sizes reported have been moderate in sleep latency (0.63–0.73), total sleep time (0.10–0.46), and wake after sleep onset (0.81).[31,32]

Sleep hygiene education

Sleep hygiene education targets health practices (e.g., diet, exercise, and substance use) and environmental factors (e.g., light, noise, temperature, and mattress) that may be either detrimental or beneficial to sleep.[38] Although these factors are rarely severe enough to be the primary cause of chronic insomnia, they may complicate an existing sleep problem and hinder treatment progress. Additional recommendations, which tend to overlap with stimulus control and sleep restriction, may also include curtailing daytime napping and time spent in bed. While poor sleepers are generally better informed about sleep hygiene, they also engage in more unhealthy practices than good sleepers. Thus, the objectives of sleep hygiene are to promote better health practices. In a meta-analysis of sleep hygiene, effect size observed was modest in all parameters.[31]

Behavioral intervention

Having the patient keep a sleep diary for 2 weeks may be helpful. Depending on the findings in the sleep diary, a discussion of sleep hygiene may be beneficial to the patient. Adopting the practices of good sleep hygiene is often helpful regardless of whether the patient has primary insomnia or a sleep disturbance related to a medical condition.[30] Behavioral psychologists focus on encouraging the patient to eliminate behavior incompatible with sleep, such as lying in bed and worrying, by instructing the patient to leave the bedroom at these times. Patients can condition themselves to be insomniacs, and treatment focuses on de-conditioning the patient from associating the bedroom with a place of restlessness.

Summary of non-pharmacologic strategies

There are three recently published meta-analyses which serve to establish the efficacy of psychological and behavioral methods. Pallesen and colleagues[39] evaluated behavioral and psychological interventions in an elderly insomniac patient population (mean age > 60 years). Significant effect sizes in sleep latency (0.64), wake after sleep onset (0.59), and total sleep time (0.37) were observed for psychological/behavioral treatments. Similarly, Irwin and colleagues[40] evaluated treatment efficacy of cognitive behavioral intervention in older adults >55 years old and found significant effects for sleep latency (0.50), wake after sleep onset (0.69), and total sleep time (0.17). However, Montgomery and Dennis[41] reviewed psychological/behavioral and other non-pharmacologic strategies in a similar population and observed minimal changes in sleep latency (mean decrease: 3 minutes) and modest effects on wake after sleep onset (mean decrease: 22 minutes) and total sleep time (mean increase: 14.6 minutes).

Pharmacologic management strategies

Drug treatment is indicated for patients as short-term alleviation of insomnia but is insufficient for long-term management of chronic insomnia. In combination with behavioral therapy, it however, yields the most durable improvements in sleep patterns.[42]

Although clinical trials of pharmacotherapeutic agents recently approved by the FDA have demonstrated their efficacy and safety, common general practice dictates that five basic principles be followed which characterize rational pharmacotherapy for insomnia, especially chronic insomnia, in both adult and geriatric patients:[43] using the lowest effective dose, using intermittent dosing (two to four times weekly), prescribing medication for short-term use (i.e., regular use for no more than 3–4 weeks), discontinuing the medication gradually, and remaining alert for rebound insomnia following discontinuation.

The therapeutic options include the following.

First line pharmacotherapy

These drugs carry the highest level of evidence supporting efficacy and safety.

Benzodiazepines

Benzodiazepines are frequently prescribed to treat insomnia. These hypnotics reduce latency to sleep onset and total awakenings by increasing total sleep duration. Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-amino butyric acid (GABA) by increasing the affinity of GABA for its receptor. Benzodiazepines non-selectively bind to an allosteric site and affect the GABA-A receptor complex to allow a greater number of chloride ions to enter the cell when GABA interacts with the receptor and therefore enhance the inhibitory action of GABA. This accounts for their sedative, anxiolytic, myorelaxant, and anticonvulsant properties. Five benzodiazepines (estazolam, flurazepam, quazepam, temazepam, and triazolam) have an FDA-approved indication for the management of insomnia. Dose, distinguishing pharmacokinetic properties (absorption rate, distribution, and elimination half-life), and risk-benefit ratio should be considered when selecting the most appropriate medication. The lowest effective dose should be used to minimize side effects, and long-acting benzodiazepines with active metabolites should be avoided in the elderly.

Major side effects of short-acting benzodiazepines include rebound insomnia and anterograde amnesia. Intermediate-and longer-acting benzodiazepines are less effective for inducing sleep, but are indicated for sleep maintenance and decreasing nocturnal awakenings.[44] Long-acting medications are best indicated for people with insomnia as well as concomitant daytime anxiety. Accumulation of active metabolites is problematic in elderly patients and in those patients with impaired liver function as it can cause confusion and cognitive dysfunction. Benzodiazepines are contraindicated in patients with acute alcohol intoxication with depressed vital signs, a history of substance abuse, and during pregnancy.

Benzodiazepines should be used cautiously in patients with chronic pulmonary insufficiency or untreated sleep apnea. They are frequently used in mood disorders but a worsening of the dysphoric symptoms and precipitation of suicide has been noted in depression, while hypomania or frank mania and paradoxical hyper-excited states can also occur.[42] However, long-term use (beyond 4 weeks) is associated with dependence, discontinuation syndrome, difficulty in new learning abilities, and blunting of emotions.[45]

Non-benzodiazepine hypnotics

Non-benzodiazepine hypnotics include zopiclone, zolpidem, and zaleplon.

Zopiclone

Zopiclone is a non-benzodiazepine hypnotic of the cyclopryrrolone class. It is effective for reducing sleep latency and nocturnal awakenings and increasing total sleep time. Zopiclone delays the onset of rapid eye movement (REM) sleep but does not reduce consistently the total duration of (REM) periods. Rebound effects have been reported but are minimal. The incidence of adverse effects is low at recommended doses (3.75–7.5 mg).[46]

Zolpidem

Zolpidem is a non-benzodiazepine hypnotic of the imidazopyridine class. It exhibits hypnotic effects with minimal myorelaxant, anticonvulsant, and anxiolytic properties, as it preferentially binds with the GABA-A receptor complexes with an alpha-1 subtype. Zolpidem is effective for reducing sleep latency and nocturnal awakenings and increasing total sleep time. Rebound effects are minimal. Common side effects include drowsiness, dizziness, and headache.[47]

Zaleplon

Zaleplon, like zolpidem, belongs to the imidazopyridine class of non-benzodiazepine hypnotics. The pharmacology of these two drugs is similar; however, zaleplon has an ultra-brief duration of effect.[48] It is effective for reducing time to sleep onset, but is not as effective for reducing nighttime awakenings or increasing total sleep time. No next-day sedation or rebound insomnia is documented with zaleplon at recommended doses (5–10 mg).

