Insomnia

What is Insomnia?

Insomnia is a sleep disorder characterized by difficulty falling and staying asleep. A person with insomnia wakes up after falling asleep and finds it hard to sleep again. Sleeplessness results in low energy, poor concentration, and irritability, affecting daily activities. Trouble sleeping can be experienced primarily in adults. It can also be found in children as well as in teens.

Alternate names

• Sleeplessness
• Trouble sleeping

Is Insomnia a Medical Emergency?

Insomnia is not a medical emergency.

Types

Insomnia is of the following types:

• Transient Insomnia: This type of sleeplessness generally lasts less than a week. It is usually caused due to jet lag, shift work, sleeping in a new place, or an acute illness.
• Acute Insomnia: It is also known as short-term or stress-related Insomnia. This type lasts for less than a month. Stressful events like work pressure, the death of a loved one, relationship issues, or illness can cause it. Others include environmental factors like noise, bright lights, hot or cold temperatures, etc.
• Chronic Insomnia: It lasts for over a month to 3 months. It may be caused either due to other medical conditions or can be a primary disorder. Environmental changes, unhealthy sleeping habits, certain medications, irregular work shifts, and chronic illnesses cause a long-term pattern of insufficient sleep.

Causes

Insomnia can be a primary diagnosis, or it can be caused due to other medical conditions or side effects of certain medications. Various factors that can cause sleeplessness are:

• Psychological stress such as fear, anxiety, problems at work, financial stress, emotional tensions, giving birth to a child, or the death of a loved one
• Workings in late shifts, early morning shifts, or changing shifts frequently
• Travelling across multiple time zones
• Suffering from chronic pain
• Having other medical conditions such as a deviated nasal septum, sleep apnea, heart failure, hyperthyroidism, heartburn, constipation, restless leg syndrome, arthritis, back pain, asthma, or menopause
• Sleeping habits such as irregular sleep timings, uncomfortable sleeping environment, sleeping in a noisy environment, staying awake till late at night due to involvement in other activities, and watching TV, movies, mobiles, or computer screens before sleep
• Overeating before bedtime
• Other mental health disorders like PTSD, anxiety disorders, depression, ADHD, bipolar disorder, etc.
• Certain medications, such as anti-depressants, blood pressure medications, or painkillers
• Using stimulants or withdrawing from stimulants like opioids, alcohol, sleeping pills, and other drugs
• Lack of physical activity

Risk factors

Some factors that influence insomnia include the following:

• Working night shifts or early morning shifts
• Having medical conditions like sleep apnea, asthma, restless leg syndrome, arthritis, chronic pain, and acid reflux
• Advanced age: Sleeplessness is most common in older adults above the age of 60
• Mental disorders like depression, anxiety, PTSD, bipolar, etc.
• Undergoing stress from work, relationships, finance, or bereavement
• Travelling in different time zones
• Consuming heavy alcohol, drugs, and tobacco
• An uncomfortable environment with noises, bright lights, etc.
• Being a pregnant woman or a woman in menopause
• Being an adolescent or a young adult student

Signs & symptoms

Signs and symptoms include:

• Difficulty falling asleep
• Waking up too early from sleep
• Inability to have a continuous sleep
• Daytime sleepiness, tiredness, and low energy
• Irritability, depression, and anxiety
• Trouble concentrating and focusing
• Feeling aggressive and impulsive

Investigations

Apart from a complete physical examination, a sleep history is taken, and a sleep study test is also performed to rule out Insomnia. A questionnaire about sleeping habits, sleep-wake patterns, and daytime sleepiness is filled out.
The following aspects are reviewed:

• Sleeping habits
• Medications are taken, if any
• Amount of alcohol consumption
• Amount of nicotine and caffeine intake
• Sleeping environment
• Other medical conditions

An overnight sleep study test is conducted, which consists of polysomnography and multiple sleep latency test. This sleep study test is performed to monitor and record heartbeat, eye movements, brain waves, and body movements during sleep. Insomnia is measured using the Athens Insomnia Scale, which assesses an individual's sleeping patterns. Epworth Sleepiness Scale is used to evaluate daytime sleepiness and helps to determine Insomnia.

