by Lina Hamid and Christopher M. Cirino, DO MPH, Editor

Having trouble getting to sleep? You are not alone. In the United States, 50-70 million people reported sleep problems. How can we better understand insomnia? What treatments are available? This article will provide readers with information regarding insomnia to measures to take for a restful night.

Introduction to Insomnia

Insomnia is a growing problem for the world population. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders defines insomnia as “a complaint regarding the quantity, quality, or sleep timing at least 3 times a week for at least 1 month.”

The American Sleep Association found that there are between:

• 50 -70 million people suffer from sleep disorders.
• 30% suffer from small bouts of insomnia.
• 48% with sleep disorders snore.
• 37.9% have snoozed during daytime hours at least once involuntarily.
• 4.7% have snoozed at least once whilst driving.

Approximately 30% of adults have short-term bouts of insomnia, while 10% have chronic insomnia (American Sleep Association). Symptoms lasting less than three months are considered to be acute. Symptoms more than three months at three nights a week are considered chronic.

People who have severe insomnia carry a risk of daytime injuries or accidents. A study published in the journal Sleep (2014) evaluated 54,399 men and women as a cohort. In an insomnia survey, the greater the number of symptoms, the more likely risk of unintentional fatal injuries, including motor crashes, falls and drowning.

What are the Most Common Causes of Insomnia? 

There are two types of insomnia: primary and secondary.

Primary insomnia

Primary insomnia is a condition with no known causes related to medical, psychiatric, or substance abuse. Between 20% -25% of cases of insomnia are estimated to be primary. Doctors are unable to pinpoint a single cause for insomnia. Anyone may be at risk for insomnia, but the prevalence is higher in the middle-aged to elderly, women, those with underlying health conditions, and/or on prescription medications.

Several factors contribute to the presence of insomnia: genetics and chemical dysregulation of the body. Researchers have found that individuals with the gene apolipoprotein E are likely to report that they have symptoms of insomnia. This gene is involved in fat metabolism. This gene encodes a protein that partners up with lipids within the body to form lipoprotein molecules. 

A hyperactive or hyperarousal state plays an important role in primary insomnia. This condition impairs the ability for the body to rest, because a stress response is being triggered. This process is likely a coalescence of multiple changes in the body, including endocrine, neural, and circadian disruption.

Diagnostic methods include:

• Elevated Body temperature
• Elevated Metabolic rate
• Increased Heart rate
• Decreased Heart rate variability

Secondary Insomnia

Secondary insomnia is when the patient suffers from physical or mental health conditions alongside insomnia. Secondary insomnia can be attributed to medical, psychiatric, substance abuse, and other sleep disorders. Sleep apnea can trigger insomnia and should be considered in anyone with high blood pressure, diabetes, and/or is overweight.

What are Risk Factors of Insomnia

• Substance abuse.
• A sedentary lifestyle.
• Night workers or those that change shifts frequently.
• Disorderly hours in shift work.
• Pregnancy.
• The responsibilities of looking after a newborn.
• Stress.
• Family/work relationships.
• Depression/ Anxiety.
• Noise/Light.
• Commuting at different time zones.
• Individuals with a medical history of asthma, chronic obstructive pulmonary disease, head trauma, chronic pain, thyroid disorders, menopause symptoms, heartburn, irritable bowel syndrome, and restless leg syndrome.
• Fluids and drug consumption, caffeine, cocaine, diet drugs, and alcohol.

How does a doctor diagnose insomnia?

The diagnosis involves a combination of:

• Medical inquiries, medication effects, and sleep history.
• Psychiatric conditions.
• Behavioral and cognitive factors. 
• Circadian rhythm factors.

How Might Insomnia Affect the Individual?

• Tiredness
• Low mood
• Annoyance or fury
• Feeling sleepy during daylight hours
• Worrying oversleep 
• Inability to concentrate
• Difficulty in memory recall
• Underperformance at work 
• Low in motivation or energy
• Headaches or tension
• Stomach upset
• Making errors at work or whilst driving
• Accidents during work/driving

Effects of Insomnia on the Body: A Deeper Look

Lack of sleep or poor-quality sleep increases the risk of other physical and mental conditions, such as obesity and depression. The neurotransmitter Gamma-aminobutyric acid (GABA) is deficient in patients suffering from major depressive disorder and anxiety disorder. GABA helps to lower activity in the brain. 

