You are lying awake in bed, fighting the urge to check your phone once again; it's been three hours of attempting to fall asleep, and you know you might not get any sleep at all and have to face the next day while feeling severely sleep-deprived.
Once you fall asleep, you wake up rapidly and check the time. It's 4am, and you struggle to fall asleep once again. What can you do in that scenario? It's not so simple for some to force themselves to fall asleep. While Insomnia can be a persistent and challenging condition for many people, there are several ways to manage insomnia symptoms, which we will discuss today.
Insomnia affects your sleep quality and quantity, freepik.com
What is insomnia?
Insomnia is a sleep disorder characterised by difficulty falling or staying asleep. A person experiencing insomnia will often lay awake at night and then experience tiredness and impaired functioning during the day. Insomnia can lead to significant health consequences as sleep is important for maintaining physical and mental health.
Let's now review some of the symptoms and potential causes of insomnia to understand better how they can be managed.
Symptoms of insomnia
Here is an overview of the symptoms of insomnia.
- Difficulty falling asleep
- Difficulty staying asleep, e.g. waking up frequently throughout a night
- Difficulty falling back to sleep
- Impaired social, occupational or educational functioning, often due to:
- Tiredness
- Difficulty concentrating
- Irritability
- Decreased energy
Causes of insomnia
Often, insomnia symptoms are attributed to lifestyle factors which disrupt our sleep schedules, like shift work or excessive use of electronics at night. Another common cause is medication or substance use; excessive intake of caffeine or alcohol can affect the amount and quality of sleep we can get. Moreover, insomnia can be a side effect of some medications, including antidepressants.
Insomnia is often caused by Stress, freepik.com
An underlying health condition might also cause insomnia, whether psychological or physical. Mood disorders, PTSD or psychological distress due to Stress and grief can all take a tremendous toll on our body, including sleep disruption. Similarly, physical conditions such as heart disease, diabetes, or any condition that causes pain can affect our ability to get the rest we need.
Management of insomnia disorder
To effectively manage insomnia symptoms, it is important to consider what caused the symptoms to occur in the first place and address the issue. If the insomnia was caused by lifestyle factors, working on one's Sleep Hygiene might be the solution.
However, if the symptoms persist, consult your symptoms with a clinician as they might be attributed to the medication you are taking or some underlying health conditions. Let's discuss how insomnia is typically managed and how effective different techniques can be.
Management of insomnia aims to reduce the severity and prevent future insomnia symptoms and help people cope with the symptoms they are currently experiencing.
Pharmacological management of insomnia
While pharmacological management of insomnia is rather effective at relieving the patient from symptoms, one of its drawbacks is the addictive potential and possible side effects of common sleep medications.
Benzodiazepines act by enhancing the action of the neurotransmitter GABA. GABA is a central nervous system inhibitor; it calms the body down and regulates sleep onset. However, dependence on benzodiazepines builds quickly. The patient may need to take more and more of the medication to maintain the effects.
Benzodiazepines are also associated with significant abuse potential due to their sedative effects (Lie et al., 2015).
A two-year longitudinal study followed 2512 adults suffering from chronic insomnia, of which 24% were using sleep medication, predominantly benzodiazepines (Hohagen et al., 1993). At the end of the study, only 22% of the patients taking sleep medication saw an improvement in symptoms. The study concluded pharmacological treatment to be ineffective in the long term treatment of insomnia.
Non-benzodiazepine medications, developed to provide a less addictive and safer alternative for benzodiazepines, have effectively reduced insomnia symptoms (Huedo-Medina et al., 2012). Unfortunately, many of these medications have also been associated with severe side effects impairing one's daily functioning, including headaches, dizziness, problems maintaining balance or drowsiness.
Melatonin agonists enhance melatonin's action, a hormone that helps regulate the sleep cycle. Melatonin agonists effectively manage chronic insomnia and hold no potential for Addiction. They can still result in adverse side effects (Lie et al., 2015).
Attribution theory
Kelley's attribution theory proposes that people make causal attribution about their behaviour, including sleep difficulties. According to Storms and Nisbett (1970), if patients attribute arousal to their own emotions, they can experience greater emotions and difficulties falling asleep. However, attributing arousal experiences to an external factor like medication can reduce their emotions and difficulty falling asleep.
Storms and Nisbett (1970) found that patients with insomnia who were given a placebo, which they were told induces relaxation, experienced more difficulty falling asleep. However, patients who were given a placebo and told it would increase their arousal fell asleep quicker. The authors theorised this is because, in the relaxing placebo condition, patients attributed their arousal to their own emotions, while in the arousing placebo condition, their arousal was attributed to the pill.
Nonpharmacologic management of chronic insomnia
Chronic insomnia, where symptoms occur at least 3 times a week for at least 3 months, has been associated with stress-related hyperarousal (Basta et al., 2007). In this case, the extreme levels of stress a patient is experiencing are probably causing much more damage to their health beyond insomnia.
