Living with
Insomnia

Insomnia

Insomnia is a common sleep disorder where you have difficulty falling asleep or staying asleep, which ultimately interferes with your functioning during the day. We need good quality sleep for our overall well-being, similarly to the way we need nutritious food and exercise. Poor quality sleep deteriorates our immune response, and conversely, a good night’s sleep can increase our immunity.

For those suffering from insomnia, not only do they feel fatigued and devoid of energy, chronic insomnia also has an effect on cognitive ability, emotional health and physical functioning, putting them at risk for accidents, diminished work performance, decreased quality of life, and increased health care utilisation. Insomnia is frequently a comorbid condition with depression, as well as with chronic pain and cardiovascular disease.

While the prevalence of insomnia depends on the criteria used to define insomnia, population-based studies estimate that about 30% of adults worldwide report one or more of the symptoms of insomnia.321§

What is insomnia?

Insomnia is characterised by difficulty falling asleep, staying asleep or having nonrestorative sleep, despite adequate opportunity and circumstance to sleep. The lack of sleep is associated with daytime impairment or distress/ anxiety, and happens at least three times per week, for at least one month.

Insomnia differs from sleep deprivation, where you don’t get the chance of a full night’s sleep. Insomniacs also differ from those that are short sleepers who can function normally on only five hours of sleep or less.

Insomnia is most often classified by duration:

• Transient insomnia lasts for less than one month.

• Acute/ short-term/ adjustment insomnia lasts between one and six months, and is usually caused by stress or a traumatic life event, such as losing a loved one, a major relationship change, or a serious medical diagnosis. Acute insomnia is usually the precursor to chronic insomnia.

• Chronic insomnia is when a person has insomnia for at least three nights per week for more than six months. It can be persistent, or recurrent with months-long episodes at a time.

Types of insomnia 

There are generally two types of insomnia: 

1. Primary insomnia is sleeplessness that is not linked to any health condition or problem. For some, it may begin in childhood, and can even be lifelong. It also called idiopathic insomnia. 

2. Secondary insomnia is when symptoms arise from an existing medical, psychiatric or environmental cause (e.g. drug abuse, medications or exposure to certain substances). This is also known as comorbid insomnia. 

A number of other terms are also used to describe insomnia, including: 

• Sleep onset insomnia: When the person has difficulty falling asleep at the beginning of the night, or in the case of shift workers, whenever they attempt to initiate sleep. People with sleep onset problems can’t fall asleep even after spending 20-30 minutes in bed. Sleep onset insomnia also affects children – when a child associates falling asleep with an action (being held or rocked), object (bottle) or setting (parents’ bed), and is unable to fall asleep if separated from that association. 

• Sleep maintenance insomnia: This describes an inability to stay asleep through the night, where the person wakes up at least once during the night and then struggles to get back to sleep for at least 20-30 minutes. 

• Early morning awakening insomnia: This involves waking up well before a person desires. 

• Mixed insomnia: Although not a formal term, it may be applied to people who have a combination of problems related to sleep onset, sleep maintenance, and early morning awakenings. 

• Psychophysiological insomnia: This occurs when there is an excessive amount of anxiety and worry regarding sleep and sleeplessness. 

• Paradoxical insomnia: This occurs when a person feels their sleep is greatly disturbed but no other evidence confirms the presence of sleep difficulties, and may greatly underestimate how much sleep they are getting. This is also known as sleep state misperception (SSM). 

What are the symptoms? 

Symptoms include: 

• Fatigue 

• Daytime sleepiness 

• Irritability or moodiness 

• Depression or anxiety 

• Lack of concentration 

• Increased errors or accidents 

• Anxiety about sleep 

• Poor memory 

• Poor quality performance at school or work 

• Lack of motivation or energy 

• Headaches 

• Upset stomach 

When to see a doctor 

People should see a doctor if insomnia makes it hard for them to function during the day. Before the doctor’s appointment, it’s advised that the patient keeps a sleep diary that lists sleep times, how long it takes for them to fall asleep, how deeply they think they sleep and how much time is actually spent asleep. 

What causes insomnia? 

Insomnia can be a primary problem, or it’s associated to other conditions. Common causes of chronic insomnia include: 

Primary causes: 

• Stress: concerns about work, school, health, finances or relationships 

• Traumatic life events: divorce, death of a loved one or a debilitating illness, for instance 

• Travel: jet lag 

• Work schedule: shift work or frequently changing shifts 

• Poor sleep habits – irregular bedtimes, stimulating activities before bed, an uncomfortable sleep environment, screen time before bed. 

• Overeating late at night 

• Ageing: once you reach the age of 60, your sleep patterns change as your internal clock advances to rise earlier and go to bed earlier. 

Secondary causes: 

• The use of certain medications – blood pressure medications (e.g. beta blockers), asthma medications (e.g. theophylline), certain antidepressants, some pain medications, weight loss products, some steroids 

• Mental health disorders – anxiety, post-traumatic stress disorder, depression 

• Medical conditions – chronic pain, cancer, diabetes, heart disease, asthma, gastroesophageal reflux disease (GERD), overactive thyroid, Parkinson’s disease, Alzheimer’s disease, bladder and prostrate issues, dementia 

• Sleep-related disorders – sleep apnea, restless legs 

• Caffeine, nicotine and alcohol 

• Pregnancy, menopause, PMS 

• ADHD 

Risk factors 

The following factors can increase the risk of insomnia: 

• Hormonal shifts during the menstrual cycle, PMS, menopause and pregnancy 

• Being over the age of 60 

• Mental health disorders, such as depression and anxiety 

• Some physical health conditions [as mentioned above] 

• Stress 

• Irregular work schedules 

• Certain medications that have insomnia as a side-effect 

• Long-term illness 

How is it diagnosed? 

