Dr Chireka: Let’s talk about sleep problems (insomnia)
“Avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed. This advice is very important to couples not to make the bedroom a courtroom where issues are argued. The bed should be for sex and sleeping only”, says Dr Chireka.
We all need it and must get it in the right amounts and quality. I am talking about sleeping as it plays a vital role in good health and well-being throughout our lives. Getting enough quality sleep at the right times does help to protect our mental health as well as physical health, quality of life and our safety. The way we feel while we are awake depends in part on what happens while we are sleeping. If we do not get enough quality sleep we may suffer instant problems such as sleeping at the wheel and crashing our cars, or it can harm us over time. For example, ongoing sleep deficiency can raise our risk for some chronic health problems. It can also affect how well we think, react, work, learn, and get along with others.
Sleeping problems are very common and are often referred to as insomnia. Insomnia means poor sleeping. About one third of adults do not get as much sleep as they would like. Poor sleep (insomnia) can mean:
Not being able to get sleep
Waking up too early
Waking for long periods in the night
Not feeling refreshed after a night’s rest
The symptoms of insomnia depend on the type of sleeping problem you have.
In the UK, up to a third of people are thought to experience insomnia at some point each year. Symptoms can include:
lying awake for long periods at night before falling asleep
waking up several times during the night
waking up early in the morning and not being able to get back to sleep
feeling tired and not refreshed by sleeping
not being able to function properly during the day and finding it difficult to concentrate
Not sleeping enough can also affect your mood and cause tiredness and fatigue during the day
Duration of Insomnia
Insomnia is often categorized by how long it lasts:
Transient insomnia lasts for a few days.
Short-term insomnia lasts for no more than 3 weeks.
Chronic insomnia occurs at least 3 nights per week for 1 month or longer.
Studies have found that as many as 30% of the adult population are affected by insomnia. One study in America found that only 5% of adults reported never having trouble sleeping. Insomnia is particularly common in women, children and those over 65. Half of the elderly population complains of insomnia. You should not be surprised to have trouble sleeping at some point in your life. People get distressed when they feel they are not getting a good night’s sleep, which can make it harder to fall asleep.
How much sleep do we need?
Thank you for asking this question. The answer is that people vary greatly in their need for sleep. There is a popular idea that I grew up being told that we all need 8 hours sleep every night. This is not true. Many studies have shown that people range between 4 hours a night up to needing 10 hours or more. Also, as we grow up the amount of sleep a person needs varies. For example a new-born baby spends 16 to 17 hours sleeping per day. As children grow older, they require less sleep, possibly 11 hours around the age of 5 years and maybe 8 hours as a teenager. By the time someone reaches their thirties they may require less than 8 hours, and as time progresses this becomes less and less. Many people in their seventies require less than 6 hours sleep.
Let’s talk more about sleep
Sleep is not like a light bulb which is either on or off, but has different stages, varying from light to deep sleep. Sleep consists of two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity: Non-Rapid Eye Movement Sleep (NonREM) is termed quiet sleep and Rapid Eye-Movement Sleep (REM) is termed active sleep. Most vivid dreams occur in REM sleep.
How does light affect sleeping?
The response to light signals in the brain is an important key factor in sleep. Light signals from the eye travel to a tiny cluster of nerves in the hypothalamus in the centre of the brain, the body’s master clock, which is called the supra chiasmatic nucleus (SCN). The approach of dusk each day prompts the SCN to signal the nearby pineal gland to produce the hormone melatonin. Melatonin is thought to act as the body’s clock-setting hormone. The longer a person is in darkness the longer the duration of melatonin secretion.
Secretion can be diminished by staying in bright light. Melatonin also appears to trigger the need to sleep. This is the reason why we need to switch off the lights when we go to bed and make sure that all gadgets that can generate light such as iPads, iPhones, clocks, TVs etc are switched off. Parents need to train their children to sleep in darkness otherwise you will have a child who has insomnia as you are not allowing darkness to prevail in order for “the hormone of darkness” – melatonin to be formed which promotes sleep.
