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Insomnia Advice

Please find below an article about insomnia, including general insomnia information, insomnia symptons, insomnia causes, insomnia diagnosis, treating insomnia, sleeping tablets for insomnia and insomnia prevention.

About | Symptoms | Causes | Diagnosis | Treatment | Sleeping Tablets | Prevention

About Insomnia

"Insomnia is difficulty getting to sleep or staying asleep for long enough to feel refreshed the next morning, despite having enough opportunity to sleep."

Insomnia is a symptom which can accompany several sleep, medical and psychiatric disorders, characterized by persistent difficulty falling asleep and/or difficulty staying asleep. Insomnia is typically followed by functional impairment while awake.

One definition of insomnia is "difficulties initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month."

It is thought that between 1/3 - 1/5 people suffer from insomnia every year. Insomnia is reported to be 40% more common in women than in men, and is more likely to occur with age.

Symptoms of Insomnia

An insomniac may experience:

  • Difficulty falling asleep - sleep-onset insomnia (most common in younger people)
  • 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)

Insomnia can last for days, weeks, or even years, and is split into:

  • Short term insomnia - lasting 1-4 weeks
  • Long term (persistent) insomnia - lasting 4 weeks or longer.

Causes of Insomnia

There are a number of possible causes for insomnia, such as stress and anxiety, a disrupted sleeping environment, or an underlying physical condition or mental health problem.

Stressful Event

For some people, their insomnia starts in response to a stressful event and continues even when the stress has been resolved. This is because they have learnt to associate the sleeping environment with a state of being alert.

Causes of stress can be:

  • situational - ie: worrying about work, money or health
  • environmental - ie: noise or poor sleeping environment
  • death or illness of a loved one

Psychiatric problem

Underlying mental health problems can affect your sleeping patterns, including:

  • mood disorders - ie: depression or bipolar disorder
  • anxiety disorders - ie: generalised anxiety, panic disorder or post-traumatic stress disorder
  • psychotic disorders - ie: schizophrenia

Physical condition

Insomnia can be caused by an underlying physical condition, including:

  • heart disease - ie: angina
  • respiratory disease - ie: asthma
  • neurological disease - ie: Alzheimer's, Parkinson's
  • hormone problems - ie: overactive thyroid
  • joint or muscle problems - ie: arthritis
  • gastrointestinal disease - ie: irritable bowel syndrome
  • problems with the genital or urinary organs - ie: incontinence
  • sleep disorders - ie: restless legs syndrome, narcolepsy or sleep apnoea
  • chronic (long-term) pain

Drug and substance misuse

This includes the misuse of:

  • alcohol
  • recreational drugs
  • caffeine
  • nicotine

Medication

Some prescribed or over-the-counter medicines can cause insomnia, including:

  • anti-depressants
  • epilepsy medicine
  • medication for high blood pressure
  • hormone treatment
  • non-steroidal anti-inflammatory drugs
  • stimulant drugs
  • some medicines for asthma

Insomnia Diagnosis

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

Determining factors including sleeping routines, daily alcohol and caffeine consumption and general lifestyle habits including diet and exercise are all important for your GP to provide an accurate assessment.

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 recreational drugs.

Your GP may suggest you keep a sleep diary, which can help you understand the pattern of your insomnia. Usually, you and your GP will be able to identify a cause for your insomnia by carrying out these investigations.

The aim is to identify and treat factors that contribute to your insomnia (which might include health problems). Your GP may ask you to make some lifestyle changes or prescribe you medication for a condition.

Once these factors have been successfully addressed, the insomnia will often disappear without further medical help.

Treating Insomnia

The first step in treating insomnia is to diagnose and treat any underlying medical condition that is causing your insomnia. Once your condition is treated, your insomnia will often disappear without further medical help.

If further medical help is needed, the next step will depend on whether you have short-term or long-term insomnia.

Short-term insomnia:

  • your GP will advise you on good sleep hygiene
  • if your insomnia is severely affecting you during the day, they may prescribe you a short course of sleeping tablets

Long-term insomnia:

  • your GP will recommend cognitive and behavioural treatments,
  • they will advise you on good sleep hygiene
  • you may be prescribed a short course of sleeping tablets for immediate relief or to manage a particularly bad period of insomnia, although these are not recommended for long-term use.
All these treatments are described below.

Good sleep hygiene

Sleep hygiene aims to make you more aware of the different factors that may affect sleep.

Your GP may advise you to:

  • establish fixed times for going to bed and waking up (and avoid sleeping in after a poor night's sleep)
  • try to relax before going to bed
  • maintain a comfortable sleeping environment (not too hot, cold, noisy or bright)
  • avoid napping during the day
  • avoid caffeine, nicotine and alcohol within six hours of going to bed
  • avoid exercise within four hours of bedtime (although exercise earlier in the day is beneficial)
  • avoid eating a heavy meal late at night
  • avoid watching or checking the clock throughout the night
  • only use the bedroom for sleep and sex

Cognitive and behavioural treatments

Cognitive and behavioural treatments aim to change unhelpful thoughts and behaviours that may be contributing to your insomnia

Your doctor may recommend any of the following for you:

  • Stimulus-control therapy - which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern
  • Sleep restriction therapy - where you limit the amount of time spent in bed to the actual amount of time spent asleep, creating mild sleep deprivation. Sleep time is then increased as your sleeping improves.
  • Relaxation training - which aims to reduce tension or minimise intrusive thoughts that may interfere with sleep.
  • Paradoxical intention - which means you try to stay awake and avoid any intention to fall asleep. It is only used if you have trouble getting to sleep, but not maintaining sleep.
  • Biofeedback - where sensors connected to a machine are placed on your body to measure body responses like muscle tension or heart rate. The machine then produces pictures or sounds to help you control your breathing and body responses.
  • Cognitive behavioural therapy (CBT) - which aims to examine and change your beliefs and attitudes about insomnia

These techniques may be carried out by a specially trained GP, although you may be referred to a clinical psychologist for CBT.

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
  • if the non-drug treatments mentioned above have failed to have an effect

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However, doctors can be 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.

You should be given the smallest effective dose possible for the shortest length of time necessary 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
  • 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' are the preferred prescripted medicines for insomnia.

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
  • 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
  • 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.

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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
  • weight gain

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

Insomnia Prevention

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.

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