Insomnia

• Difficulty falling asleep
• Difficulty staying asleep
• Getting up too early
• Problems in day-to-day functioning due to insufficient sleep
• Problems with concentration and memory
• Tiredness and sleepiness during daytime
• Problems with work, family, and social life
• Irritability, grumpiness, mood swings, and anxiety
• Increased errors or accidents

To understand the causes of insomnia, it is important to grasp the basics of sleep. Several structures within the brain are involved in sleep mechanisms. Two internal biological mechanisms—circadian rhythm and homeostasis—work together to regulate when you are awake and asleep. One of the key hormones responsible for the maintenance of the sleep-wake cycle is melatonin, which is secreted by the pineal gland in our body.

Circadian Rhythms

Circadian rhythm influences many functions, including:

• Daily fluctuations in wakefulness
• Body temperature
• Metabolism
• Release of hormones

It controls the tendency to feel sleepy at night and the inclination to wake in the morning without an alarm. The body’s biological clock, which is based on a roughly 24-hour day, regulates most circadian rhythms. Circadian rhythms synchronize with environmental cues, such as light and temperature, about the actual time of day, but they continue even in the absence of cues, as they are not solely driven by the environment.

Sleep-Wake Homeostasis

This mechanism keeps track of your need for sleep. The homeostatic sleep drive reminds the body to sleep after a certain time and regulates sleep intensity. This sleep drive strengthens every hour you are awake, leading to longer and deeper sleep after a period of sleep deprivation.

Factors that influence your sleep-wake needs include:

• Medical conditions
• Medications
• Stress
• Sleep environment
• Dietary habits

Almost everyone might have experienced difficulty in sleeping at one point in their life. However, your risk of suffering insomnia is high if you:

• Are a woman due to hormonal changes during periods and pregnancy.
• Are above 60 years of age, as changes in sleep patterns occur with age.
• Have a chronic health condition that can impact both physical and mental health.
• Are taking certain medications such as steroids, decongestants, and antihypertensives, which may cause sleeping problems as a side effect.
• Are stressed due to family matters, job pressure, or other stress triggers.
• Have an irregular lifestyle pattern, such as night shifts, a poor sleep environment, exercising, or using devices close to bedtime.
• Excessively use stimulants like coffee or tea, especially in the evening or close to bedtime, which can interfere with your sleep schedule.
• Consume alcohol, which may help you fall asleep but, when consumed in excess, prevents deeper stages of sleep and often causes awakening in the middle of the night, thus deteriorating sleep quality.

The diagnosis of insomnia includes taking an extensive history of the patient that covers the following aspects:

• Duration of sleep during nighttime
• Daytime napping, if any
• Frequency of having difficulty sleeping
• Medical conditions, if any
• Any stressful events in the recent past

A doctor may conduct several tests such as:

1. Blood tests: Tests for thyroid disorders, anemia (low hemoglobin), and uremia (high uric acid levels) are recommended to rule out any underlying health problems.
2. Imaging tests: These are recommended to identify any issues with the brain or nerve problems that may be responsible for sleep disturbances. Imaging tests such as CT and MRI scans may be advised in some cases.
3. Sleep record tests (sleep log): A sleep record over a period of two weeks is maintained to track the time at which a patient falls asleep, along with the duration of sleep during both daytime and nighttime. The patient may be asked to document these details in a diary.
4. Wrist actigraphy: This method detects movements during sleep. A device called actigraphy is worn on the wrist during sleep to record body movements, helping to distinguish wakefulness from sleep.
5. Sleep quality tests: These tests measure the quality of sleep, such as the Insomnia Severity Index or the Pittsburgh Sleep Quality Index.
6. Polysomnography: This test is performed if the cause of insomnia is unclear or if there are signs of another sleep disorder, such as sleep apnea or restless legs syndrome. It records various parameters including brain waves, heart rate, breathing, oxygen levels, and eye and leg movements during sleep. The patient may need to spend a night at a sleep center for this test.