Eszopiclone

Eszopiclone, which is the active stereoisomer of zopiclone, acts as an agonist at benzodiazepine (BNZ) receptors. Well absorbed orally, about 3 mg of eszopiclone is equivalent to 10 mg of diazepam.[49] Although FDA approved for the management of chronic insomnia, there have been several reports of adverse effects like headaches, day-time drowsiness, loss of coordination, GI effects, decreased sexual desire, painful menstruation, and breast enlargement in males, leading a major reviewer to comment that the risk-benefit ratio should be weighed carefully due to the possible adverse effects such as cancer, infection, and death.[50]

Ramelteon

A melatonin agonist, it acts by selectively binding to the melatonin receptors (MT1, MT2) in the suprachiasmatic nucleus (SCN). It has also recently been approved for the treatment of insomnia and is the only non-scheduled prescription drug available in the United States for the treatment of insomnia. It has been shown to be effective in the elderly.[51]

No specific agent within this group is recommended as preferable to the others in a general sense; each has been shown to have posi-tive effects on sleep latency, total sleep time (TST), and/or wake after sleep onset (WASO) in placebo-controlled trials.[52-55]

Second line pharmacotherapy

These drugs have moderate level of evidence supporting their efficacy and tolerability.

Antidepressants

Tricyclic antidepressants (TCAs) such as amitriptyline, doxepin, and nortriptyline are effective for inducing sleep and improving sleep continuity.[56] These agents should be used at their lowest effective dose to minimize anticholinergic effects and to minimize cardiac conduction prolongation, especially in the elderly. The overdose potential of TCAs is greater than with other hypnotic agents, and daytime sedation can be significant.

Trazodone

Trazodone is a potent sedating antidepressant. Trazodone improves sleep continuity and is an attractive option in persons prone to substance abuse, as addiction or tolerance is not a problem.[57] Trazodone is also used in conjunction with stimulating antidepressants such as some SSRIs and bupropion in depressed patients with insomnia. Adrenergic blockade can result in oversedation and orthostatic hypotension, especially in elderly patients. The risk of priapism, a condition of painful, prolonged erection in men, is rare. Other antidepressants used include Mirtazapine due to its sedative properties. Evidence for their efficacy when used alone is relatively weak and hence no specific agent within this group is recommended as preferable to the others in this group.[58-61]

Antihistamines

Antihistamines are found in many over-the-counter (OTC) sleep aids. These agents are effective for mild insomnia; however, next-day sedation may be a problem. Antihistamines commonly cause psychomotor impairment and anticholinergic effects. Tolerance may also develop with repeated use and evidence for their efficacy and safety is very limited.[62]

Alternative medications

These are drugs with variable evidence and are useful only in individual cases.

Valerian is a perennial plant that appears to increase GABA concentrations in animal studies, but its exact mechanism is not known. Valerian should not be used for the acute management of insomnia because its hypnotic effect is delayed for 2–4 weeks. Valerian appears to be well tolerated; however, it can cause headache and daytime sedation[63] and is currently still being evaluated.[64]

Other herbs used to promote sleep include skullcap, passion flower, California poppy, and Lemon balm.[65] Melatonin and l-tryptophan are two other molecules undergoing evaluation for the treatment of chronic insomnia.[66] There is currently very little evidence for their use.[67] Indiplon, a novel GABA_A potentiator, till recently being studied,[68] has now been abandoned due to its toxicity.

The recommended drugs according to the level of clinical evidence are summarized in .

Table 3

Summary of clinical evidence of pharmacotherapy

Insomnia: Assessment and Management in Primary Care

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Insomnia: Causes, Risks & Treatments

Overview

What is insomnia?

Insomnia is a common sleep disorder that is characterized by difficulty:

• Falling asleep initially.
• Waking up during the night.
• Waking earlier than desired.

What are the symptoms of insomnia?

Chronic insomnia may cause:

• Difficulty falling asleep and/or waking up in the middle of the night.
• Difficulty returning to sleep.
• Feeling tired/fatigued during the daytime.
• Irritability or depressed mood.
• Problems with concentration or memory.

What are the types of insomnia?

Insomnia can come and go, or it may be an ongoing, longstanding issue. There is short term insomnia and chronic insomnia:

• Short term insomnia tends to last for a few days or weeks and is often triggered by stress.
• Chronic insomnia is when the sleep difficulties occur at least three times a week for three months or longer.

How common is insomnia?

Sleep disorders are very common. They affect up to 70 million Americans every year.

Insomnia symptoms occur in approximately 33% to 50% of the adult population while Chronic Insomnia disorder that is associated with distress or impairment is estimated at 10% to 15%.

How much sleep do most people need?

Most adults need around seven to nine hours of sleep per night but the amount of sleep needed to function at your best varies between individuals. The quality of your rest matters just as much as the quantity. Tossing and turning and repeatedly awakening is as bad for your health as being unable to fall asleep.

Symptoms and Causes

What causes insomnia?

Many things can contribute to the development of insomnia including environmental, physiological and psychological factors, including:

• Life stressors including your job, relationships, financial difficulties and more.
• Unhealthy lifestyle and sleep habits.
• Anxiety disorders, depression and/or other mental health problems.
• Chronic diseases like cancer.
• Chronic pain due to arthritis, fibromyalgia or other conditions.
• Gastrointestinal disorders, such as heartburn.
• Hormone fluctuations due to menstruation, menopause, thyroid disease or other issues.
• Medications and other substances.
• Neurological disorders, such as Alzheimer’s disease or Parkinson’s disease.
• Other sleep disorders, such as sleep apnea and restless legs syndrome.

What are the risk factors for insomnia?

Insomnia occurs more often in women than in men. Pregnancy and hormonal shifts can disturb sleep. Other hormonal changes, such as premenstrual syndrome (PMS) or menopause, can also can affect sleep. Insomnia becomes more common over the age of 60. Older people may be less likely to sleep soundly because of bodily changes related to aging and because they may have medical conditions or take medications that disturb sleep.

