Insomnia can be short-term or a chronic condition , but it always involves problems falling asleep or staying asleep. Short-term (transient) insomnia can be caused by illness, stress, travel or environmental factors. Long-term (chronic) insomnia may be due to the underlying psychological or physical conditions.
Who is at risk for Insomnia?
Anyone can have insomnia, but in general it is more common in women than in men. The elderly are particularly at risk for insomnia.
Insomnia is often classified by its duration:
- Transient insomnia lasts a few days.
- Short-term insomnia lasts no longer than 3 weeks.
- Chronic insomnia occurs at least three nights a week for a month or more.
Insomnia can also be defined in terms of inability to sleep, sometimes conventional. The following examples refer to circadian rhythm disorders as:
Delay in the Sleep-Phase syndrome . It’s the delayed sleep phase syndrome is the term for a circadian clock that runs late, but reliably. People who have this condition (usually teenagers) get to sleep very late at night or in the early hours of the morning, and have difficulty waking up in the morning.
Advanced sleep phase syndrome. This syndrome tends to develop in the elderly. It produces excessive sleepiness in the morning and early unwanted awakening (3-5 hours) in the morning.
In sleep studies, subjects spend about a third of their time sleeping, suggesting that most people need about 8 hours of sleep each day. The siblings differ in the amount of sleep they need to feel well rested, however. (Babies can sleep up to 16 hours a day.)
The daily cycle of life, which includes sleeping and waking, is called (which means “about a day”) the circadian rhythm, commonly known as the biological clock . Hundreds of bodily functions follow biological clocks, but sleep and wakefulness comprise the most prominent circadian rhythm. And this is how the regular cycles of human beings are designed for daytime activity and nighttime rest.
- Problems falling asleep or falling asleep.
- Fewer hours of sleep despite the adequate opportunity to sleep.
- Attention problems.
- Mood disorder.
- Daytime sleepiness
- Worries about sleep.
- Headaches by tension.
- Problems with motivation, energy or the propensity to make mistakes.
If the problem persists for more than three months, it is considered to be chronic insomnia, and less than three months is called acute insomnia.
Our model for understanding insomnia is that it arises from factors that predispose, precipitate and perpetuate, which work together to interrupt the normal impulses toward sleep.
The predisposing factors for insomnia include potential genetic and familial factors that increase the likelihood of high states of arousal and tendency to excessive introspection.
There is an inherited form of insomnia known as Familial Fatal Insomnia , which has been observed specifically in 40 families in the world. This is carried by a specific genetic trait that affects the production of a necessary protein.
This condition is incredibly rare, but it has given us an idea of how insomnia could be inherited.
More commonly, heredity is probably related to sensitivity within the circadian system (internal clock), sleep metabolism or the tendency to be anxious.
The precipitating factors can be periods of intense stress, greater demand of time and / or important changes in the routine.
For many people, a stressful experience in life (good or bad) can trigger an interrupted sleep pattern.
It is true that some people can go through significant stress and sleep well, but most people will have some changes in their sleep pattern when they are stressed.
Perpetuating factors include maladaptive behaviors and thought patterns that can cause insomnia to persist.
These may include napping during the day, changing daytime activity to cope with lack of sleep, spending too much time in bed and worrying excessively about sleep.
Sometimes, people will become almost ritualistic in their approach to sleep because of the desire to try to control it and are devastated by their inability to force it to happen.
The more we focus on our dream, the worse our dream becomes. When the perpetuating factors are well addressed, the drive toward homeostasis will usually correct the sleep cycle to a normal rhythm.
The lack of control over sleep is really the core of why this is such an important problem for so many people.
You can want to sleep, you can recognize its importance and you can do everything possible to sleep well, but you can not turn off your brain and leave you unconscious.
In fact, we see that there are some unique characteristics of the brains of people who struggle with insomnia.
These differences include additional electrical activity during sleep, which we believe actually allows a small degree of awareness when you are really sleeping.
This additional activity also supports the idea that people who suffer from insomnia tend to focus much more on their sleep, paying more attention to night-time vigil.
There are also deficits in the production of the neurotransmitter, gamma-aminobutyric acid (GABA), which is the neurotransmitter that is responsible for inhibition in the brain, whose main function is sleep.
Another common difference is the tendency to be much more agitated or reactive during the day and night.
Sometimes people will know exactly where their brain is going with their concerns, and other times people say they can skip issues quickly.
When a person who experiences insomnia and anxiety wakes up at night, he is more likely to feel very worried about the awakening and the effect it will have on his day.
Some people in this state will wake up in the middle of a panic attack or an extreme nightmare.
The anguish that precedes their awakening becomes a great obstacle to overcome because we simply can not put out the anguish and go back to sleep.