Melatonin and Sleeping
A detailed explanation of this hormone (chemical) that is produced in the brain by a gland called pineal is beyond the scope of this article. But I will summarise as follows: Melatonin is a natural sleep-inducing agent. Because daylight reduces melatonin production, blood levels of melatonin are usually high at night and low during the day. Remember that even artificial light reduces melatonin production hence shift workers can be prone to insomnia as they try to sleep during daylight.
The solution is for shift-workers is to sleep in darkened rooms (use dark curtains) with their eyes closed as this can increase melatonin production during the daylight hours. For people who sleep “normal hours”, natural melatonin production starts to increase at 10pm and peaks between 2am and 4am. The peaks become smaller with advanced age such that people over age 60 may show no increase in melatonin production at night. This is also one of the reasons why insomnia is common in the elderly population.
Causes of insomnia
I will try to explain some of the causes of insomnia and give some examples where appropriate so that it becomes clear to everyone. A reaction to change or stress is a common cause of short-term and transient insomnia. This condition is sometimes referred to as adjustment sleep disorder. The trigger could be a major or traumatic event such as: An acute illness, injury or surgery, loss of a loved one or job loss.
Temporary/transient insomnia can also develop after a relatively minor event, including:
Extremes in weather, an exam, travelling, particularly across time zones, trouble at work. In most cases, normal sleep almost always returns when the condition resolves, the individual recovers from the event, or the person becomes used to the new situation.
Some people develop insomnia in response to a stressful event, and it continues even when the stress has been resolved. This is because they have become used to associating the sleeping environment with being alert. This week it’s the congress week for Zanu PF and some people are stressed about it such that they are having sleepless nights. This can be short lived as these people may be stress-free after the congress but some may have permanent stress resulting in chronic insomnia.
Also worrying about things, such as work and health, is likely to keep you awake at night. Worrying about not being able to fall asleep can also stop you from actually falling asleep, creating a ‘vicious circle’. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary and some people may not experience insomnia at all, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.
Underlying psychiatric problems can often affect a person’s sleeping patterns. For example mental health conditions – such as depression or bipolar disorder. Anxiety disorders – such as generalised anxiety, panic disorder or post-traumatic stress disorder can cause sleep problems. Psychotic disorders such as schizophrenia often affect a person’s sleeping patterns.
Insomnia can also be caused by underlying physical conditions including, heart disease, respiratory disease such as asthma, neurological disease such as Alzheimer’s disease, hormonal problems such as overactive thyroid, joint problems such as arthritis, problems with the genital organs such as urinary incontinence or enlarged prostate. Other medical causes are long term pain and obstructive sleep apnoea, to just mention a few. I will expand on obstructive sleep apnoea below.
Alcohol and drug misuse
Drinking too much alcohol and taking drugs can affect a person’s sleeping pattern. Stimulants, such as nicotine and drinking too much caffeine (contained in tea, coffee and energy drinks) can also affect your sleep.
Some prescribed treatments or medicines available over-the-counter can cause insomnia. These include medication for depression, epilepsy, blood pressure, pain killers such as ibuprofen. Also stimulant drugs such as methylphenidate, which is often used to treat Attention Deficit Hyperactivity Disorder (ADHD) can cause insomnia. Medication for asthma such as salbutamol and theophylline can cause insomnia.
A disturbed sleep pattern is one of the most common symptoms of jet lag. After a long-haul flight, you may find it difficult to sleep at the correct times. For example, you may be awake at night and sleep during the day.
Shift workers are at considerable risk for insomnia as explained above under melatonin. Workers over the age of 50 and those whose shifts are always changing are particularly susceptible to insomnia, although night shift workers also have a high rate of sleeplessness. Night shift workers are at risk for falling asleep on the job at least once a week, implying that their internal clocks do not adjust to unusual work times. (They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher risk for health problems in general.)
Obstructive Sleep Apnoea
This sometimes occurs in people who snore, most commonly in obese people. In this condition the large airways narrow or collapse as you fall asleep. This not only causes snoring, but also reduces the amount of oxygen that gets to the lungs. This causes you to wake up to breathe properly. You may wake up many times each night which may result in daytime tiredness. Note: most people who snore do not have sleep apnoea, and do sleep well. If you are obese and you snore as well as feeling tired and sleepy during the day you need to see your doctor as soon as possible.