What are the consequences of insomnia?

When you can’t fall asleep or your rest is fitful, you may:

• Be irritable, anxious or depressed.
• Feel fatigued or low on energy throughout the day.
• Have memory problems or difficulty concentrating.
• Struggle at work, school or in relationships.

Diagnosis and Tests

How is insomnia diagnosed?

There is no specific test to diagnose insomnia. Your healthcare provider will perform a physical exam and ask questions to learn more about your sleep problems and symptoms. The key information for the diagnosis of insomnia is reviewing your sleep history with your doctor. Your provider will also review your medical history and medications you are taking to see if they may be affecting your ability to sleep. You may also:

• Get a blood test: Your doctor may want you do a blood test to rule out certain medical conditions such as thyroid problems or low iron levels that can negatively impact sleep.
• Keep a sleep diary: You may be asked to write down your sleep patterns for one to two weeks (bedtime, wake time, naps, caffeine use, etc.) This information can help your provider identify patterns or behaviors that interfere with rest.
• Complete a sleep study: Sleep studies (polysomnograms) are not necessary for diagnosing insomnia. If your doctor has concerns that your insomnia may be caused by sleep apnea or another sleep disorder, you may be referred. You may go to a sleep disorders center or do the study at home.

Management and Treatment

What are the complications of insomnia?

Over time, lack of sleep or poor quality sleep can negatively affect your physical and mental health. Insomnia can contribute to:

How is insomnia managed or treated?

Short-term insomnia often gets better on its own. For chronic insomnia, your healthcare provider may recommend:

• Cognitive Behavioral Therapy for Insomnia: Therapy (CBT-I): CBT-I is a brief, structured intervention for insomnia that helps you identify and replace thoughts and behaviors that cause or worsen sleep problems with habits that promote sound sleep. Unlike sleeping pills, CBT-I helps you overcome the underlying causes of your sleep problems.
• Medications: Behavior and lifestyle changes can best help you improve your sleep over the long term. In some cases, though, taking sleeping pills for a short time can help you sleep. Doctors recommend taking sleep medicines only now and then or only for a short time. They are not the first choice for treating chronic insomnia.

Can melatonin help me sleep?

Your body produces a hormone called melatonin that promotes sleep. Some people take melatonin supplements as a sleep aid. But there’s no proof that these supplements work. Because the U.S. Food and Drug Administration (FDA) doesn’t regulate supplements the same as medications, you should talk to your healthcare provider before taking one.

Prevention

How can I prevent insomnia?

Lifestyle changes and improvements to your bedtime routine and bedroom setup can often help you sleep better:

• Avoid large meals, caffeine and alcohol before bed.
• Be physically active during the day, outside if possible.
• Cut back on caffeine, including coffee, sodas and chocolate, throughout the day and especially at night.
• Go to bed and get up at the same time each day, including weekends.
• Put away smartphones, TVs, laptops or other screens at least 30 minutes before bedtime.
• Quit smoking.
• Turn your bedroom into a dark, quiet, cool sanctuary.
• Unwind with soothing music, a good book or meditation.

Outlook / Prognosis

What is the prognosis (outlook) for people who have insomnia?

Some people with insomnia sleep better after changing daytime and nighttime behaviors. When these changes don’t help, therapy or medications can improve slumber.

Living With

When should I call my healthcare provider?

You should call your healthcare provider if you experience:

• Difficulty concentrating or memory problems.
• Extreme fatigue.
• Mood problems, such as anxiety, depression or irritability.
• More than three months of sleep problems.

What should I ask my healthcare provider about insomnia?

If you have insomnia, you may want to ask your healthcare provider:

• Am I taking any medications keeping me awake?
• What changes can I make to sleep better?
• How does cognitive behavioral therapy improve sleep?
• How do I find a therapist?
• Could I have other sleep disorders like sleep apnea?

If you’re suffering from insomnia, don’t hesitate to reach out to your healthcare provider for help. They may offer tips for managing issues that interfere with your sleep. Many people with insomnia rest better after changing their diet, lifestyle and nighttime routines. Or they may also recommend medications or cognitive behavioral therapy.

90,000 causes, symptoms, diagnosis and treatment methods on the website “Alpha Health Center”

Violation of falling asleep and maintaining sleep, insomnia, and cessation of breathing during sleep is accompanied by a drop in the level of oxygen in the blood, apnea.

Sleep is a normal physiological state, accompanied by depression of consciousness and activity. Distinguish between sleep without rapid eye movements, or slow sleep (depending on the depth, divided into four stages), and sleep with rapid eye movements, or REM sleep, characterized by a complete loss of muscle tone and a change (compared with the period of wakefulness) in blood pressure, pulse breathing.Despite muscle relaxation, rapid eye movements are observed during REM sleep. If you wake up a person during this period, he talks about vivid dreams.

In the process of falling asleep, wakefulness is replaced by drowsiness, and then the stage of slow wave sleep. In a healthy young man, when going to sleep, sleepiness with its characteristic fantasies is quickly replaced by slow sleep. REM sleep occurs after about 90 minutes. During REM sleep, dreams appear lasting 5-10 minutes.During the night, there are 4-5 periods of REM sleep, and each subsequent period lasts longer than the previous one. REM sleep is replaced by slow sleep again. The duration of one cycle is approximately 90 minutes. The duration of REM sleep, as well as deep NREM sleep, decreases after 50 years.

Insomnia

Insomnia is a disorder of falling asleep and maintaining sleep. Insomnia is the most common sleep disorder and, at the same time, one of the most common reasons for seeking medical attention.Disturbed falling asleep, interrupted sleep or waking up too early are considered manifestations of the disease only in those cases when they bother the patient, since some people may consider even a three-hour night’s sleep to be their norm. In most cases, psychological factors are the cause of insomnia.

Insomnia treatment consists of improved sleep hygiene and a short course of drug therapy. Alcohol, nicotine and caffeine are contraindicated. Eliminate emotional disorders, treat diseases accompanied by shortness of breath, pain, dysfunction of the bladder and gastrointestinal tract.The bedroom should be quiet and dark and should only be used for sleeping. If you cannot fall asleep within 15 minutes, you need to move to another room and read until you feel like sleeping again. Watching TV is not recommended as the bright screen and TV shows are exciting. In the morning, you should get up at the same time, regardless of how much sleep you manage. Restriction of sleep is also used; with this technique, they are allowed to stay in bed no longer than sleep usually takes. The duration of sleep is gradually increased, and each week the bedtime is moved 15 minutes earlier.

