Are you ready to get a glimpse of what it is like to live with insomnia?

Introduction

Insomnia condition explained by Idorsia

“It’s like a barrier. I can’t feel much other than tired. If something happy happens, rather than being excited about it, I’m just too tired”

- Patient

We spend approximately a third of our life asleep and, good quality sleep is vital to our health and well-being. For most of us, sleeping is as natural as walking and breathing, but what is it like for people who struggle to get a good night’s sleep, a condition known as insomnia? How does it affect their lives? This resource takes you inside the world of insomnia.

Understanding insomnia

Insomnia condition explained by Idorsia

“It really annoys me when people say ‘if you were really tired, you would sleep’. If only it were that simple! Unless you have suffered from true insomnia, you have absolutely no idea what it’s like.”

- Patient

Most of us take sleep for granted. We may experience the odd sleepless night or even suffer longer periods of poor quality sleep, but the problem usually improves without the need for intervention. For most of the time, we simply go to sleep without even having to think about it.

Insomnia is a persistent condition that has a negative impact on daytime functioning. Poor quality sleep can affect many aspects of daily life, from the ability to concentrate or work effectively to driving skills.

Treatments are available to help restore more restful sleep, but they are often associated with side effects or are not suitable for long-term use. However, self-management programs can be very helpful at improving the quality of sleep.

What is sleep?

Before we look at insomnia in more detail, it is useful to understand exactly what sleep is. Sleep can seem like quite a mysterious process that takes us from consciousness to unconsciousness. In fact, some of its complexities are still not fully understood.

It has been said that we could survive three times longer without food than we could without sleep.

  • + What happens during sleep?
    • Sleep is vital for repairing and restoring our body and brain.
    • The process of sleeping complex. The pattern or structure of sleep is often described as ‘sleep architecture’.
    • During sleep, our heart rate drops, body temperature falls and there are changes in brain activity. Sensory stimulation is blocked out and the muscles become relaxed or, at some times, paralyzed.
    • Sleep is divided into cycles, lasting around 90 minutes each. On average, we go through four cycles a night.
    • A number of hormones called neurotransmitters (chemical ‘messengers’ between cells) and neuromodulators (that manage the effects of the ‘messengers’) are involved in the sleep-wake cycle. These include dopamine, orexin, histamine, acetylcholine, norepinephrine, glutamate, GABA, adenosine and serotonin.
  • + What is NREM sleep?
    • Non-rapid eye movement (NREM) sleep is divided into four stages: stages 1 and 2 are light sleep, 3 and 4, deep sleep. Deep sleep is a very refreshing type of sleep and is needed to restore the mind and body.
    • On average, NREM accounts for 75-80% of the total sleep in an adult.
  • + What is REM sleep?
    • Rapid eye moment (REM) sleep completes the sleep cycle.
    • As its name suggests, eyes move rapidly behind eyelids and the brain is active, while the muscles become so relaxed that we cannot move our limbs.
    • On average, an adult has 2 hours REM sleep a night.
    • Most dreams occur during REM sleep.

What is insomnia?

Insomnia is very different from a short-term period of poor sleep, and can take its toll on both the physical and mental health. It is officially defined as dissatisfaction with sleep quality or quantity on at least three nights per week for at least 3 months, despite adequate opportunity to sleep, i.e. there is nothing obvious preventing sleep. It can cause significant distress for those affected, with a negative impact on daytime functioning due to effects such as fatigue, poor concentration or feeling down.

Insomnia can take different forms: difficulty falling asleep; problems staying asleep; waking too early; or a combination of these.

  • + Types of insomnia
    • In the past, insomnia was categorized into two classes: primary insomnia, which could not be explained by another cause, and secondary insomnia, which was associated with other conditions.
    • Nowadays there are more ways to describe the different types of insomnia: episodic, in which symptoms of insomnia have been present for at least 1 month, but less than 3; persistent, with symptoms lasting three months or longer; and recurrent, where the person has experienced at least 2 episodes of persistent insomnia (3 months or more) over the course of a year.
    • Insomnia is now recognized as a condition that requires clinical attention, regardless of any other medical problems the patient might have.
    • Insomnia is just one of a group of more than 70 sleep-wake disorders. These include disorders such as obstructive sleep apnea (a condition in which the airway becomes obstructed, causing the person to wake up repeatedly during sleep), circadian rhythm disorders (often caused by jet lag or shift work), parasomnias (nightmares, sleepwalking, night terrors and limb movement disorders), and narcolepsy (excessive sleepiness).

