Insomnia: The Hidden Epidemic

Insomnia defined

Insomnia is defined as persistent difficulty in either falling asleep and/or staying asleep which may be accompanied by functional impairment while awake. There is no set definition of the amount of sleep required or the minimal amount which qualifies as insomnia and if you are not feeling unduly tired during the day, then the amount of sleep that you are getting is considered adequate for you.

Insomnia: The scale of the problem

We sleep an hour and a half less a night than we did 100 years ago which means that the bench marks for a decent night's sleep may have been collectively moved. Even so, insomnia is now at epidemic proportions. An estimated 50-75 million Americans – one in five – has difficulty sleeping. Approximately 10- 20% of the world population are reliant upon using pharmaceutical sleep aids and a third of the over-60s rely upon sleeping tablets to which they may have become involuntarily addicted. The global sleep aid market doubled in the five years to 2007 with 56 million prescriptions for sleeping aids being written in the US in 2008 which represented an increase of 54% over the previous 4 years.

Then there are the other costs of sleep deprivation which can literally be deadly. Twenty per cent of all serious motor accidents are associated with sleepiness and according to a Harvard study conducted by Charles Czeisler in 2004, one in twenty young medics confessed to having made a mistake due to tiredness that resulted in the death of a patient. Then there are the societal costs of insomnia in terms of lost productivity at work, and the personal costs of strained relationships and a lack of enjoyment of life. 

The mechanisms that control sleep

The coordination of sleep/wake cycles is a concert of activity governed by the following:

The hypothalamus in the base of the brain governs the circadian rhythm and regulates the chemicals that promote sleep and arousal. The hypothalamus contains a tiny cluster of cells called the venterolateral preoptic nucleus (VLPO) which is triggered by the daily accumulation of adenosine. The VLPO then signals the arousal centres to stop producing the chemicals such as histamine that are responsible for keeping us alert. 

The thalamus is the body clock which coordinates input from the senses.

The suprachiasmatic nucleus (SCN) is another tiny cluster of cells which lies just above the optic chiasma which is where the optic nerves cross over. It coordinates information about daylight from the cells in the retina of the eye and then sends a signal to the VLPO to stop suppressing the chemicals responsible for arousal causing us to awaken from sleep. 

The pineal gland converts serotonin to melatonin when darkness comes in preparation for sleep.

The hippocampus replays memories for storage during REM sleep.

The pons is involved in both arousal and dreaming during REM sleep. It blocks signals to the spinal cord preventing us from acting out our dreams and potentially hurting ourselves during sleep.

The cerebral cortex is activated during REM sleep by signals from the pons and dreaming may be an attempt to make sense of the information collated during the day. 

Specialised cells in the retina send signals to the brain when they sense light.

Types of insomnia

Some people experience difficulty in getting to sleep and this is referred to as onset insomnia and may relate to anxiety disorders. Some waken in the middle of the night (also referred to as nocturnal awakenings) and are unable to return to sleep (middle insomnia) which may be associated with pain or illness or they may wake very early (terminal insomnia) and this can be associated with clinical depression. As mentioned above, some individuals appear to sleep for the required amount of time, but have poor sleep quality failing to reach restorative stage 4 or delta sleep.

Allopathic medicine defines transient insomnia as lasting for less than a week, acute insomnia as lasting for between a week and a month and chronic insomnia as lasting for more than a month. 

There are 90 recognised sleep disorders including:

Sleep apnoea This is where the muscle relaxation associated with sleep allows the trachea (windpipe) to close depriving the body of oxygen until an alarm signal is sent from the brain to awaken and draw breath. The affected individual then falls asleep until the next episode and so on throughout the night. This effectively means that the sufferers are getting lots of tiny naps and not entering the deeper stages of sleep. Sleep apneoa is the most common sleep-disorder with two-thirds of people attending sleep clinics being diagnosed with it. It is recognised to cause an increased risk of heart attacks and strokes and to be associated with premature ageing. Advice and treatment currently involves losing weight (if possible), stopping drinking alcohol, and the use of either a face mask with positive pressure oxygen or a jaw-repositioning device to keep the airway open. Many sufferers are completely unaware that they have sleep apnoea, with a partner more likely to be concerned about extended periods of suspension of breathing (or snoring) during sleep. People with sleep apnoea are typically tired during the day and unrefreshed by their night's sleep.

Narcolepsy In narcolepsy the affected individual suddenly and unexpectedly passes straight from full wakefulness into deep sleep.

Restless leg syndrome (RLS) causes pain, discomfort or a compulsion to move the legs during sleep which can seriously disrupt the healthy patterns of sleep. 

Periodic limb movement disorder (PLMD) is similar to restless leg syndrome but involves involuntary kicking or jerking of the limbs during sleep.

