Insomnia

Insomnia is difficulty getting to sleep or staying asleep for long enough to feel refreshed the next morning. The most common problem in young people with insomnia is difficulty falling asleep (sleep-onset insomnia). An insomniac may also experience:

• Waking in the night (most common in older people).
• Not feeling refreshed after sleep and not being able to function normally during the day, feeling irritable and tired and finding it difficult to concentrate.
• Waking when you have been disturbed from sleep by pain or noise.
• Waking early in the morning (the least common type of sleep disturbance).

Nearly everyone has problems sleeping at some point in their life and it is thought that a third of people in the UK have bouts of insomnia. Insomnia appears to be more common in women and more likely to occur with age.

There are a number of possible causes for insomnia, such as anxiety, a disrupted sleeping environment, or an underlying physical condition or mental health problem (see Causes, above, for more information).

How long does insomnia last?

Insomnia can last for days, months or even years. It can be split into three categories:

• transient insomnia lasts for two to three days,
• short-term insomnia lasts for more than a few days but less than three weeks, and
• chronic insomnia occurs most nights for three weeks or longer, and can lead to mental health problems such as depression or misuse of alcohol in order to gain sleep.

How much sleep should you get?

Every individual is different, so it is hard to define what normal sleep is for you. Factors influencing the amount of sleep you need include your age, lifestyle, diet and environment.

For example, newborn babies can sleep for 16 hours a day, while school-age children need an average of 10 hours sleep.

Most healthy adults sleep for an average of seven to nine hours a night. As you get older, it is normal to need less sleep. Most people over 70 need less than six hours sleep a night, and they tend to be light sleepers.

Depending on the type of sleeping problem you have, symptoms of insomnia can include:

• lying awake for a long time at night before getting to sleep,
• waking up several times in the middle of the night,
• waking up early in the morning (and not being able to get back to sleep),
• feeling tired and not refreshed by sleep,
• not being able to function properly during the day and having difficulty concentrating, and
• being irritable.

The common underlying causes of insomnia are outlined below.

Physical condition

Insomnia can be caused by an underlying physical condition that causes involuntary movement, pain or discomfort. Examples include:

• restless legs syndrome (an overwhelming urge to move your legs),
• coughing,
• arthritis, headaches or back pain,
• hot flushes (due to the menopause),
• head injury,
• gastrointestinal disorders, such as reflux disease,
• excessive itching, and
• Parkinson's disease.

Psychiatric problem

Underlying mental health problems can affect your sleeping patterns, such as:

• depression,
• dementia, or
• anxiety.

Sleeping environment

Disruptions within the sleeping environment or to bedtime routines can cause insomnia. Factors include:

• noise,
• light,
• snoring,
• partner moving about,
• jet lag, and
• activities before bedtime, like watching television, playing computer games or doing exercise.

Working hours

If you are a night or shift worker, your job can disturb your ability to sleep properly as your natural body clock will be affected. Your body is designed to release chemicals to wake you when there is daylight and chemicals to encourage sleep when it gets dark, so your body will not be used to sleeping during the day.

Psychological problems

Bereavement or worrying can make sleeping difficult. Examples of when this might occur are:

• loss of a person close to you,
• relationship problems,
• exam stress,
• work problems, or
• anxiety about being unable to sleep.

Medicines and drugs

Withdrawal from certain medicines such as sleeping tablets (prescribed for short-term insomnia) may cause rebound insomnia, which means if you stop taking them, the sleeping problems can come back.

Taking other medicines or drugs can produce side effects that reduce the quality of sleep. Examples are:

• alcohol,
• antidepressants,
• appetite suppressants,
• decongestants,
• thyroid hormones,
• beta-blockers (to treat heart problems or high blood pressure), and
• corticosteroids.

Sleep disorders

Sleep disorders can also affect your ability to get a good night's sleep. Examples include:

• Narcolepsy - this disorder causes extreme tiredness, where you can fall asleep at any time of the day without being able to control it.
• Sleepwalking.
• Sleep apnoea - this disorder causes irregular breathing at night, so sleep is disturbed and you are extremely tired during the day.
• Sleep starts - these are muscle jerks or a sensation of falling when you are just going off to sleep.

If you have difficulty getting to sleep or staying asleep, then consider seeing your GP to discuss your problem.

Your GP will want to know about your sleeping routines, how much alcohol and caffeine you drink each day and your general lifestyle habits, such as diet and exercise.

They will check your medical history for any illnesses or medications that may be contributing to your insomnia, and will ask if you are taking any other substances, such as drugs.

Usually, you and your GP will be able to identify a cause for your insomnia by exploring these factors.

If the cause is not immediately obvious, your GP may suggest you keep a sleep diary (see box), which can help you understand the pattern of your insomnia.

Tests

A polysomnography is a physical test for identifying sleep problems, although this is mainly used to diagnose sleep apnoea. Sensor leads (electrodes) are placed on various places on your body and head. While you are asleep, the test will record:

• electrical activity in your brain,
• eye and jaw muscle movement,
• leg muscle movement,
• airflow,
• chest and stomach movement during breathing,
• heart activity (using an electrocardiogram or ECG), and
• oxygen saturation (amount of oxygen being absorbed by your lungs).

If carried out in a sleep research centre (rather than your home), you may also be videotaped during the test, to compare the electronic readings with what was happening in the room.

The first step in treating insomnia is to diagnose any underlying causes and treat any condition that may be causing the insomnia, such as depression. Once the condition is treated, the insomnia will often disappear without further medical help.

