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Insomnia

Insomnia

Insomnia is a sleep disorder that causes people to have difficulty getting to sleep and staying asleep. People with insomnia may wake up during the night or early in the morning, and feel irritable and tired during the day. Stress and anxiety are common causes of insomnia. Insomnia tends to be more common in women and is more likely to occur in older people. There are self-help tips that can aid sleep. Other treatments include cognitive behavioural therapy and medication. Foods recommended to eat, for the casefile in the programme, are a high carbohydrate evening meal like pasta and eating two kiwi fruits one hour before bedtime.

Introduction

Insomnia is difficulty getting to sleep or staying asleep for long enough to feel refreshed the next morning, even though you've had enough opportunity to sleep.

Most people have problems sleeping at some point in their life. It's thought that a third of people in the UK have bouts of insomnia. Insomnia tends to be more common in women and more likely to occur with age.

It's difficult to define what normal sleep is as everyone is different. Your age, lifestyle, environment and diet all play a part in influencing the amount of sleep you need. 

The most common symptoms of insomnia are:

  • difficulty falling asleep
  • waking up during the night
  • waking up early in the morning
  • feeling irritable and tired and finding it difficult to function during the day

Read more about the symptoms of insomnia.

Stress and anxiety are a common cause of insomnia, but it can also be caused by conditions such as depression, schizophrenia or asthma, some medications and alcohol or drug misuse. 

Read more about the causes of insomnia.

What to do

There are things you can do to help you get to sleep, such as avoiding caffeine later in the day or heavy meals late at night, trying to set regular times to wake up and using thick blinds or curtains, an eye mask and earplugs to prevent light and noise from waking you up.

Try to relax by taking a warm bath one hour before you sleep or listen to calming music before bedtime.

Read more self-help tips for insomnia.

 

When to see your GP

You should consider visiting your GP if a lack of sleep is affecting your daily life and you feel that it's a problem. Fatigue due to insomnia can affect your mood and create problems within your personal relationships and work environment.

Keeping a sleep diary may help you and your GP understand your sleep patterns.

Treating insomnia

The first step in treating insomnia is to diagnose and treat any underlying health condition, such as anxiety, that may be causing your sleep problems. 

Your GP is likely to discuss self-help tips for insomniawhich can help you sleep better (this is referred to as good sleep hygiene).

Cognitive behavioural therapy (CBT) may sometimes be recommended, as it can help you to avoid thoughts and behaviours that are affecting your sleep. CBT is a type of talking therapy that can be carried out by your GP or a clinical psychologist.

Sleeping tablets are usually the last resort and are often only used in the short-term with the smallest possible dose. This is because they can sometimes relieve the symptoms of insomnia but they don't treat the cause. If you have long-term insomnia, sleeping tablets are unlikely to help.

Read more about treating insomnia.

 

Symptoms

The symptoms of insomnia depend on the type of sleeping problem that you have. A lack of sleep can affect your mood and cause tiredness and fatigue during the day.

It's thought that up to a third of people in the UK have symptoms of insomnia at some point in the year, which can include:

  • lying awake for a long time at night before falling asleep
  • 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 refreshed by sleep
  • not being able to function properly during the day and finding it difficult to concentrate
  • being irritable

How much sleep do I need?

As every individual is different, it's difficult to define what ‘normal sleep’ is. Factors that influence 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 to have 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's normal to find sleep more difficult to maintain, although you still need the same amount of sleep.

When to visit your GP

You should consider visiting your GP if a lack of sleep is affecting your daily life and you feel that it's a problem. Fatigue caused by insomnia can sometimes affect your mood and create problems within your personal relationships and work environment.

Read more about simple methods that may help prevent insomnia.

Causes

Insomnia can be caused by many different things, including stressful events, psychiatric problems, underlying physical conditions, and drug and substance misuse. It can also be a side effect of certain medications.

Stressful events

Some people experience insomnia in response to a stressful event, and it continues even when the stress has been resolved. This is because they have learnt to associate the sleeping environment with being alert.

Worrying about work, money or health, a loved one becoming ill or dying, and even noise and light are all causes of Stress and are likely to keep you awake at night. 

Psychiatric problems

Underlying mental health problems can affect your sleeping patterns. They include:

Physical condition

Insomnia can be caused by underlying physical conditions, including:

Drug and substance misuse

Alcohol and drug misuse, nicotine and drinking too much caffeine (contained in tea, coffee, energy drinks) can also affect your sleeping patterns.

Medication

Some prescribed treatments or medicines that are available over the counter can cause insomnia. These include:

Diagnosing insomnia

You should consider visiting your GP if you're finding it difficult to get to sleep or to stay asleep and it's affecting your daily life.

Investigating the problem

You're likely to be asked about your sleeping routines, how much alcohol and caffeine you drink each day, and your general lifestyle habits, such as diet and exercise.

Your GP will also check your medical history for any illness or medication that may be contributing to your insomnia. 

