Insomnia

Insomnia Image by: Steve Lodefink

While many people take falling asleep every night for granted, many others suffer from insomnia. This can be temporary - brought on by travel; or change in a job or relationship. Sometimes, however, it is a chronic condition which can have medical or psychological causes. How can we tell the difference between the two, and what treatment options are available?

What is Insomnia?

Insomnia is the experience of inadequate or poor quality sleep, and is characterised by one or more of the following sleep complaints:

  • Difficulty falling asleep;
  • Difficulty staying asleep;
  • Waking up too early in the morning, feeling unrefreshed.

Types of Insomnia

Insomnia is classified into two categories – acute and chronic.

Acute Insomnia

Acute insomnia is short-term insomnia. It can last days or weeks, but not more than one month. It is often due to a temporary situation such as jetlag, change or loss in a job and change or loss of a relationship. Treatment always involves addressing the underlying cause.

Chronic Insomnia

Chronic insomnia is long-term insomnia and is experienced for a month or longer. It is often due to medical or psychological conditions, or medications and substances. It is essential to get a medical diagnosis to find out the underlying reason for the insomnia, and treat it accordingly. In addition, learning good sleep hygiene techniques can improve sleep. (Read below for more on sleep hygiene) .

What Causes Insomnia?

There's no one specific trigger for insomnia, but certain conditions seem to make individuals more likely to experience it:

  • People aged over sixty;
  • Females;
  • Those with a history of depression.

Other causes include:

  • Stress;
  • Traumatic events; (For more about this refer to my article "Tackle Trauma") 
  • Acute illness, injury or surgery;
  • The loss of a loved one; (For more about this refer to my article "Survive Your Sorrow") 
  • Exams;
  • Trouble at work.

In these cases, normal sleep almost always returns when the individual recovers from the event or adapts to the new situation.

Jet lag can also cause insomnia. Travelling east across time zones is more difficult to adjust to than travelling west, to earlier times. Usually one day of adjustment is all that is required to overcome the insomnia. 

Environmental or lifestyle factors may also come into play – if you are not consistently getting a good night's sleep and waking up feeling refreshed, then you need to look at habits that may be harming your sleep – such as consuming too much caffeine, having a weekend lie-in or a nightcap before going to bed! Developing good sleep hygiene will make a huge difference to the quality of your sleep. (Read below for more on sleep hygiene)

Can Insomnia be Treated?

Fortunately there are treatment options available, ranging from behavioural and cognitive-behavioural therapy, alternative and complementary medicine, to the use of prescription medications. A combination of treatments is often used.

Treatment is always related to the cause - if the cause can be determined. Patients are usually assessed with the help of a medical and sleep history (a sleep diary).

Behavioural and cognitive–behavioural therapy involving relaxation and reconditioning are typically offered by psychologists or other health practitioners with specialised training. Several visits to the therapist are usually required to learn and implement the techniques of specific behavioural therapies.

Prescription medications that promote sleep are called hypnotics. Medications differ by dose and duration of action. The most common side-effects include morning sedation, memory problems, headaches and a few nights of poor sleep after stopping the medication.

One of the best ways to prevent insomnia is to maintain a healthy lifestyle and develop good sleep hygiene. Sleep hygiene refers to the principles of behaviour and the techniques that you need to develop to ensure you get a good night's sleep and wake up feeling great. (Read below for more on sleep hygiene)

Avoid going to bed feeling stressed and worried about not sleeping. If you're worried about falling asleep, it will be more difficult to fall asleep. Just remember, the less you worry about it, the more likely you'll be able to get a good night's sleep!

Why Should Insomnia be Treated?

Insomnia can significantly affect the quality of your life. Consequences of not getting enough sleep include:

  • Daytime fatigue;
  • Impaired mood;
  • Increased irritability;
  • Depression;
  • Psychological distress;
  • Reduced reaction time;
  • Impaired memory;
  • Decreased ability to concentrate;
  • Decreased ability to problem-solve;
  • Decreased ability to make decisions;
  • Increased risk of accidents (including workplace accidents and motor vehicle accidents);
  • Increased risk of injury;
  • Increased risk of illness, due to a suppressed immune system.