Findings from the National Sleep Foundation report that adults in the US get 6.9 hours of sleep time during the weeknights and 7.5 over the weekends. Among the population, 70 million sleep poorly for more than half that time. Both experimental and observational studies on adults have shown that acute and chronic sleep conditions disturb the natural flow of leptin and ghrelin. Leptin and ghrelin are key mediators in helping maintain a good sleep-wake cycle. 

These two counter-regulating hormones also contribute to a satiety state and weight set-point. Poor sleep decreases leptin, a hormone that tells you that you are full, while it increases the hormone ghrelin which keeps hungry. This in part explains the drive for late-night snacking in insomniacs. Similarly, eating for comfort is what many people do who suffer from depression or stress. These behaviors can begin to add up with weight gain. 

Sleep disorders and lifestyle interact with each other. Poor sleep can affect practices such as exercise during the day, while a sedentary lifestyle and obesity impacts the quality of sleep. A negative cycle reveals itself through lack of physical exercise, sleep difficulties, and emotional dysregulation which then can then fire up stress levels. The Centre for Disease Control advocates moderate to high-intensity exercise. This way forward will deliver the best results.

Sleep loss can have a negative input on the brain and mental health., in terms of response to stress and brain cognition. The hyperarousal state, in which the brain is too alert and unable to slow down and disengage, can add to increased stress on physical and mental health. The quality of sleep factors into mental health resilience and the development of depression. Individuals are prone to a depressed mood when sleep is disturbed, interrupted, or shortened. 

There appear to be gender differences in stress management. While more research is needed to clarify, there may be biological factors that make women more prone to stress dysregulation. They have a two- to three-fold higher risk of developing PTSD. Women may have a more sensitive hypothalamus-pituitary-adrenal axis (HPA) (i.e. the fight or flight response) than men and increased amygdala reactivity.

Insomnia and the COVID-19 Pandemic

The COVID-19 pandemic brought about sickness, isolation, and fatalities. COVID -19 put a halt on movement, disturbed commercial activities, and raised stress levels, anxiety, and depression, to such a degree that it had a detrimental impact on sleep health. This increase in fear and stress over COVID -19 can lead to a hyperarousal state, where the brain is stimulated to a degree that the individual is too excitable and not able to disengage and relax. One study (Jahrami, 2021) showed a high prevalence of sleep problems globally during the pandemic, affecting approximately 36%. Those with COVID-19 infection had a markedly high rate of insomnia (74.8%).

Ways to Approach to Insomnia

The recommended hours of sleep are 7 hours each night. These hours are recommended by the American Academy of Sleep Medicine. Here is a checklist of things to try to address insomnia. These might be things you can try for a few weeks before you can get to see your doctor.

• Keep a sleep diary. Get to sleep for the same amount of time nightly and at the same time.
• Try to get some natural light as the combination of natural light and night darkness can help promote a healthy sleep-wake cycle.
• Create a fixed sleep-wake routine.
• Do something that will relax your mind and body until you are tired enough for uninterrupted sleep for several hours.
• Avoid consuming anything likely to disturb you just before sleep time—upsetting images, audio, and arguments. Also, avoid any late-night tasks that are likely to disturb your sleep just before sleep time.
• Consider replacing your mattress and pillow with one that is going to help induce sleep and relaxation. You may also want to include;
• Eye masks to cover ambient light
• Earplugs for ambient noise
• White noise machines to neutralize ambient noise
• Humidifiers
• Fans to keep the body cool
• Scents, e.g., aromatherapy, may be useful
• Create a good sleeping environment in your bedroom for sleep.
• Try yoga, massage, reflexology, aromatherapy, or cognitive behavior therapy.
• Try limiting time lying in bed when you are unable to sleep.

