What is insomnia?

Approximately one third of the U.S. population suffers from insomnia, making it the most prevalent sleep disorder. In fact, a person with insomnia exhibits this sleep disorder in one of three ways: unable to initiate sleep, unable to maintain sleep continuity, or not able to sleep well. Even though there are sufficient opportunities and circumstances for sleep, these symptoms occur and interfere with daily functioning. Besides, the chronicity of insomnia can pose adverse effects on the patients’ health and social life. Insomnia increases the risk of motor vehicle accidents, makes workers less productive at work, gives them short temper, and causes them to sleep during the day. It also affects their health, quality of life, and academic performance. As a matter of fact, a lack of sleep is also linked to medical conditions such as asthma, cardiovascular disease, diabetes, chronic pain syndrome, depression, anxiety, and obesity.

Types of insomnia:

1. Chronic insomnia: in the last three months, there have been at least three sleep disturbances per week.
2. Short-term insomnia: it has been over 3 months since the sleep disturbances began.
3. Sleep-initiating insomnia: you can’t fall asleep easily.
4. Sleep-maintaining insomnia: you can’t keep sleeping all through the night, or you wake up shorty after falling asleep.
5. Mixed insomnia: this sums together sleep-initiating insomnia and sleep-maintaining insomnia.
6. Paradoxical insomnia: when you sleep around 8 hours and still feel you barely slept.

Chronic insomnia causes:

• Working night shifts
• Traveling often
• Inappropriate sleeping environment
• Being a light sleeper
• Going under stress
• Psychiatric disorders: anxiety, depression, and post-traumatic stress disorder
• Underlying medical problems: chronic pain, respiratory problems, gastroesophageal reflux disease (GERD), restless legs syndrome, and immobility
• Separation anxiety in children
• Personality characteristics: neuroticism, perfectionism, low extraversion, ambitiousness, overthinking, and vulnerability to depression
• Alcoholism
• Substance abuse
• Unpleasant social events: divorce, death, and unhappiness in family.

Symptoms:

• Being less productive
• Trouble concentrating
• Troublesome Memory
• Fatigue
• Headache
• Losing day hours due to napping

Diagnosis:

Before starting specific diagnostic methods to confirm insomnia, physical examination and detailed sleep history are first conducted. Above all, it’s important to note other problems that may be causing sleep disturbances including underlying medical and/or psychiatric disorders and medications.

Laboratory testing:

The results of the laboratory test can provide useful information to evaluate the medical conditions contributing to insomnia. Indeed, the tests include:

• Thyroid function test
• Complete blood count
• Liver function test
• Renal function test
• Serum iron analysis
• Glycosylated hemoglobin test

Survey questions:

To evaluate sleep disorders and sleep quality, self-evaluating questionnaires and scales for assessment are helpful. Thus, two scales are mostly used:

• The Epworth Sleepiness Scale (from 0 to 24 with a score of 15 or more indicating extreme sleepiness during the day) is among the most commonly used.
• A Pittsburgh Sleep Quality Index score of more than 5 indicates poor sleep quality.

Sleep log or sleep diary:

Keeping a sleep diary can provide quality information about a person's sleep-wake cycle. Sleep logs are maintained for 2 to 4 weeks; it also mentions alcohol and caffeine consumption and sleep activities. In most sleep studies, sleep logs determine how much sleep occurred, wakefulness following sleep onset, sleep efficiency, and whether there were any circadian rhythm disturbances.

Actigraphy:

In fact, wrist actigraphs are noninvasive devices that monitor gross motor activity throughout the day and while sleeping. According to actigraphy, four variables are assessed:

• Total sleep duration
• Wakefulness after sleep onset
• Sleep latency
• Daytime napping

Polysomnography:

Polysomnography is ideal for diagnosing a range of sleep disorders including sleep apnea, hypoventilating during sleep, and parasomnias. However, this method is a primary insomnia assessment only if a co-existing sleep disorder is in doubt.