Non-drug treatments

Doctors usually prefer to prescribe non-drug treatments as the first course of action. These treatments can include:

• Counselling, if the insomnia is related to bereavement or stressful life events.
• Cognitive behavioural therapy - a type of counselling that addresses problems with thinking patterns and behaviours (see What does CBT for insomnia involve?).
• Lifestyle advice and problem-solving approaches - this includes restricting caffeine, nicotine and alcohol consumption, taking regular exercise (at least 30 minutes of moderate exercise such as brisk walking or cycling five or more days a week), keeping regular times for sleeping and waking, and maintaining a good sleeping environment.

Sleeping tablets

Sleeping tablets (hypnotics) are medictions that encourage sleep. They may be considered:

• if your symptoms are particularly severe,
• to ease short-term insomnia, or
• if the non-drug treatments mentioned above have failed to have an effect.

However, doctors are usually reluctant to prescribe this type of medication as they relieve symptoms but do not treat the cause of your insomnia. If you experience long-term insomnia, sleeping tablets are unlikely to help and your doctor may consider referring you to a clinical psychologist to discuss other approaches to treatment.

General information

Sleeping tablets should only be used when the expected period of treatment will be short; for example, during an illness, for an overnight stay in a busy hospital ward, or because of jet lag.

You should be given the smallest effective dose possible for the shortest length of time necessary (for no longer than a week). In some cases, your doctor may advise that you only take the medication two or three nights a week, rather than every night.

These hypnotic medicines cause the following side effects:

• a feeling that you are hungover, and
• drowsiness during the day.

It is best to take the medicines at night, before you go to bed. In some people, especially older people, the hangover effects may last into the next day, so you should be cautious if you are likely to be driving the next day.

It is very easy to become dependent on these medicines, even after a short-term course. You should take note of any possible side effects before starting treatment. If you start treatment in hospital during a short stay, you should not automatically continue it when you leave.

If you are regularly taking sleeping tablets every night, you should consider reducing or stopping them. Do not stop taking the medicine suddenly, as withdrawal symptoms can include panic attacks, shaking and rebound insomnia. Speak to your doctor for advice.

Short-acting benzodiazepines or the newer 'Z medicines' (see below) are the preferred medicines for insomnia and are only available on prescription.

Benzodiazepines

Benzodiazepines are tranquillisers designed to reduce anxiety and promote calmness, relaxation and sleep.

These medicines should only be considered if your insomnia is severe or causing you extreme distress. All benzodiazepines make you feel sleepy and can lead to a dependency. If they are needed to treat insomnia, then only the short-acting benzodiazepines (with short-lasting effects) should be prescribed, such as:

• temazepam,
• loprazolam, and
• lormetazepam.

Z medicines

Z medicines are a newer type of sleeping tablet that work in a similar way to benzodiazepines. They are also short-acting medicines and include:

• zopiclone,
• zolpidem, and
• zaleplon.

There is little difference between the benzodiazepines and Z medicines, so if one does not work, it is unlikely that swapping to another will have a different effect.

For more information, read Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (2004 guidelines from the National Institute for Health and Clinical Excellence).

Melatonin (Circadin)

Medicines containing melatonin have been shown to be effective in providing short-term relief for insomnia. Melatonin is a naturally occurring hormone that helps regulate the sleep cycle (known as the circadian rhythm).

At present, the only licensed medicine for the treatment of insomnia that contains melatonin is called circadin. Circadin is only available on prescription for people who are 55 or over.

Circadin is designed as a short-term treatment for insomnia and should not be taken for more than three weeks. It is not recommended for people with a history of kidney or liver disease.

As yet, there is not enough evidence to say whether it is safe to take Circadin during pregnancy or when breastfeeding, so its use is not recommended in these circumstances.

As Circadin can make you feel drowsy, you should not drive or operate heavy machinery after taking the medicine at night, or if you still feel drowsy the next morning.

Side effects of Circadin are uncommon but include:

• irritability,
• dizziness,
• migraines,
• constipation,
• stomach pain, and
• weight gain.

If you find these side effects troubling, you should stop taking Circadin and contact your GP.

Some simple measures may help you to get a good night's sleep. Try the below methods for at least three to four weeks. When you find you are asleep for most of the time you are in bed, try going to bed 15 minutes earlier, but make sure you get up at the same time.

Daytime habits

• Set a specific time for getting up each day. Stick to these times, seven days a week, even if you feel you have not had enough sleep. This should help you sleep better at night.
• Do not take a nap during the day.
• Take daily exercise, such as 30 minutes walking or cycling, at least four hours before you are planning to go to bed, to give your body temperature a chance to cool down.

Bedtime habits

• Stop drinking tea and coffee four hours before bedtime.
• Avoid drinking alcohol and smoking, as these are also stimulants. Alcohol may make you sleepy at first but will wake you up when the effects have worn off.
• Do not eat a big meal or spicy foods just before bedtime. A small snack that contains tryptophan (a natural sleep-promoting amino acid) may help, such as turkey, banana or fish.
• Only ever go to bed when you are feeling tired.
• Try to create a bedtime routine, such as a bath and warm milky drink every night. These activities will then be associated with sleep and will cause drowsiness.
• If it takes longer than 20 or 30 minutes to get to sleep, do not lie in bed feeling anxious about sleeping. Instead, get up and go to another room for a short period and do something else such as reading or watching television, then try again.
• Do not watch the clock, as this will only make you anxious.
• Write a list of your worries and any ideas you have to solve them; then forget about it until the morning.

Bedroom environment

• Use thick blinds or curtains or wear an eye mask if the early morning sunlight or bright streetlamps affect your sleep.
• Wear ear plugs if noise is a problem.
• Do not use the bedroom for anything other than sleeping or sex. Do not watch television, make phone calls, eat, or work while you are in bed.
• Make sure you have a comfortable mattress, a pillow you like, and adequate bed covers for the time of year.