Insomnia (insomnia) is a sleep disorder. It is usually accompanied by symptoms such as daytime sleepiness, loss of energy, irritability, and depressed mood. All of this can lead to an increased risk of traffic accidents, as well as problems of attention and training. Insomnia can be short-term, lasting for several days or weeks, or long-term, lasting more than one month.
Insomnia may occur as an independent symptom or as a result of another mental or somatic pathology. Risk factors that can lead to insomnia are psychological stress, chronic pain, heart failure, hyperthyroidism, heartburn, restless legs syndrome, menopause, some medications, caffeine, nicotine, and alcohol. Other conditions for the occurrence of insomnia include working night shifts and apnea.
Depression also contributes to insomnia. It leads to changes in the function of the hypothalamic-pituitary-adrenal system, which, in turn, causes an excessive release of cortisol, which can lead to poor sleep quality.
Polyuria at night, excessive nighttime urination, as well as depression, can significantly worsen sleep.
Other causes of insomnia include:
- the use of psychoactive substances (psychostimulants), including certain drugs, herbs, cocaine, amphetamines, methylphenidate, aripiprazole, MDMA (methylenedioxymethamphetamine), modafinil,
- thoracic surgery (surgical treatment of chest organs) and heart disease,
- curvature of the nasal septum and nightly breathing problems.
Restless legs syndrome, which causes insomnia at the initial stage of sleep, does not allow a person to fall asleep due to uncomfortable sensations and the need to move legs or other parts of the body in order to alleviate these sensations.
Periodic disturbance of limb movement that occurs during sleep can cause agitation, which the sleeping person does not know about.
Pain, trauma, or a condition that causes pain can prevent a person from finding a comfortable position in which to fall asleep, and also cause awakening.
Also, the appearance of insomnia is affected by:
- hormonal changes, such as those that precede menstruation or occur during menopause,
- life events, such as fear, stress, anxiety, emotional or mental stress, work problems, financial stress, having a baby or losing a loved one,
- gastrointestinal issues (heartburn or constipation),
- mental disorders such as bipolar disorder, clinical depression, generalized anxiety disorder, post-traumatic stress disorder, schizophrenia, obsessive-compulsive disorder, dementia and ADHD (attention deficit hyperactivity disorder),
- some neurological disorders, brain damage,
- poor sleep hygiene, such as noise or excessive caffeine consumption,
- physical activity (insomnia in athletes in the form of increased latency of the onset of sleep caused by training),
- a rare genetic disease, a rare incurable hereditary (dominantly inherited prion) disease in which the patient dies of insomnia. Only 40 families affected by this disease are known.
Circadian rhythm disturbances (for example, shift work) can cause inability to sleep at a certain time of the day and excessive drowsiness in another period of time. Chronic circadian rhythm disturbances are characterized by similar symptoms.
Changes in sex hormones in both men and women as they age can partly explain the increased prevalence of sleep disorders in older people.
In general, insomnia affects people of all age groups, however, people belonging to the groups listed below are more likely to get insomnia.
- Persons 60 years and older
- the presence of mental health disorders, including depression and other disorders,
- emotional stress
- night shift work
- change of time zones while traveling.
Symptoms of Insomnia
Symptoms of insomnia include:
- difficulties associated with falling asleep, including difficulty finding a comfortable sleeping position,
- waking up at night and being unable to return to sleep is often also a symptom of anxiety disorders. Two-thirds of patients with this disease wake up in the middle of the night, and more than half of them have problems returning to sleep after waking up in the middle of the night,
- daytime drowsiness, irritability or restlessness,
- early morning awakening - awakening (more than 30 minutes), which occurs earlier than we would like, with the inability to return to sleep, and before the total sleep time reaches 6.5 hours. Early morning awakening is often characteristic of depression.
Poor sleep quality can result from, for example, restless legs syndrome, sleep apnea, or severe depression. Insomnia is caused by the fact that a person does not reach the stage of sleep, which has restorative properties.
Pathogenesis of insomnia
Based on data from sleep studies using polysomnography, scientists have suggested that people who suffer from sleep disorders have elevated levels of nocturnal circulating cortisol and adrenocorticotropic hormone. Also, people with insomnia have an increased metabolic rate, which is not observed in people with a lack of insomnia, deliberately woken up during a sleep study. Studies of brain metabolism using positron emission tomography (PET) show that people with insomnia have a higher metabolic rate at night and day. The question remains open whether these changes are the causes or consequences of prolonged insomnia.
The physiological model is based on three main conclusions obtained as a result of studies of people with insomnia:
- an increase in the level of cortisol and catecholamines in the urine, suggesting an increase in the activity of the hypothalamic-pituitary-adrenal (GGN) axis and excitation,
- increased global cerebral utilization of glucose during wakefulness and slow sleep in people with insomnia,
- increased metabolic rate of the whole body and heart rate in people with insomnia.
All these data together indicate a dysregulation of the excitation system, the cognitive system and the GGN axis, which contribute to insomnia. However, it has not been precisely established whether hyper-excitation is a consequence or cause of insomnia. Changes in the levels of the inhibitory neurotransmitter GABA were also detected, but the results were inconsistent, and therefore the consequences of the altered levels of the neurotransmitter could not be unambiguously determined. Studies of whether insomnia is controlled by circadian (daily) sleep control or depends on the wakefulness process have shown inconsistent results, but some literature still suggests circadian rhythm dysregulation based on core temperature. Among other things, electroencephalograms showed increased beta activity and a decrease in delta wave activity, but the consequences of this are also unknown.
