Insomnia. Psychological Medicine

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1 Insomnia Psychological Medicine

2 Introduction Sleep is normal, something we take for granted most of the time. We need sleep to keep our minds and bodies healthy. However, lack of sleep, or insomnia, is a common and distressing symptom. It is often just for a short time, perhaps when we are worried or excited. After a few days, things settle down and we get back to sleeping normally. However, if it persists for days or weeks, It may be due to ordinary, everyday causes or it may be a symptom of more serious underlying problems. What is sleep? Sleep is the regular period in every 24 hours when we are unconscious and unaware of our surroundings. There are two main types of sleep: Non-REM sleep The brain is quiet, but the body may move around. Hormones are released into the bloodstream and our body repairs itself after the wear and tear of the day. Rapid Eye Movement (REM) sleep It comes and goes throughout the night, and makes up about one fifth of our sleep time. During REM sleep, our brain is very active, our muscles are very relaxed, our eyes move quickly from side to side and we dream. We move between REM and non-rem sleep about five times throughout the night, dreaming more as we get towards morning. During a normal night, we will also have short periods of waking. These last 1 or 2 minutes and happen every 2 hours or so. We aren't usually aware of them. We are more likely to remember them if we feel anxious or there is something else going on - noises outside, our partner snoring etc. 2

3 How much sleep do we need? This depends mainly on our age but varies a lot between people of the same age. Babies sleep for about 17 hours a day Older children sleep 9 or 10 hours per day Most adults need between 7 and 8 hours sleep each night, less as they get older. There is a lot of difference between individuals and some people can manage on only 3 hours a night. Older people need the same amount of sleep, but will often only have one period of deep sleep during the night, usually in the first 3 or 4 hours, after which they wake more easily. We also tend to dream less as we get older. They also often find their sleep at night is broken, particularly if they take naps during the daytime. What if I don't sleep? The occasional night without sleep will make you feel tired the next day, but it won't harm your physical or mental health. However, after several sleepless nights, you will start to find that: you are tired all the time you drop off to sleep during the day you find it difficult to concentrate you find it hard to make decisions you start to feel depressed. This can be very dangerous if you are driving or operating heavy machinery. Lack of sleep may also make us more vulnerable to high blood pressure, obesity and diabetes. 3

4 What is insomnia? Insomnia is the complaint of inadequate or poor quality sleep such as difficulty falling asleep, waking up frequently during the night with problems getting back to sleep, waking up too early in the morning and unrefreshing sleep. It can be transient or chronic. What causes Insomnia? Insomnia is most commonly due to simple things such as too much noise, change in surrounding environment, uncomfortable temperature or bed, irregular routines, too little physical activity or side effects of medications. Eating too much may make it difficult to get to sleep, eating too little may lend to early waking. Cigarettes, alcohol and drinks containing caffeine, such as tea or coffee, will also disturb sleep. We sleep badly if we are in pain or running a high temperature. Chronic insomnia is more complex and often results from a combination of factors including physical and emotional problems. Physical illnesses like kidney disease, asthma and arthritis can lead to insomnia. It may also be due to behavioural factors such as disruption of sleep/wake cycles as may occur in shift work and other night-time activity or chronic stress and other psychological problems. Repeated thoughts about day to day problems will affect sleep. People with severe anxiety find it very difficult to get to sleep. In depression, people may wake early or even in the middle of the night, and then be unable to get back to sleep. 4

5 How is insomnia diagnosed and treated? People with insomnia are evaluated with the help of a medical and sleep history. Specialised sleep studies may be recommended only if there is suspicion that there may be a primary sleep disorder such as sleep apnoea or narcolepsy. Treatment will depend on what is the cause of the insomnia. A combination of behavioural approaches and medications are usually offered. What are common behavioural approaches to treat Insomnia? Relaxation therapy These techniques help to reduce or eliminate anxiety and body tension. As a result, your mind is able to stop racing, the muscles relax and restful sleep can occur. It takes much practice to learn the techniques and achieve effective relaxation. Reconditioning This technique helps to recondition you such that you associate the bed and bedtime with sleep only. You are advised to go to bed only when sleepy. If unable to sleep, you should get up and stay up till sleepy and then return to bed. You should avoid naps and wake up and go to bed the same time each day. Eventually your body will be conditioned to associate the bed and bedtime with sleep. Sleep restriction Some people suffering from insomnia spend too much time in bed unsuccessfully trying to sleep. If this is the case for you, then you may benefit from a sleep restriction programme that allows a few hours of sleep during the night. Gradually the time is increased until a more normal night s sleep is achieved. 5

