Insomnia – What You Should Know

Insomnia means having problems with sleep. Sleep is an incredible part of our life when we are not conscious. It is one of our important daily routines that help reset our ability to remain focused in the wakeful period and to understand insomnia we need to have some little knowledge of the chemistry of sleep and what makes us sleep.

Emerging from sleep feeling well rested is everybody’s desires but what not everyone knows is that alternating between sleep and being awake is the result of the combined action of various chemicals and processes in the brain. Among the most important are adenosine, melatonin, cortisol and the circadian rhythm.

These play a very active role in sleep regulation.

1. Adenosine

Adenosine is a molecule produced from the degradation of adenosine triphosphate (ATP), a chemical in the generation of energy. The more you are awake, the more adenosine is produced. The cumulative effect of the increasing presence of adenosine after 12-14 hours of wakefulness is what promotes or drives sleep hunger.

For coffee lovers, caffeine directly opposes the effect of sleep pressure by competitively   blocking adenosine-binding sites on the receptor and thus blocking the signals that make one feel sleepy. 

2. Melatonin

This is a hormone produced by the pineal gland, part of the endocrine system (a very small gland in the centre of the brain shaped like a pinecone, which is where it got its name. Light suppresses the function of the Pineal gland; hence it is also called the ‘darkness gland’.

The main function of the pineal gland is to receive information about the state of the light-dark cycle from the environment and make use of this information through the production and secretion of the hormone melatonin.

As darkness sets in, a nucleus in the hypothalamus (brain) called the suprachiasmatic nucleus (SCN) also called the ‘central clock’, receives signals about light and dark from the retina of the eye and sends signals to the pineal gland for the release of melatonin.

This helps one fall asleep but cannot maintain sleep. It is endogenous and so we have no control over its function. The 2^nd function of melatonin is the suppression of the onset of puberty.

3. Circadian Rhythm

Circadian rhythm is the 24-hour internal clock in our brain that regulates cycles of alertness and sleepiness by responding to light changes in our environment. Within this rhythm, one is asleep only for 8 hours and is awake for 16 hours.

The suprachiasmatic nucleus (SCN), which is the centre for integrating rhythmic information and establishing sleep patterns, controls the circadian cycle. The SCN after receiving information from the retina signals the release of melatonin. In anticipation of wake time, the circadian clock also sets off a cascade of hormones that results in the release of cortisol at least 2 hrs before awakening (Cortisol is an alertness-boosting hormone.)

Past the early morning spike, the body’s cortisol reserves gradually decline as the day goes on thus Melatonin eases one into sleep, while cortisol helps one get up and keep awake. Viewing the light early in the morning helps set the normal sleep-wake rhythm. 

You’ve probably had nights when you couldn’t fall asleep, no matter how desperately you tried, if this difficulty of falling or staying asleep, early awakening, or a sensation of unrefreshing sleep persists, it is called insomnia.

Sleep Patterns

It is also important to know about sleep patterns. There are 2 states of sleep patterns viz:

1. Nonrapid eye movement (NREM)

NREM sleep constitutes about 75 to 80% of total sleep time in adults. Heart rate and body temperature tend to decrease. NREM sleep consists of 3 stages (N1 to N3) in the increasing depth of sleep. 

• • Stage N1

This is the changeover from wakefulness to sleep.  During this short period (lasting several minutes) of relatively light sleep, the heartbeat, breathing, and eye movements slow, and the muscles relax with occasional twitches.  Your brain waves begin to slow from their daytime wakefulness patterns.

• • Stage N2

N2 is a period of light sleep before you enter deeper sleep. The heartbeat and breathing slow, and muscles relax even further also, the body temperature drops and eye movements stop.  Brain wave activity slows but is marked by brief bursts of electrical activity (K complexes and sleep spindles on the EEG).

One spends more of the repeated sleep cycles in stage 2 sleep than in other sleep stages.

• • Stage N3

N3 is the period of deep sleep that you need to feel refreshed in the morning.  It occurs in longer periods during the first half of the night.  The heartbeat and breathing slow to their lowest levels during sleep.  Your muscles are relaxed and it may be difficult to awaken you.  Brain waves become even slower. People may perceive this stage as high-quality sleep.

2. Rapid eye movement (REM)

REM first occurs about 90 minutes after falling asleep.  The eyes move rapidly from side to side behind closed eyelids.  Mixed-frequency brain wave activity becomes closer to that seen in wakefulness.  The breathing becomes faster and irregular, and the heart rate and blood pressure increase to near waking levels.  Most of your dreaming occurs during REM sleep, although some can also occur in non-REM sleep.  Your arm and leg muscles become temporarily paralyzed, which prevents you from acting out your dreams.  As you age, you sleep less of your time in REM sleep.  Memory consolidation most likely requires both non-REM and REM sleep. Normally, 20 to 25% of sleep is REM.