The 8-Hour Myth

"You need to get 8 hours sleep a night" is one of those injunctions like "drink plenty of water and rest", that most people take at face value, without ever really thinking about it. It's nonsense. It's like saying everybody should have size 6 shoes or be 1.8 meters tall!

When it comes to sleep there is a normal distribution like everything else. Studies have shown that the average length of sleep for an adult is seven-and-a-quarter hours, but many people report needing more or less than the average.

The US National Sleep Foundation suggests that seven to nine hours a night is advisable for adults. Children need more sleep. Below is a guide showing how much sleep different age groups need.

How Much Sleep do you Really Need?

AgeHours
 Newborns (1-2 months)  10.5 – 18 hours
 Infants (3-11 months)  9-12 hours during the nights and 30-minute to two hour naps, one to four times a day
 Toddlers (1-3 years)  12 – 14 hours
 Preschoolers (3-5 Years)  11- 13 hours
 School aged Children (5 – 12 years)  10 – 11 hours
 Teens (11 – 17 years)  8.5 – 9.25 hours
 Adults  7- 9 hours
 Older Adults  7- 9 hours

Stages of Sleep

Sleep occurs in a five-stage cycle that takes between 90 and 110 minutes to complete. A full night’s sleep involves four or five of these cycles. Importantly, sleep debt is only repaid if you reach Stages 3, 4 & 5.

Stage 1: Dropping off

Stage 1 involves the transition between wakefulness and light sleep. It is short-lived and accounts for less than 5% of your sleep.

It’s the stage where you ‘drop off’. Sometimes you may experience what seems to be an actual drop – like falling off a cliff – which can wake you up again. This is caused by your muscles suddenly relaxing as sleep approaches.

Stage 2: Light sleep

Stage 2 accounts for around 50% of your sleep.

Stages 3 and 4: Deep sleep

Stages 3 and 4 are progressively deeper stages of deep sleep.

These are the stages in which physical and mental recovery happens. The amount of deep sleep increases with the amount of fatigue experienced before sleep. The deeper the sleep stage, the harder it is to wake you – and the longer it takes for you to become fully alert. At the same time, disturbances to sleep – such as a loud noise – take you back to a lighter sleep stage, interrupting the essential recuperative effect of the deep sleep stage.

Stage 5: REM sleep

Stage 5 is also known as Rapid Eye Movement (REM) sleep. It is during this stage that you dream. It is probably for this reason that muscle and spinal reflexes are now maximally suppressed to prevent you acting out your dreams. REM sleep is critical for mental stability, memory and learning. Lack of REM sleep is responsible for irritability, poor judgment and hallucinations. If you are sleep deprived, you usually recover your deep sleep debt on the first night and your REM sleep debt on the second night.

Sleep Hygiene

Sleep Hygiene refers to the principles of behaviour and the techniques you need to develop to ensure you get a good night's sleep and wake up feeling great. These principles apply to all of us, and if you make them into habits you will be amazed at how much better you will sleep.

Get the Right Amount of Sleep for YOU:

Many people complain of insomnia, when in fact they are simply misinterpreting their body's needs. It may be that they are not tired at night or are waking up early because they don't need as much sleep as others, eg. waking up at 4:00 am because they went to bed at 8:00 pm the night before – they have actually had their full quota of sleep and are ready to wake up naturally.

If you want to work out how many hours of sleep you need, then keep a sleep diary for at least 7 days when you are relaxed (for example when you are on holiday), not drinking alcohol and are able to go to sleep when you want to and wake up when you want to without an alarm clock. By the end of the week you should be in your natural pattern of sleep, and will be able to see how many hours you should sleep for.