What causes sleep
problems and who
gets them?

“It started when we had young children. The sleepless nights got to my brain, so even though the kids are long gone, the psychological damage was long-term – by that I mean my paranoia at being short of sleep.”

- Patient

Poor sleep patterns can develop out of the blue for no apparent reason, but in some cases, an underlying cause or trigger can be identified.

Often, the impact on sleeping patterns is temporary and things improve when these external factors are no longer an issue. For some people, however, poor sleep can become an entrenched habit. Fear of not getting enough sleep adds to stress and tension, which can worsen sleep problems, leading to a vicious cycle.

  • + Associated causes

    Sleep problems and sleep disorders are often associated with:

    • Major life events, such as a relocation or the loss of a family member
    • Stress at work
    • Jetlag or shift work
    • Other medical problems such as heart disease, pain or restless legs
    • Some prescribed medicines – e.g. steroids, diuretics and some antidepressants
    • Poor sleeping environment – too much noise or light, or an uncomfortable bed
    • Over-use of stimulants such as alcohol, caffeine or nicotine
    • Depression and anxiety

Diagnosis and treatment of insomnia

Insomnia condition damage to long-term health

“I am always amazed how I cope at work with minimal sleep. You just get used to it, but I do wonder about the damage to my long-term health”

- Patient

Insomnia is often under-diagnosed and under-treated. It is estimated that around 70% of people with persistent insomnia never seek medical help.

Insomnia is usually diagnosed and treated by a family doctor, but some patients may be referred to a sleep specialist or a sleep clinic for further investigation, particularly if sleep apnea is suspected.

  • + When to seek medical advice
    • Occasional periods of poor sleep are not unusual, and as such not necessarily linked to insomnia. In many cases, self-help measures can be enough to restore normal sleep patterns.
    • It is sensible to seek medical advice if sleep disturbance is affecting daily life or if it persists for more than a few weeks.
  • + What tests are used to diagnose insomnia?
    • The family doctor will discuss patient history, sleeping patterns, symptoms and lifestyle habits and will explore whether underlying health conditions are involved.
    • Some patients are asked to keep a diary of symptoms and intake of substances such as coffee, tea and alcohol.
    • Some patients may be asked to wear an actigraph (a device that records movement) for a couple of days.
    • Others may be referred for an overnight stay in a specialist sleep clinic and may be tested with polysomnography equipment, which measures brain activity (electroencephalograph), eye movement (electro-oculograph) and muscular activity (electro-myograph).
    • These tests can help to distinguish between difficulty getting to sleep and difficulty in staying asleep.

What treatments are available for insomnia?

A variety of approaches can be tried, depending on the likely cause of insomnia and the degree of severity. The main options are: ‘sleep hygiene’ techniques, cognitive behavioral therapy, short courses of prescription sleeping tablets or melatonin. Medication may also be provided to treat underlying health problems.