To prevent insomnia, you need to have a good night’s sleep. Here are a few simple and effective habits that you can adopt to ensure that you get sound sleep:

• Maintain a sleep schedule and follow sleep hygiene guidelines, including sleeping and waking up at the same time every day.
• Get early morning sunlight. Spending 15-30 minutes in sunlight helps keep the body’s biological clock in order.
• Stay active during the day, as a sedentary lifestyle can hinder a good night's sleep.
• Limit daytime naps.
• Be mindful of your diet by avoiding large meals and beverages before bedtime.
• Switch off the television and computers two hours prior to sleep. The light from screens interferes with the sleep cycle.
• Discourage the use of tablets and smartphones in bed, as the blue light from these devices disrupts the release of melatonin, the sleep hormone.
• Avoid caffeine, nicotine, and alcohol before sleeping.
• Create a relaxing pre-bedtime ritual, such as taking a warm bath, reading, or listening to soft music.
• Sleep in complete darkness to eliminate night lights and any other light coming from outside. This promotes the secretion of melatonin and encourages sound sleep.

Treatment of insomnia includes making changes in sleep habits, taking medicines, doing relaxation exercises, and treating the underlying condition that causes insomnia.

1. Cognitive Behavioral Therapy

Cognitive behavioral therapy for insomnia (CBT-I) can help you control or eliminate negative thoughts and actions that keep you awake and is generally recommended as the first line of treatment for people with insomnia. Typically, CBT-I is equally or more effective than sleep medications. The cognitive part of CBT-I teaches you to recognize and change beliefs that affect your ability to sleep, while the behavioral part of CBT-I helps you develop good sleep habits and avoid behaviors that keep you from sleeping well.

2. Medications

1. Benzodiazepines

Benzodiazepines inhibit the reticular activating system (RAS), also known as the awakening center, thereby inducing sleep. They carry a risk of addiction and abuse, especially in patients with a history of alcohol or sedative abuse, so medical supervision is advisable. Common examples include:

• Alprazolam
• Lorazepam
• Clonazepam

2. Barbiturates

These drugs act on the GABA receptor, thereby aiding in sleep. They cause long-term changes, ensuring that the effect of the drug lasts for a long time. Examples include:

• Thiopentone sodium
• Methohexitone
• Phenobarbitone

3. (Z) Drugs

These are newer drugs of the benzodiazepine agonist class, acting specifically on the alpha 1 subunit of the GABA-A receptor. They are recommended for early phase insomnia, late phase insomnia, and middle-of-the-night awakening problems. Medications in this group include:

• Zolpidem
• Zopiclone
• Zaleplon

4. Heterocyclic Antidepressants

These are commonly prescribed alternatives to benzodiazepine receptor agonists due to their lack of abuse potential and lower cost. Common examples include:

• Trazodone
• Amitriptyline

5. Melatonin Receptor Agonists

These drugs act on the melatonin receptor to induce sleep. They are mostly recommended for people with sleep cycle disorders, shift workers, and insomnia due to jet lag. Common drugs include:

• Ramelton
• Agomelatine

6. Orexin Pathway Inhibitors

These drugs inhibit the chemical orexin, which is known to keep the RAS center active. Suvorexant is a commonly used drug in this class.

7. Antihistamines

Antihistamines, such as diphenhydramine, are the primary active ingredients in most over-the-counter sleep aids. Some side effects include dry mouth and constipation.

Do’s and Don’ts When Using Sleeping Pills

• Never mix sleeping pills with alcohol or other sedative drugs.
• Always consult your doctor prior to taking any sleeping pill, as most of these medicines have abuse potential.
• Don’t take a second dose in the middle of the night.
• Start with the lowest recommended dose.
• Avoid frequent use of sleeping pills to prevent dependency and minimize side effects.
• Never drive a car or operate machinery after taking a sleeping pill.
• Carefully read the package insert for any potential side effects and drug interactions.

Note: Medications for insomnia may increase the risk of injurious falls and confusion in the elderly. Hence, they should be taken cautiously at the lowest effective dose and under strict medical supervision.

Your need for sleep and your sleep patterns change as you age, but this varies significantly across individuals of the same age. There is no magic number of sleep hours that works for everybody of the same age.

Babies initially sleep as much as 16 to 18 hours per day, which may boost growth and development, especially of the brain.

School-aged children and teens, on average, need about 9.5 hours of sleep per night.