It is not uncommon for people to start participating in their anxious roll of thought, which will keep their brain agitated and busy for hours.
Sleep disorders tend to have a high degree of comorbidity (co-occurrence) with other psychological disorders, physical disorders and even other sleep disorders.
Lack of sleep significantly affects mood during the day, which tends to increase vulnerability to the development of anxiety or depression .
Anxiety and insomnia share the same pathways in the brain, so they are actually different presentations of the same problem. In both conditions, there is a high degree of activity of the central nervous system in the sympathetic nervous system.
The diurnal effects of enhanced sympathetic activity include vulnerability to panic attacks , high heart rate, shallow breathing and hyperreactivity.
For example the high startle reflex, the gastrointestinal discomfort and even the intensified sensory information.
The nocturnal effects of intensified sympathetic activity are more or less the same, but people are more aware of accelerated thoughts, the urge to move and the inability to fall asleep.
In the day, these symptoms are characterized as anxiety or panic disorder, at night these symptoms would be a firm diagnosis of insomnia.
How does insomnia affect people?
There are many short and long term effects that are associated with insomnia. The interruption of sleep creates a physical and psychological agitation, which includes a low mood, problems of temperament and inhibits healthy coping strategies.
Someone who can run to help improve their mood may feel they do not have the energy to run, so they may find themselves, once again, eating the donut in their office to meet the brain’s demand for additional carbohydrates, and then have an additional help of disappointment about their poor coping.
This cycle increases the physiological and psychological agitation, which worsens the likelihood that they can be established as the night approaches.
In pediatrics, we often talk about a condition called “tired and wired” in which a child stimulates himself like crazy to try to maintain attention and wakefulness.
The way this can appear in adults is that their body is overwhelmingly tired, but their mind is so connected that they can not settle down.
Caffeine is not always the culprit, but it can play an important role in the development of this state; It can take up to 12 hours for people to completely metabolize caffeine.
Using too much caffeine too late in the day will intensify the insomnia experience for many people.
Insomnia is associated with mood disorders and changes in sleep tend to be key to diagnosing depression and bipolar disorder.
Many people experience excessive sleepiness with depression, but there are people who have depression and insomnia; This group is particularly vulnerable to suicide, so it should be monitored with additional caution.
The relationship between insomnia and bipolar disorder follows the same pathways as depression, but it has the additional component that insomnia can be a key indicator of the presence of a manic episode in bipolar disorder.
For people with bipolar disorder, it is very important to make sure that the circadian rhythm stabilizes.
For example, during a depressed period, they may have little activity, little exposure to the sun and excessive consumption of food. When they enter a manic phase, these patterns are reversed, with a high degree of activity, exposure to light and little food consumption.
In fact, we can have some good effects in the management of bipolar disorder if we can create a stable clock system and regulate controlled behaviors such as food and activity.
Adaptations during the day to the loss of sleep tend to be driven by the state of agitation that causes and continues insomnia.
Sleep disruption creates dysregulation in neurotransmitters related to appetite, and we see a significant increase in the impulse for food consumption, particularly carbohydrates.
A classic example of this challenge comes when you get to work, you have not slept well, and you receive the box of donuts; Much of your brain wants to eat donuts that there is little room for rational thinking.
How high the sugar creates can eventually go into a significant shock, which reinforces the carbohydrate boost and relieves food; It is not unusual for clients to report that they have had problems with bad eating habits that may have originated in their sleep continuity problems.
We all experience a slight crash of energy in the early afternoon as a normal part of our circadian rhythm, but this collapse is greatly amplified when we are deprived of sleep and potentially suffering dramatic changes in blood sugar.
The increase in the availability of sugary coffee drinks has created an additional insult in the continuity of sleep: we experience changes in blood sugar during the day and then we have brains too stimulated to reconcile to sleep at night.
For physical health, there are many conditions that create a vulnerability to insomnia or can be intensified by sleep problems.
People who are blind can have significant challenges with their circadian rhythm and, as a result, experience chronic loss of sleep.
There has been a lot of research on the relationship between diabetes and insomnia because insulin is a key component of the circadian system.
People who have Type I Diabetes have lost their ability to produce their own insulin and need to take insulin daily to allow their cell to use the nutrition they eat.
The development of insulin pumps has helped significantly with the regulation of blood sugar, and also provides some support to stabilize the sleep of these people, since high changes in blood sugar create challenges in the circadian rhythm.
People who have problems with chronic pain can have long periods of inactivity during the day and night, which generates significant challenges to maintain sleep.
People who have spent prolonged periods in bed after a major illness will also experience sleep challenges; They may sleep excessively while their body recovers, but then they discover that they can not sleep well at all.