  • + Sleep hygiene techniques
    • This approach is designed to establish more positive habits and improve sleep quality. Key elements include: regular sleeping hours, avoiding daytime naps, a restful sleeping environment, regular exercise, restricting stimulants, relaxation techniques and restricting time in bed.
    • We will look at some of these in more detail in the ‘Practical Guidance’ section.
  • + Cognitive behavioral therapy
    • This is a form of talking therapy to help people avoid or re-frame the thoughts or behaviors that are preventing sleep. Psychological approaches can help to establish better sleep patterns or to develop a more positive mental outlook about sleep.
    • Specific techniques such as Stimulus Control Therapy or Sleep Restriction Therapy may be taught.
    • Unfortunately, there are often long waiting lists to access this type of therapy but patients can try some of the key principles outlined in this resource.
    • We will look at some of these in more detail in the ‘Practical Guidance’ section.
  • + Sleeping tablets
    • If other approaches have failed, a short course of sleeping tablets may be prescribed to try and restore sleeping patterns. In most cases, benzodiazepines or one of the ‘Z drugs’ (zolpidem, zaleplon and zopiclone) are prescribed.
    • Benzodiazepines are general sedative agents prescribed for people with anxiety-associated insomnia and can cause side effects such as drowsiness the next day.
    • The Z drugs, approved for insomnia specifically, have a more selective mode of action, but can still be associated with some degree of ‘hangover’ effect the next day. They may also become less effective over time.
    • Both benzodiazepines and the Z drugs are only recommended for short-term use (2-4 weeks) as they can be associated with risk of addiction.
    • Some people use over the counter herbal supplements and antihistamines to help them sleep better, but these offer limited proven benefit and are not licensed as a treatment for insomnia.
  • + Melatonin
    • Melatonin is a sleep-regulating hormone, whose production is triggered during the night.
    • Older people may produce less melatonin and are more likely to suffer from insomnia.
    • Melatonin has recently been licensed in Europe for the short-term treatment of primary insomnia characterized by poor quality of sleep in patients who are aged 55 or over.
  • + Medication for other conditions

    Medication may be provided to treat other conditions that are affecting sleep, e.g. pain associated with arthritis, restless legs syndrome, depression, heart disease and night sweats associated with the menopause.

Burden of insomnia

insomnia gets in the way of everything

“When I am going through a bad patch, insomnia gets in the way of everything. Work, going out, doing exercise. Everything just seems like too much of an effort. I try not to think about it too much – you can so easily get obsessed with getting a good night’s sleep – but it’s always there at the back of my mind”

- Patient

The impact of insomnia is often underestimated. In reality, it can be a distressing condition that can reduce quality of life. It may affect many aspects of daily life from studying and employment to social activities and relationships.

Insomnia can have a significant economic impact and increases the risk of accident and injury on the road or in the workplace.

  • + Work and employment

    Insomnia is a leading cause of absenteeism and reduced productivity at work. The estimated global cost of insomnia is around USD 100 billion each year.

    People with insomnia are three times more likely to lack concentration during the day compared with good sleepers, and twice as likely to suffer from poor energy levels.

  • + Emotional wellbeing

    People with insomnia are three times more likely to experience feeling down or depressed, compared to people with normal sleep patterns.

    Worrying about sleep can cause stress, leading to negative thought patterns which may make it more difficult to sleep, setting up a vicious circle.

  • + Friends and family

    Sleepless nights can leave people feeling irritable and out of sorts – this may impact relationships.

    People who suffer from insomnia may lack the energy or motivation to exercise or to take part in social activities.

    Family, friends and colleagues may not realize the true impact that insomnia can have, and people affected by insomnia may perceive them as not very supportive or empathetic.

  • + Insomnia and accidents

    Insomnia increases the risk of accident and injury.

    Driver fatigue affects reaction times: going just 17 hours without sleep can compromise speed and accuracy as much as having two alcoholic drinks.

    A survey of statistics across Europe estimates that around 20% of car accidents are linked with fatigue.

    The National Sleep Foundation estimates that 100,000 vehicle accidents occur in the US annually due to ‘drowsy driving’ – driving while concentration is impaired due to lack of sleep.

    In the UK, the Health and Safety Executive estimates that fatigue costs the UK £115-240 million in terms of work accidents.

Practical guidance on managing insomnia

Guidance on managing insomnia

“Some mornings you get up and wonder how on earth you are going to get through the day. Somehow you do, but it can be a massive struggle”

- Patient

People with insomnia can take practical steps to improve their physical and mental wellbeing and to improve the quality of their sleep. This section outlines some of the strategies that can be helpful.

Taking positive control

Some of the approaches that have been developed to improve sleep quality can be very effective. Sometimes even relatively small adjustments in our lifestyle or attitude to sleep can make it easier to get a good night’s sleep. It is worth persevering. If one approach does not work, it is worth trying something else.