Most adults need 7 to 9 hours of sleep a night, but after age 60, nighttime sleep tends to be shorter, lighter, and interrupted by multiple awakenings.

Poor sleep habits are one of the common causes of insomnia. Here are eight effective ways to improve your child's sleeping habits.

Sleep problems are associated with short and long-term effects on health and well-being. The immediate effects include poor performance, daytime sleepiness, and fatigue. The long-term complications caused by sleep deprivation include:

• Premature mortality
• Cardiovascular disease
• Hypertension
• Obesity
• Diabetes
• Impaired glucose tolerance
• Psychoactive disorders such as anxiety and depression

Some of the common effects of sleep deprivation include:

1. Accidents: Fatal road accidents are often caused by sleepiness or driver fatigue.
2. Heart disease: Insomnia and obstructive sleep apnoea are linked to higher rates of hypertension. Sleep loss can affect inflammatory markers, increasing the risk of heart disease. Studies indicate that inflammatory responses are heightened in individuals with obstructive sleep apnoea.
3. Obesity: The relationship between obesity and sleep loss is bidirectional. The prevalence of obstructive sleep apnoea is over double among the obese. It is estimated that 3–5% of obesity in adults may be attributable to short sleep duration.
4. Diabetes: Sleep restriction and poor sleep quality are associated with an increased risk of diabetes. Lack of sleep can lead to glucose dysregulation and heightened hunger and appetite due to hormonal imbalances, causing down-regulation of the satiety hormone leptin and up-regulation of the appetite-stimulating hormone ghrelin.
5. Stress and anxiety: Insufficient sleep can lead to mental disorders such as stress and anxiety. Depression is also prevalent among conditions associated with troubled sleep. Poor sleep can elevate stress hormone levels, negatively impacting mental health over time. Insomnia can impair work performance, decision-making, relationships, and overall quality of life.
6. Poor performance: Sleep is directly linked to school or job performance through its effects on mental functioning. Known issues associated with sleep deprivation include decreased attention, which is crucial for learning and academic success. Insufficient sleep reduces attention and focus.

Here are a few tips to help you achieve a good night's sleep and avoid complications of insomnia. Check Here!

If you are one of those who has problems falling asleep, read on to know about some of the best foods to have before you hit the bed.

• Cherries: Cherries contain melatonin, which is a sleep-regulating hormone. A study shows that drinking 200 ml tart cherry juice twice a day helps increase sleep quality and duration. This is an excellent remedy for people suffering from insomnia. Drink a glass of cherry juice before going to bed. You can add some water if you do not like its taste.
• Kiwis: Kiwis have high levels of antioxidants and serotonin, a hormone that aids in sleep. As low levels of serotonin can lead to insomnia, munching two kiwis an hour before sleep can help you sleep better.
• Walnuts (Akhrot): Like cherries, walnuts are also a source of melatonin. Eating a handful of walnuts will help you sail through the night. Since nuts are high in calories, just having 20-30 grams of them would be sufficient.
• Banana (Kela): Bananas are a rich source of potassium and magnesium, which act as muscle-relaxing agents. In addition, they contain the amino acid tryptophan, which the body converts to serotonin. Plus, they are a source of carbohydrates that will make you feel sleepy as well.
• Leafy green vegetables: Leafy green vegetables such as turnip greens and spinach have calcium, which is used by the brain to produce the sleep-inducing hormone melatonin. Try a leafy vegetable salad for dinner.
• Almond butter: Almond butter is a source of magnesium, low levels of which are related to insomnia. Munch on whole grain toast coated with almond butter as a pre-sleep snack.
• Sleep-inducing teas: Teas like chamomile (babunah ke phul) tea, passion flower tea, magnolia bark tea, peppermint (pudina) tea, and lavender tea can promote good sleep.

However, remember not to eat too much just before trying to sleep. Scheduling your dinner time in the evenings may help you sleep better. Doing regular light exercise can also help you get a good sleep. Try yoga, meditation, or breathing exercises to relax.

