Insomnia: What's keeping you up at night?

Are you happy and satisfied by what you’re getting, in the bedroom? 30% of us regularly don’t get enough (although some people seem to need more than others, with teenagers needing lots and lots) and this can make us feel irritable and unwell – performance at work can suffer, and relationships can be blighted. Not getting enough can even make us die younger! What am I talking about? Why, sleep, of course! There are many, many reasons why people may not experience adequate, refreshing sleep; if you or someone you care about is an insomnia sufferer, please read on – the good news is, there is a great deal that can be done to help this distressing condition, which does not need necessarily to involve medication. 

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Sleep disorders are often poorly understood and overlooked by medical practitioners, so choose a doctor who is sympathetic to the situation; sleeping and mood are intimately associated, and we all deserve to have the sense of overall well-being which good quality sleep allows. The third of our lives that we (should) spend asleep ought to vastly improve the enjoyment and productiveness of the other two-thirds - if this is not happening, medical help needs to be sought.

Am I an insomniac?
Insomnia can be defined as unsatisfactory sleep (either trouble falling asleep or staying asleep, waking too early or just not feeling refreshed after waking) which has negative daytime consequences. These can range from feeling snappy, through to overeating, through to very serious consequences such as road traffic accidents (17 hours of continued wakefulness leads to a decrease in judgment, reaction time and general performance equivalent to a blood alcohol level of 0.05%). Poor sleep can be associated with, or complicate, other medical conditions – it lowers pain thresholds and seizure thresholds, and is implicated in the development of cancer and heart disease. (For further information on sleep and snoring, obstructive sleep apnoea and restless legs syndrome, please CLICK HERE). Many, many cases of insomnia are linked to depression and anxiety. It’s a problem not to be taken lightly, and yet many patients avoid seeking help from a doctor because they may believe it’s not a “real” or “serious” condition. They may also be self-treating the condition with caffeine or other stimulants, which just makes the situation worse.

Sleep- who needs it? 
So, why do we sleep at all? Sleeping is a behaviour common to all animals, but it’s a risky strategy – it involves being unconscious and paralysed for several hours at the end of every day (hey predators, anyone fancy a snack?); however, all animals do it, and some have developed very creative ways to make sure it happens. Dolphins, for example, which need to keep swimming to stay breathing, shut down half their brain at a time so that one hemisphere is asleep while the other is awake. So, there must be a very valid point to sleeping for it to have been preserved throughout evolution – in other words, it must be good for us. We all know that babies cry when they are tired, and that adults experience very unpleasant symptoms when sleep deprived (sleep deprivation is a well-known torture technique) – but what actual benefits do we gain by sleeping? The short answer is: we don’t know for sure. Scientists think that sleeping helps to process and make sense of experiences that happen during the day, by strengthening new, important connections between brain cells and getting rid of unimportant ones. We also know that, in addition to this memory consolidation, deep sleep is associated with the release of chemical messengers which promote healing and repair, as well as reducing the release of inflammatory or “stress” hormones.

Sleep- here comes the science bit! 
So, what happens when we fall asleep? Healthy sleep patterns involve repeating, about every 90 minutes, the “sleep cycle”. This is divided up into Non-REM Sleep, which accounts for 75% of time spent asleep, and REM (or Rapid Eye Movement) sleep for the rest of the time. In Non-REM sleep, people initially fall asleep (this stage may be associated with so-called hypnic jerks – you may have experienced literally being jerked out of sleep as you’re drifting off, because of a sensation of falling) and then become progressively deeper and deeper asleep as they progress through the stages 1-4 of Non-REM sleep. The deepest stages, stages 3 and 4, are associated with restoration and repair of the body, as well as a reduction in body temperature, pulse and blood pressure. In REM sleep, the body normally becomes effectively paralysed and the eyes dart back and forth, as dreams occur; REM sleep contributes to daytime energy and performance. The entire cycle is then repeated. Naturally, animals including humans begin to feel tired at the end of the day, partly due to the release of a hormone called melatonin which is produced by the brain when the light starts to fade, and partly due to the build-up of a chemical called adenosine in the brain – this is the one that we can manipulate using caffeine (see below); to really understand how sleep works, and how it can be affected, we need to understand the sleep-wake 24 hour cycle, or circadian rhythm.

Your circadian rhythm, or body clock, is a series of processes which occur in a cycle over a 24-hour period to alternate periods of sleepiness and wakefulness. Melatonin levels start to build up as it begins to get darker, late in the afternoon or early in the evening, and this promotes restfulness and sleep. This is a throwback to our ancient, ocean-dwelling ancestors, who evolved mechanisms by which they could sense daylight and alter their activity according to when the most food would be available. This primitive response, to be more alert when there is light, still exists in humans today. However, since the invention of electric lights, humans have been able to artificially extend their “awake time” to unhealthily long periods. Ever since oil lamps were installed in Paris (the City of Lights) in the early 18th century, coinciding with the so-called Age of Enlightenment, people had the choice as to whether to go to bed at sunset or to carry on enjoying all that the wonderful modern world had to offer. In the last ten years, possession of mobile devices such as smartphones, tablets and laptops is almost ubiquitous in Western society and, guess what? The short wavelength bluish light they give out is precisely the sort of light which will stop melatonin production and “wake up” the brain again. Well over 75% of people admit to using such a device to “wind down” before bed – no wonder we now have a generation of people too wired to drift off, because their technology is keeping them super-charged. Rule of thumb? No devices for 2-3 hours before bed – read, take a bath, or snuggle up instead.

