Dr Neil Stanley Independent Sleep Expert
© Dr. Neil Stanley 2013-2022
What is insomnia? Insomnia is a common sleep disorder. It is thought to affect at least 1 in 10 people in the U.K. However, some studies indicate that the disorder could affect as many as 1 in 3 people. It is particularly common for older adults to from insomnia. For some people, a period of insomnia will pass without causing any serious problems, but for others, the problem can persist for months or years. Chronic or persistent insomnia can have a significant impact. It is associated with daytime fatigue, reduced quality of life, and increased ill-health. It commonly accompanies conditions such as depression, anxiety and chronic pain but often persists even after these ‘primary’ conditions have been resolved. The diagnostic criteria for insomnia are according to the American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014. Criteria A-F must be met A. The patient reports, or the patient’s parent or caregiver observes, one or more of the following: 1. Difficulty initiating sleep. 2. Difficulty maintaining sleep. 3. Waking up earlier than desired. 4. Resistance to going to bed on an appropriate schedule. 5. Difficulty sleeping without parent or caregiver intervention. B. The patient reports, or the patient’s parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty: 1. Fatigue/malaise. 2. Attention, concentration, or memory impairment. 3. Impaired social, family, occupational, or academic performance. 4. Mood disturbance/irritability. 5. Daytime sleepiness. 6. Behavioural problems (e.g., hyperactivity, impulsivity, aggression). 7. Reduced motivation/energy/initiative. 8. Proneness for errors/accidents. 9. Concerns about or dissatisfaction with sleep. C. The reported sleep/wake complaints cannot be explained purely by inadequate opportunity (i.e., enough time is allotted for sleep) or inadequate circumstances (i.e., the environment is safe, dark, quiet, and comfortable) for sleep. D. The sleep disturbance and associated daytime symptoms occur at least three times per week. E. The sleep disturbance and associated daytime symptoms have been present for at least three months. F. The sleep/wake difficulty is not better explained by another sleep disorder. Note the diagnostic criteria for insomnia requires that the disturbance of sleep occurs most nights and, importantly, that it leads to adverse daytime consequences, i.e. you will feel sleepy during the day, feel your work performance suffers, etc. It is also important to note that the diagnostic criteria do not mention any specific number of hours that denote ‘good’ or ‘bad’ sleep. There is no ‘magic’ number of hours of sleep; everyone is different; what’s important is whether you feel you get enough sleep and whether your sleep is of good quality. Different types of insomnia. Insomnia is a medical diagnosis with specific diagnostic criteria; this means that many people who are sleeping poorly or feeling a bit jaded during the day do not strictly speaking have insomnia disorder. There are three specific types of insomnia and although most people think that insomniacs have a problem falling asleep, the prevalence of each type of insomnia would seem to be roughly equal (of course, it is possible to suffer from a combination of them): Sleep-onset insomnia is where there is difficulty in falling asleep. On average, most people take less than twenty minutes to fall asleep after turning the light off. Regularly taking more than 30 minutes to fall asleep on the majority of nights could be indicative of insomnia. Sleep-maintenance insomnia is a problem staying asleep, i.e., you repeatedly wake up during the night. You usually wake many times momentarily during sleep to check that all is right with the world; however, such awakenings are very short and you are not aware of them. The person with sleep maintenance insomnia wakes, for whatever reason, during the night and then finds it difficult to get back to sleep. Anxiety is a common cause of sleep maintenance insomnia, other cause are conditions such as pain or nocturia (repeatedly getting up to go to the toilet during the night). When assessing your sleep, it is important to be aware of what wakes you up and what then keeps you awake, e.g., you may wake needing to go to the toilrt, but once you have ben, it may be pain or anxiety that keeps you from falling back to sleep. Early morning waking this is where you wake earlier in the morning than you wish and cannot then fall back to sleep. This type of insomnia is has a strong link to depression but may also be related to the changes in our circadian rhythm that occur naturally as we get older. Generally, young people most commonly suffer from difficulty falling asleep (sleep-onset insomnia). In contrast, older people more commonly have problems with waking during the night or early in the morning (N.B. as we get older, our sleep naturally becomes lighter and thus more easily disturbed, so problems sleeping are not necessarily indicative of insomnia in the elderly). Insomnia can last for days, months or even years. According to the latest NICE guidelines, short-term or acute, insomnia lasts up to 3 months here. Chronic insomnia is that which lasts for more than three months. Find out why you can’t sleep A small number of people have chronic insomnia for no discernible reason; however, for most others, their insomnia is a symptom of another problem. There are numerous causes of insomnia, some more obvious than others. Some reasons you can remedy yourself while others need to be addressed by your G.P. Insomnia can be linked to psychological, sleep environment and lifestyle factors, medical conditions, prescribed and recreational drugs and sleep-related disorders. Below are some of the problems that can cause disturbed sleep. Physical Medical conditions – Insomnia can be caused by several underlying physical conditions, such as heart disease, respiratory disease, neurological disease, joint or muscle problems, gastrointestinal disease or chronic pain. If your sleep is disturbed by physical illness, then the effective treatment of the physical condition may, by itself, improve sleep. However, some treatments may have side effects that could make your sleep worse, so make sure you mention that you have problems sleeping to your doctor, particularly if this occurs when starting a new medication. Mental health problems such as stress, anxiety, depression, schizophrenia, bipolar disorder and dementia are also linked to disturbed sleep. Again, treatment of the primary condition may lead to improved sleep. Medications - Many prescribed and over-the-counter medicines can also cause insomnia, including some antidepressants, some epilepsy medicines, medications for high blood pressure, hormone treatments, non-steroidal anti-inflammatory drugs, and some medicines for asthma. If you are having problems sleeping, you must check with your G.P. the possible effects on sleep of any medications prescribed; this is especially so if you are taking several different medications. Withdrawal from some medicines, including antidepressants and sleeping pills, can lead to sleep problems. Many lifestyle/environmental problems can disturb sleep. If you take a moment to reflect, it should be pretty straightforward if your sleep is being disturbed by your lifestyle or your environment; in reality, you should try and address these issues yourself. When to go to your G.P.? Suppose you have had difficulty getting to sleep or staying asleep, or you feel unrefreshed by sleep on the majority of nights and this is having a significant effect on your daytime well-being. In that case, you should go and see your G.P. to discuss your problem. Useful References Roth T. Insomnia: definition, prevalence, etiology, and consequences. Journal of clinical sleep medicine. 2007 Aug 15;3(5 suppl):S7-10. Drake CL, Roehrs T, Roth T. Insomnia causes, consequences, and therapeutics: an overview. Depression and anxiety. 2003 Dec;18(4):163-76. Bonnet MH, Arand DL. Consequences of insomnia. Sleep Medicine Clinics. 2006 Sep 1;1(3):351-8. Bjorvatn B, Jernelöv S, Pallesen S. Insomnia–a heterogenic disorder often comorbid with psychological and somatic disorders and diseases: A comprehensive review with focus on diagnostic and treatment challenges. Frontiers in Psychology. 2021;12:289. Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019 Oct;18(3):337-52. Mukku SS, Harbishettar V, Sivakumar PT. Insomnia in elderly: A neglected epidemic. Journal of Geriatric Mental Health. 2018 Jul 1;5(2):84. Wardle-Pinkston S, Slavish DC, Taylor DJ. Insomnia and cognitive performance: A systematic review and meta- analysis. Sleep medicine reviews. 2019 Dec 1;48:101205.