Of course, even this will change as your levels of stress and physical activity change, and will not be the same when you are a child as when you are an adult. (Refer to the guide above 'How Much Sleep Do You Really Need?')

The test of insufficient sleep is whether you are sleepy during the day or if you remain alert through most of the day. In a nutshell, if you sleep for eight hours a night and yet find yourself lolling and drooling on the keyboard at work, you aren't getting enough, but if you're sleeping for five hours and running the company with energy, you probably are getting enough!

Set a Regular Bedtime and Wake-up Time

Create a habit of going to bed and waking up at the same time each day, even on days off and weekends. This helps anchor your body clock to these times. Resisting the urge for a lie-in can pay dividends in alertness.

Try to avoid alarm clocks. If you need an alarm clock to wake you up every day you are not going to bed early enough.

If you feel you haven't slept well, resist the urge to sleep in longer than normal - getting up on schedule keeps your body in its normal wake-up routine. Remember, even after only four hours, the brain has gained many of the important benefits of sleep.

Avoid Alcohol

Alcohol is a depressant - it slows brain activity. This means that it helps to induce sleep initially, but disrupts it later on. 'Nightcaps' can result in awakenings, nightmares and early morning headaches.

Alcohol is also a diuretic, which means it encourages you to urinate – you wake up because your body tells you have to go to the toilet!

Drinking is also more likely to lead to snoring, which can restrict airflow into the lungs. This reduces oxygen in your blood which disturbs your sleep and contributes to your hangover.

You should avoid alcohol within 4 – 6 hours of bedtime.

Avoid Stimulants

Stimulants include caffeine, nicotine and some prescription and non-prescription drugs. Do not have them within 3 – 4 hours of bedtime.

Caffeine is a stimulant which can stay in your system for many hours. So avoid sources of caffeine such as energy drinks, Red Bull, coffee, hot chocolate, Milo, cola drinks, non-herbal teas and chocolate bars close to your bedtime.

Caffeine withdrawal can also disturb sleep, so while you are cutting back you may actually experience more sleep disturbance for a period of time.

Watch What you eat

Eating a large, heavy meal too close to bedtime will interfere with your sleep. Spicy or fatty foods may cause heartburn, which leads to difficulty in falling asleep and discomfort throughout the night.

Foods containing tyramine (bacon, cheese, ham, aubergines, pepperoni, raspberries, avocado, nuts, soy sauce and red wine) might keep you awake at night. Tyramine causes the release of norepinephrine, a brain stimulant.

If you get the munchies close to bedtime, eat something that triggers the hormone serotonin, which makes you sleepy. Carbohydrates such as bread, cereal or fruit will do the trick.

Milk contains a sleep promoting substance called Tryptophan. The so-called 'old wives' tale' of drinking a cup of hot milk laced with honey before bed, is actually true. It does help you sleep. (The milk must not be boiled though, as it loses its sleep-inducing properties).

Exercise Regularly – but not Before bed

Regular, moderate exercise is a great way to improve your sleep. Just be careful not to do it close to bedtime as exercise produces stimulants that stop the brain from relaxing quickly. You should avoid exercise within 4 – 6 hours of bedtime.

Since exercise produces stimulants, exercising in the morning is an excellent way to wake up the body. Going for a run, swim, paddle or doing some other aerobic exercise releases stimulants into the body, which perks you up.

If you are injured or disabled, you can still benefit from exercise.

Create a Calm Bedroom Environment

Your bedroom should be for sleep (and sex) only. Avoid turning it into an entertainment centre with televisions, computers and stereos.

It is important that you have a comfortable bed – with a good quality mattress. Cotton bedding is best as it helps keep your body at a constant temperature, and reduces the amount you perspire.

Make sure you are warm or cool enough to sleep - make use of temperature regulators like electric blankets, hot water bottles, fans and air-conditioning to ensure you are at a comfortable temperature for YOU.