Diagnosis

The diagnosis is made by reviewing the finding of physical examination, sleeping habits, and results of a sleep study test.

Treatment options

In many people, sleep pattern returns to normal within a week. However, chronic or resistant insomnia requires treatment with hypnotics and behavioural therapy.

Medical treatment

Medical treatment includes sleeping tablets and sedatives. The following medications are effective in treating insomnia.

• Benzodiazepines: These are the most commonly used sleeping pills
• Anti-depressants: These are also effective in treating Insomnia
• Melatonin: It is used to treat Insomnia in individuals with ADHD, autism, or other neurological disorders. Prolonged-release melatonin improves the quality of sleep in older adults.
• Antihistamines: Antihistamines such as diphenhydramine or doxylamine are effective to a certain extent in treating Insomnia

Medications are only prescribed on a short-term basis because long-term use can lead to dependence and withdrawal problems.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

The first line of treatment for Insomnia is cognitive-behavioural therapy. It is more effective than medications.

• It helps to control or eliminate negative thoughts and worries that keep a person awake
• It helps to develop good sleep habits
• It helps to identify and replace behaviours that cause sleep problems
• It helps to overcome the underlying cause of sleep problems

Behavioural sleep medicine provides the following strategies are:

• Sleep hygiene: This therapy refers to good sleeping habits such as reducing caffeine, nicotine, and alcohol at bedtime, avoiding daytime naps, minimizing medications, regular exercises, etc.
• Stimulus control therapy: This therapy takes steps to improve the sleep environment and improve sleep hygiene.
• Sleep restriction therapy: This therapy eliminates daytime naps and decreases the time spent in bed. This results in sleep deprivation and tiredness, which leads to sound sleep the next night.
• Paradoxical intention: In this therapy, instead of attempting to fall asleep, an attempt is made to stay awake. This therapy reduces worry and anxiety about falling asleep.
• Relaxation therapy: Muscle relaxing exercises and breathing exercises are performed to reduce anxiety at bedtime and help the mood to relax.
• Light Therapy: Light therapy or phototherapy is effective in treating Insomnia. Exposure to bright light at specific times helps the body to reset the sleep clock and promote sleep.

Lifestyle changes and preventive measures include the following:

• Keep a consistent bedtime schedule, sleep, and wake up at a fixed time daily
• Be physically active during the day and maintain a regular exercise
• Avoid or limit daytime naps
• Avoid eating large meals or drinks before bedtime
• Avoid the use of caffeine, alcohol, or nicotine before bedtime
• Arrange a comfortable bed and make the bedroom environment comfortable to sleep like keeping it dark, calm, and free of electronic devices like clocks, phones, and televisions
• Avoid using the bed for other activities except to sleep
• Avoid noises or bright lights that disrupt or prevent sleep
• Sleep in loose and comfortable clothes
• Avoid going to bed empty stomach

Complications

Sleep is essential for persons of all age groups. Incomplete sleep can adversely impact both mental and physical well-being. It can lead to the following complications:

• Increased risk of a motor vehicle accident
• Problems with concentration and learning
• Poor performance at the workplace or school
• Risk of developing depression and anxiety
• Risk of developing obesity and heart problems
• Risk of developing high blood pressure and diabetes
• Poor immune system function
• It decreases the overall quality of life

Prognosis

For short-term Insomnia, the prognosis is very good. Sleep patterns return to normal within a week. In the case of chronic Insomnia, the prognosis depends upon the underlying cause of Insomnia.

When to contact the doctor? / How to identify the complications?

If insomnia lasts over a few weeks, disrupting daily activities, causing mood disturbances and difficulty concentrating. In that case, a medical consultation is recommended to identify the cause of Insomnia and to rule out a possible sleep disorder.

Indications for hospitalization if required

It does not require any hospitalization.

Suggested clinical specialists/ Departments to consult for this condition

• Psychiatry
• Sleep medicine