What is Insomnia

Insomnia is a symptom consisting of difficulty initiating sleep, maintaining sleep and/or waking too early in the morning. Insomnia is perceived to be causing daytime symptoms such as irritability, tension, helplessness, feeling unhappy, low in energy, and a reduction of interest in usual activities. The person may complain of poor concentration, lethargy, or may be feeling uncoordinated and not functioning as they would like to be. This can lead to worrying about one’s health, increased risk of infection and poor health in general.

Insomnia therefore does not just affect bedtime and night time but has an important daytime component. It is the combination of both the difficulty with sleep and the poor daytime function that constitutes insomnia as an important symptom. Seen in this context insomnia is a highly subjective feeling. It is a very common problem, which affects one in 10 of the population and, in a severe manner, at least 5% (one in 20).

Insomnia = difficulty sleeping and poor daytime function

In some cases insomnia is of brief duration, perhaps up to a month or so and is usually triggered by well recognized factors such as an important event in life. In most people eventually the difficulty with sleep subsides and daytime function resumes. In other people however, the poor sleep quality and the poor daytime function persists well beyond a few months and this is what we refer to as chronic insomnia. Insomnia can be continuous and be experienced most nights of the week, in other cases insomnia can be intermittent, sometimes with seasonal variability.

This book is predominantly concerned with chronic insomnia even though some of the principles outlined in the next few chapters can be applied successfully to insomnia of shorter duration.

Need to Know

In order to treat insomnia successfully there are some ideas and principles that need to be understood as they are the basis for successful treatment.

The following points are important to understand.

How much sleep a person needs

People frequently ask this question. The answer is each individual has different needs. It is often quoted that on average we need between 7½-8 hours of sleep. In reality the amount of sleep that the person needs changes during their lifetime. For example teenagers due to hormonal and maturation factors often need longer hours than adults. It would not be uncommon for a teenager to need at least 9 hours sleep compared to an older or younger person who may need a slightly less amount of time. However, even in adulthood the amount of sleep needed can vary from 5 hours (short sleepers) and 9 hours or more (long sleepers).

If you want to know how much sleep you need you should have available a week or 10 days where you are allowed to go to bed when sleepy and get up when you are ready without any commitments or stress which may interfere with sleep (perhaps on holiday from work). If you are able to have that amount of time you can record bedtime and wake up time each day and then average the number of hours slept over the period. That will tell you how much sleep your body needs if left to its own devices, which answers the question “how much sleep do I need?”

Insomnia as a symptom not a disease

There is some debate among people involved with sleep medicine of whether insomnia should be regarded as a symptom or a disease. Everybody agrees that insomnia is a symptom. However, some health professionals would also argue that once insomnia has been going on for a long time it could potentially be regarded as a disease. For the purpose of our discussion and throughout this book it is important that insomnia is seen as a symptom not as a disease. We usually say that we treat symptoms and we cure diseases. There are many conditions in medicine where symptoms are treated without necessarily curing the disease. For example the headache (a symptom) in migraine (a disease) can be treated but usually migraine is unlikely to be cured.

Looking at insomnia as a symptom is useful because as we will see in the next few pages there are many causes for insomnia and often it is useful to identify what triggers the symptom of insomnia and what makes it persist over time.

Insomnia is a symptom of poor function during the 24 hours not just a bedtime or night time problem

This is a very important idea to be understood. For cultural reasons often people say ‘If I could have a good night’s sleep I would not be feeling so tired during the day’ or ‘If I could have a good night’s sleep I would be able to do certain things which I am not able to do during the day’. This is to some degree correct. However, this is only part of the story, and no more than 50% of the problem.

sleep-wake

The other part of the story can be described as ‘If you have a good day you will have a good night’s sleep’. This is to say that often what we have done between 8am-8pm is as relevant to sleep as night time is relevant to daytime function.

From a practical point of view it is very useful to consider insomnia a symptom of poor function within the 24 hours whereby daytime influences bedtime and sleep time and bed time influences daytime. As you will see in the next chapter what the person does and what the person feels during the day is important to be addressed in order to successfully treat insomnia.