How to prevent insomnia:

• Reading or studying (Don’t tell anyone) can make you drowsy, making it easier to fall into dreams.
• We all know overthinking is a major reason behind insomnia, all you can do is make a plan for tomorrow’s problems.
• Avoid daytime naps because it reduces your chance to fall asleep at night.
• Set a regular or routine sleeping hour and a waking hour to use daily.
• Don’t exercise right before going to bed.
• Turn off lights including computers, laptops, phones and e-books.
• Stay away from both alcohol and caffeine before bed.
• It’s preferable to avoid a big meal before going to sleep. If you feel hungry, try using a light snack
• If noise and sound prevent you from sleep, try earplugs.
• If light can’t be avoided, use eyes mask.

Treatment of insomnia:

Therapy measurements:

• Sleep hygiene: it is important to educate patients about sleep hygiene, which includes lifestyle changes such as limiting daytime naps and avoiding late night meals or excessive alcohol or caffeine consumption after dinner. Besides, traditional sleep hygiene measures such as diet, exercise schedules, and regular sleep and wake times can also be used. Nevertheless, the use of sleep hygiene alone is ineffective in the treatment of chronic insomnia. Therefore, it must be combined with other cognitive behavior therapy techniques.
• Sleep restriction therapy: based on this theory, a reduced sleep time might result in a better sleep drive and a better night's sleep. Consequently, there is a possibility that the sleep loss may lead to daytime sleepiness. Finally, the treatment could gradually extend the nighttime sleep.
• Relaxation therapy: yoga, breathing exercises, meditation, and other relaxation techniques can improve sleep quality and reduce anxiety.
• Stimulus control therapy: patients should be instructed to refrain from unproductive behaviors such as reading or eating in bed, using digital devices late at night, and going to bed only if extremely sleepy.
• Cognitive Behavioral Therapy for insomnia (CBTi): includes 6 sessions over 6 to 8 weeks of relaxation methods, sleep education, cognitive and behavioral theraoy, stimulus control therapy and sleep restriction therapy. Not only CBTi is superior over pharmaceutical measures, it also can be attained online. For example, an online CBTi program called “SHUTi" is dedicated to help patients. Furthermore, a smartphone app called "Sleep Ninja" is a phone-based CBTi.

Pharmacological measurements:

• Drugs acting on GABA-A receptors: these work by acting on the GABA receptor sites to achieve sedation, anxiolysis, muscle relaxation, and hypnosis. Examples are benzodiazepines and benzodiazepine receptor agonists.
• Drugs acting as orexin receptor antagonist: the drug suvorexant inhibits the activity of dual orexin receptors (OX1 and OX2) to counteract the orexin/hypocretin-induced insomnia. Suvorexant is effective for treatments for insomnia onset and sleep maintenance at doses of 5 mg, 10 mg, 15 mg, and 20 mg.
• Drugs acting on melatonin receptors: over the counter melatonin is approved by the food and drug administration (FDA), where a 2 to 8 mg dose can fix circadian rhythm problems.
• Drugs acting as Histamine-1 receptor antagonist: despite its tricyclic antidepressant nature, doxepin is effective in the treatment of sleep maintenance insomnia when given at low doses of 3 mg and 6 mg. Indeed, it improves total sleep time, wakefulness after sleep onset, and the efficiency of sleep.
• Off label drugs: for the management of insomnia at low doses, the most commonly prescribed antidepressants are trazodone, mirtazapine, and amitriptyline. Actually, there has been research showing that taking 50 mg of trazodone once daily can improve sleep latency, wakefulness after sleep onset, and sleep length.

Complications:

• Cardiovascular disease
• Anxiety
• Depression
• Hypertension
• Sleep drugs dependency
• Type 2 diabetes

References:

-Kaur H, Spurling BC, Bollu PC. Chronic Insomnia. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

-Sleep Foundation: "Types of Insomnia”

-National Sleep Foundation: “Insomnia”

-Momin RR, Ketvertis K. Short Term Insomnia. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.