Sleeping pills are prescribed in minimal doses and are allowed to be taken not every day, but, for example, 3-4 times a week. Sleeping pills are canceled gradually. The elderly are given half the usual dose. Barbiturates (phenobarbital) are currently not used, since with prolonged use they further disturb sleep, cause daytime sleepiness, and discontinuation of their use leads to withdrawal syndrome. Tryptophan has a slight hypnotic effect, so it is better to prefer a cup of warm milk to all drinks before bed.For severe insomnia, tricyclic antidepressants, such as amitriptyline, are used, but they also cause daytime sleepiness.

Benzodiazepines – triazolam, temazepam, lorazepam and diazepam – can also be used for insomnia, but it is best to use them no more than 3-4 times a week, as they cause daytime sleepiness, coordination disorders and sometimes depression.

Now for insomnia, zopiclone is most widely used (Imovan, Somnol). It is taken 40 minutes before going to bed, you can start with small doses (3.75 mg), if they do not help, then you should take the whole tablet – 7.5 mg.

Sleep apnea

Periodic cessation of breathing during sleep is accompanied by a drop in blood oxygen levels and awakenings. With 15 or more episodes of apnea per hour, there are complaints of restless intermittent sleep, asthma attacks during sleep, daytime sleepiness, headache in the morning, irritability. Most commonly, sleep apnea is accompanied by snoring, anxiety during sleep, daytime sleepiness, decreased mental performance, personality changes, morning headaches, and sleep disturbances.Numerous neurological diseases, primarily those affecting the brain stem, can be the cause. There are two main types of sleep apnea – central and obstructive.

The most common type of sleep apnea, obstructive sleep apnea, is characterized by periodic obstruction (obstruction) of the upper airways. In this case, the diaphragm and chest continue to make respiratory movements. Obstructive sleep apnea is most commonly caused by a collapse of the upper airways.Patients are often unaware that they are suffering from sleep apnea, so relatives should be asked to confirm the diagnosis.

Sleep apnea is more common in obese men who smoke and abuse alcohol. They usually complain of daytime sleepiness, headache and dry mouth in the morning, changes in character (primarily irritability) and decreased mental performance. In mild cases, obstructive sleep apnea stops with weight loss, smoking cessation, and alcohol consumption.

In more severe cases, breathing under constant positive pressure through a mask is indicated. At the same time, constant positive pressure maintains airway patency. Since sleep apnea increases the risk of hypertension, stroke, heart failure, treatment is mandatory in all cases.

90,000 Sleep disorders – causes of occurrence, under what diseases it occurs, diagnostics and methods of treatment

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-medication.In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician. For a diagnosis and correct prescription of treatment, you should contact your doctor.

Sleep disturbance: causes of occurrence, for what diseases it occurs, diagnostics and methods of treatment.

Definition

Sleep disturbance, or insomnia (insomnia), is a generic term for falling asleep poorly, having trouble maintaining sleep, and waking up too early.As a result, during sleep, a person cannot fully restore strength and performance, which reduces the quality of life. Sleep disturbance to one degree or another is observed in almost half of the adult population, but only in 9-15% of people this problem becomes clinically significant. Chronic insomnia is much more common in older people than in younger people, in more than 55% of cases.

In case of any sleep disorders, a person records fatigue, decreased attention or memory, depression, depression, decreased vital activity.

Types of sleep disorders

Depending on the cause of sleep disturbance, a distinction is made between primary and secondary insomnia. When diagnosing primary insomnia, organic, psychiatric, neurological reasons for sleep disturbance are not noted. Secondary insomnia is the result of various diseases, the use of stimulating drugs, or any unfavorable external conditions.

Sleep disorders can be acute (transient), short-term (up to 6 months.) and chronic (more than six months). Acute sleep disturbance can occur in every person under the influence of stress, overexcitation, in connection with a change in time zone. Chronic insomnia develops in people predisposed to this. Usually, this condition affects elderly patients, women, people who, for one reason or another, sleep no more than 5 hours a day, as well as those who experience prolonged absence from work, marital divorce, psychological and psychiatric trauma, and patients with chronic diseases.

Possible causes of sleep disorders

Difficulty falling asleep is the most common complaint of patients. The desire to sleep, which a person experiences before going to bed, but it disappears under the influence of various factors when a person goes to bed. These can be unpleasant thoughts and memories, inability to find a comfortable position due to restless legs, pain or itching, extraneous sounds. Light drowsiness is disturbed even by the slightest noise, and sometimes a person who is asleep thinks that “he has not slept for a minute.”

The reasons for such difficulty falling asleep can be many, in particular, insufficient fatigue, staying in bed for a long time during the day, irregular falling asleep time, anxiety, diseases that cause itching or pain.

A common complaint is discomfort in the lower extremities (crawling, shivering, tingling, burning, twitching) that make you constantly change the position of your legs (restless legs syndrome). Symptoms are greatly reduced or disappear altogether with movement.Walking or just standing most often has the best effect.
Recently, the proportion of patients who have a problem with falling asleep has increased due to the use of stimulating drinks (tea, coffee, energy drinks) in the evening, as well as the abuse of drugs (caffeine, psychostimulants, some antidepressants, neuroleptics, nootropics).

Problems with maintaining sleep mainly consist in frequent awakenings, after which it is difficult to fall asleep again, and a feeling of “shallow” sleep.The reasons for awakening can be very different (dreams, fears, nightmares, respiratory failure, palpitations, urge to urinate).

Most often, chronic insomnia is a symptom of neurological and mental illness.

Complaints about poor sleep are typical for patients with stroke, dementia, Parkinson’s disease, Alzheimer’s. Mental illnesses such as depression, schizophrenia, anxiety and manic states are also accompanied by sleep disturbances.

In many cases, frequent awakening at night is associated with sleep apnea syndrome.

