Insomnia: Everything You Need to Know

Co-authored and medically reviewed by Dr. Temitope Oyetunji

Insomnia is a sleep disorder which makes it difficult for one to fall asleep or enjoy a sound and uninterrupted sleep at night. Insomnia is one of the major causes of sleeplessness. In this article, we explore insomnia especially its attendant causes and remedies that work. 

You may have found yourself in situations where you want to sleep at night, and you are just laying down there on your bed, willing the sleep to come. The clock keeps ticking, yet you are still awake. Only for you to sleep off an hour or two before your alarm wakes you up to face another new day. 

In another case, you might actually sleep off, only to wake up in the middle of the night and for one reason or the other you find yourself unable to go back to sleep. This is one of the most common sleep complaints and it is known as Insomnia. 

Insomnia can make you to be tired and sleepy all through the next day, you may have a headache, and you will feel irritated, depressed and anxious. Also, insomnia may make you not to be able to focus on your activities for the day.

Sleep

Sleep is very important for the body system to work efficiently. It is a necessary restorative process that affects all aspects of human functioning. It is an active process for the brain. Early in sleep, slow-rolling eye movements occur (non-rapid-eye movement). This is followed by rapid eye movements (REM) associated with irregular breathing and increased heart rate.

 Non-rapid Eye Movement (NREM)

• Stage 1: 5% total time
• Stage 2: 50% total time
• Stages 3 and 4:10-20% total sleep time

Restful and restorative sleep is achieved here before moving on to the rapid eye movement.

Rapid Eye Movement (REM)

• 20-25% total sleep time

What is Insomnia?

Insomnia is defined as repeated difficulty with sleep initiation, maintenance, consolidation, or quality that occurs despite adequate time and opportunity for sleep. This results in some form of daytime impairment.

Specific criteria for identifying insomnia vary, but common ones include:

• Taking longer than 30minutes to fall asleep
• Staying asleep for less than 6hours
• Waking more than three times a night, or
• Experiencing sleep that is chronically nonrestorative or poor in quality

Insomnia is not a disease; it is a sleep disorder resulting from someone’s habit or as a symptom of an underlying mental or health condition. It can affect your day-to-day activities; it makes you weak and sleepy during the day. Insomnia also affects your memory and ability to stay focused throughout the day.

Signs and symptoms of Insomnia

The signs and symptoms of insomnia tend to vary greatly among those who suffer from it. Generally, the signs and symptoms of insomnia reported are: 

• Having a hard time falling asleep.
• Only being able to stay asleep for short periods. Waking up frequently at night and having difficulty going back to sleep.
• Not feeling well-rested after a night sleep
• Waking up very early
• Feeling tired and sleepy during the day
• Having difficulty in staying focused on your activities during the day
• Feeling of frustration, irritation, depression, confusion and anxiety.
• Having a headache
• Increased appetite and craving for sugary food 
• Weight gain
• Breakouts, dry skin, dark circles around the eyes and premature ageing

Side effects of insomnia

• Accident in the workplace and on the road.

Insomnia can make you react very slowly, and according to a recent study,  lack of sleep is linked to increased risk of accident at home, on road and in the workplace.

• Increased risk of serious health condition

Chronic insomnia can increase your risks for serious health conditions such as stroke, high blood pressure, diabetes, coronary diseases and obesity.

• Affects mental health.

Insomnia does not only make you feel fatigued but worrying about lack of sleep can also make you to be anxious, depressed, confused and easily irritated.

• Premature ageing.

Chronic insomnia can affect your skin health. It causes dark circles under your eyes, loose skin and appearance of age lines.

• Obesity.

Lack of proper sleep can cause one to be more hungry than usual, increasing our cravings for sugary food. It also makes you snack late in the night, and all these can result in weight gain.

Causes of Insomnia

Insomnia usually results from an interaction of biological, physical, psychological, and environmental factors.

Although transient insomnia can occur in any person, chronic insomnia appears to develop only in a subset of persons who may have an underlying predisposition to insomnia.

Stress and Anxiety

Stress is a major cause of insomnia. It makes it difficult for you to be comfortable and well relaxed to enjoy a sound sleep. Many people develop insomnia after a stressful event, such as bereavement, problems at work or financial difficulties.

This can continue long after the event has passed because they start to associate, going to bed with being awake. This develops into anxiety about sleep itself.

