Insomnia

What is insomnia?

Insomnia is the inability to fall asleep, or remain asleep through the night resulting in a feeling of fatigue and tiredness through the day. The patient has a disturbed sleep pattern during the night, may sleep in patches or have absolutely sleepless nights.

Most adults need about 8 hours of sleep during the night till the age of 60. After that even 6 hours of sleep may suffice; but these patterns differ for different individuals. Babies till the age of 1 year sleep about 16 hours a day. However, there are no fixed hours of sleep. If a person feels refreshed when he wakes up from sleep, he is getting enough sleep.

What are the causes?

The patient may not be able to sleep at all or may sleep very lightly. He may get up in the early hours and may not be able to go back to sleep again. Due to lack of sleep, the patient’s work efficiency may go down, concentration may be affected and he may remain confused and irritable. In the long term, insomniacs may develop ailments like stomach disorders, excessive lethargy and disinterest in work. There may be psychological problems like depression and the person may cause injury to himself and others by being involved in accidents. The experience is characterised by one or more of the following problems:

• difficulty falling sleep
  
• difficulty maintaining sleep
  
• waking up too early in morning
  
• sleep that is not refreshing
  
• daytime consequences such as fatigue, lack of energy, difficulty concentrating and irritability
  
• sleepiness during day
  
• negative mood
  
• impairment of performance

How is it diagnosed?

If the patient is unable to sleep for 3-4 nights at a stretch, he may consult a doctor. When sleeping problems last for more than two weeks, they are considered to be insomnia. If this problem lasts for more than 4 weeks, chronic insomnia is diagnosed. This diagnosis is made after a thorough analysis of the patient’s medical history, his work productivity since the onset of the problem, concentration span and memory. If all these are considered to be functioning below par, the diagnosis is confirmed.

How can it be managed?

General Sleep Hygiene Measures: -

Sleep hygiene measures may help promote sleep and relate to help practices and environmental influences on sleep.

• Wake up and sleep at approximately the same time each day.
  
• Discontinue caffeine intake four to six hours before bedtime and minimise total daily use, as it is a stimulant and also avoid nicotine (stimulant).
  
• Avoid the use of alcohol in late evening to facilitate sleep onset.
  
• Avoid heavy meals too close to bedtime and prefer having light snacks.
  
• Regular exercise in the late afternoon may deepen sleep.
  
• Avoid vigorous exercise near to bedtime.
  
• Make sure your bed is comfortable, bedroom is dark, quite and cool.
  
• Take a warm bath (not hot) before going to bed.
  
• Deal with stress. Leave stress at the bedroom door, if you can.
  
• Save the bed for sleep and sexual activity. Avoid paying bills, reading the paper or watching TV in bed.

What is the treatment?

The best way to prevent insomnia is to develop good sleeping habits. A routine should be maintained of going to sleep and getting up at the same time everyday. This helps set a body clock for a predictable sleep schedule. Regular exercise is important for a healthy body, but it should not be done within 2 hours of bedtime. Beverages containing caffeine should be limited. A light snack of milk or meat can be taken just before bedtime. These foods have a natural sleep inducer, which helps to bring on sleep.

• A patient should not force himself to sleep. Leisure activities like reading or listening to soft music at bedtime help to relax. A comfortable bedroom temperature should be maintained. The surroundings should be conducive to sleeping; they should be away from loud noises or any other disturbing stimuli. Seek to change maladaptive sleep habits, reduce autonomic arousal and alter dysfunctional beliefs and attitudes, which are presumed to maintain insomnia.
  
• Relaxation therapy- Progressive muscle relaxation and autogenic training seek to reduce somatic arousal (e.g. muscle tension), also attention-focusing procedures such as imagery training and meditation are intended to lower presleep cognitive arousal (e.g. intrusive thoughts, racing mind). Abdominal breathing may be used also.
  
• Sleep restriction therapy- Consists of curtailing the amount of time spent in bed to increase the percentage of time spent asleep. This improves the patient’s sleep efficiency.
  
• Stimulus control therapy- It involves going to bed only when sleepy, using the bed and bedroom only for sleep, getting out of bed and going to another room when unable to fall asleep or return to sleep easily and returning to bed only when sleepy again.
  Cognitive therapy- Involves identifying dysfunctional beliefs and attitudes about sleep and replacing them with more adaptive substitutes.

Certain medications like diazepam may be prescribed to treat the disorder, which basically calm the nerves and help a person relax so as to be able to sleep easily. But these drugs are prescribed only as a last resort, since some of them may have side effects that may compound the problem. Also long term use of these drugs may cause dependence on them and the person may not be able to sleep at all without taking the drugs. Some drugs also have unpleasant side effects like nausea and so should only be taken on the doctor’s advice.