What is Insomnia?

It is well known that quality sleep is essential to our physical and mental health and wellbeing. However, despite its importance, a worrying percentage of people find themselves regularly deprived of quality sleep with around a third of adults in Western countries experiencing sleep problems at least once a week.

Findings from insurer Aviva’s Wellbeing Report estimate that as many as 16 million UK adults are suffering from sleepless nights, as a third (31%) of respondents to their survey say they have insomnia.

From their survey responses, they compiled a list of the top ten cities whose residents reported suffering from insomnia:

• Cardiff 37%.
• Sheffield 36%.
• Glasgow 35%.
• Newcastle 35%.
• Norwich 34%.
• Belfast 33%.
• Bristol 33%.
• Manchester 33%.
• Leeds 33%.
• Nottingham 32%.

More than half (51%) of these say they don’t currently take any measures to help them sleep better, although improving sleep is the biggest health ambition for a quarter (26%) of UK adults.

Sleep issues including insomnia are a considerable health issue in the UK. In May 2019, the NHS issued 87,990 prescriptions for synthetic Melatonin at a cost to the NHS of £2.6 million.

Melatonin is a hormone that occurs naturally in your body, and it helps control your sleep patterns. In the same month, the NHS also issued 438,399 prescriptions for Zopiclone, a type of sleeping pill that can be taken for short-term treatment of severe insomnia, costing £292,354.

What is insomnia?

According to the National Institute for Health and Care Excellence (NICE), insomnia is difficulty in getting to sleep, difficulty maintaining sleep, early wakening, or non-restorative sleep which occurs despite adequate opportunity for sleep, and results in impaired daytime functioning.

Anyone can experience insomnia, but it appears to affect more women than men. More than one in four women experience insomnia, compared with fewer than one in five men, and older women are at a higher risk of insomnia.

Insomnia in children is very common and is characterised by struggles around going to bed, difficulty falling asleep at bedtime or problems staying asleep during the night, and children with insomnia may also wake up very early. Insomnia can occur in children of all ages, from infants to toddlers, school-aged children and adolescents, and in some cases can develop into a long-term problem.

What are the types of insomnia?

Insomnia is categorised by the National Institute for Health and Care Excellence (NICE) according to duration or likely duration:

• Short-term insomnia lasts less than 3 months.
• Long-term (or chronic) insomnia lasts for 3 months or longer.

However, research from the Netherlands Institute for Neuroscience, published in The Lancet Psychiatry journal in 2019, found that there are actually five types of insomnia.

These are described as:

• Acute insomnia – Acute insomnia is the most common type of insomnia. It is short term and lasts for a few days up to a month. It is also commonly called adjustment insomnia because it is usually caused by a change in environment or stressful events.
• Chronic insomnia – In some cases, insomnia can become chronic or long term. Insomnia is said to be chronic if someone experiences difficulties in sleeping at least three days a week for at least a month. Chronic insomnia may be primary or secondary. Primary chronic insomnia is also called idiopathic insomnia because there is no specific cause. Secondary chronic insomnia is also called comorbid insomnia. Comorbid insomnia is more common than primary insomnia and occurs due to other underlying medical conditions (comorbidities).
• Onset insomnia – Onset insomnia includes trouble initiating sleep. It can be either short term or chronic.
• Maintenance insomnia – Maintenance insomnia is when someone has difficulty staying asleep or waking up too early and difficulty going back to sleep. Maintenance insomnia may be caused by chronic medical conditions or psychological conditions such as depression, anxiety or stress.
• Behavioural insomnia of childhood – This occurs due to negative associations with sleep, such as needing to go to sleep by being rocked or nursed or watching TV while going to bed or the child’s refusal to go to bed.

What causes insomnia?

There are a wide range of causes and types of insomnia. Primary insomnia is a disorder. It is not a symptom or a side effect of another medical condition.

A doctor may diagnose sleeplessness as primary insomnia after ruling out other medical conditions as a cause. Secondary insomnia, on the other hand, is caused by or happens alongside other health conditions or as a side effect of prescribed medicines. It can be acute (short term) or chronic (long term). Most people with chronic insomnia have secondary insomnia.