Having more general worries about work, family, or health is also likely to keep you awake at night. 

Poor Sleep Routine and Sleeping Environment

Going to bed at inconsistent times or nap during the day can affect your night sleep.

A poor sleeping environment can also contribute to insomnia; for instance, an uncomfortable bed or a bedroom that’s too bright, noisy, hot or cold can disrupt your sleep. To enjoy a sound sleep, you need an environment that is peaceful, quiet and relaxed.

Lifestyle factors

Your habits and activities during the day and before your bedtime can affect your sleep. Some activities carried out during the day can affect your sleep at night. Some of those habits are

• Drinking alcohol before going to bed, and taking certain recreational drugs can affect sleep, as can stimulants such as nicotine (found in cigarettes) and caffeine (found in tea, coffee and energy drinks).
• Changes to sleeping patterns can also contribute to insomnia, for example, because of shiftwork or changing time zone after a long-haul flight (jet lag). 
• Using your electronic devices, watching movies and TV when is almost bedtime can also affect your sleep

Age

Insomnia can occur in people of any age group, but your chances of having it increase as you age. This may result from a change in sleeping pattern and health conditions that come with age and medications.

Sex

The risk of insomnia is higher in women than in men. Sleeplessness in women is caused mostly due to hormonal changes that occur during pregnancy, menopause and premenstrual syndrome.

Mental Health Conditions

Underlying mental health problems can often affect a person’s sleeping patterns. Conditions like:

• Mood disorders –such as depression or bipolar disorder
• Anxiety disorders –such as generalized anxiety, panic disorder or post-traumatic stress disorder
• Psychotic disorders –such as schizophrenia

Physical health conditions

Insomnia can also be caused by underlying physical conditions, including:

• Heart conditions – such as angina or heart failure.
• Respiratory conditions –such as chronic obstructive pulmonary disease (COPD) or asthma
• Neurological conditions –such as Alzheimer’s disease or Parkinson’s disease
• Hormonal problems – such as an overactive thyroid
• Joint or muscle problems – such as arthritis
• Problems with the genital or urinary organs –such as urinary incontinence or an enlarged prostate.
• Sleep disorders – such as snoring and sleep apnea, restless leg syndrome, narcolepsy, night terrors and sleepwalking.

Medications

Some prescriptions or over-the-counter medications can cause insomnia as a side effect.

These include:

• Antihypertensives –such as beta-blockers.

Steroids

• Non-steroidal anti-inflammatory drugs (NSAIDs).
• Stimulant medicines used to treat attention deficit hyperactivity disorder (ADHD) or narcolepsy.
• Some medicines used to treat asthma –such as salbutamol, salmeterol and theophylline.

Classifications of insomnia

Insomnia can be classified based on its cause and how it manifests. 

1. Primary Insomnia

Also referred to as Idiopathic, this form of Sleeplessness usually cannot be attributed to a medical, psychiatric or environmental cause.

2. Secondary Insomnia

This is also more commonly referred to as Comorbid Insomnia. When insomnia is being caused by some other outside factor, illness, or disorder including:

• Drug Abuse
• Psychiatric Disorders
• Medical Problems
• Other Sleep Disorders disruptive to sleep

3. Acute Insomnia

Another name for this is Adjustment insomnia. It entails a brief episode of difficulty sleeping. Acute insomnia is often caused by a life event such as a stressful change in a person’s job, receiving bad news or travel. It is important to note that this kind of insomnia often resolves without any treatment.

4. Chronic Insomnia

This involves a long-term pattern of difficulty in sleeping. It is usually considered if a person has trouble falling asleep or staying asleep at least three nights per week for three months or longer. 

5. Sleep onset insomnia

This manifests in persons who always have a hard time falling asleep. This type of insomnia occurs in people who have difficulty falling asleep after lying down on their bed for a long time.

6. Sleep maintenance insomnia

This type of insomnia occurs in people who have difficultly staying asleep or going back to sleep after waking up in the night for whatever reason

A combination of both sleep-onset and sleep maintenance difficulties and people with chronic insomnia may find that these symptoms shift over time.

DIAGNOSIS

1. History

The patient history is the most important part of the evaluation for insomnia.