Insomnia is not a disease, so there is no specific test to diagnose it. Often, insomnia is related to another cause. Doctors will look at the patient’s medical history, any existing medical problems, and any medications that the person is on. The doctor may also want to do blood tests to rule out certain medical conditions such as thyroid problems. 

Complications 

Insomnia or poor-quality sleep negatively affects your physical and mental health overtime, eventually affecting your quality of life. Insomnia can contribute to: 

• Diabetes 

• Driving accidents, injuries and falls 

• High blood pressure (hypertension) 

• Heart disease and stroke 

• Weight gain and obesity 

• Depression 

• Anxiety 

• Reduced memory functioning 

• Poor emotional and behavioural control 

Common comorbid, bidirectional conditions 

Insomnia has a bidirectional relationship with chronic pain, depression and cardiovascular disease. 

1. Chronic pain is bidirectional because pain disrupts sleep and poor sleep quality lowers the pain threshold and increases the risk for spontaneous pain. Epidemiological studies have shown that poor sleep quality and insufficient sleep duration are risk factors for the development of chronic pain. Furthermore, there is strong evidence that having short or disturbed sleep can cause hyperalgesia (i.e., an increased sensitivity to painful stimulation) and the development or exacerbation of spontaneous pain symptoms (e.g., muscle pain, headache) pain1. The cycle then perpetuates and intensifies over time. 

2. Depression is also a risk factor for insomnia and a consequence of insomnia. It’s estimated that about 40% of adults with insomnia have a diagnosable psychiatric disorder—most notably depression. Poor sleep leads to increased tension and irritability, which affects mood, and those with untreated depression may be dealing with emotional trauma which triggers sleep disturbances. 

3. Cardiovascular disease: Non-rapid eye movement sleep decreases arterial blood pressure and heart rate and increases the parasympathetic function of the heart at specific points in the night. Thus, insomnia affects circadian heart regulation, which may lead to cardiovascular disease  and stroke. On the other hand, complications of heart failure can affect sleep. For instance, chest pain and discomfort make it hard to relax and fall or stay asleep or lying in bed can make one feel short of breath. 

Treatment 

Treatment for insomnia can include any of the following, depending on the cause. However, over the long term, behaviour and lifestyle changes can best help you improve your sleep. 

1. Cognitive behavioural therapy (CBT) 

CBT involves any combinations of the following therapies: 

• Cognitive therapy: changing attitudes and beliefs that impede your sleep 

• Relaxation training: relaxation techniques to relax your mind and body 

• Sleep hygiene training: correcting bad sleep habits that contribute to poor sleep 

• Sleep restriction: severely limiting and then gradually increasing your time in bed 

• Stimulus control: reducing the amount of stimulus in the bedroom (e.g. screens, bright light) and before going to bed 

• Light therapy: exposing your eyes to light (naturally with sunlight or with a light box) to help reset your circadian rhythms. 

2. Over-the-counter products 

• Medication: Most of the OTC sleep medication contain antihistamine, which helps you sleep better but can also cause daytime sleepiness. 

• Herbs and supplements*: There are various natural sleep aids that can potentially address mild to moderate insomnia. The most popular supplements for sleep problems include melatonin, Gamma-aminobutyric acid (GABA), tryptophan, 5-hydroxytryptophan (5-HTP), cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC), valerian root, lavender and magnesium. [Please note that supplements are not evaluated by the South African Health Products Regulatory Authority (SAPHRA) for efficacy.] 

3. Prescription sleeping pills 

Prescription hypnotics can improve sleep quality.

These include:

• Benzodiazepine receptor agonists (typically prescribed for short-term use)
  
• Nonbenzodiazepines 

4. Other prescription medication 

While not indicated specifically for insomnia, the following other medications are also prescribed for insomnia, including: 

• antidepressants, such as trazodone 

• anticonvulsants 

• antipsychotics 

• barbiturates 

• nonhypnotic benzodiazepines 

*When choosing your supplement, always check if there is a full list of ingredients on the product, a package insert, a valid company address with contact details and compliance to Good Manufacturing Practices (GMP), which is a prerequisite for health product manufacturing.  

How can I prevent insomnia? 

With minor improvements to your bedtime routine and some lifestyle changes, you can sleep better: 

• Keep your bedtime and wake time consistent, including weekends. 

• Be physically active during the day. 

• Spend time outside. 

• Don’t eat large meals in the evening. 

• Avoid caffeine and alcohol before bed. 

• Put away screens at least 30 minutes before bedtime. 

• Quit smoking. 

• Make your bedroom conducive to sleep, and don’t use the space for non-related activities such as watching television or working. 

• Create a soothing bedtime ritual, such as taking a warm bath, reading or listening to soft music. 

• Avoid or limit naps because they make it harder to fall asleep at night. If you have to nap, limit it to no more than 30 minutes and don’t nap after 3pm.