Insomnia

Insomnia is a condition where a person has difficulty falling and staying asleep, as well as problems with the overall quality of their sleep. Although problems sleeping can have a whole range of contributing factors, it is diagnosed as insomnia if there are two specific traits: sleep problems occur despite there being adequate conditions for sleep and the problems affect you during the day (directly resulting from lack of sleep and poor sleep.)

There are two main types of insomnia disorder. Sleep-onset insomnia is where you have difficulties falling asleep whilst sleep maintenance insomnia is where you have difficulties staying asleep. Some people experience symptoms of both types which are referred to as mixed insomnia.

Most people experience problems sleeping occasionally, however, if you experience any of these symptoms repeatedly, you most likely have insomnia. Signs include:

• finding it hard to get to sleep
• waking up several times in the night
• lying awake at night
• waking up early and not being able to get back to sleep
• still feeling tired after waking up
• having trouble napping in the day even though you feel tired
• feeling sleepy or irritable throughout the day
• having difficulties with memory and concentration throughout the day

Some people only experience these symptoms for less than three months. This is called short-term insomnia. However, some experience symptoms for a lot longer, which is referred to as chronic insomnia. In these cases, symptoms occur at least 3 times a week for 3 months.

In these more severe cases, your GP may refer you to a sleep specialist to try and find a cause. You’ll usually undergo an overnight sleep study, which involves a test called PSG (polysomnography). Beforehand, you may be asked to keep a sleep diary and avoid certain substances like caffeine to ensure the effectiveness of the study.

There are many underlying causes of insomnia and everyone is affected differently. Insomnia caused by poor sleep habits or by other external factors, such as other health conditions or medications, is called secondary insomnia.

Primary insomnia is where there is no attributable reason for sleep difficulties and thus a specific biological cause has been difficult to pinpoint. The most discussed potential cause is hyperarousal. Experts have attributed a state of hyperarousal to insomnia. Hyperarousal means there is overactivity in both your neurobiological (brain and nervous system) and psychological systems (such as your cognition). Although research is still divided on the specific mechanisms linking hyperarousal to insomnia, we do know that hyperarousal can be triggered by a range of circumstances and other health problems.

Lifestyle

One of the most common causes of insomnia is having certain lifestyle habits. This can include:

• using electronic devices or playing video games before bed - this causes the brain to be over-stimulated
• napping late in the afternoon or sleeping in late - both can confuse your body’s internal clock (circadian rhythms) and can make it difficult to establish a healthy sleep schedule
• using your bed for activities besides sleep - this can create associations between your bed and wakefulness
• smoking - nicotine is a stimulant, that stays in your symptom for hours and can cause difficulties sleeping
• recreational drugs - regular use can cause sleep abnormalities

There are also some dietary factors that can influence your sleep such as:

• caffeine - another stimulant that can be attributed to insomnia if consistently ingested late in the evening
• alcohol - a sedative that can make you sleepy, which can disturb your sleep schedule
• heavy / spicy meals - are more difficult to digest, so can cause sleeping problems if consumed late at night

There could be even simpler causes to insomnia that are due to a poor sleeping environment such as a room being too hot or cold; too much noise or an uncomfortable bed. All of the above factors contribute to ‘sleep hygiene’, and tackling these elements will be the first steps in treating insomnia. Equally, there are factors that can cause insomnia that cannot be helped such as working late nights or having jet lag (when your normal sleep pattern is disturbed by changing time zones when travelling).

Stress, anxiety and depression

Stress affects all of us every day. From facing significant life events or changes to having health difficulties, it’s very normal to experience stress. However, unmanaged stress can be a huge factor in causing insomnia. It has a profound effect on the body and the mind which leads to hyperarousal. Research has also shown that some people may be more at risk of stress affecting their sleep than others, and they are known as having a higher “sleep reactivity”. Not being able to sleep may also become a greater source of stress, reinforcing the cycle of insomnia and stress.

Similarly, certain mental disorders such as anxiety disorders, depression and bipolar disorder have a high prevalence with insomnia, so much so that an estimated 40% of people with insomnia have an associated mental disorder. The consistent negative thoughts that are symptomatic of mental health issues cause and can worsen mental hyperarousal.

Other conditions

As well as mental health conditions, there are other medical conditions that have been linked to insomnia. These include other sleep conditions such as sleep apnoea, PLMD, restless leg syndrome (RLS) as well as abnormal sleep behaviours (parasomnias) such as sleep walking, sleep paralysis and nightmares.

There is also a strong link between insomnia and neurodegenerative disorders such as Alzheimer’s, Parkinson’s disease and other conditions that cause dementia. This is because these conditions can disrupt circadian rhythms and other perceptual cues that regulate the sleep-wake cycle. Additionally, neurodevelopmental disorders like ADHD (attention-deficit hyperactivity disorder) and ASD (autism spectrum disorder) can lead to higher levels of mental activity which can cause hyperarousal.

In addition, women going through menopause; those with respiratory and neural diseases or chronic pain have all been linked to insomnia. These conditions make it difficult to lie in the bed comfortably or dwell on your sleeplessness, all of which can lead to excess stress. Complications from Type II diabetes can also cause insomnia due to frequent urination (nocturia), rapid blood sugar changes, nerve damage (peripheral neuropathy) and obstructive sleep apnoea (OSA). Obesity is another risk factor for insomnia and other sleep disorders due to increased fatigue during the daytime and discomfort due to excess weight.