‘True’ or psychophysiological insomnia is classified by allopathic medicine as either being organic or non-organic and accounts for 25% of insomnias. The body and/or mind may just not slow down making sleep impossible. Organic insomnia is secondary to another recognised condition such as depression, an under-active thyroid gland, post-viral fatigue syndrome, dementia, bipolar disorder or Alzheimer's disease whereas in non-organic insomnia an underlying medical cause cannot be identified. 

Neurotransmitter imbalances People with neurotransmitter imbalances may be the most resistant to allopathic treatment. Up to 90% of adults with depression are found to have sleep difficulties and depression disrupts the normal patterns of sleep. In fact, most of the pharmaceuticals that work for depression may work by re-establishing normal sleep patterns and not vice versa. 

Nocturnal urination Bed wetting in children or adults can be a sign of an underactive thyroid gland as the body is not prompted to wake from deep sleep in order to urinate. Taking diuretics or the frequent need to urinate associated with the fatiguing disorders or prostate hyperplasia in men can also be highly disruptive of a decent night's sleep. 

Side-effect of medications Insomnia or a disruption of the normal patterns of sleep can also be a side-effect of medications such as antidepressants or minor tranquillisers. 

Pain Many people are frequently prompted awake by pain during the night or may find difficulty getting to sleep or getting comfortable because of chronic pain. 

Anxiety and worry Often erroneously assumed to be the primary cause of sleeplessness.

Jet lag or shift-work The body clock can sometimes be permanently disrupted by an erratic work shedule or changes in time zones. 

Stimulants Taking stimulants such as amphetamines, caffeine, cocaine, energy drinks, ‘ecstasy’ (MDMA), alcohol and nicotine can all adversely affect sleep. In fact, the average smoker sleeps 30 minutes less every night than a non-smoker. 

Sleep requirements: The Ideal

No one truly seems to understand the significance of sleep, but it occupies a third of our lives and is common to all living creatures. One proposed function of sleep is energy conservation. In the Traditional Chinese Medicine view yin and yang must always be in balance so sleep is thought to be an anabolic state during which the immune, nervous, skeletal and muscular systems can be restored and growth can occur and wakefulness is a catabolic state during which the individual acquires nutrients, reproduces and is active. 

There appears to be an optimal amount of sleep of about 7 hours in adults with those who sleep less or more all showing increased mortality. In fact sleeping more than 8.5 hours or less than around 4 hours both resulted in a 15% increase in mortality although with lack of sleep it may be the underlying condition rather than the insomnia itself that produces this effect. Interestingly, insomnia was associated with an increase in longevity, whilst the use of sleeping pills was found to be associated with an increased mortality rate. So the moral is: the lack of sleep may not kill you, but the sleeping pills might!

Women are twice as likely to suffer from insomnia than men and many women find that they sleep badly before or during their period and during menopause. Women are thought to be biologically programmed to be lighter sleepers because they are required to wake if their children require comfort or assistance in the night.

Substances that can affect sleep

Stimulants that can prevent sleep include: amphetamines, caffeine, nicotine, cocaine, energy drinks, ‘ecstasy’ (MDMA) and the pharmaceutical drug methylphenidate (Ritalin and Concerta). 

Hypnotics Sleeping tablets work by decreasing mental activity thus enabling sleep. However, the amount of light sleep is increased and although you may be unconscious for longer you may wake feeling unrefreshed. The manufacturers claim that the sleeping patterns induced by some of the newer pharmaceuticals such as Zopiclone and Zolpidem induce are more natural.

Most sleeping tablets work by enhancing the activity of the GABA neurotransmitters which regulate overall anxiety and alertness. As with many pharmaceuticals, you can become addicted to sleeping tablets. The sleep induced may not be refreshing and you may experience a worse 'rebound insomnia' when you try to wean yourself off them.

Antihistamines Over-the-counter antihistamines such as diphenhydramine (Benadryl) and doxylamine (NyQuil) can induce drowsiness during the day and promote sleep at night.

Alcohol Whilst alcohol can induce sleep there is a rebound effect later in the night and alcohol also reduces the amount of REM sleep. There are strong links between alcoholism and insomnia.

Barbiturates Barbiturates induce drowsiness but cause rebound insomnia a few hours later and inhibit REM sleep. They should not be used as a long-term sleep aid. 

Benzodiazepines Like hypnotics, benzodiazepines also target the GABAA receptor and are commonly used sleep aids although they have been shown to decease REM sleep.

Melatonin This is a naturally occurring hormone synthesised in the pineal gland of the brain by converting serotonin into melatonin which is released at night to induce and maintain sleep. This is why you may feel drugged and why all your problems feel worse if you awaken in the middle of the night.

Nonbenzodiazepine hypnotics These are the most commonly prescribed pharmaceuticals for insomnia and this category includes eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien). 

Natural sleep aids Supplementing 5HTP or herbal preparations including those containing Passion flower, California poppy, Kava kava, and Valerian may also help. St John's Wort has also been shown to be helpful in cases of insomnia accompanied by mild depression.

 Reference:

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