One cycles through all stages of non-REM and REM sleep several times (5 to 6 times a night) during a typical night, with increasingly longer, deeper REM periods occurring toward morning.

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. Often, insomnia is driven by the mind, body clock or habit.

Types of Insomnia

1. Acute Insomnia (short-term insomnia)

This is also called adjustment insomnia and it is a brief episode of difficulty sleeping lasting for less than three months, and symptoms may fade on their own as time passes and a person copes with the stressful incident that gave rise to their sleeping problems, often caused by a stressful life event such as the loss of a loved one, medical diagnosis causing one to feel unsettled, rebounding from the cessation of a drug or marijuana, or a major job or relationship change.

Acute insomnia, however, can be persistent and become chronic insomnia.

2. Chronic insomnia

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

Some people with chronic insomnia have a long history of difficulty sleeping. The inability to sleep may be persistent or goes away and recurs with months-long episodes at a time.

Like acute insomnia, it can be tied to stressful situations, but it may also be related to irregular sleep schedules, poor sleep hygiene, persistent nightmares, mental health disorders, underlying physical or neurological problems, medications, a bed partner, and certain other sleep disorders.

3. Other ways of describing insomnia

While the sleep disorder of insomnia is principally classified as either acute or chronic, other terms may be used to describe insomnia. These terms may be used informally.

• • Sleep onset insomnia

This describes difficulty falling asleep at the beginning of the night, or in the case of shift workers, whenever they attempt to initiate sleep. 

• • Sleep maintenance insomnia

Sleep maintenance insomnia describes an inability to stay asleep through the night. Most often, this means waking up at least once during the night and struggling to get back to sleep for at least 20-30 minutes.

The fragmented sleep associated with poor sleep maintenance means a decrease in both sleep quantity and quality, creating higher chances of daytime sleepiness or sluggishness.

• • Early morning awakening insomnia

This type of insomnia involves waking up well before a person wants or plans to in the morning. Some experts view this as a component of sleep maintenance while others consider it separately.

The inability to get the desired amount of sleep can impair one’s physical and mental function the next day.

• • Mixed insomnia

Though not a formal term, mixed insomnia may be applied to people who have a combination of problems related to sleep onset, sleep maintenance, and early morning awakenings.

• • Secondary insomnia (Co-morbid insomnia)

In the past, sleeping problems were sometimes labelled as secondary insomnia. This meant that insomnia was believed to arise as a result of other conditions such as anxiety, depression, sleep apnea physical pain etc.

Studies have shown that this type of insomnia often has a bidirectional relationship with other health issues. For example, while anxiety may contribute to insomnia, insomnia may exacerbate anxiety as well. Furthermore, insomnia triggered by another condition does not always go away even after that underlying issue is resolved.

Because of the complexity of these relationships, it becomes difficult to classify insomnia as strictly co-morbid or secondary. Similarly, the presence of multiple contributing factors makes identifying a single cause of insomnia challenging for many patients.

Causes of Insomnia

Causes of insomnia can either be primary or secondary viz

1. Primary causes of insomnia include:

Stress related to big life events.

• Like a job loss or change.
• The death of a loved one.
• Divorce.
• Moving

Things around you. 

• Like noise.
• Light.
• Temperature

Changes in sleep schedule

• Like jet lag.
• A new shift at work.
• Bad habits picked up when you had other sleep problems.

Genes.

• Research has found that a tendency for insomnia may run in families.

2. Secondary causes of insomnia include:

• • Mental health challenges e.g. depression and anxiety.
  • Medications for colds, allergies, high blood pressure, asthma, and depression.
  • Pain or discomfort at night.
  • Caffeine, tobacco or alcohol use, as well as the use of illicit drugs.
  • Hyperthyroidism and other endocrine problems.
  • Other sleep disorders, like sleep apnea or restless leg syndrome. 
  • Pregnancy.
  • Alzheimer’s disease and other types of dementia.
  • Attention deficit hyperactivity disorder (ADHD)
  • Premenstrual syndrome (PMS) or menopause.

Symptoms of insomnia

Insomnia can be recognized by the following symptoms:

• Waking too early and finding yourself unable to fall back asleep.
• Spending a lot of the night lying awake, worrying you won’t fall asleep
• A consistent pattern of interrupted or broken sleep that doesn’t refresh you.
• Trouble falling asleep after going to bed.
• As a result, you might begin to experience other symptoms related to lack of sleep, including 🙁 fatigue, irritability and other mood changes, difficulty concentrating or remembering things).

Diagnosis /Investigation

There is no specific test to diagnose insomnia. The GP performs a physical exam and asks questions to learn more about the patient’s sleep issues and symptoms. 

The key information for the diagnosis/investigation of insomnia is reviewing the patient’s sleep history, medical history and medications with your doctor to see if they may be affecting your ability to sleep. Also, blood work is to rule out certain medical conditions such as thyroid issues or low iron levels that can negatively impact sleep.

