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  Insomnia

Inability to sleep or to maintain sleep for a reasonable period of time is known as insomnia. Typically, insomniacs complain of being unable to close their eyes or “rest their mind” for more than a few minutes at a time. They may also complain to being too tired even after an overnight’s sleep. Both an organic or nonorganic insomnia constitute a sleep disorder.

Insomnia
Insomnia


Medical insomnia is classed as not being able to sleep or sleeping but for less than 4 hours at a time. Deliberately staying awake does not constitute insomnia.

There are three different types of insomnia:

1. Transient insomnia - lasting from one night to a few weeks (e.g. jet lag)
2. Acute insomnia – inability to consistently sleep well for a period of three weeks to six months.
3. Chronic insomnia – the most serious, if it persists almost nightly for at least a month, and sometimes longer.

Insomnia can be further classified as to primary or secondary. Primary insomnia is sleeplessness that is not due to a medical or environmental cause. Secondary insomnia is when the person is suffering from the sleep problems because of something else such as ill-health (medical condition) or other psychiatric condition ( e.g. generalized anxiety disorder).

Some of the most common causes of insomnia are the following:

1. Circadian rhythm sleeps disorders – cause insomnia at some times of the day and excessive sleepiness at other times of the day. Examples of this disorder include jet lag, shift workers and delayed sleep phase syndrome. People who travel through multiple time zones experiences jet lag. In this case, the time relative to the rising and falling of the sun no longer coincides with the body’s internal concept of it.
2. Gastroesophageal Reflux Disease (GERD) – this is due to burning sensations resulting from stomach acid regurgitation starting from the epigastric region flowing upward to the chest area up to the throat while asleep. This is termed as “heartburn” which causes repeated awakenings during the night. Risk factors are: obesity, overeating at night, assuming a recumbent position immediately after eating, cigarette smoking, excessive caffeine, stress.
3. Parasomnia – include disorders of arousal or disruptive sleep events such as nightmares, sleepwalking, violent behavior while sleeping, and REM behavior disorder. In REM behavior disorder, a person moves his/her physical body in response to events within his/her dreams.
4. Mania or Hypomania – seen in cases of bipolar mood disorder wherein a person has difficulty in falling asleep. In these instances, sleep deprivation can worsen a manic episode, or cause hypomania to develop into mania.

A person in pain can produce insomnia therefore; symptomatic relief of pain can provide relief. Another common misperception about sleep is among the elderly age group. Some believe that as a person ages, the amount of sleep one requires decreases. The ability to sleep for long periods, rather than the need for sleep appears to be lost as people get older. In addition, a rare genetic condition known as Fatal Familial Insomnia is a permanent and eventually fatal form of insomnia. In sleep apnea, the sleeping person’s breathing pattern is interrupted and thus, interrupting the normal sleep cycle. The obstructive sleep apnea (OSA) is one example wherein the person’s sleep cycle is interrupted because of periods of intermittent apnea (absence of breathing) for few seconds. Causes of obstructive sleep apnea are the following: poor pharyngeal muscle tone, enlarged uvula and soft palate, macroglossia, receding mandible (jaw), obesity. Patients with OSA may eventually result to partial collapse of the respiratory airways leading to hypoxemia. Although these things happen in patients with OSA , often they do not even remember any of this and complain of excessive sleepiness during the day despite sleeping overnight.

Central sleep apnea is another condition wherein there is an interruption of the normal breathing stimulus of the central nervous system (CNS) hence, the individual must actually wake up to resume breathing. This is usually associated to congestive heart failure, cerebrovascular accidents and premature aging. Excessive urination at night or nocturnal polyuria can contribute to insomnia. The micturition process produces strong signals to the brain to wake up. Disorders that may lead to nocturnal polyuria are: nephrogenic (kidney disease), prostate enlargement (e.g., prostatitis, benign prostatic hypertrophy BPH), endocrine disorders, (diabetes mellitus- relative or absolute deficiency of insulin, diabetes insipidus-deficiency of antidiuretic hormone (ADH or vasopressin).

Medical or psychological approach may be useful in the treatment for insomnia. Sedative-hypnotics class of drug is most commonly prescribed for insomnia. Most of these drugs have potential addictive properties and may cause psychological dependence especially if taken over long periods of time. The most popular sedative drug class are the benzodiazepenes (e.g. diazepam, lorazepam, temazepam, nitrazepam and midazolam). The non-benzopdiazepine group including Ambien and Lunesta are slowly replacing the benzodiazepines as a first-line treatment for insomnia. There are still controversies regarding this matter. Low doses of antipsychotics are also prescribed for their sedative effect but these drugs are not a good choice to treat insomnia because of its dangerous cognitive and neurological side effects. Herbs like chamomile, lavender, hops, valerian and passion-flower appears to be effective for insomniacs. Other traditional remedies to promote sleep include: drinking warm milk before bedtime, taking a warm bath in the evening, exercising vigorously for half an hour in the afternoon, eating heavy lunch and a light evening meal at least 3 hours before bedtime, avoiding mentally stimulating activities at night and to retire at a reasonable hour. Alternative medicine such as traditional chinese medicine utilizing acunpuncture, aromatherapy (using essential oils), relaxation techniques (meditation) may be helpful with the goal of resolving the sleep problem in a subtle way.

Some helpful advice:

1. Avoiding all stimulating substances/activities such as caffeine and exercise before bedtime.
2. Avoidance of distractions in the bedroom including excessive light and noise, television, alarm clocks etc.
3. Avoidance of stressful thoughts and feelings before bedtime.
4. Combat worries and preoccupations about the day ahead by tending to plans and schedules before bedtime
5. Background noise such as fan or soft rhythmic music can serve to ease some individuals to sleep.

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