The room should be dark – invest in curtains or blinds which block out the light, especially if you live in an area where the sun rises early (or doesn't go down).

The room should be quiet. Use ear plugs for noise problems or create 'white noise' (for example, an overhead fan) if that helps.

Get out of bed if you Can't Sleep

Don't lie in bed for hours tossing and turning. If you are brooding over your worries, or the fact that you are not going to sleep – you won't!

If you don't fall asleep after 20 minutes get up and leave the room. Read a 'boring' book, watch 'boring' TV, do a jigsaw or do some other quiet, non-stimulating activity, until you feel drowsy again and go back to bed. Repeat as often as necessary until sleep adjusts and quality returns.

It is important to get out of bed to do these activities because you want to train your brain that bed is a place to sleep, not be active.

Set Electronic Devices to 'Reduced Light' at Night

Electronic devices, such as computers, laptops, tablets, readers and mobiles devices emit a certain kind of light – light in the blue-and-white range – which has an effect on our body.

Our bodies operate according to Circadian Rhythms which help us adapt to the daily cycle of day and night, or light and dark, as the Earth rotates every 24 hours. Our Circadian system controls various functions, including when we sleep and rest, and when we are awake and active. Melatonin is a key hormone in our circadian system. A night-time Melatonin is released, which tells your body that it is night and helps to make you sleepy so you can get a good night's sleep.

But, bright light emitted from devices such as laptops, tablets and reading devices suppresses our normal night-time release of Melatonin which in turn can delay sleep. Research indicates that "if you do that for many years, it can lead to a disruption of the circadian system," which can have serious health consequences. 

Backlit screens are implicated in depression, anxiety disorders and sleep disorders. Depression and sleep disorders are implicated in decreased immune function, obesity and heart disease.

The actual dose of light makes a difference - its wavelength, it's brightness and the length of time we are exposed to the light all determine whether it affects melatonin or not. You can do a lot to help by switching to white text on a black screen at night to minimize the light dose. You can also turn down the brightness of your screens at night —there are apps that can do that for you - or switch back to good old-fashioned books!

Relax Your Mind

An overactive, stressed mind is one of the main contributors to sleep problems. Start preparing for sleep 30 minutes before going to bed. Stop working, turn down your bed, subdue the lighting, and have a warm bath or shower (not hot).

Some people find that lavender, valerian or other herbs help them to sleep. Use essential oils or fresh herbs in your bath. Put fresh herbs under your pillow. (Remember essential oils are powerful agents. Be sure to have proper advice on how to use them safely).

Make sure you have checked your diary, write down what you have to do and/or remember for the next day and let them go!

Have a pen and paper by your bedside so that if something does pop into your head you can write it down and then forget about it until morning.

Try not to argue with your spouse/partner and don't discuss finances at night!

Relax by doing all or some of the following:

  • Listen to beautiful, relaxing music, or play a musical instrument to clear your mind;
  • Do some gentle yoga exercises to clear your mind and release tension in your body;
  • Simple breathing exercises can help. Breathe, using your abdomen not your chest; (Refer to my article Stressed To Kill for a useful breathing technique).
  • Meditate and / or pray – tell God your worries and lay them at His feet.Don't take long afternoon naps.

Most of us have a natural dip in alertness between 2 - 4pm. That is normal and doesn't necessarily mean you are not getting enough sleep.

A 15 - 20 minute nap when you're tired can be a very effective way of staying alert throughout the day. Don't nap for longer than 20 minutes, however, as you will then enter a deep sleep and feel even worse when you wake up.

Never sleep during the day if you suffer from insomnia.

 

Seek Treatment if Your Problem Continues

If you have trouble falling asleep night after night, or if you always feel tired the next day, you might have a sleep disorder. It is advisable to seek more advice from a psychologist who treats sleep disorders, your doctor or homeopath, or a sleep specialist. Most sleep disorders can be treated effectively.

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