Other medications

Insomnia can also be one of the side effects of some medications. People who are taking antidepressants, blood pressure medications, asthma medications as well as a lot of sedating medicines that can make you drowsy during the day. This can disrupt your sleep schedule and can lead to insomnia. Withdrawal from these medications can also cause difficulties sleeping, so it’s important you know about the medications you’re taking and the potential side effects. If you’re not sure, always consult a healthcare professional.

Aging

Insomnia occurs in 30-48% of the elderly. Like younger people, insomnia in the elderly is caused by a combination of health complications, mental health problems and poor sleep hygiene. However, older people are more sensitive to insomnia due to more age-specific factors such as social isolation, higher risks of chronic conditions as well as a higher volume of prescription medications that could cause insomnia as a side effect. Research has also found that older adults over the age of 60 have less sleep efficiency, meaning their sleep is more easily disturbed.

Pregnancy

There are a multitude of factors whilst pregnant that disrupt your sleep and make you more at risk of insomnia, including:

• increased weight/ shift in body composition - makes finding a comfortable sleeping position difficult. Uterus growth can also place pressure on the lungs and disrupt your breathing
• hormonal changes - can increase chances of snoring and sleep apnoea, which disrupts your breathing
• heartburn and acid reflux - caused by slower digestion. These can also cause gastroesophageal reflux (GERD)
• nocturia - frequent urination which can make you get up a lot in the night

More than half of pregnant women experience insomnia. They tend to sleep more total hours in the first trimester, but sleep quality reduces as they reach the second and third trimesters.

The NHS recommends adults need 7-9 hours of sleep a day, on average. If you get less than that consistently, it can affect your overall health and well-being. The most common side effects of not having enough sleep are well-known, such as irritability, lack of concentration and difficulty focusing. However, few people know that getting a good night’s sleep regularly can increase your risk of developing more long-term physical conditions. Lack of sleep has been linked to obesity, heart disease, low sex drive, high blood pressure, diabetes and mental health issues. Therefore, it’s important to get your insomnia or related sleep conditions treated so you can have an overall healthier life.

There are a variety of medications available over the counter or on a prescription that help you get better sleep and treat your insomnia. If you are taking one treatment, you should not take any other form of sleeping aid as they can increase drowsiness and incur other side effects.

Herbal sleeping aids

The simplest and the most gentle sleep aids are those that contain herbal ingredients. They are available in liquid or tablet form and some of the most common active ingredients are valerian, passionflower, hop and chamomile. They may be a good alternative for those with long-term health conditions or who take other medications. Research is always divided on the effectiveness of herbal remedies, so it’s important that you do your own research or speak to a healthcare professional before taking a natural aid.

Over the counter medications

There are other medications available at pharmacies that you can take for insomnia. The main over-the-counter medicines available in the UK for insomnia are antihistamines such as diphenhydramine (Nytol Original / One-A-Night) or promethazine (Sominex). They are usually used to treat allergies, but a main side effect of antihistamines is drowsiness, so they have been registered to use as sleeping aids. They are not suitable for everyone, so a pharmacist will have a quick consultation with you before purchasing them.

Prescription medications

There are several medicines that can be prescribed for insomnia. They are often prescribed for short-term use and only if all other treatments have not worked. They usually fall under a family of drugs called ‘sedatives’, which are used to induce, extend and improve sleep as well as reduce wakefulness. The most common type of sedatives are called benzodiazepine receptor antagonists (BZRAs) which include benzodiazepines such as diazepam and non-benzodiazepine alternatives like zolpidem or zopiclone. It’s important to note that these medications can cause addiction and other adverse effects so you should speak to your GP before taking them.

Another common medication prescribed for insomnia is Melatonin (Circadin). Melatonin is a natural hormone released in the body during the evening that signals ‘darkness’, associated with sleepiness during the sleep-wake cycle. It thereby works by helping to regulate your sleep-wake cycle and helping to maintain and induce sleep.

Melatonin for insomnia comes in the form of prolonged-release tablets that mimic the natural process of the hormone’s release in the body. It’s different to Melatonin supplements, herbal formulations that can be bought over-the-counter, as these are rapidly absorbed. Melatonin, like most prescription medicines, has side effects and can interact with other medications and conditions, so it’s important to discuss with a healthcare professional before taking Melatonin.

The key to a good night’s sleep and improving your insomnia is keeping good sleep hygiene. Improving your sleep hygiene is simple, and involves some easy lifestyle changes such as:

• limiting naps, especially late in the day
• avoiding alcohol, caffeine or tobacco products in the evening
• avoiding late-night heavy meals
• limiting screen time before bed (like watching TV or using your phone)
• maintaining a healthy diet and doing regular physical activity
• maintaining a regular sleep schedule
• avoiding using your bed for work and other stimulating activities
• relaxing at least 1 hour before bed, such as reading a book or having a bath
• making sure your bedroom is dark and quiet
• making sure your mattress, pillows and covers are comfortable

Therapy is also a highly recommended additional treatment for insomnia, due to the high influence stress has on sleep. In particular, research has found that cognitive behavioural therapy (CBT) is one of the most lastingly effective treatments for persistent insomnia. Your GP will most likely refer you if they diagnose you with insomnia and find stress to be the major cause, but you can still find CBT and other forms of therapy yourself through the NHS with the IAPT service (Improving Access to Psychological Therapies) or privately.

You can buy Melatonin (Circadin) prolonged-release tablets here at euroClinix for the treatment of insomnia. You can also buy Melatonin for the treatment of jet lag, however, the dosage is different. In both cases, a prescription for Melatonin is required. All you have to do is complete an online consultation and it will be reviewed by one of our registered doctors. Once they have found that you are suitable for treatment, your medication will be dispensed and dispatched from our pharmacy with next-day delivery.