Pharmacological treatments will reduce the symptoms for some time, but they won't solve the underlying problem. Non-pharmacological approaches to treating insomnia involve Sleep Hygiene interventions and Cognitive Behavioural Therapy for Insomnia.
Sleep Hygiene
Sleep hygiene refers to maintaining healthy habits, routines and an appropriate bedroom environment, which help facilitate a regular sleep schedule and prevent insomnia. Important elements of good sleep hygiene involve avoiding caffeine, alcohol and electronic devices before sleep, having a relaxing bedtime routine, implementing regular healthy habits like exercise during the day or making sure your bedroom is dark and quiet.
A systematic review and meta-analysis of the effectiveness of sleep hygiene education as a treatment for insomnia concluded that sleep hygiene education is generally less effective than Cognitive Behavioural Therapy treatments. However, since its implementation differs widely, it is hard to conclude how effective it is (Chung et al., 2018).
Cognitive Behavioural Therapy for Insomnia (CBT-I)
Cognitive behavioural treatments of insomnia are based on the 3P model of insomnia, proposed by Spielman and colleagues in 1987. Spielman's model accounts for factors which predispose, precipitate and perpetuate the condition.
Predisposing factors may involve our genetic makeup or personality traits that make some people vulnerable to insomnia.
Precipitating factors are the triggering events that can lead to episodes of insomnia.
CBT-I interventions focus on addressing specifically the perpetuating factors; these are the unhelpful behaviours or thought patterns that maintain and exacerbate the symptoms after the precipitating event has passed.
A meta-analysis comparing pharmacological treatment and behavioural treatment of insomnia found both treatments to be equally effective in reducing short-term insomnia symptoms (Smith et al., 2002). However, behaviour therapy was found to be more effective in reducing the time it took patients to fall asleep after going to bed.
CBT-I interventions include identifying and challenging maladaptive beliefs and behaviours and making connections between our thoughts and outcomes related to sleep quality. Therapy for insomnia will also include techniques like stimulus control.
Stimulus control aims to reframe how people struggling with insomnia think of their bedtime environment. They are encouraged to only go to bed when they are tired and not use the bed for other activities. If they cannot fall asleep, they are encouraged to get up and only go to bed again when they feel tired.
Doing this will cause the bed to be associated with sleeping.
Relaxation techniques are also often used due to the association between insomnia and stress-related physiological hyperarousal. Examples of relaxation techniques include breathing exercises, meditation, progressive muscle relaxation and biofeedback.
Biofeedback teaches people how to self-regulate their body's physiology to promote relaxation. Technology monitoring bodily functions like heart rate or breathing are used, and the person is then encouraged to try to, for example, slow down their heart rate using the technology as a source of feedback.
Relaxation interventions can help reduce the chronic stress response, freepik.com
Management of insomnia in teenagers
Insomnia is common but often under-recognised in adolescence. Due to the severe consequences of untreated sleep disorders, it is important to address and manage the symptoms as quickly as possible. Due to the possible side effects and addictive potential of sleep medication, the recommended first line of treatment in adolescence is cognitive Behavioural Therapy, which has shown promising results so far (Zambotti et al., 2019).
Non-addictive pharmacological interventions are still understudied in younger populations. However, some studies indicate that melatonin could be a safe and effective way of reducing insomnia in children and adolescents (van Geijlswijk et al., 2010).
Management of insomnia in adults
In the adult population, insomnia is managed often using a combination of pharmacological and non-pharmacological treatments depending on the severity of symptoms and other co-existing conditions.
Management of insomnia in pregnancy
During pregnancy, it is important to avoid sleep medication, including melatonin, which can disrupt the sleeping patterns of the fetus. The recommended treatment for insomnia symptoms during pregnancy involves non-pharmacological interventions like CBT-I.
In the case of severe and long-term insomnia, NICE (National Institute for Health and Care Excellence) recommends promethazine. This sedative antihistamine drug can help people calm down and are safe to use during pregnancy.
Management of Insomnia - Key takeaways
- Insomnia is a sleep disorder characterised by difficulty getting or staying asleep and impaired daytime functioning.
- Common pharmacological treatment options for insomnia involve benzodiazepine medication, non-benzodiazepine medication or melatonin agonists. Medication targeting melatonin is generally considered safer and doesn't come with the potential of Addiction and severe side effects associated with other sleep medications.
- Non-pharmacological treatments involve sleep hygiene education and CBT-I.
- Sleep hygiene focuses on healthy habits and environmental factors that contribute to good sleep quality.
- CBT-I involves working with unhelpful thoughts, behaviours, and habits that may reinforce insomnia symptoms and learning relaxation techniques to decrease stress-related physiological arousal.
- Management of insomnia in teenagers and during pregnancy focuses mainly on non-pharmacological interventions. However, there are some safe pharmacological interventions for these populations as well.
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