Insomnia – A Guide

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

Introduction
Symptoms of insomnia
Causes of insomnia
Diagnosing insomnia
Treating insomnia
Preventing insomnia

See also:
Sleep and Relaxation Products
Restless Leg Syndrome

Introduction

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).

How long does insomnia last?

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

• short-term insomnia, which lasts for one to four weeks
• long-term (or persistent) insomnia, which lasts for four weeks or longer.

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.

The Effortless Sleep Method: The Incredible New Cure for Insomnia and Chronic Sleep Problems

Overcoming Insomnia and Sleep Problems: A Self-Help Guide Using Cognitive Behavioral Techniques

An Introduction to Coping with Insomnia and Sleep Problems (Overcoming: Booklet series)

Symptoms of insomnia

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 having had refreshed by sleep,
• not being able to function properly during the day and having difficulty concentrating, and
• being irritable.

Causes of insomnia

There are many possible causes of insomnia, outlined below.

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 – for example, worrying about work, money or health,
• environmental, such as noise, or
• death or illness of a loved one.

Psychiatric problem

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

• mood disorders, such as depression or bipolar disorder,
• anxiety disorders, such as generalised anxiety, panic disorder or post-traumatic stress disorder, and
• psychotic disorders, such as schizophrenia.

Physical condition

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

• heart disease, such as angina or heart failure,
• respiratory disease, such as chronic obstructive pulmonary disease or asthma,
• neurological disease, such as Alzheimer’s or Parkinson’s disease,
• hormone problems, such as an overactive thyroid,
• joint or muscle problems, such as fibromylagia or arthritis,
• gastrointestinal disease, such as gastro-oesophageal reflux disease or irritable bowel syndrome,
• problems with the genital or urinary organs, such as incontinence or an enlarged prostate,
• sleep disorders, such as restless legs syndrome, narcolepsy or sleep apnoea, and
• chronic (long-term) pain.

Drug and substance misuse

This includes the misuse of:

• alcohol,
• recreational drugs,
• caffeine, or
• nicotine.

Medication

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

• antidepressants,
• epilepsy medicine,
• medication for high blood pressure, such as beta-blockers,
• hormone treatment,
• non-steroidal anti-inflammatory drugs (NSAIDs),
• stimulant drugs, such as methylphenidate to treat ADHD or modafinil to treat narcolepsy, and
• some medicines for asthma, such as salbutamol, salmeterol and theophylline.

Diagnosing insomnia

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 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 doing these investigations.

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

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

Keeping a sleep diary

This should be kept for a minimum of two weeks and should contain information about:

• time of going to bed,
• time taken to get to sleep,
• the number of episodes of waking throughout the night,
• the time of getting up,
• episiodes of daytime tiredness and naps, and
• times of meals, alcohol consumption, and significant events during the day such as exercise or stress.

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.

If you have short-term insomnia:

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

If you have long-term insomnia:

• your GP will recommend cognitive and behavioural treatments,
• they will advise you on good sleep hygiene, and
• 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.

If you are over 55, your GP may consider prescribing you melatonin.

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, and
• 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 medications 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.

Driving

If you have insomnia, it may have implications for driving. You should inform the Driver and Vehicle Licensing Agency (DVLA) about your sleep problem.

Complementary and alternative therapies

There is very limited evidence that acupuncture may be effective for treating insomnia, and there is no good quality evidence that hypnotherapy is effective.

Certain herbal remedies such as chamomile and passionflower have had some reported positive effects, but have not been thoroughly clinically investigated to support their use and long-term safety.

Preventing Insomnia

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 that 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. This gives 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 to solve them; then forget about it until 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.