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 underlying psychological or physical conditions.
Who is at risk for Insomnia?
Anyone can have Insomnia, but it is generally 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 three weeks.
- Chronic Insomnia occurs at least three nights a week for a month or more.
Insomnia can also be defined as the inability to sleep, sometimes conventional. The following examples refer to circadian rhythm disorders:
Delay in the Sleep-Phase syndrome. 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 morning hours and have difficulty waking up in the morning.
It 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 sleep studies, subjects spend about a third of their time sleeping, suggesting that most people need about 8 hours of sleep each day. However, the siblings differ in the amount of sleep to feel well-rested. (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. Moreover, this is how the regular cycles of human beings are designed for daytime activity and nighttime rest.
- Problems are 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 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 a tendency to excessive introspection.
There is an inherited form of Insomnia known as Familial Fatal Insomnia, explicitly observed in 40 families worldwide. This is carried by a specific genetic trait that affects the production of a necessary protein.
This condition is scarce, 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 for time, and essential changes in the routine.
A stressful experience in life (good or bad) can trigger an interrupted sleep pattern for many people.
Some people can indeed go through significant stress and sleep well, but most people will have some changes in their sleep patterns 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 rest.
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 vision 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 why this is a significant problem for so many people.
You can want to sleep, recognize its importance, and do everything possible to sleep well, but you can not turn off your brain and leave yourself unconscious.
We see some unique characteristics of the brains of people who struggle with Insomnia.
These differences include additional electrical activity during sleep, which we believe allows a small degree of awareness when you are sleeping.
This additional activity also supports the idea that people who have Insomnia tend to focus much more on their sleep, paying more attention to the nighttime vigil.
There are also deficits in producing the neurotransmitter gamma-aminobutyric acid (GABA), the neurotransmitter responsible for inhibition in the brain and whose primary 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 precisely 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 its effect 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 significant obstacle because we can not put out the agony and go back to sleep.
It is not uncommon for people to start participating in their anxious roll of thought, which will keep their brains agitated and busy for hours.
Sleep disorders tend to have a high degree of comorbidity (co-occurrence) with other psychological disorders, physical conditions, and sleep disorders.
Lack of sleep significantly affects mood during the day, increasing vulnerability to the development of anxiety or depression.
Anxiety and Insomnia share the same pathways in the brain, so they are different presentations of the same problem. There is a high degree of activity in the central nervous system in the sympathetic nervous system in both conditions.
The daily effects of enhanced sympathetic activity include vulnerability to panic attacks, high heart rate, shallow breathing, and hyperreactivity.
For example, the high startle reflex, gastrointestinal discomfort, and even the intensified sensory information.
The nocturnal effects of the intensified sympathetic activity are more or less the same. Still, people are more aware of accelerated thoughts, the urge to move, and the inability to fall asleep.
During 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?
Many short and long-term effects are associated with Insomnia. Sleep interruption creates physical and psychological agitation, including low mood and temperament problems and inhibiting 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 extra 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,” A child stimulates himself like crazy to maintain attention and wakefulness.
This can appear in adults because their bodies are overwhelmingly tired, but their minds are so connected that they can not settle down.
Caffeine is not always the culprit, but it can play an essential role in developing 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 vital in diagnosing depression and bipolar disorder.
Many people experience excessive sleepiness with depression, but some 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. Still, it has the additional component that Insomnia can be a crucial indicator of the presence of a manic episode in bipolar disorder.
People with bipolar disorder need 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 food consumption. When they enter a manic phase, these patterns are reversed, with a high degree of activity, exposure to light, and little food consumption.
We can have some sound effects in managing bipolar disorder by creating a stable clock system and regulating 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, mainly carbohydrates.
A classic example of this challenge comes when you get to work, have not slept well, and receive a box of donuts; Much of your brain wants to eat donuts, but there is little room for rational thinking.
How high the sugar created 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 energy crash in the early afternoon as a regular part of our circadian rhythm. Still, this collapse is greatly amplified when we are deprived of sleep and potentially suffer dramatic blood sugar changes.
The increase in the availability of sugary coffee drinks has created an additional insult to the continuity of sleep: we experience changes in blood sugar during the day, and then we have brains too stimulated to reconcile to rest at night.
For physical health, many conditions 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 much research on the relationship between diabetes and Insomnia because insulin is a critical component of the circadian system.
People who have Type I Diabetes have lost their ability to produce their insulin and need to take insulin daily to allow their cells to use the nutrition they eat.
The development of insulin pumps has helped significantly with blood sugar regulation. Also, it provides some support to stabilize these people’s sleep since significant 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 in maintaining 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 they can not sleep well.
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 other sleep disorders.
Most sleep disorders share the same symptoms: daytime sleepiness, problems waking up in the morning, fatigue, and constant feeling that sleep needs are not being met.
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 treating 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 treating sleep apnea. Still, 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 intervention.
How is Insomnia measured?
Critical 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 of 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 their activities 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 actigraphy, which measures sleep and wakefulness over a more extended period (usually two weeks). Actigraphy is generally 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 for 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 drugs 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 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.
Many people may face a challenge because medications can create a 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 intended to address the psychological and physiological factors related to Insomnia.
It includes interventions to make the sleep environment conducive to sleep, limiting bedtime 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 crucial to diagnosis and treatment, so they are usually maintained throughout CBT-I.
The biggest challenge facing people with CBT-I is that there are not many professionals with the 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 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 beginning of the desired rest.
- Exercise every day
- Regular exposure to sunlight.
- Limit bedtime to a reasonable sleep period, 7-8 hours.