Keeping a sleep diary (see below), can help you and your GP understand the pattern of your insomnia, which may help to decide the method of treatment. 

Read more about how insomnia is treated.

Keeping a sleep diary

You should keep a sleep diary for a minimum of two weeks. It should record information such as:

  • the time you go bed
  • the time it takes to get to sleep
  • the number of times that you wake up during the night
  • the time at which you wake up
  • episodes of daytime tiredness and naps
  • the times of meals, alcohol consumption and significant events during the day, such as exercise and stress

Treating insomnia

The first step in treating insomnia is to find out whether the problem is being caused by an underlying medical condition.

If it is, once the condition has been treated your insomnia may disappear without the need for further medical help.

Your GP should advise you on what you can do at home to help you sleep. This is often referred to as good sleep hygiene, and includes:

  • establishing fixed times for going to bed and waking up (avoid sleeping in after a poor night's sleep)
  • trying to relax before going to bed
  • maintaining a comfortable sleeping environment (not too hot, cold, noisy or bright)
  • avoiding napping during the day
  • avoiding caffeine, nicotine and alcohol within six hours of going to bed
  • avoiding exercise within four hours of bedtime (although exercise in the middle of the day is beneficial)
  • avoiding eating a heavy meal late at night
  • avoiding watching or checking the clock throughout the night
  • only use the bedroom for sleep and sex

Read more about simple methods that may help prevent insomnia.

If you have long-term insomnia (lasting more than four weeks):

  • your GP will advise you about good sleep hygiene
  • your GP may recommend cognitive and behavioural treatments
  • you may be prescribed a short course of sleeping tablets for immediate relief or to manage a particularly bad period of insomnia (although they aren't recommended for long-term use)
  • If you're over 55 years old, your GP may consider prescribing melatonin.

Cognitive and behavioural treatments

Cognitive behavioural therapy (CBT) aims to change unhelpful thoughts and behaviours that may be contributing to your insomnia. CBT is usually recommended if you've had sleep problems for more than four weeks. It includes:

  • stimulus-control therapy, which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern
  • sleep restriction therapy – 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 – this aims to reduce tension or minimise intrusive thoughts that may be interfering with sleep
  • paradoxical intention – you try to stay awake and avoid any intention of falling asleep; it's only used if you have trouble getting to sleep, but not maintaining sleep
  • biofeedback – sensors connected to a machine are placed on your body to measure your body’s responses, such as muscle tension and heart rate; the machine produces pictures or sounds to help you control your breathing and body responses

Sometimes, CBT is carried out by a specially trained GP. Alternatively, you may be referred to a clinical psychologist.

Sleeping tablets

Sleeping tablets (hypnotics) are medications that encourage sleep. They may be considered:

  • if your symptoms are particularly severe
  • to help ease short-term insomnia
  • if the non-drug treatments that are mentioned above fail to have an effect

However, doctors are usually reluctant to prescribe sleeping tablets as they relieve symptoms but don't treat the cause of your insomnia. If you have long-term insomnia, sleeping tablets are unlikely to help. Your doctor may consider referring you to a clinical psychologist to discuss other approaches to treatment.

Read more about why sleep medication only offers short-term relief.

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, you may be advised to only take the medication two or three nights a week, rather than every night.

Sleeping tablets can cause the following side effects:

  • a feeling that you're hungover
  • drowsiness during the day

It's best to take sleeping tablets at night, before you go to bed. In some people, particularly older people, the hangover effects may last into the next day, so be cautious if you're likely to be driving the next day.

It's very easy to become dependent on sleeping tablets, even after a short-term course. 

If you're regularly taking sleeping tablets every night, consider reducing or stopping them. 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 that are 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're needed to treat insomnia, only the short-acting benzodiazepines (with short-lasting effects) should be prescribed, such as:

Z medicines

Z medicines are a newer type of sleeping tablet that work in a similar way to benzodiazepines. They're also short-acting medicines and include:

There's little difference between the benzodiazepines and Z medicines. If one doesn't work, then swapping to another is unlikely to have a different effect.

For more information, see the NICE guidance about the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia.

Melatonin (Circadin)

Medicines that contain melatonin have been shown to be effective in relieving insomnia for up to 26 weeks in elderly people. Melatonin is a naturally occurring hormone that helps regulate the sleep cycle (known as the circadian rhythm).

At present, Circadin is the only medicine that contains melatonin. It's licensed to treat insomnia. Circadin is only available on prescription for people who are 55 years old or over.

Circadin is designed as a short-term treatment for insomnia and shouldn't be taken for more than three weeks. It's not recommended for people with a history of kidney disease or liver disease.

As yet, there's not enough evidence to say whether it's safe to take Circadin during pregnancy or while breastfeeding, so its use isn't recommended under these circumstances.

Side effects of Circadin are uncommon but include:

If you find these side effects troublesome, stop taking Circadin and contact your GP.