People with insomnia who are sleepy during the day and people with insomnia who are not sleepy

When people feel they are not sleeping well at night (difficulty initiating sleep, staying asleep and waking up early) an important question to ask is how sleepy they feel during the day. Often the person complains of insomnia, feels tired but does not fall asleep during the day. In other situations the person suffers from insomnia and tends to fall asleep very easily during the day. These are two completely different groups of people although both suffering from insomnia. People, who suffer from insomnia and fall asleep easily during the day, often have some specific disturbances of sleep during the night (see examples in table 1).

Table 1. Some Examples of conditions causing insomnia and daytime sleepiness

Obstructive sleep apnea
Restless legs syndrome
Abnormal movements in sleep
Depression
Heartburn and oesophageal reflux
Chronic pain
Bladder problems
Coffee, alcohol in excess

On the contrary, people with insomnia who do not fall asleep easily during the day are people who tend to be hyper-aroused.

We are hyper-aroused when our stress system is continuously activated. As human beings we only have one stress system, which is activated irrespective if we are under a physical or mental threat. The stress system is very useful for survival. It involves activation of hormones such as adrenaline, nor-adrenaline and cortisone. These hormones allow us to have an emergency response such as the flight or fight response, which helps us under threatening conditions. The body, however, does not make a distinction between a physical threat and a mental threat. If something is in our minds and upsetting us for whatever reason the stress system is activated and the body is not in a state conducive to sleep. If the stress system is activated for a limited period of time it is very important to our defense response. However, if constantly activated, it is detrimental to our health, as it leads to physical exhaustion. Hyper-arousal is a common reason why insomnia persists over time. Some people tend to be more likely to have their stress system activated as part of their genetic make up. Some individuals may not be able to fall asleep if they hear a noise in the middle of the night and they have to go and check it out. Other people instead are able to turn around and go back to sleep. Both are within normal limits but the first type, who is unable to fall asleep if there is a noise in the house, tends to be hyper-alert, meaning that his alert system tends to be more responsive and more likely to keep them awake compared to the second type of person.

In this society there are many circumstances that cause our stress system to be continuously activated due to personal and relationship problems, emotional issues, the work environment, family concerns and so forth.

Psycho-physiological ‘insomnia’ (learned insomnia)

This is a common mechanism and state of health, which sets in once the symptom of insomnia has been present for a few weeks or months. No matter how the problem started, psycho-physiological insomnia sets in. This refers to the situation where after a few weeks or months of not being able to sleep, but having to continue our daily duties (family, work commitments) the person starts longing more and more to finally get a good night’s sleep. The more the longing and desire to have a good night’s sleep the more the anxiety and the expectation to fall asleep increases and the person is less and less able to fall asleep. After a while going to bed, bedtime and often the bedroom itself become negatively associated with falling asleep and the person becomes more and more anxious around bedtime with the expectation that once again he will not be able to fall asleep. This negative state of affairs is what we refer to as psycho physiological insomnia. It appears that despite any effort, falling asleep cannot be achieved. Therefore the person has a feeling of having lost sense of control over his ability to fall asleep. Learned insomnia sets in irrespective of how the insomnia started once the problem has been going on for some time. It is one of the main reasons that perpetuate insomnia and it is one of the targets of our treatment.

Individual body clock

Each individual has a different body clock. The body clock is what regulates our sleep and wake pattern in synchrony with the light and night cycling due to the earth rotation. We identify approximately 3 types of body clocks. The morning type body clock are people who tend to go to sleep early in the evening, perhaps about 9-10pm and by 6am it is difficult to keep them in bed. The evening type are people who tend to fall asleep preferably between 11pm-midnight and if left undisturbed in the morning they tend to sleep in until 8am and are somewhat sluggish in getting up. There is an intermediate type in between these two types. The kind of body clock the person has can influence the symptom of insomnia. The questionnaire in appendix 00 is a simple way to assess body clock types. Keep in mind that work schedules, in particular shift work, and medications used for other medical problems can affect our body clock.

In summary the following ideas are very important to be understood in order to properly manage the symptom of insomnia.