Obesity and Insomnia
If we gain more weight we will have problems with sleeping and lack of good quality sleep results in us gaining more weight. It’s a vicious cycle where we sleep poorly, we are less motivated to increase physical activity, and so we gain more weight, which leads to obesity related issues including sleep apnoea.
Dehydration and Insomnia
Most people don’t drink as much fluid as they need for optimum health. Dehydration can affect sleep in a variety of ways. One of them is that as membranes around the brain become too dry, you may also experience headaches which will disrupt your sleep. Also dehydration can lead to melatonin deficiency, another leading cause of insomnia. An easy way to tell if you might be dehydrated is to examine the colour of your urine. If it is very pale yellow or colourless, you are probably alright. If it is very dark in colour (throughout the day), you may need to consume significantly more fluid.
My suggestion is that you should avoid drinking fizzy drinks and coffee. You should drink water according to the size of your body. This idea of one size-fits-all is wrong as you cannot expect my one-year-old son to drink the same amount of water as me. It is recommended that we (adults) drink 33mls x body weight in Kgs per day. If you weigh 70kgs then you should drink at least 33×70 mls, which is 2310mls (2.31litres). Please remember that even if you feel thirsty, drinking right before you go to bed can cause sleep problems when you wake up needing to empty your bladder. If you drink half a pint to a pint of water about 2 hours before you’re ready for bed, most of it should pass through you before you go to sleep, and your body will have what it needs to run natural processes as you sleep.
What can you do to improve your sleep?
Sleep hygiene is an important first step for controlling insomnia. This will be covered in detail below. Another method of managing insomnia is by behavioural therapy. This method includes various approaches for training new sleep behaviours and helping people relax and sleep well.
Some people rush to their doctors asking for a quick fix for their insomnia and request “sleeping tablets”. Tablets have their place but they are only for a short period as they can be addictive and have unpleasant side effects. Many people get disappointed when their doctors talk about sleep hygiene instead of dishing out tablets.
Sleep hygiene is a variety of different practices that are necessary to have normal, quality night-time sleep and full daytime alertness.
What are some examples of good sleep hygiene?
The most important sleep hygiene measure is to maintain a regular wake and sleep pattern seven days a week. It is also important to spend an appropriate amount of time in bed, not too little, or too excessive. In addition, good sleep hygiene practices include:
Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness.
Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well known to speed the onset of sleep and many people use it, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
Exercise can promote good sleep. Vigorous exercise should be taken in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
Food can be disruptive right before sleep. Stay away from large meals close to bedtime. Also dietary changes can cause sleep problems, if one is struggling with a sleep problem, it’s not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine.
Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle.
Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed. This advice is very important to couples not to make the bedroom a courtroom where issues are argued. The bed should be for sex and sleeping only.
Associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio, or read books as well as surfing the Internet, especially Facebook.
Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the room should not be too hot, too cold, or too bright.
Herbal medicine in the treatment of insomnia
It is estimated that more than 1.5 million Americans use complementary and alternative therapies to treat insomnia. Medical advice is that there is only limited scientific evidence to show that herbal and dietary supplements are effective in making us fall asleep. I would recommend that these products should be taken only if approved by a doctor. Be sure to talk to your doctor if you are considering taking any herbal or dietary supplement.
I urge you to try the suggestions discussed here and then see your doctor if not better. It will be helpful to yourself and your doctor if you keep a record of your sleeping habits for at least two weeks. This should includ details of:
the time you go to bed
how long it takes to get to sleep
the number of times you wake up during the night
the number of daytime naps
the times of meals, alcohol consumption, exercise and stress
Insomnia is a huge topic and cannot be covered in one article. I hope that I have managed to call you to action to do something about your sleeping. There is a lot that you can do and please do drop me a line via my email about your experiences. Please do not forget to visit your doctor.
This article was compiled by Dr Brighton Chireka, who is a GP and a Health Commissioner in South Kent Coast in the United Kingdom. You can contact him at: firstname.lastname@example.org and can read more of his work on his blog at DR CHIREKA’S BLOG
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Dr Chireka has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other health-care professional for diagnosis and treatment of medical conditions. Views expressed here are personal and do not in any way, shape or form represents the views of organisations that Dr Chireka work for or is associated with.