The experience of insomnia is related to the vulnerability to catching a cold because it results in decreased immune function.
People who have experienced chronic insomnia also tend to have an increased risk of cardiovascular disease, cancer, metabolic syndrome, high blood pressure , diabetes and stroke.
Finally, people who have experienced insomnia can often also be diagnosed with additional sleep disorders.
Most sleep disorders share the same set of symptoms: daytime sleepiness, problems waking up in the morning, fatigue and constant feelings that sleep needs are not being met.
The sleep apnea , a condition in which there is trouble breathing at night, will any additional symptoms of snoring, nocturnal breathlessness, dry mouth and frequent awakenings.
Restless legs syndrome involves problems with impulses to move the body and may also manifest in some movements of the limbs that create nighttime awakenings.
The syndrome of the periodic movement of the extremities consists of kicking the legs during sleep, which causes night awakenings.
Almost all disorders that disturb sleep at night have the potential to create a continuous experience with insomnia.
Generally, we expect that the treatment of the condition that is causing the awakening will treat the insomnia, but there are many cases in which the residual insomnia persists.
The treatment of positive airway pressure is the gold standard for the treatment of sleep apnea, but it can also trigger an experience of claustrophobia that can intensify the insomnia experienced.
When we have discussed all the potential causes of nocturnal awakening, what is left is often called ” psychophysiological insomnia ” and requires its own intervention.
How is insomnia measured?
Key factors in the evaluation of insomnia include:
- Sleep efficiency: the amount of sleep time divided by the time spent in bed.
- Sleep latency: the amount of time a person takes to fall asleep.
- Interruption of sleep: the number of disturbances or awakenings at night.
We can evaluate these variables according to the discussion in the clinic or extract information from sleep diaries.
Sleep diaries can provide an idea of sleep patterns and also what kind of activities they have throughout the day.
Sleep studies are rarely used to diagnose insomnia because they offer very few details to help with your treatment; It does not make sense to lock someone in a sleep lab and watch them stay up all night!
An optional evaluation for insomnia is something called actigraphy, which measures sleep and wakefulness over a longer period of time (usually 2 weeks). Actigraphy is usually only beneficial if we think that the person has an additional struggle with their clock system.
According to the position paper published by the American Academy of Sleep Medicine on the diagnosis and treatment of insomnia, there are two main objectives with the treatment of insomnia: improving the quality and quantity of sleep and improving daytime functioning.
Effective sleep intervention addresses the underlying physiological changes associated with insomnia (nocturnal hyperexcitation, shallow sleep, decreased GABA production).
The most common intervention for insomnia is hypnotic medication, and there are several classes of medications used to sleep.
Common hypnotic medications include:
Non-benzodiazepine GABA receptor agonists:
- Ambien (zolpidem).
- Lunesta (eszopiclona).
- Sonata (zaleplon).
- Restoril (temazepam).
- Xanax (alprazolam).
- Klonopin (clonazepam).
- Valium (diazepam).
- Ativan (lorazepam).
- Desyrel (trazodona).
- Remeron (mirtazapina).
- Sinequan (doxepina).
- Belsomra (suvorexant).
- Seroquel (quetiapina).
- Neurontin (gabapentina).
Although medication is the most commonly used intervention for insomnia, it is actually only indicated for short-term treatment.
The AASM practice guidelines indicate that the goal should be the lowest effective dose and the reduction of medication as soon as possible.
The challenge many people may face is that medications can create habit and it can be difficult to sleep without them once dependence has been established.
The gold standard for the treatment of insomnia is cognitive behavioral therapy for insomnia (CBT-I). CBT-I was developed by Jack Edinger and his colleagues and consists of several principles that are intended to address the psychological and physiological factors related to insomnia.
It includes interventions aimed at making the sleep environment conducive to sleep, limiting bed time to the amount of adequate sleep, regulating the sleep schedule and the circadian rhythm and addressing any thoughts or behavior that may interfere with sleep.
Sleep diaries are key to diagnosis and treatment, so they are usually maintained throughout CBT-I.
The biggest challenge facing people with CBT-I is the fact that there are not many professionals with credentials and skills to use the intervention.
Most people are familiar with the standard recommendations for improving sleep, but it is good to summarize them. Some standard practices for a healthy sleep include:
- Maintain a fixed schedule 7 days a week.
- Dark dream environment, fresh and comforting.
- Eliminate exposure to light from the devices 1-2 hours before the start of the desired sleep.
- Avoid caffeine 10-12 hours before the start of the desired sleep.
- Exercise every day
- Regular exposure to sunlight.
- Limit bed time to a reasonable sleep period, 7-8 hours.