Insomnia is an extremely common sleep disorder. A third of the population in the western world experiences regular difficulties with falling asleep or staying asleep. However, for about 10% of the population, the insomnia also causes problems in the daytime, such as tiredness, poor concentration, or irritable moods. So what is insomnia? Well, insomnia disorders diagnosed when someone has the following features: difficulties going to sleep, staying asleep - where it takes longer than 30 minutes, non-restorative of sleep, impairment of daytime functioning, and symptoms that are present for at least three months. The essence of insomnia is that the person feels unsatisfied with the amount or quality of sleep. So much so that it leads to significant distress or an inability to function in important areas of life. This can affect the person's relationships, work, education, social life, or other important areas. Any sleep problems that are present for less than three months are not considered to meet the criteria for insomnia disorder. It is simply thought of as an episode of insomnia rather than a disorder. Sometimes people's sleep experience does not meet their expectations. For example, many people wake often at night but are still able to function well during the day. This does not constitute insomnia. Impacts of insomnia on everyday life includes things such as a person feeling wired and tired, while fatigue is the overwhelming symptom. If the person often feels sleepy, they may also have another type of sleep disorder, such as untreated obstructive sleep apnoea and/or restless leg syndrome, periodic limb movement. The most important factor in the sleepy insomnia individual is depression where there is a strong bidirectional relationship. Both of these disorders require equal treatment. People with insomnia often feel that their performance is significantly reduced. But the research does not always show objective impairments. People with insomnia often have difficulty switching tasks along with some aspects of memory. In one study, a functional MRI, a top of brain scan, was used to measure blood flow in certain areas of the brain. Individuals with insomnia had reduced blood flow in some areas when asked to participate in some cognitive tasks in the scanner. Perhaps the most important thing is the way people think about the sleep. Some people with insomnia can become extremely preoccupied with their sleep and develop a condition termed sleep anxiety. Instead of being an important component of healthy life, sleep becomes a stressful focal point of all the activities the person is not able to do due to their chronic poor sleep quality, perceived or otherwise. Behavior may become ritualized to ensure better sleep. And individuals might also give up the little pleasures of life, such as exercise, coffee or socializing, for fear that these activities will negatively impact on sleep. Many people start spending more and more time in bed trying to achieve at least 50% of that time sleeping. This is a common but unhelpful behavior as it is the development of sleep anxiety. Interestingly, in a recent study of nurses doing shift work: tiredness, anxiety, depression, bullying in the workplace, and spillover between work and family life were significant factors related to insomnia. However, insomnia was more likely to be caused by personal and work related factors rather than being a cause of the problems. We also have a number of sleep myths. And there are three common misperceptions regarding sleep. One being that good sleepers sleep through the night and do not wake until the morning, then they wake refreshed. Number two, we start the night in light sleep and finish sleep in deep sleep. So if the sleep period is shortened, in any way, then sleep will be severely compromised. Number three, rapid eye movement sleep is deep sleep. This hypnogram shows the stages of sleep that a normal adult will cycle through during a good night's sleep. REM sleep means rapid eye movement and is a lighter sleep stage during which dreams occur. Stage three or N3 is the deepest stage of sleep. In humans, most of the night is spent in relatively light sleep. An evolutionary overflow, most likely from our caveman days, when it was important to be alert for predators. Only 20% of the night is spent in deep sleep and 25% in REM sleep. We cycle through all the stages of sleep every 90 minutes and most of our deep sleep is in the first one third of the night with mostly lightest stages in the latter part of the night. The onset of sleep is triggered by increasing darkness that causes the brain to produce melatonin. Light suppresses melatonin and leads to waking. The role of temperature is also important and changes with sleep onset and waking. A healthy 70 year old will cycle through the same stages of sleep but somewhat more rapidly during the night. So sleep patterns change of a person's lifetime. So how do we treat insomnia? Medication is usually the first line of treatment when an individual presents to their GP with insomnia. In a 2010 study, 95% of people were given a sedative medication with almost half being prescribed Temazepam. Only 2% were referred to a psychologist for psychological treatment, which we know is the proven and most effective treatment long-term. Cognitive behavioral therapy or CBT aims to enable a person with insomnia to gain confidence about his or her sleep by giving factual information about sleep in order to combat the many common myths. Some examples are: 'I must stay in bed longer to make up for my lost or poor quality sleep' and 'I only doze in the second half of the night.' CBT is approached as a retraining in sleep with the aim of reducing some of the pressure that people tend to place on themselves when trying to change the behavior. Along with the behavior changes is the need to change perceptions and expectations of sleep which is equally important. There are some strategies for managing sleep patterns. One is bed or sleep restriction therapy which means reducing the time spent in bed but either going to be later or getting up earlier. This can improve the length and quality of a sleep. Avoiding unhelpful cues associated with the bed, such as using computer screens or television in the bedroom, can also be helpful. The quarter hour rule means that if you are awake for more than a quarter of an hour, it is helpful to get out of bed and do a quiet activity until you are comfortable with that but not necessarily sleepy. Paradoxical intention is a strategy that involves putting the effort into staying awake. Paradoxically, this makes you sleepy. It is also important to have exposure to early morning light, regular exercise, and a healthy diet. Avoiding caffeine or alcohol close to bed time can also be useful. If depression is an issue, managing your mood in conjunction with changing sleep behaviors and thoughts is both effective and useful. Relaxation and mindfulness strategies help to reduce anxiety and can promote sleep. These are covered in other sections of the course. Using these strategies, people with insomnia learn to go from being a victim of poor sleep to changing the boundaries around the bed and the night, and can learn to sleep well again.
