Insomnia - what is Insomnia and why is Insomnia important - what should we do about Insomnia

Insomnia - this remains and justifiably so - one of the top reasons persons seek medical help. This problem is at the best of times resistant to remedies.

Insomnia refers to repeatedly difficulty in falling asleep or staying asleep, waking up too early, and or feeling unrefreshed the following day.  If you have had difficulty falling asleep or had woken repeatedly at night but could function normally the next day, indicates that you have had sufficient appropriate sleep.

You do not have to sleep for eight hours or fit a social norm of sleep. You have to sleep the amount of time that is just right for you. All of us are different.

Some of us believe that we can abuse our sleep patterns by working all day and night - with a minimum of sleep and not get enough sleep. These people will soon realise that sleep is rigid and is madatory for survival. The birds, insects, animals, fish and all that is created needs to sleep - yes this includes all of us - inclusive of man and beast. Dolphins are fortunate to sleep with one brain hemisphere at a time - the other half of the brain remains awake to keep swimming.

The only being that does not have to sleep is God himself - "slumber does not seize him nor sleep" and "there is none like unto him." For us simple  mortals we will have severe problems with every system of our bodies and mind if we deprive ourselves of sleep.

There are those that are short sleepers and require less sleep than average - the function perfectly well on 5 to 6 hours of sleep.  These short sleepers are few and far between. For the average Joe we have to sleep on average 8,15 hours - a SA high school metric student requires 9 hours sleep!

Epidemiology and importance: Insomnia is known to affect 58% of western adults.

People that do not get sufficient appropriate sleep run the risk of having impaired cognition, memory, attention, and ability to plan , execute and follow up. They usually appear more irritable, more aggressive, and develop an underlying anxiety (more than depression). They perform poorly in their daily tasks - in whatever they choose to do. They have more motor vehicle accidents than average. Some suggest they have the same number of accidents as alcoholic drivers - I hope the authorities are reading this.

Definition of Insomnia
Insomnia is defined by time - there are 3 basic types:

• Transient: Insomnia that lasts for less than a few weeks
• Intermittent: Recurring transient insomnia
• Chronic Insomnia: Insomnia that occurs for most nights for more than one month

Insomnia may be classified according to when it causes trouble: Recalling the definition of insomnia we may divide sleep into sleep onset insomnia, sleep maintenance insomnia and early morning awakening.

• sleep onset insomnia, occurs when a person has trouble falling asleep in the first place
• sleep maintenance insomnia, when a person wakes up at night and cant go back to sleep and 
• early morning awakening - waking up too early in the morning. 

One may also get a combination of the above - mixed insomnias.

The time that it takes for the average South African to fall asleep differs - on average it takes people 7 minutes to fall asleep but you may require 20 to 30 minutes to fall asleep. The key question is are you able to function the next day, do you feel restored after sleep.

If you dont feel restored or you cant stand your inability to fall asleep or maintain sleep then its time to seek help from a Sleep Medicine Specialist.

How would I recognise an Insomniac? 
Apart from those with underlying medical and psychiatric problems that need a sufficient appropriate diagnosis by their medical service provider there is a spectrum of Insomniacs -
The first are those that do all the right things to get ready for sleep and feel ready for sleep but just cant fall asleep.

The next are those that have no trouble falling asleep but are parting or working all night - burning the candle on both ends thinking that sleep is for the dead - they are of the mistaken belief that sleep is like a soccer ball that can be kicked about without any implication on their long term health.

There are also those that are being kept awake by the environment - the husband snoring, the wife with the restless moving legs, the sleep talking and sleep walking bed partners, a child with night terrors.  We must never forget the nursing mothers that sacrifice their sleep for the suckling babes in the middle of the night (Breast remains best).

So who gets insomnia?
Anyone can get insomnia but these are the groups that have the highest risk of getting insomnia:

• Elderly persons - the older you are, the more likely you are to have insomnia. One third of persons greater than 65 have insomnia.
• Worriers: Those that are prone to anxiety are more likely to have insomnia.
• Women have a slightly higher incidence of insomnia
• Psychiatric disorders: those that have psychiatric disease such as anxiety, depression really do need the assistance of a registered psychiatrist.
• Physical disorders: Pain, heart disease (cardiac disease)
• Alcohol abuse and drug abuse: Alcohol induces sleep but does not allow you to have the deep stage 3 and 4 slow wave sleep required to restore the body or the REM sleep required to file the information for the day.
• Certain Jobs - the more repetitive jobs that required less mental engagement had more difficulty falling asleep - as if the brain protests compelling you to use it before it will allow you to rest. If you dont use your brain - it will not allow you to sleep.