  • + Avoid stimulants

    Everyday choices about what we eat and drink can affect the quality of our sleep. Some substances and activities can stimulate the central nervous system, making it harder to sleep:

    • It is best to avoid products containing caffeine such as coffee, tea, cola and even chocolate for around 4-6 hours prior to bedtime. Decaffeinated products or herbal teas can be chosen as an alternative.
    • Even a small amount of alcohol can interfere with your sleep. Drinking alcohol close to bedtime typically reduces the number of REM cycles, which means you may wake feeling exhausted.
    • Large meals close to bedtime should be avoided as they can be difficult to digest.
    • Smoking may also affect sleep, and stopping or cutting down smoking may provide long-term improvement in sleep patterns.
  • + Remain active
    • When we feel tired, exercise is usually the last thing we feel like doing, but it can help to improve sleep.
    • Any form of exercise is helpful – even a short walk. 30 minutes of moderate exercise on at least 5 days a week is a sensible goal.
    • However, it is best to avoid vigorous exercise later in the day as this can be too stimulating.

Specific approaches

“Lying awake in the small hours is an incredibly lonely experience. You start worrying about what you have to do next day and your mind fills with other fears and anxieties. Everything seems worse in the dead of the night”

- Patient
  • + Make your bedroom a sanctuary

    It may seem obvious, but a good sleeping environment is vital to promote restful sleep:

    • Too much light can affect melatonin levels and should be restricted at bedtime. Black-out blinds or curtains and eye masks can help to block out light.
    • Earplugs or noise-cancelling earphones can be helpful if exterior noise is an issue.
    • Partners who snore should be encouraged to seek medical advice.
    • Bed and mattress should be back-friendly and comfortable.
    • It is important to ensure that the bedroom is not too hot and not too cold. Wearing natural fabrics and using layers of bedding can help to avoid over-heating.
    • Some people find it helpful to cover or switch off illuminated time displays – checking on the time during the night can increase anxiety about not sleeping.
  • + Stimulus control therapy

    This is a specific program that may be taught as part of cognitive behavioral therapy (CBT) to overcome negative patterns created through unsuccessful attempts to fall asleep. Key principles are:

    • Go to bed only when you feel sleepy.
    • Use your bed only for sleep – avoid watching TV, reading or working in bed.
    • If you don’t fall asleep within 20 minutes, get out of bed and do something else.
    • Return to bed when you feel sleepy.
    • Set your alarm to wake you at the same time every day.
    • Try to avoid afternoon naps and don’t be tempted to sleep in at weekends.
  • + Sleep restriction therapy

    A program designed to limit the amount of time spent in bed at night. This system may be taught as part of cognitive behavioral therapy (CBT). Key principles are:

    • Keep a diary to see how long you are actually sleeping at night.
    • Restrict your time in bed to the time you are actually sleeping and get up at the same time every day.
    • Gradually adjust time in bed on a weekly basis until you are achieving a longer period of sleep.
  • + Tackle technology
    • Many of us spend a large proportion of our day checking our phone or tablet or working at a computer.
    • The backlit blue light emitted by these devices can suppress melatonin production, which can lead to sleep disruption.
    • Ideally, all technology should be banned from the bedroom, and it is sensible to switch off phones, computers etc. for an hour before going to bed.
    • It is best to avoid having a TV in the bedroom.
  • + Relax the body
    • Regular exercise can be helpful in restoring restful sleep.
    • Complementary treatments such as massage, reflexology or acupuncture can be relaxing, but it is important to find a reputable and experienced practitioner.
    • A warm (not hot) bath before bedtime can be relaxing.
    • Gentle stretching before bedtime can help to relax the body.
    • Learning yoga or progressive muscle relaxation techniques can be beneficial to people with insomnia.
  • + Calm the mind
    • Many people with insomnia find that they cannot switch off mentally when they go to bed.
    • Worrying about not sleeping leads to even poorer sleep so it is important to break the cycle.
    • Avoid anything mentally challenging within 90 minutes of going to bed. This includes stimulating TV programs, video games or books.
    • Mindfulness, meditation or visualization can be effective at calming a racing mind. A range of CDs or audio guides are available to buy and many free resources and apps can be found online.
    • It is helpful to keep a notebook by the bed and to write down any concerns/worries before going to sleep.