Millions of people are using smart technology (smartphone apps) bedside monitors, and wearable items (including bracelets, smart watches, and headbands) to informally collect and analyze data about their sleep.  Smart technology can record sounds and movement during sleep.

Using a companion app, data from some devices can be synced to a smartphone or tablet or uploaded to a PC.  Other apps and devices make white noise, produce light that stimulates melatonin production, and use gentle vibrations to help us sleep and wake.

Problems of insomnia

      The role of sleep health in the development and management of chronic diseases has grown. Notably, insufficient sleep has been linked to the development and management of several chronic diseases and conditions, including type 2 diabetes, cardiovascular disease, obesity, and depression.

1. Diabetes

Research has found that insufficient sleep is linked to an increased risk for the development of type 2 diabetes. Specifically, sleep duration and quality have emerged as predictors of levels of glycosylated haemoglobin (Hemoglobin A1c), an important marker of blood sugar control. Recent research suggests that optimizing sleep duration and quality may be important means of improving blood sugar control in persons with type 2 diabetes.

2. Cardiovascular Disease

Sleep apnea has been found to increase the risk for several cardiovascular diseases viz hypertension, stroke, coronary heart disease and irregular heartbeats (cardiac arrhythmias) are more common among those with disordered sleep than their peers without sleep abnormalities. Likewise, sleep apnea and hardening of the arteries (atherosclerosis) appear to share some common physiological characteristics, further suggesting that sleep apnea may be an important predictor of cardiovascular disease.

3. Obesity

Laboratory research has found that short sleep duration results in metabolic changes that may be linked to obesity. 

4. Depression

The relationship between sleep and depression is complex. While sleep disturbance has long been held to be an important symptom of depression, recent research has indicated that depressive symptoms may decrease once sleep apnea has been effectively treated and sufficient sleep restored thus suggesting interrelatedness between sleep and depression.

Insomnia Treatment

There are several treatment options for insomnia viz: Therapy, medication and supplements, and natural remedies.

1. Therapy

Cognitive behavioural therapy (CBT) for insomnia. This is the first line of treatment for insomnia in adults.

• • Stimulus control

In this technique you are taught to get out of bed and find a quiet and relaxing activity until you feel sleepy, limiting the time you spend lying awake and worrying about falling asleep.

• • Sleep restriction

Here, the time in bed is curtailed to the actual sleep time. The aim is to consolidate sleep over a shorter period.

• • Bright light therapy

This technique involves exposure to bright light in the morning or evening, depending on whether you have more trouble falling asleep or staying asleep.

• • Relaxation techniques/Sleep Hygiene practices

The therapist helps identify underlying mental health symptoms contributing to insomnia or making the symptoms worse and also addresses behaviours preventing one from getting enough quality sleep like:

• Drinking caffeinated beverages near bedtime.
• Eating large or heavy meals or spicy foods close to bedtime.
• Engaging in the intense exercise near bedtime.
• Using your bed for anything other than sleep or sex.

Addressing these triggers and contributing factors can go a long way toward helping relieve insomnia.

2. Medications

• • Eszopiclone (Lunesta)

This is in a class of medications called hypnotics. It works by slowing activity in the brain to allow sleep.

• • Zolpidem (Ambien)

This is a hypnotic drug that improves sleep in patients with insomnia.

• • Triazolam (Halcion)

This belongs to a class of drugs called benzodiazepines. It acts on your brain to produce a calming effect. Over-the-counter (OTC) sleep aids and supplements like melatonin can also offer some relief from insomnia.

Tips on getting a good and quality sleep

• Set a schedule – go to bed and wake up at the same time each day.
• Exercise 20 to 30 minutes a day but no later than a few hours before going to bed.
• Avoid caffeine and nicotine late in the day and alcoholic drinks before bed.
• Relax before bed – try a warm bath, reading, or another relaxing routine.
• Create a room for sleep – avoid bright lights and loud sounds, keep the room at a comfortable temperature, and don’t watch TV or have a computer in your bedroom.
• Don’t lie in bed awake.  If you can’t get to sleep, do something else, like reading or listening to music, until you feel tired.

Conclusion

Insomnia is a sleep disorder that can affect both mental and emotional health along with physical well-being and is associated with a wide range of impaired daytime functions across several emotional, social, and physical domains. P

People with persistent sleep disturbances are also more prone to accidents, higher rates of work absenteeism, diminished job performance, decreased quality of life, and increased health care utilization. 

Approximately 40% of adults with insomnia also have a diagnosable psychiatric disorder—most notably depression. Recent research suggests that insomnia and depression share common pathological processes that make individuals vulnerable to both conditions.

See a doctor if you have a problem sleeping or if you feel unusually tired during the day.  Most sleep disorders can be treated effectively.