The role of caffeine
Adenosine is another chemical involved in your circadian rhythm. It starts to build up in your bloodstream as soon as you wake up, binding to special receptors, and steadily increases the longer you have been awake. When it reaches a certain threshold, you will start to feel irresistibly tired. Caffeine is structurally similar to adenosine, and blocks the “real thing” from attaching to its receptors. You therefore feel more alert and awake after drinking it. Interestingly, caffeine is an end-product of nitrogen metabolism in plants, and acts as a natural pesticide because insects that try to eat caffeine-containing leaves will be poisoned and die (slightly worrying?). A dose of caffeine equivalent to 50 cups of coffee would be fatal to a human, but many people regularly report drinking 10 or more cups a day. Caffeine is psychotropic, meaning it is mood-altering – coffee drinkers experience a transient “rush” of the feel-good hormone dopamine – but it is also addictive, with regular users needing more and more caffeine to get the same effects, and experiencing unpleasant withdrawal symptoms if they stop drinking it. The effects of caffeine are temporary, and completely reversible, with the liver breaking it down – and guess what happens to all that adenosine that has been hanging around, building up in the body waiting for its receptors to be free again? That’s right – as soon as the caffeine is broken down the adenosine rushes to fill the receptors up, making you feel more tired than before you put the kettle on in the first place……. So, off for another cup. The feel-good factor of caffeine means it is now being added to several foodstuffs – in the USA, you can buy “wired waffles” – and the consumption of energy drinks, particularly by children, is on the rise here.

Sleep hygiene- how to do the basics well
So, we can avoid device backlighting and learn to rationalise our relationship with stimulants as a first step to avoiding insomnia. These are just some of the factors involved in so-called “sleep hygiene”, which is a number of key good practices to get into the habit of doing every night to get as good a night’s sleep as possible. These include using the bed only for sleeping and sex, and not for working or watching TV. Other good habits to get into are avoiding alcohol, which interferes with the sleep cycle, and employing “stimulus control” to keep the body clock ticking over nicely – this means going to bed and getting up at the same time every day, irrespective of whether you are working or resting, avoiding napping during the day, and getting up to read or listen to music if you can’t fall asleep (rather than lying there and fretting). Blocking out the light with sleep masks and good blinds can help, as can using earplugs or a white noise machine to drown out unwelcome sounds. Lavender and other essential oils can be calming and restful, and a good mattress and clean bed linen in a cool bedroom also promote good quality sleep. Foods rich in tryptophan, such as turkey, can help people to feel sleepy, whereas very spicy, rich foods can have the opposite effect. Talk to your doctor about other ways of helping to obtain a deep, restful, natural sleep.

Further help for shift workers and globe trotters
But sleep hygiene, although evidence-based best practice, is sometimes not enough to cure insomnia in some people. Shift workers, for example, or those who regularly cross time zones, may need extra help re-setting their body clocks; some people respond well to non-pharmacological, psychological therapies such as cognitive behavioural therapy and some will do very well trying mindfulness or hypnotherapy (even via an App) or other complementary/alternative therapies, and a good general diet and exercise routine is always beneficial: yoga in particular is a good choice of exercise for relaxation. There are also many possible medications which can be used, as short-term or longer term treatments for insomnia, and your doctor will be able to talk to you about which might be best for you. Because some of the available medications can have significant side effects and interactions with other medicines, and some can cause dependence/addiction, it is vitally important that you seek the proper advice from a doctor before trying “sleeping tablets”.

How can your doctor help? 
The first thing your doctor will want to do is find out whether your insomnia is due to an obvious underlying cause (“secondary insomnia”) which might need to be treated, or whether it is primary insomnia (without an obvious cause). A very common cause of insomnia is anxiety and/or depression; your doctor will want to explore your mood and psychological well-being with you, to get a feel for how the way you feel is affecting the way you sleep. Treatment of mood disorders can have hugely beneficial effects on sleep, and some anti-depressants such as mirtazapine or the older, tricyclic antidepressants such as amitriptyline, have a sedating effect. Other physical/medical causes of insomnia, such as hyperthyroidism, can be detected or excluded by the doctor taking a careful history and performing a physical examination or any necessary blood tests, and treatment started if appropriate. Then there are medications which specifically target primary insomnia - melatonin is licensed for use in older adults with insomnia; some antihistamines with sedating side effects, such as promethazine, are sometimes used off-licence. Finally, there are the so-called “sleeping tablets” – Z-drugs like zopiclone and zolpidem are hypnotics which are usually effective in putting people into a deep sleep. Hypnotics need to be prescribed under close medical supervision, with a clear agreement on timescales (they are not a long-term option) and after a risk assessment, including driving habits. Your doctor may well want you to complete a sleep questionnaire, such as the Auckland questionnaire (for more details CLICK HERE) to assess the extent of the sleeping problem before and after any treatment. Occasionally, unusual sleep problems may need referral onto specialists for sleep lab studies, which your GP can also arrange.

Sleeping problems are extremely prevalent, and cause significant distress to affected individuals and their loved ones. Happily, there is much that a caring, well-informed doctor can do to help you get back into a restful and restorative sleeping pattern. Don’t suffer in silence – book an appointment to discuss your sleep issues, and take the first step towards feeling better about what goes on in your bedroom! Nighty-night then……..  Zzzzzzzzzzzzzzzz