Primary insomnia may be caused by:

• Stress – Stress can provoke a profound reaction in the body that poses a challenge to quality sleep. The body’s physical response to stress contributes to hyperarousal, and mental stress can have the same effect. The inability to sleep may itself become a source of stress, making it increasingly harder to break the cycle of stress and insomnia.
• Irregular sleep patterns – The body has an internal clock, known as its circadian rhythm, and this closely follows the daily pattern of day and night. Many people have sleep patterns that cause misalignment of their circadian rhythms such as shift work or jet lag. Jet lag disturbs sleep because a person’s body can’t adjust to a rapid change in time zones. Napping in the afternoon can throw off your sleep timing and make it hard to fall asleep at night. Sleeping in later to make up for lost sleep can confuse your body’s internal clock and make it difficult to establish a healthy sleep pattern. In some people, circadian rhythms can shift forward or backward without a clear cause, resulting in persistent difficulties in sleep timing and overall sleep quality.
• Lifestyle – Unhealthy lifestyle habits and routines and certain foods and drinks can increase a person’s risk of insomnia.
  For example:
  – Activities such as working late, watching TV, playing video games, or using other electronic devices keep the brain stimulated until late in the evening and prevent the brain from switching off.
  – Drinking tea or coffee late in the evening can prevent restful sleep. Caffeine is a stimulant that can stay in your system for hours, making it harder to get to sleep and potentially contributing to insomnia. Nicotine is another stimulant that can negatively affect sleep.
  – Alcohol, which is a sedative that can make you feel sleepy, can actually worsen your sleep by disturbing your sleep cycle and causing fragmented, non-restorative sleep.
  – When consumed later in the evening, heavy meals and spicy foods can be hard on your digestive process and have the potential to generate sleeping problems.
  – A partner with sleep problems – If you sleep with a partner who snores or has sleep apnoea, your sleep may be more restless and interrupted.
  – A bad sleep environment. Having a bed or place to sleep that is uncomfortable, unsafe, noisy, or too bright can make it difficult to fall asleep.
  – Lack of exercise, sedentary lifestyle.

Secondary insomnia may be caused by:

• Mental health disorders – Mental health conditions such as anxiety, depression and bipolar disorder frequently give rise to serious sleeping problems. It is estimated that 40% of people with insomnia have a mental health disorder. These conditions can incite pervasive negative thoughts and mental hyperarousal that disturbs sleep. In addition, studies indicate that insomnia can exacerbate mood and anxiety disorders, making symptoms worse and even increasing the risk of suicide in people with depression.
• Physical illness and pain – Almost any health condition that causes pain can disrupt sleep by making it harder to lie comfortably in bed. Thinking about the pain when sleepless in bed may amplify it, increasing stress and sleeping problems.
  Particular health conditions that are known to interfere with sleep and that can be part of an underlying cause of insomnia include:
  – Health complications related to type 2 diabetes such as rapid blood sugar changes that interrupt sleep.
  – Conditions such as cancer, stroke, chronic obstructive pulmonary disease (COPD), heart failure.
  – Neurological (brain) disorders, such as Alzheimer’s disease or Parkinson’s disease.
  – Conditions that make it hard to breathe, such as asthma and obstructive sleep apnoea (OSA).
  – Physical illnesses that affect the respiratory or nervous system such as ME or fibromyalgia.
  – Gastrointestinal disorders, such as heartburn.
  – Conditions that cause chronic pain, such as arthritis, musculoskeletal conditions.
  – More frequent need for hydration and urination.
  – Other sleep disorders, such as restless legs syndrome (RLS).
  – Hormonal issues, including thyroid problems.
  – Certain types of prescription or over-the-counter medications.

Women may be more likely to have insomnia than men because women experience unique hormonal changes that can cause insomnia symptoms.

These include hormonal changes during:

• The menstrual cycle, especially in the days leading up to their period when many women report problems going to sleep and staying asleep. This is especially common in women who have premenstrual tension (PMT).
• Pregnancy, especially in the third trimester, when women may wake up often because of discomfort, leg cramps, or needing to use the bathroom.
• Changing hormone levels after childbirth can disrupt your sleep. Very young babies do not usually sleep longer than a few hours at a time and need to be fed every few hours.
• Perimenopause and menopause, when hot flushes and night sweats can disturb sleep.

What are the signs and symptoms of insomnia?

Almost everyone experiences insomnia from time to time, but sleep difficulties are only categorised as insomnia when they cause a person distress and begin to negatively affect aspects of their life, such as work or relationships.

Talk with your doctor if you are having ongoing difficulties with sleep and you are experiencing some of the following signs and symptoms of insomnia that include, but are not limited to:

• Trouble falling asleep after going to bed.
• Spending a lot of the night lying awake, worrying you won’t fall asleep.
• The inability to stay asleep.
• Waking too early and finding yourself unable to fall back asleep.
• A consistent pattern of interrupted or broken sleep that doesn’t refresh you.
• Fatigue.
• Irritability and other mood changes.
• Difficulty concentrating or remembering things.
• Resisting sleeping at bedtime (for children and teens).
• Behavioural issues, such as hyperactivity or aggressiveness.

Can insomnia be prevented?

Anyone with symptoms of insomnia should see a doctor to get tailored advice about how to improve their sleep, but there are some sleep hygiene strategies that can be used to help with healthy sleep.