Insomnia may be caused by changes in the environment, physical medical causes, and psychological causes.

• The changes in the environment may be a change in routine, and sudden change in the weather or poor sleeping conditions.  
• My patients that have illness be it the flu or a serious heart, lung, kidney or stomach problem have worsening insomnia. Those that suffer the most are those with chronic pain conditions. Medication given by homoeopaths and doctors may cause change in the wake sleep cycle. 
• Changes in hormones - menstruation, pregnancy, menopause and hot flushes really cause havoc in my female patients sleep.
• Caffeine and smoking: Tea, coffee, coke and dark chocolate are stimulants that keep most patients awake - patients should not consume caffeine 6 hours before bedtime.  You should have your last cigarette four hours or more before you sleep. 

I still wonder how James Bond managed to smoke, have alcohol and still look refreshed.

There are a number of psychological causes for Insomnia :

• Anxiety
• Depression
• Stress
• Worry about sleep 

SO WHAT SHOULD I DO IF I HAVE INSOMNIA?

• Don't lie there - get out of bed and do something else - if you are not sleeping you should not be in your bedroom. 
• Keep a constant schedule: remember dont change your waking time no matter what time you go to bed
• Exercise early - Do not exercise at night
• Avoid napping if you an insomniac - remember daytime napping improves performance if you are not an insomniac
• Sterilise the bedroom: the bedroom must be free of the TV, the Blackberry,the cell phone, the iPhone, Books, the alarm clock - the bedroom is only for sleep and sleeping with your partner.
• Quit smoking
• No alcohol
• No tea, coffee and chocolate
• Restrict your sleep: if you feel you only sleep 4 hours a night out of the eight hours you lie in bed than restrict your sleep to to the 4 hours that you need - this will improve your sleep efficiency. Use only the time you need to sleep.
• Reduce environmental distractions.
• Stop all over the counter supplements and medication for sleep unless prescribed - there is little evidence that using non-prescribed medication works - why waist your money and risk you health with these drugs or supplements - if they are proven not to work. If insomnia remains a problem than contact your health care provider that will direct the treatment at the underlying cause of the insomnia.

Medications of you must:

There are 3 classes of drugs that are approved for the treatment of Insomnia:

1. The Benzodiazepines - these work in an undirected manor on the brain - and may allow you to have sleepiness the next morning.
2. The non-benzodiazepines - The "Z" drugs - zolpidem and zaleplon. These act with the benzodiazepine receptor of the brain. Their advantage is the rapid absorption and lack of active metabolites, and low risk for side effects. 
3. Melatonin - this has some interesting promise when used alone or in combination with the other approved sleep drugs. Melatonin is a naturally occurring hormone that is secreted by the pineal gland and controls the day night cycle in the brain - the circadian rhythm. Melatonin does not put you to sleep, but gets your night time hormones ready for sleep and in the event that you are asleep - makes your sleep more efficient. Please ensure that the melatonin that you buy is from a regulated pharmaceutical manufacturer - that apply the highest standards of quality or you may not be getting the melatonin you paid for as I have come to see with my SA patients.
4.  Herbal remedies: Although there are very few studies proving the value of herbal treatments - Valerin and Keva are the most commonly promoted herbal remedies.  

MOST EFFECTIVE TREATMENT

Prescription medication with behavioural treatments work best in combination. Cognative Behavioural therapy  appears to be the most effective behavioural therapy. Sleep hygiene is imperative, limiting or controlling stimulus at bedtime. 

Remember Insomnia is not a way of life - you need to seek appropriate medical help from your health care provider. 

Dr Yacoob Omar Carrim

Sleep Medical Specialist 

Zuid Afrikaans Hospital

zasleep@gmail.com

http://zasleep.blogspot.com