6 How can medication help? People have used sleeping tablets for many years, but we now know that they: don't work for very long. leave you tired and irritable the next day. lose their effect quite quickly, so you have to take more to get the same effect. some people become addicted to them. The longer you take sleeping tablets, the more likely you are to become physically or psychologically dependent on them. there are some newer sleeping tablets (Zolpidem, and Zopiclone), but these seem to have many of the same drawbacks as the older drugs, such as Valium and Ativan. Sleeping tablets should only be used for short periods (less than 2 weeks) - for instance if you are so distressed that you cannot sleep at all. If you have been on sleeping tablets for a long time, it is best to cut down the dose slowly after discussing it with your doctor. In some cases, antidepressant tablets may be helpful. Over the counter medications are not usually recommended for treatment of insomnia. Things to avoid Alcohol. Everybody knows that alcohol can help you to fall asleep. The problem is that you will usually wake up halfway through the night. If you drink alcohol regularly to help you sleep, you will find that you need to drink more and more to get the same effect. If you drink regularly and you stop drinking suddenly, you may find it hard to sleep for a week or two. Slimming tablets make it hard to sleep, as do street drugs like Ecstasy, cocaine and amphetamines. 6

7 Helping yourself Here are some simple tips that many people have found helpful. Do's Make sure that your bed and bedroom are comfortable - not too hot, not too cold, not too noisy. Make sure that your mattress supports you properly. It should not be so firm that your hips and shoulders are under pressure or so soft that your body sags. Generally, you should replace your mattress every 10 years to get the best support and comfort. Get some exercise. Don't overdo it, but try some regular swimming or walking. The best time to exercise is in the daytime - particularly late afternoon or early evening. Exercising later than this may disturb your sleep. Try to relax properly before going to bed. If something is troubling you, and there is nothing you can do about it right away, try writing it down before going to bed and then tell yourself to deal with it tomorrow. If you can't sleep, get up and do something you find relaxing. Read, watch television or listen to quiet music. After a while you should feel tired enough to go to bed again. Don'ts Don't go without sleep for a long time - go to bed when you are tired and stick to a routine of getting up at the same time every day, whether you still feel tired or not. Caffeine hangs around in your body for many hours after your last drink of tea or coffee. Stop drinking tea or coffee by midafternoon. If you want a hot drink in the evening, try something milky or herbal (but check there's no caffeine in it). Don't drink a lot of alcohol. It may help you fall asleep, but you will almost certainly wake up during the night. Don't eat or drink a lot late at night. Try to have your supper early in the evening rather than late. If you've had a bad night, don't sleep in the next day - it will make it harder to get off to sleep the following night. When do you need to seek help? You should consider seeking medical advice if your sleep has been disturbed at least several times over the past month, has gone on for weeks and months, or if it interferes with the way you feel or function during the day. You can talk over any problems that may be stopping you from sleeping. Your doctor can make sure that your sleeplessness is not the result of physical illness, a prescribed medicine, or emotional problems and make appropriate recommendations and treatment. 7

8 For appointments and enquiries, please call CGH Appointment Centre at Tel: (65) CGH Appointment Centre operating hours: 8.30 am to 8.00 pm (Monday to Friday) 8.30am to pm (Saturday & Sunday) Closed on Public Holidays For more information, please visit 2 Simei Street 3 Singapore Tel: Fax: Reg No R All information is valid at the time of printing (November 2008) and subject to revision without prior notice. Organisation Accredited by Joint Commission International

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