Including:

• Try to go to bed at the same time each night and wake time every day regardless of how well you slept, even on weekends. If you get sleepy, don’t ‘cat-nap’ on the sofa, go to bed.
• Don’t check the clock to see how long it is taking to fall asleep.
• If falling asleep is taking too long or causing anxiety, get out of bed and do something relaxing until you feel sleepy.
• Reserve use of the bedroom for only relaxation and sleep.
• Keep the bedroom both dark and quiet.
• Don’t consume caffeine, alcohol or nicotine, especially near bedtime.
• Before bedtime, try to avoid bright, artificial light from computer screens, mobile phones or televisions. Do not allow electronic devices in the bedroom.
• Avoid eating large or spicy meals too close to bedtime.
• Go outside every day for at least 15 to 20 minutes. The natural light will help you get into a natural pattern of sleeping.
• Get regular physical activity during the daytime. Exercise or physical activity close to bedtime, or anytime in the five or six hours before sleeping, can make it harder to fall asleep.
• Natural aromatherapy oils such as lavender are believed to aid sleep.

For parents of children with sleeping problems, establishing firm, consistent limits around bedtimes and bedtime activities can help prevent a child from becoming dependent on any item or routine to fall asleep.

How is insomnia diagnosed?

To establish whether you are suffering from insomnia, your doctor will do a physical examination and ask you about your symptoms, daily habits and stress levels. They will ask you about your sleep habits, so try to keep a sleep diary for one or two weeks before you see your doctor. Write down the times you go to sleep, wake up, and take naps. Keep track of how long you sleep each night and how you feel throughout the day.

The doctor may arrange tests to rule out other medical problems that might cause insomnia. These might include blood tests to check for thyroid problems or other medical conditions.

As some medicines, including some used to treat heart problems and depression, may cause sleep problems, the doctor will discuss these with you and may suggest changing your medication. You should also tell the doctor about all over-the-counter medicines you may be taking.

How is insomnia treated?

If your insomnia is caused by a short-term change in your sleeping pattern, such as the effects of jet lag, your sleep pattern will probably return to normal on its own, although using some of the strategies outlined above can help.

Chronic or long-term insomnia can be treated using the strategies outlined above. To sleep better, however, your doctor may suggest cognitive behavioural therapy (CBT), which is a talking therapy that can help you change the thoughts and behaviours that keep you from sleeping.

Over-the-counter sleep remedies should only ever be taken short term and it is a good idea to get advice from your doctor before taking them.

Doctors now rarely prescribe sleeping pills to treat insomnia. Sleeping pills can have serious side effects and you can become dependent on them. If your doctor does decide to prescribe sleeping pills, it will only be for a few days or weeks at the most, and then only if your insomnia is very bad or other treatments have not worked.

You may be referred to a sleep clinic if you have symptoms of another sleep disorder such as sleep apnoea.

Sleep experts have identified a handful of relaxation techniques that can benefit people with insomnia. These include breathing exercises and muscle relaxation such as aromatherapy.

How much sleep do people need?

There are no official guidelines about how much sleep you should get each night because everyone is different. On average, a normal amount of sleep for an adult is considered to be around seven to nine hours a night; however, older adults may sleep less. Children and babies may sleep for much longer; children need 9 to 13 hours and toddlers and babies need 12 to 17 hours.

Sleep is essential for good health. During sleep, our bodies and brains repair themselves. Some research suggests our brains use the time during sleep to clear away toxins that build up during the day. Sleep is also important to our ability to learn and form memories. Not getting enough sleep puts people at risk for health problems, including high blood pressure, obesity and depression.

Living with insomnia

For anyone living with insomnia, you should try to implement the sleep hygiene strategies listed above in how to prevent insomnia – Used on a regular basis these should improve the quality of your sleep.

If your doctor has not already referred you for CBT, ask if it is possible to be referred, as up to 75% of people with chronic insomnia who go through CBT improve their sleep and not only do they get back into a normal sleep pattern, but they also get 30% more of the deepest, most restful type of sleep (slow-wave sleep) than they did before.

If your insomnia and excessive sleepiness is having, or is likely to have, an adverse effect on your driving, then you must inform the DVLA. For more detailed guidance, see the DVLA At a glance guide.

You can also get advice and support for any sleep issues from:

• Insomniacs.
• The National Sleep Helpline 03303 530 541
• The Sleep Council 0800 018 7923
• British Snoring and Sleep Apnoea Association Freephone Helpline: 0800 085 1097
• MIND 0300 123 3393
• Young Minds
• Childline 0800 1111

Final thoughts

There are many reasons why you may have trouble sleeping. Many of them are linked to daily habits, lifestyle and personal circumstances, but whatever the reason for your sleep issues, insomnia is treatable so talk to your doctor or NHS 111.