This breathing disorder occurs during snoring due to the collapse of the tissues of the pharyngeal ring during inhalation and is characterized by a short-term cessation of breathing, which is accompanied by a decrease in blood oxygen levels and interruption of sleep.
Circadian rhythm disturbances almost always lead to chronic insomnia. This situation arises during shift and shift work, as well as for those who sit for a long time in the evening at the TV or computer. An excess of blue light from screens in the evening and at night causes desynchronosis – a violation of the daily biorhythm, which, in turn, leads to sleep disturbance.

Frequent awakenings can be a consequence of cardiovascular (arrhythmias, arterial hypertension), pulmonary (COPD), musculoskeletal (arthritis, rheumatism), genitourinary (prostatitis, urinary incontinence) and endocrine diseases.

Problems of early morning awakening are observed in the elderly, persons suffering from depressive disorders, and panic attacks. As a rule, sleep is interrupted at 4-5 o’clock in the morning and does not resume. Immediately after waking up, patients notice a flood of negative thoughts rushing over them.In the morning and during the day, they complain of a “broken” state, they have reduced efficiency, constant drowsiness.

Which doctor should i contact for sleep disorders

Initially, you should consult a general practitioner to determine the true cause of insomnia and to identify possible comorbidities that can lead to sleep disturbance.

If you suspect a depressive syndrome, you should consult with a psychotherapist or neurologist.With successful treatment of neuropsychiatric disorders, sleep is usually normalized.

In the event that the diagnosis of sleep disorders is difficult, the therapist refers the patient to a sleep doctor.

Diagnostics and examinations for sleep disorders

When diagnosing sleep disorders, the first step is to understand whether insomnia is primary or secondary. It should be borne in mind that about 80% of sleep disorders are caused by various diseases. Along with complaints of poor sleep, the following factors should be considered: snoring, excess weight, arterial hypertension, neurological disorders (stroke, traumatic brain injury), the presence of diseases that can cause pain at night (rheumatism, myalgia, arthritis of various etiologies) or itching (psoriasis, herpes, thyroid or liver disease).

Chronic insomnia: why we can’t sleep

May 15, 2018

Photo author, Getty Images

Prolonged sleep deprivation – or so-called chronic insomnia – affects every aspect of our life – from mood and behavior to physical and mental health.

How to identify the problem

Insomnia is associated with unsuccessful attempts to sleep, frequent awakening in the middle of the night or waking up at dawn, followed by the inability to return to sleep.

In 2015, the star of the cult TV series “Sex and the City” Kim Cattrall turned down a role in a production of London’s Royal Court Theater due to chronic insomnia, which she likened to a three-ton gorilla.

“I am losing the ability to think clearly … I cannot grab hold of ideas, thoughts, even tasks,” she wrote in her diary.

Pidpis to photo,

Kim Cattrall has documented in her diary her struggle with chronic insomnia

According to a survey conducted among two thousand Britons and published by the British Royal Society of Public Health, on average, British residents sleep 6.8 hours a day.And on average, it takes them about 30 minutes to fall asleep.

The UK’s National Health Service advises adults to get 7 to 8 hours of sleep every night – although, as ridiculous as it sounds, world leaders such as Winston Churchill, Margaret Thatcher and Donald Trump are among those who claim they have enough and four hours of sleep a night.

Stress, illness, jet lag or life changes – like changing jobs or having a baby – can cause short-term insomnia.It usually goes away in one to two months.

We are all certainly familiar with these tips for improving your night’s sleep:

• Stay asleep;
• Stop eating, alcohol, or caffeine late at night;
• Do not use gadgets before bed;
• Try to relax and calm down before bed and sleep in a cool, dark room.

When to seek help

So what’s the difference between just having a bad, restless sleep and the illness – insomnia?

“It is normal for every person to have some sleep disturbance from time to time,” says Dr. Anna Wyhall, professor of psychology at the University of Leeds.“It becomes chronic when it recurs over most nights, most weeks, when it interferes with family and friends and makes it impossible to get work done.”

According to the National Health Service, the signs of chronic insomnia are:

• sleep problems do not help;
• Sleep problems last several months;
• Lack of normal sleep affects and complicates your life

According to independent sleep expert Dr. Neil Stanley, people rarely try to overcome sleep problems.Although they can indicate stress or other – more serious – health problems.

At that stage, says Stanley, when natural remedies or advice on how to improve sleep are no longer working, you should see your doctor.

“The insomnia that affects your life during the day is already a problem,” he concludes.

Pills or Image Life?

Although sleeping pills are quite common in many countries, UK doctors rarely prescribe them for insomnia due to concerns about side effects and possible addiction.

Typically, patients with insomnia are referred to a cognitive behavioral therapy specialist for an eight-week course designed to help the patient “change the thoughts and behaviors that keep them awake.”

At the end of the day, it could be a lifestyle change — for example, not taking shift work or staying late.

“Many British adults have trouble sleeping due to being too busy at work or at home – because if you are not in bed for 7-8 hours, you will not get 7-8 hours of sleep,” says Dr. Wyhall …

However, those who are “chronically sleep deprived” – that is, they regularly sleep less than 5 hours – “are more likely to suffer from health problems, in particular from overweight, cardiovascular disease and diabetes,” the scientist notes.

“It is a fact that in our modern rhythm of life – longer working hours, media, Internet, watching TV in bed – it is more difficult for people to relax and disconnect. relaxing, “adds Dr. Stanley.

He notes that prolonged insomnia can be very debilitating, but “for most of us, this is what we do to ourselves.”

“Sleep is a sacrament. And there is no magical way to help people sleep. It all depends on the person himself,” concludes Dr. Stanley.

Science of sleep: why insomnia is dangerous

In scientific language, insomnia is called insomnia. And doctors who research and treat insomnia and other sleep-related diseases are somnologists.From the point of view of somnologists, insomnia is problems with falling asleep or poor sleep at least three times a week. That is, three times a week you cannot fall asleep for a long time, thoughts about the past day interfere. You wake up in the middle of the night and toss and turn for a long time, again because of the endless scrolling in your head of the details of a conflict with your boss or a quarrel with your family. Or, on the contrary, you fall asleep quickly, sleep well, but wake up long before the alarm clock and then sleep in either eye. These are all signs of insomnia.

