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Insomnia

NHS Direct Online Health Encyclopaedia

Introduction
Insomnia is when a person cannot sleep properly. It is hard to define what is normal sleep because it varies from person to person.

Difficulties with sleep can appear in a variety of ways:

Difficulty getting to sleep (sleep onset insomnia) - most common in young people.
Waking in the night (frequent nocturnal awakening) - most common in older people.
Waking early in the morning - the least common type of sleep disturbance.
Not feeling refreshed after sleep. The person has trouble functioning normally during the day, feeling irritable, tired, and having difficulty concentrating.
A person has chronic (severe or long-lasting) insomnia if it continues for several weeks (more than three). Chronic insomnia can lead to psychiatric (mental health) problems such as depression, or abuse of alcohol or other drugs.

Adults usually need, on average, 7 to 8 hours sleep a night, but this can be more or less depending on the individual. As people get older, they tend to find they need less sleep but they are also more likely to take naps during the day. Young babies may spend the majority of their day asleep, while children of school age require an average of 10 hours.

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

Lying awake for a long time at night before getting to sleep;
Waking up several times in the middle of the night;
Waking up early in the morning (and not being able to get back to sleep);
Feeling tired and not revitalised by sleep;
Irritability during the day;
Inability to function properly during the day, especially having difficulty concentrating.
Causes
The common underlying causes of insomnia can be split into a number of categories.

Physical

Insomnia can be caused by an underlying physical condition causing involuntary movement, pain or discomfort. Examples include restless leg syndrome, obstructive sleep apnoea, arthritis, headaches, hot flushes (due to the menopause), pruritus (excessive itching), and Parkinsons disease.

Physiological

Disruptions within the sleeping environment or to bedtime routines can cause insomnia. Factors include noise, light, snoring or movements of a partner, jet lag, or intellectual or physical activity immediately before bedtime (such as sports or heavy reading).

Psychological

Loss or worry, caused by events such as bereavement, can make sleeping difficult. Other examples include relationship problems, work worries, and even anxieties about being unable to sleep.

Psychiatric

Underlying mental health problems such as depression, dementia or anxiety, can be a source of insomnia.

Pharmacological

Sleeping problems can result from the effects of drugs. Withdrawal from certain drugs such as hypnotics (prescribed for short-term insomnia) may cause re-bound insomnia when the person stops taking them the sleeping problems reoccur. Taking other drugs can also reduce the quality of sleep, for example: alcohol, antidepressants, appetite suppressants, beta-blockers and corticosteroids.

Diagnosis
The GP will ask questions about a persons sleeping routines, their consumption of alcohol, caffeine and other related substances, and find out about other aspects of their lifestyle such as exercise. They will also look at any other illnesses and medications that might be causing insomnia. Often a cause can be identified through these simple measures.

If the cause is not immediately apparent, the doctor may suggest keeping a sleep diary to show when you went to sleep, how long for, and whether you had disturbances in the night.

The most common type of physical test for identifying sleeping problems is polysomnography. This is a diagnostic test during which a number of physiologic variables are measured and recorded during sleep. Sensor leads (electrodes) are placed on various places on the patients body (torso, head, etc) in order to record:

Brain electrical activity
Eye and jaw muscle movement
Leg muscle movement
Airflow
Respiratory effort (chest and abdominal movement during breathing)
Heart activity (using an electrocardiogram or ECG)
Oxygen saturation (amount of oxygen being absorbed by the lungs)
This test can diagnose conditions such as sleep apnoea. If carried out in a sleep research centre (rather than the patients home) the patient may also be videotaped during the test, to compare the electronic readings with what was happening in the room.

Treatment
The first step of treatment is to diagnose any underlying causes, where relevant, and to treat these. For example, if insomnia is being caused by depression, then once the depression is treated, the insomnia will often disappear without further medical help.

Non-drug treatments are usually the preferred first course of action. These treatments can include:

Counselling
Cognitive behavioural therapy (altering behaviour and thinking patterns)
Referral to a clinical psychologist
Problem-solving approaches to make the patient feel in control (for example, keeping a sleep diary)
Lifestyle advice. This includes restricting caffeine, nicotine, and alcohol; taking regular exercise; keeping regular times for sleeping and waking; maintaining good sleeping environment.
Patient education about sleep and relaxation.
Drug treatment may be considered in a number of cases, either because the symptoms are particularly severe, or to alleviate short-term insomnia, or because the non-drug treatments mentioned above have failed to have an effect.

Short-acting benzodiazepines or the newer hypnotic 'Z drugs' are the current preferred drugs when drug treatment for insomnia is needed.

Z drugs are not a distinct drug group but have similar structure. Examples are Zopiclone, Zolpidem, and Zaleplon.
Benzodiazepines should only be considered where insomnia is severe, disabling, or subjecting the individual to extreme distress. All Benzodiazepines have hypnotic and anxiety-reducing (anxiolytic) effects.
There is little difference between these two groups of drugs but the individual properties suit individual cases of insomnia in different ways. Some have less addictive properties, some have less daytime effects, some work for a shorter period, and so on.

Hypnotic and anxiolytic drugs, such as temazepam, should only be used when the anticipated period of treatment is short (for example during an illness, or an overnight stay in a busy hospital ward.). Minimal effective dosage should be used and for a maximum period of one week, wherever possible.

These drugs have many side effects and it is easy for people to become dependent on them. Hypnotics lead to a kind of drug-induced hangover, with daytime drowsiness and increased chance of accidents; they also have a high incidence of dependence even after a short term course and withdrawal has adverse effects (rebound insomnia). Patients need to be warned of side effects and if the treatment is started in hospital during a short stay, it should not be automatically continued by the GP.

Other types of drugs, including barbiturates, sedative antidepressants, and antipsychotic drugs, are less preferred because of their side effects (which range from gastric irritation to high risk of addiction). These may be prescribed if other drugs are being taken or for particular types of insomnia, but are generally found to be less effective.

An alternative remedy for insomnia is valerian, a herbal medicine that has some reported positive effects but has not been exhaustively clinically investigated. Other drugs that are reputed to help are kava kava and melatonin, but neither of these are available for use in the UK.

Prevention
In order to get a good nights sleep, there are some simple measures that can be taken:

Setting a specific time for getting up and going to sleep. These times should be stuck to, even at weekends and during periods of insufficient sleep. This will train the body to sleep at night.
Try to create a bedtime routine, such as a warm bath and warm milky drink every night. These activities will then be associated with sleep and will cause drowsiness.
Do not nap during the day if this prevents sleeping well at night.
If it is necessary to sleep during the day, then use thick blinds or an eye mask to create a dark environment.
If noise is a problem, wear ear plugs.
Do not use the bedroom for watching television, talking on the phone, eating, working and so on. Associate it only with sleep and sex.
Try to reduce stress levels. Rather than worrying about things in bed, try to make a list of your worries and solutions, before you go to bed.
Avoid or limit tea, coffee, chocolate, cold remedies containing caffeine, alcohol and tobacco. These are all stimulants.
Do not eat a big meal just before bedtime a small snack may help though.
Take exercise during the day, but not in the immediate few hours before bed.
If it takes longer than 20 or 30 minutes to get to sleep, do not lie in bed becoming anxious about sleeping. Instead, get up and go to another room for a short period and do something else such as reading or watching television, then try again.

© Queen's Printer and Controller of HMSO, 2005

Crown copyright material is reproduced with the permission of the controller of HMSO and the Queens Printer for Scotland.

 

 

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