Avoid these activities before you lay down to sleep:

• Naps longer than 20-40 minutes in mid-day.
• Consumption of caffeine and nicotine, 4 to 6 hours before sleeping.
• Limit fluid intake just before sleeping.
• Heavy meals before bedtime.
• Exercising too late in the night.

As a last resort, pills are available. You can see your doctor and try a short course. However, there is a risk of side effects such as daytime sleepiness, dependency, and even fatality if misused. Like many issues with the body, sleep offers a chance to discover and problem-solve what obstacles may be preventing it. Medications offer no such opportunity.

A self-assessment tool is available here http://epworthsleepinessscale.com. This is to assess daytime sleepiness for adults. For children and adolescents go here http://epworthsleepinesscale.com/about-the-ess-chad. 

Sleep has been a major focus for the Your Health Forum website. For more information on sleep, check out other posts on the site.

Lina is a health content writer and a featured writer at Your Health Forum. She lives in the UK, where she has a family. When she is not writing, she can be found jogging in the local park or making smoothies in her kitchen. She endeavors to have a good sleep each night. Her favorite quote is, ” Health is your first wealth.”

References 

1. Ringdale, E. Pereira, S. and Delzell, J. (2004, May 1).Treatment of primary insomnia. Retrieved from https://doi.org/10.3122/jabfm.17.3.212 
2. Gehrman P, “Cognitive-behavioral and chronotherapeutic interventions for insomnia”. Retrieved from https://www.sleepsociety.org.uk/wp-content/uploads/201 (( 20%-25% statistics page1) 
3. American Academy of Sleep Medicine, Retrieved from aasm.org/resources/factsheets/insomnia.pdf (30% and 10% statistics page page1) 
4. Cadet M, Tucker L, Allen H, Lawal E, Dickson D, Denis A, (2019, July) Assessing for and managing chronic insomnia in primary care settings. Retrieved from https://journals.lww.com/tnpj/fulltext/2019/07000/assessing_for_and_managing_chronic_insomnia_in.6.aspx  
5. Amihaesei I and Mungiu O, (2012, Jul-September) Main neuroendocrine features and therapy in primary sleep troubles. Retrieved from https://pubmed.ncbi.nlm.nih.gov/23272543/ 
6. Harvard Health Publishing,(2020, June 17) Insomnia: Restoring restful sleep.Retrieved from https://www.health.harvard.edu/staying-healthy/insomnia-restoring-restful-sleep  ( 6.9 hours sleep and 70 million figure) 
7. Hagen E, Starke S and Peppard P, (2015, October 16) The association between sleep duration and leptin, ghrelin and adiponectin among children and adolescents.Retrieved from https://link.springer.com/article/10.1007/s40675-015-0025-9
8.  Li L, Wu Chunmei, Gan Yong, Qu Xianguo and Lu Zuxun ( 2016, November 5)Insomnia and the risk of depression: a meta-analysis of prospective cohort studieshttps://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-1075-3
9.  Hein M Lanquart J, Loas G, Hubain P and Linkowski P (2017, July 28) Similar polysomnographic pattern in primary insomnia and major depression with objective insomnia: a sign of common pathophysiology? Retrieved from https://doi.org/10.1186/s12888-017-1438-4 
10. Johansson M, Frojmark M, Clarke A and Linton S (2021, January 12) Changes in insomnia as a risk factor for the incidence and persistence of anxiety and depression: a longitudinal community study. Retrieved from https://doi.org/10.1186/s41606-020-00053-z
11. Siddique RF, Ahmed O and Hossain KN (2021, May 15) Relationship between the fear of COVID -19 disease and sleep quality: the mediating role of stress. Retrieved from https://europepmc.org/article/PMC/PMC8123159
12. Sun Q, Qingsong Q, Basta M, and Chen B and Li Y ( 2021, January 8) Psychological reactions and insomnia in adults with mental health disorders during the COVID -19 outbreak. Retrieved from https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-03036-7
13. Rizzo D, Libman E, Baltzan M Fichten C and Bailes S (2021, March 1) Impact of the COVID -19 pandemic on obstructive sleep apnea: recommendations for symptom management. Retrieved from https://doi.org/10.5664/jcsm.8922
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