About Insomnia

What is Insomnia?

Insomnia is a condition that may involve problems falling asleep at bedtime, waking up in the middle of the night, or awakening too early in the morning and not being able to go back to sleep. Sleep can also be perceived as light and of poor quality. Insomnia becomes a clinical problem when a person experiences trouble falling or staying asleep three or more nights per week, daytime functioning is impaired, and sleep difficulties have persisted for more than one month.

How prevalent is insomnIa?

One-third of the adult population reports insomnia symptoms, and for about one third of them (10% of the population), it is a persistent problem that impairs daytime functioning. Insomnia is more common among women, older adults, shift workers, and people with medical or psychological disorders.

What are the main causes?

Stress, anxiety, and depression are the most common causes of insomnia. Chronic insomnia may, on the other hand, increase the risk of developing depression. Medical illnesses can also disrupt sleep due to underlying symptoms (pain), the treatment used to alleviate those symptoms, or the emotional distress about the illness. Prescribed and over-the-counter medications can cause insomnia as a side effect. Insomnia can also be induced by excessive use of caffeine, nicotine, and alcohol.

Insomnia may be caused by another sleep disorder. The restless leg syndrome is a condition that produces an uncomfortable sensation in the calves and an irresistible urge to move the legs during wakefulness, particularly in the evening. It is often associated with periodic limb movements, a condition characterized by frequent movements of the legs or arms during sleep. Sleep apnea (a breathing disorder during sleep) can also cause insomnia, although it is more frequently associated with excessive daytime sleepiness.

What are the treatment options?

The first step in treating insomnia is to identify and treat the underlying cause (e.g., pain, depression). Insomnia may sometimes persist after the underlying condition is treated. Then, the two main treatment options for insomnia are medications and behavioural interventions.

Sleep Medication

Hypnotic medications are helpful to alleviate sleep disturbances resulting from situational stress (e.g., hospitalization, separation), changes in sleep schedule due to jet lag, and for sleep disturbances associated with some medical or psychiatric conditions. These medications should be used only for a short period of time because they lose their efficacy and there is a risk of dependency when used on a nightly basis over a prolonged period of time. Some of these medications may produce residual effects the next day (e.g., drowsiness) and interfere with your daytime functioning. Despite their widespread availability, over-the-counter sleep aids and herbal/dietary supplements are of limited benefits for insomnia. Because Health Canada does not regulate these products, there is always a risk that they do not contain exactly what is on the product labels.

Behaviour Therapy

There are several behavioural treatment methods for insomnia. These interventions are designed to reduce tension, change poor sleep habits and scheduling factors, alter misconceptions about sleep, and teach coping strategies to manage the effects of insomnia.

• Learn to relax.
  Relaxation is helpful when stress or anxiety is part of an insomnia problem. Some relaxation exercises are designed to reduce physical tension, whereas others seek to eliminate intrusive thoughts and worries at bedtime.
• Give yourself at least one hour to unwind before bedtime.
  Use this transitional period to read, watch television, listen to music, or simply relax. Do not ruminate about events of the day. Rather, write down your worries and set aside another time to deal with them.
• Go to bed only when sleepy.
  Insomniacs often go to bed too early. Such practice is counterproductive because the bed becomes a cue for wakefulness rather than for sleep. Postpone your bedtime until you are sleepy.
• Get out of bed if you can't sleep.
  If you can't fall asleep or return to sleep within 15-20 min., get up, go to another room, and engage in some quiet activity. When you feel that sleep is imminent, return to bed. Do not sleep on the couch, as this would only create an association between sleep and the couch, not with your bed.
• Arise at the same time every morning.
  Set the alarm clock and get out of bed at the same time every morning, weekdays and weekends, regardless of the amount of sleep obtained on the previous night. Sticking to a schedule will help regulate your internal biological clock and synchronize your sleep/wake rhythm.
• Reserve your bed and bedroom for sleep only.
  Do not read, watch television, or worry in bed either during the day or at night. When you engage in these practices, the bedroom becomes associated with wakefulness rather than with sleepiness.
• Avoid daytime napping.
  Among insomnia sufferers, napping is generally counterproductive. A nap disrupts the natural sleep/wake rhythm and interferes with nighttime sleep.
• Restrict the amount of time you spend in bed to your actual sleep time.
  Insomniacs often spend excessive amounts of time in bed in a misguided attempt to ensure that they get enough sleep. Spending too much time spent in bed, may actually lead to poorer sleep quality.

Sleep hygiene

Several lifestyle factors may promote or interfere with sleep.

Maintaining good sleep hygiene practices helps prevent or minimize sleep difficulties.

• Avoid stimulants (e.g., caffeine, nicotine) several hours before bedtime.
• Do not drink alcohol too close to bedtime. Alcohol consumption can lead to early morning awakenings.
• Regular exercise in late afternoon or early evening may deepen sleep.
• Keep the bedroom environment quiet, dark, and comfortable.

What results can you expect?

Clinical studies have shown that 70-80% of people with insomnia can benefit from behavioural treatment. The success of this approach depends largely on how well you follow the recommendations. Guidance from a therapist can be necessary for optimal results. Behavioural and drug therapies can complement each other. Sleep medication is particularly useful in the initial phase of treatment to break the vicious cycle of insomnia, while behavioural treatment is essential in long-term insomnia for addressing psychological and behavioural factors that disturb sleep.

© Canadian Sleep Society