But in addition to sleep disorders, for the diagnosis of insomnia, there must also be complaints of poor health during the day, or, as doctors say, during wakefulness.“These are fatigue, weakness, feeling sleepy, bad mood, anxiety, palpitations, sweating, impaired memory and attention and, as a result, decreased performance,” explains the President of the National Somnological Society, Doctor of Medical Sciences, Professor, Chief Researcher of the Research Institute of Neurology First MGMU im. Sechenov Gennady Kovrov. Daytime sleepiness is another clear signal of sleep problems. And if you fall asleep while driving – this is already a reason to ring all the bells, urgently receive treatment.Those who suffer from daytime sleepiness and always snore during sleep also have serious sleep disturbances. ”

As various international studies show, up to 30% of people are unhappy with their sleep and believe that they suffer from insomnia.

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But statistics are a crafty thing. If somnologists more strictly formulate the question “Do you have wakefulness disorders that you associate with sleep disorders?”, Then only 10% of the respondents answer in the affirmative.But at least once a year each of us faces insomnia, somnologists assure.

Sleep as a system

Why is insomnia familiar to each of us firsthand? Sleep is a kind of mirror, it reacts to all daytime events and suffers immensely from them. But there is good news as well. “Sleep is not only a very subtle, delicate, sensitive recovery process. It is also a powerful system that is difficult to completely break down, ”Gennady Kovrov is convinced. “The dream tries to adapt to the conditions that a person imposes on him.”These conditions lead to two main causes of insomnia – stress and our disregard for sleep, or, as experts say, poor sleep hygiene.

A stressful situation is considered the cause of their sleep problems, according to Gennady Kovrov, 70% of patients.

This is especially true for people working in business. They have a constant high workload and irregular working hours, they are in a state of stress all the time.

This phenomenon is called the “manager’s syndrome” in medicine.The nervous system is constantly tense, the sympathetic part of the nervous system, which is responsible for the struggle, is tense. After some time, this state becomes natural for a person, he no longer notices that he is constantly on edge, in control of himself, always ready for action. For him, this is already the norm, but for the body it is not the norm, he works to the limit of his capabilities. To go into a state of sleep, the brain must go into a state of relaxation, distraction from daytime worries. And the manager’s inner tension, excitement does not allow normal sleep to develop.

Stress causes insomnia even in the healthiest people – astronauts. Gennady Kovrov has been studying insomnia in cosmonauts since 1992. He notes that the most destructive effect on sleep is not so much stressful emergency situations as predictable and significant events for a person, as well as the isolation in which the astronaut finds himself during the flight. By the way, in the first-aid kits of American astronauts, half of the pills used in space are sleeping pills, in particular, melatonin.Our cosmonauts are still coping without sleeping pills.

As for the disturbance of sleep hygiene, it is, first of all, the unequal time of going to bed and the unequal time of awakening. The greater the variation (one day you go to bed at twelve, the other at two in the morning), the more likely you are to get real insomnia.

But that’s only half the trouble. After returning home, we continue to work: urgent calls, finalizing presentations, viewing work mail. Thus, we ignore one of the main requirements of sleep hygiene – switching from daytime concerns to pleasant, relaxing activities that encourage falling asleep.As a result, one of the important reflexes is lost – the conditioning reflex. This means that when a person gets into a certain situation, he should automatically switch to the appropriate attitude for this situation. For example, if he sees a doctor in a white coat, he switches to readiness for treatment. When a person sees a bedroom with a bed taken apart, he must immediately switch to sleep. But there can be no talk of any kind of switching to sleep, when, even when we are in bed, we look through important documents for tomorrow’s negotiations, wool our feeds on social networks or, to distract ourselves from thoughts about work, play computer games.

Another significant cause of insomnia is frequent flights, since when changing time zones, the sleep-wake cycle is disrupted. Only 30% of people do not experience problems adapting to the time difference.

Those who sleep poorly work poorly

There are many studies devoted to the study of the economic consequences of insomnia. So, Canadian scientists have calculated the damage from presentationism associated with insomnia: $ 800 per person per year. The term “presentism” means that a person comes to work, but at the same time, for various reasons, is so ineffective and sometimes even dangerous for the business that it would be better to take a day off.The damage caused by absenteeism (absence from work), according to Canadian researchers, does not exceed $ 500 per person per year.

Gennady Kovrov emphasizes that daytime sleepiness can lead not only to a decrease in labor productivity, but also to industrial accidents.

The explosions of the “Challengers”, the Chernobyl accident, somnologists all over the world associate with the manifestations of drowsiness in the personnel. A detailed study of sleep in cosmonauts by Kovrov’s group is primarily associated with daytime sleepiness and decreased performance.

By the way, 80% of severe car accidents with fatalities and injuries are also associated with falling asleep while driving.

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Another consequence of sleep problems is the reduction in sleep duration. The body of each of us is genetically programmed for a specific sleep time. With a careless attitude to his sleep, he pays with the same coin: he squeezes the time allotted by nature for a person to sleep. Scientists have shown that with a lack of sleep, the incidence of diabetes mellitus, arterial hypertension increases, and the immune system is impaired.It is poor sleep that can be the root cause of persistent health problems for which doctors cannot find a clear explanation.

And, finally, the unconditional minus that insomnia entails is an unhealthy appearance. These are bags under the eyes, and sore eyes, and dull skin. And all because in a dream there is a regeneration process, cells are more actively dividing and growing.

Sleep or not sleep? 8 effective ways to combat insomnia.

Sleep or not sleep? 8 effective ways to combat insomnia.

Insomnia is a problem that brings torment to both the sufferer and his household. A person, exhausted by the lack of sleep, tosses and turns on the bed, turns on the light, walks around the apartment, thereby interfering with the normal rest of his loved ones. What to do when you can’t sleep? How to deal with insomnia?

We will not look for the reasons due to which your sleep disappeared, but we will try to figure out how to get rid of insomnia quickly and painlessly. There are many methods of dealing with insomnia, but very often they are completely ineffective, and some are unsafe.We want to offer you effective and completely harmless ways to fall asleep quickly.

But first – a little about the basic rules, the observance of which will help calm the nervous system before going to bed. What measures should be taken to fall asleep immediately and not wake up at night?

How to prepare for sleep?

• Take a short walk half an hour before bed.
• Before going to bed, ventilate and take a relaxing herbal bath or warm shower.
• Do not eat heavy foods less than 2-3 hours before bedtime.
• Before bed, read a book or listen to soothing music.
• Lying in bed, do not force yourself to fall asleep – very often it is the excessive effort to fall asleep that prevents him from coming.
• If you feel insomnia is caused by ambient noise or light, use ear plugs and a sleep mask.