It must include a: 

• Sleep history
• Medical history
• Psychiatric history
• Social history

Medication review

2. Physical Examination

The physical examination may be helpful because findings may offer clues to underlying medical disorders that predispose the patient to insomnia.

It may also facilitate the differential diagnosis or classification of insomnia

Remedies/Treatment of Insomnia

Insomnia is not a disorder that can necessarily be “cured”. Symptoms are treated in order to relieve a patient of distress. Its treatment is dependent on the cause. Treated by two different methods:

• Non-pharmacological treatment
• Pharmacological treatment

Non-pharmacological treatment

This is attempted before the use of medications, typically for at least 2-3weeks.

This mainly has to do with attempting to improve sleep habits

Some of the methods used are

• Improving Sleep hygiene
• Stimulus control therapy
• Restrictive sleep therapy

Improve Sleep Hygiene

• Don’t spend excessive time in bed, including daytime napping.
• Get into bed when sleepy.
• Maintain a regular sleep/wake schedule
• The bed is for sleep and sex only, not TV!
• Increase exercise and fitness
• Avoid caffeine and nicotine at least 4-6 hours before going to bed.
• Never use alcohol to go to sleep.
• Avoid excessive liquids or a heavy meal in the evening.
• Minimize noise, light, and temperature extremes during sleep.
• Move alarm clock away from bed if it is distracting.

Learn more on 5 Easy Ways to Improve Your Sleep Hygiene

Stimulus Control therapy

This is based on the premise that insomnia is a conditioned response based on cues associated with sleep. It trains the brain to associate the bed/bedroom with sleep.

• Don’t go into the bedroom unless you are going to sleep
• Do not go to bed unless tired
• Leave the bedroom if not sleeping within 15-20 minutes
• Be completely relaxed when in bed

This method has been seen to be very useful if used over a prolonged period of time. Effective for improving sleep onset as well as sleep maintenance.

Sleep Restriction Therapy

• Restricting sleep during the day
• The goal is to be excessively tired when it is time to sleep at night
• It has shown to be the most promising results of all non-pharmacological therapies and even more effective when sleep hygiene is improved

Pharmacologic Treatment

This is the treatment of insomnia with the use of pharmacological agents

⮚ Herbal agents/supplements

⮚ Over the counter drugs

⮚ Prescription drugs

Herbal/Supplements

• Valerian root
• Kava Kava
• Melatonin
• Chamomile tea

Over the counter drugs

• Sedating antihistamines: Diphenhydramine (Benadryl) and doxylamine

Prescription Drugs

There are four major classes of prescription agents

Benzodiazepines, e.g. Fluraepam, Triazolam

Benzodiazepine Receptor Agonists, e.g. Zolpidem, Zaleplon

Melatonin Receptor Agonists, e.g. Ramelteon

Antidepressants/Antipsychotics, e.g. Amitriptyline, Nortriptyline, Trazodone

When to see your doctor about insomnia

Speak to a Doctor for proper diagnosis and treatment should you notice any of the following:

• Your insomnia symptoms continue for more than four weeks or if the symptoms interfere with your day-to-day activities and your ability to function properly.
• You wake up several times during the night gasping for breath because you feel short of breath.
• You notice that the new medication that you are taking could be the cause of your sleeplessness.
• You notice a painful and crawling sensation in your legs that makes you uncomfortable when trying to sleep or while sitting in a place for a long period.
• You experience excessive heartburn that keeps you awake at night.
• You wake up at night as a result of physical pain.
• You start feeling depressed, agitated and having suicidal or dangerous thoughts.

Conclusively,

Insomnia can be caused by a variety of physical, mental and environmental factors. It has an impact on the quality of your life. Lack of proper sleep does not only affect your daily activities, cognitive processes and productivity but lack of sleep can also make your immune system to deteriorate resulting to health problems such as hypertension, diabetes, depression and obesity.

In severe cases, insomnia can also cause hallucination. Sleep is very important to your physical and mental well being. Improving sleep hygiene remains a very important remedy, even in cases where pharmacologic agents are employed.

Having troubles falling asleep or enjoying interrupted sleep? Speak to a Doctor Now!

ABOUT CO-AUTHOR

Temitope Oyetunji is a Resident Doctor in Family Medicine Department, National Hospital Abuja. She holds an MBBS degree from Ladoke Akintola University of Technology. She enjoys writing and teaching.