Supplements for Insomnia

There are many dietary and herbal supplements available in the market that are known for their sleep-promoting effects. As these supplements can interfere with other medications and vitamin supplements, it is best to talk to your doctor before taking them. The two common supplements for insomnia are:

• Melatonin: It is a hormone that helps to regulate the sleep-wake cycle and is known to be effective for people who are night owls (who go to bed and wake up late). It is available as an over-the-counter (OTC) supplement.
• Valerian: It is a herbal supplement known to have mild sedative (sleep-inducing) effects. There is a wide range of valerian supplements available. Pick the one that best suits your needs.

Insomnia can cause difficulty in falling asleep or can wake you up in the middle of the night. Here are a few tips to deal with these issues and improve your condition.

A. What to do when you have difficulty falling asleep

1. Maintain a sleep diary
   • Record the time you went to bed and woke up.
   • Note total sleep hours and perceived quality of your sleep.
   • Document the time spent awake and activities (e.g., got up, had a glass of milk, meditated).
   • Track the type and amount of food, liquids, caffeine, or alcohol consumed before bed, including the time of consumption.
   • Reflect on your feelings and moods before bed (e.g., happiness, sadness, stress, anxiety).
   • List any drugs or medications taken, including dosage and time of consumption.
2. Create a better sleep environment
   • Ensure your bedroom is quiet, dark, and cool; invest in a proper mattress, foam toppers, and pillows.
   • Use a sound machine or earplugs to mask outside noise and blackout curtains or an eye mask to block out light.
   • Keep your window open for proper ventilation and to maintain a cool room.
   • Stick to a regular sleep schedule by going to bed and waking up at the same time every day, including weekends.
   • Turn off all screens at least an hour before bed, as electronic devices emit blue light that disrupts melatonin production and sleepiness.
   • Avoid stimulating activities and stressful situations before bedtime, such as checking social media, engaging in discussions or arguments, or catching up on work.
   • Avoid daytime naps, as they can hinder nighttime sleep; however, power naps of 30 minutes in the afternoon can be beneficial.
3. Avoid certain things before going to bed
   • Limit liquid intake and alcohol just before bed.
   • Avoid large evening meals and spicy or acidic foods that may cause discomfort while sleeping.
   • Refrain from consuming caffeinated beverages at least six hours before bedtime.
4. Say NO to negative thoughts and worries

   The more trouble you have with sleep, the more it can invade your thoughts. Instead of thinking, "I’m never going to be able to sleep well. It’s out of my control," try a self-promoting comeback like, "Insomnia can be cured, and if I stop worrying and focus on positive solutions, I can overcome it."

5. Make your bed your buddy
   • Use the bedroom only for sleeping (and sex), not for work, watching TV, or scrolling through your phone at night.
   • Avoid hanging wall clocks in the bedroom, as watching the time can increase anxiety about sleep.
   • If you find yourself tossing and turning, leave the bedroom and do something relaxing, such as taking a stroll on your balcony or drinking herbal tea.

B. What to do if you wake up in the middle of the night

Many people with insomnia can fall asleep at bedtime but then wake up in the middle of the night and find it difficult to return to sleep. Here are a few tips that can help:

1. Do not stress too much

   Stressing over not being able to fall asleep can activate your brain and elevate stress levels. Instead, take deep breaths or close your eyes and concentrate on your breathing. Ways to practice abdominal breathing include:

   • Close your eyes.
   • Take deep, slow breaths.
   • Ensure each breath is deeper than the last.
   • Breathe in through your nose and out through your mouth.
2. Try relaxation techniques

   If you find it hard to fall back asleep, try a relaxation technique such as visualization or meditation. This can rejuvenate your mind and body. Steps for mindfulness meditation include:

   • Sit or lie quietly.
   • Focus on your natural breathing.
   • Allow thoughts and emotions to come and go without judgment.
   • Always focus on your breath and body.
3. Say yes to simple exercises

   Simple exercises such as rubbing your ears or rolling your eyes can promote calmness and relaxation, helping you sleep better.

4. Get out of your bedroom

   If you have been lying in bed for more than 30 minutes, get out of your bedroom and try reading a book or drinking herbal tea. Avoid watching TV or checking your phone.

5. Postpone your worries for the next day

   If you feel anxious or have ideas for your presentation, make a note of it on paper and return to sleep. Leave your ideas or worries for the next day and aim for a good night’s sleep.