Lying in bed: turning off thoughts and relaxing

Often, current problems and oppressive thoughts prevent us from falling asleep.In addition, overwork or, on the contrary, overexcitation, also does not allow you to relax and turn off. If you can’t calm down and stop thinking about daytime worries, you need to put your thoughts in order and achieve inner balance. Try to leave all your worries and worries outside the bedroom threshold. Tell yourself: “The morning is wiser than the evening.” But if volitional effort does not work, and you, already in bed, still continue to conduct an internal dialogue, how then to deal with insomnia? The “treatment” here can be like this:

1.The first thing to do when you are in bed is to completely release and relax your entire body and muscles. To do this, stretch your arms and legs, shake them slightly, relieving tension. Then tense all the muscles, and then completely relax. Repeat the exercise several times.

2. Place your entire body weight on the bed. Try to surrender yourself to her power, to merge with her into a single whole. Feel the full weight of the body, and how it presses on the bed.

3. Take a few deep, rhythmic breaths in and out.Breathe with your diaphragm. Close your eyes and look inside yourself. Feel your breath. Notice how you breathe, how the air enters, passes through the nose, travels through the airways, enters the lungs, and then makes its way back. Don’t try to do something with the breath, just lie there and watch it. This seemingly simple technique will help you calm down. You yourself will not notice how you fall asleep.

If you still have trouble falling asleep, try some simple mental techniques.They are very effective and allow you to quickly remove all unnecessary thought processes from your head.

How to get rid of insomnia using mental techniques?

1. When unpleasant thoughts interfere, you need to turn your attention to those things that give you pleasure. Think about something good and joyful that happened in your life, or paint an imaginary picture of the future, where you feel good. Come up with a fairy tale or an interesting story for yourself and watch it like a movie.

2.Imagine yourself lying in a hammock that is being swayed by the breeze. One – in one direction, two – in the other, one-two, one-two … Feel the wind blowing, a pleasant chill touching your face, birds singing around, the rustle of foliage … One-two, one-two … Enjoy your dreams!

3. Everyone is familiar with the method that is often used for insomnia – to count the sheep. It rarely helps, so we suggest another option: just count backwards from 100 to 0. You will most likely fall asleep before you get halfway.

4. Imagine a regular blackboard in front of you and yourself next to it. You have chalk in one hand and a rag or sponge in the other. Mentally draw a huge circle on the chalkboard with the letter “X” in it. Then, slowly erase the letter with a rag, starting from the center. Try not to touch the circle while doing this. When you erase the letter, slowly and deliberately write the word “sleep” inside the circle. Erase it. Repeat the entire procedure until you fall asleep.

5. Variant of the fourth exercise – inside the circle you need to write the number 100.Then wipe it off very slowly, make a deep entrance and exhale completely. After that, write the number 99, erase again, take a deep breath and exhale, and so on up to 0, until sleep comes. Usually, even with severe insomnia, people fall asleep at 80.

6. Another version of the same exercise. Imagine the blackboard again, and you use a large brush to very, very slowly paint the number three on the blackboard with white paint. Do you have time to complete the line before falling asleep?

7.See yourself lying on the shore of a reservoir. Listen to the sound of waves, rustle of leaves, feel the fresh scent of the sea. Experience a state of peace and bliss. You get up and go to the water, and your body seems to merge with the sea into a single whole: first the feet dissolve in water, then the legs, thighs, stomach, chest, arms – all bodies become water. Your entire body has become a huge, warm sea. It is located in a giant bowl, the water with all its weight presses on the bottom of this bowl. Your sea-body is soft, heavy and boundless.Feel his calmness and greatness, power and confidence. Then turn around (preferably on your right side) and fall asleep calmly.

8. This exercise is best done on a hard wooden surface. You lie on your back, relax, stretch your arms along your torso and feel a hard bed with your whole body. After that, transfer your attention to the fingers of your right hand and give them a mental order: “The fingers of the hand have lost their sensitivity, they have disappeared, they are no more.” Do the same with the hand, forearm, shoulder.Walk in this way over the entire body, in turn “disconnecting” arms, legs, torso, head. By doing this technique, you will not notice how sweetly you fall asleep. This method allows you not only to fall asleep very quickly, but also to recuperate in a short time.

If, despite all the efforts made, you still suffer from insomnia, buy black underwear – it has an amazing effect on quickly relieving sleep problems. But if this does not help, see your doctor, perhaps your insomnia is caused by serious problems with the nervous system.

90,000 to help relieve sleep problems

Stress

Problems with work, school, health, finances or family can negatively affect sleep, as stress can keep the brain active at night. Stressful life events or trauma, such as the death or illness of a loved one, divorce or job loss, can also lead to insomnia.

To the topic How to deal with insomnia with the help of psychotherapy: advice from a psychiatrist

Schedule travel or work

A person’s daily rhythms act like an internal clock, controlling the sleep cycle, metabolism and body temperature.Violation of these can lead to insomnia. Changes in time zones, night and morning work shifts, and frequent schedule changes can also be the cause of violations.

Poor sleep

This includes:

• Irregular sleep schedule.
• Inconvenient place to sleep.
• Using the bed for work, eating or watching TV.

In addition, computers, televisions, video games, smartphones or other screens may interfere just before bedtime.

Dinner too hearty

A light snack before bed is fine, but too much food can make you feel uncomfortable while lying down. Many people also experience heartburn, the backflow of acid and food from the stomach into the esophagus, which can keep them awake.

Hearty Dinner / Photo by MyDomaine

Mental Health Disorders

Anxiety disorders such as PTSD can disrupt your sleep.Waking up too early or not being able to fall asleep can be a sign of depression.

Medicines

Many medicines can disturb sleep, such as some antidepressants and medicines for asthma or blood pressure. Also, some pain relievers, allergy and cold medications, and weight loss medications containing caffeine and other stimulants can interfere with sleep.

Diseases

Conditions such as chronic pain, cancer, diabetes, heart disease, asthma, gastroesophageal reflux disease, overactive thyroid gland, Parkinson’s disease and Alzheimer’s disease negatively affect sleep.

Sleep disturbance

Sleep apnea causes a person to stop breathing periodically during the night, which interrupts sleep. Restless legs syndrome causes discomfort in your legs and an almost irresistible urge to move them, which can also prevent you from falling asleep.

Caffeine, nicotine and alcohol

Coffee, tea, cola and other caffeinated beverages are stimulants. Eating them in the afternoon or evening can make it difficult to fall asleep at night.

Nicotine in tobacco products is another stimulant that can interfere with sleep.Alcohol can help you fall asleep, but it negatively affects the deep stages of sleep and often wakes you up in the middle of the night.

Alcohol / Photo Stylist

Risks of insomnia

Almost everyone has a sleepless night sometimes. However, the risk of insomnia is greater if:

• Changes in the female body. It is believed that hormonal changes during the menstrual cycle and during menopause may be the cause of insomnia. Sleep problems often occur during premenopausal women when night sweats and hot flashes interfere with sleep.

Changes in the female body / Photo Reader’s Digest Asia

• Age. Insomnia worsens with age as sleep patterns change. Older people often have trouble getting enough sleep for up to 8 hours. Sometimes they need to take a nap during the day to get the recommended 8 hours of sleep over a 24 hour period. In addition, sleep often becomes less restful as we get older, so noise or light can make you wake up quickly.

• Inactivity can also interfere with a good night’s sleep.

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• Changes in health such as chronic pain due to arthritis or back problems, urinary problems, and depression or anxiety can also interfere with age sleep.

• Pregnancy. Insomnia is common during pregnancy, especially during the first and third trimesters.Fluctuations in hormones, nausea and an increased need to urinate, pain, cramps are some of the changes in the body that can keep you awake during pregnancy. Expectant mothers can also face stress and anxiety.

Chronic insomnia – MO “New Hospital”

Chronic insomnia is a common sleep disorder, which, according to the WHO, occurs in every third person on the planet. Sleep is very important for a person, but difficulty falling asleep, frequent awakening at night, daytime sleepiness and other unpleasant manifestations of sleep disorders make life painful.

Reasons

Insomnia has its causes. But the ability to identify and eliminate them on your own is not always there. Very often, the help of a doctor is required to help a person regain normal sleep that lasts all night.

Sleep disorder often occurs due to the following provoking factors:

• 1. Uncomfortable room environment – uncomfortable bed, pillow, low or high air temperature, synthetic pajamas that irritate the skin.
• 2. Long-term exposure to stress factors that can occur during the day or last for a long time.
• 3. Too high mental or physical activity in the evening.
• 4. Noise in the room, at neighbors, in the next room, on the street.
• 5. Frequent flights with a change of time zones.
• 6. Working with night shifts or daily shifts.
• 7. Long-term work at the computer, tablet, smartphone screen.
• 8.Passion for caffeine and other energy drinks.

Why a person is tormented by insomnia cannot be said unequivocally. You need to understand what exactly is the annoying factor and try to get rid of it. Sometimes insomnia can be caused by any disease of the nervous system, endocrine glands, pain, itching of the skin, infectious or colds. Then the night insomnia will not become chronic, since after eliminating the cause, falling asleep will return to normal.

Varieties

Nowadays it is customary to divide the disease into three types.They will differ both in provoking factors and in the effect on the human condition.

Presomnichesky type of disorder is characterized by a prolonged period of falling asleep. Despite the fact that a person has an urgent need for rest and goes to bed, he, nevertheless, cannot fall asleep. On average, falling asleep occurs within 7-10 minutes, sometimes this period stretches for 15 minutes. If during this time sleep does not occur, we can talk about the first symptoms of insomnia.

Usually all this happens on the eve of an exciting event, as well as when a person is in an excited state.When the emotional background returns to normal, all problems with falling asleep go away on their own and do not require treatment.

Intrasomnic disorders occur a little differently. Here insomnia disturbs after falling asleep, when suddenly in the middle of the night a person wakes up and can no longer fall asleep.

This problem makes sleep superficial, more like a nap, and very sensitive. Most often, the causes of sleep disorders here can be considered snoring, thyroid disease or diabetes mellitus, mental disorders, prolonged residence of unpleasant events in life.

Post-somnolent disorders are sleep disorders in a person, when morning awakening becomes a real torment, even if there was sleep throughout the night. The main signs are lack of strength and desire to open eyes, morning weakness and fatigue, daytime sleepiness. The provoking factors can be psychological problems, deficiency of vitamins and minerals, blues, emotional stress, late bedtime.

Why insomnia is dangerous

Episodic sleep disturbances are not a cause for panic.But if chronic insomnia appears, then you need to understand what to do first. This is where the advice of a psychiatrist comes in handy. It must be remembered that if the sleep disorder lasts more than a month, then one must be wary of the appearance of complications. The main list includes the following violations:

• 1. Decreased concentration of attention.
• 2. Difficulty learning.
• 3. Decreased performance.
• 4. Apathy and depressive states.
• 5. Irritability, and even aggression.
• 6. Chronic fatigue.
• 7. High blood pressure.
• 8. Headaches.
• 9. Faults in the work of the heart.
• 10. Weight loss due to loss of appetite due to insomnia, edema and deterioration in appearance.

A painful insomnia that lasts a long time can greatly exhaust a person, deprive him of strength and joy in life. Therefore, when the first symptoms appear, you need to go to the doctor and begin treatment for this common sleep disorder.

How to treat insomnia

Insomnia is mostly treated on an outpatient basis. Only for diagnosis may require a hospital stay.

Methods for the treatment of insomnia are chosen strictly personally and depend on what caused this condition. In the absence of pathologies on the part of the internal organs, treatment is applied without taking drugs. Then the problem of insomnia is solved by cognitive-behavioral therapy.

The specialist teaches the patient what to do if insomnia appears, how to fall asleep during this period.It is important to make a daily routine and follow the planned plan. It is worth giving up using gadgets before going to bed, taking a walk down the street, having an easy dinner, excluding alcohol. You need to give up long-term use of a computer or laptop for online games. Two disorders such as chronic insomnia and gambling addiction often go hand in hand.

To deal with anxiety and bad thoughts, it is helpful to learn relaxation or meditation techniques. You need to set aside time for sports several times a week.A visit to a psychotherapist is recommended if necessary.

Treatment of insomnia in the absence of effect from simple rules of sleep hygiene continues with medication. These are short-term benodiazepines and non-benzodiazepine hypnotics – they help you fall asleep, but do not eliminate the causes of insomnia.