Estimates of the heritability of insomnia range from 38% in men to 59% in women. The Genomic Association Study (GWAS) identified three genomic loci and seven genes that affect the risk of insomnia, and showed that insomnia is highly polygenic (i.e., a disease with a hereditary predisposition). In particular, a strong positive association was observed for the MEIS1 gene in both men and women. Research has shown that the genetic architecture of insomnia is noticeably similar to mental disorders and metabolic traits.
Insomnia, a substance-induced alcohol
Alcohol is often used as a form of self-treatment for insomnia, which can cause sleep. However, drinking alcohol at bedtime can cause insomnia. Long-term alcohol consumption is associated with a decrease in NREM levels in the third and fourth stages of sleep, as well as suppression of REM sleep (dreams) and REM fragmentation of sleep. Frequent movement between the stages of sleep with awakening occurs due to headaches, the need to go to the toilet, dehydration and excessive sweating. Glutamine rebound also plays an important role in causing insomnia: alcohol blocks glutamine, one of the body's natural stimulants. When a person stops drinking, the body tries to catch up, producing more glutamine than he needs. In this regard, an increase in the level of glutamine stimulates the brain, while a person who has consumed alcohol tries to fall asleep, keeping it from reaching the deepest levels of sleep. Stopping chronic alcohol consumption can also lead to severe insomnia. During REM withdrawal, sleep is usually exaggerated as part of the rebound effect.
Classification and stages of development of insomnia
Insomnia is divided into transient (transient), acute and chronic insomnia.
Transient insomnia lasts less than a week. It can be caused by another disorder, changes in sleep environment, sleep time, severe depression or stress. Its consequences - drowsiness and violation of psychomotor indicators - are similar to the consequences of sleep deprivation.
Acute insomnia - This is the inability to sleep well for a month (but no more). This type of insomnia is indicated by the onset of difficulty falling asleep or maintaining a prolonged sleep. Acute insomnia is also known as short-term insomnia or stress-related insomnia.
Chronic insomnia lasts longer than a month. It may be caused by another disorder or a primary disorder. People with high levels of stress hormones or shifts in cytokine levels are more likely than others to suffer from chronic insomnia. Its consequences may vary depending on the cause of insomnia. They can be muscle fatigue, hallucinations and / or mental fatigue. Chronic insomnia can cause double vision.
Complications of Insomnia
Insomnia can cause the following complications:
- the severity and increased risk of chronic diseases such as heart problems, diabetes, and high blood pressure,
- poor immune system function
- psychiatric problems, such as anxiety disorder or depression,
- slow reaction while driving,
- poor performance at school or at work.
Causes of Insomnia
All age categories (from newborn babies to the elderly) can suffer from sleep disorders. The most common causes of insomnia are:
- Temporary irritants (loud sound, bright light, cold or heat, stuffiness in the room, and so on).
- Moving, flights, changing time zones, night shifts, working with an uncomfortable schedule.
- Somatic diseases (diabetes, bronchial asthma with frequent night attacks, blood pressure, arrhythmia, deforming osteoarthritis and osteochondrosis with a constant pain syndrome, malignant tumors).
- Mental illnesses (neurosis, depression, schizophrenia, obsessive states).
- Pathology of the nervous system (epilepsy, Parkinson's disease, strokes, neuralgia, meningitis and others).
- Hormonal causes (pregnancy, menopause, hyperthyroidism).
- Taking stimulants at night (alcohol, nicotine, caffeine, drugs, doping).
- Uncontrolled treatment with sleeping pills and tranquilizers.
Signs of Sleep Disorders
Sleep disorders can occur in different ways.
Depending on the factor that led to sleep disturbance, insomnia is divided into 3 main types:
- Pilgrimage disorders (problems falling asleep).
- Intrasomnic (frequent awakenings, shallow sleep).
- Postcommunic (lack of vigor in the morning).
Diagnosis of insomnia
In medicine, the assessment of insomnia using the Athenian insomnia scale has been widely used. A person’s sleep pattern is evaluated using eight different parameters associated with sleep.
In order to diagnose any sleep disturbance, it is necessary to consult a qualified sleep specialist (somnologist) to take appropriate measures. Anamnesis and physical examination are necessary in order to exclude other conditions that may cause insomnia. After all other conditions are excluded from the comprehensive sleep history, a sleep history should be compiled. It includes sleep habits, medications (prescription and over-the-counter), alcohol, nicotine and caffeine, comorbidities, and sleep environments. A sleep diary can be used to track a person’s sleep patterns. At the same time, it should include data on the time when a person goes to bed, the total time of sleep, the time of sleep onset, the number of awakenings, the use of drugs, the time of awakening and subjective feelings of the patient in the morning. The sleep diary can be replaced or confirmed using outpatient actigraphy for a week or more, using a non-invasive device that measures movement.
In many cases, insomnia is combined with another disease, side effects from drugs, or a psychological problem. Approximately half of all identified cases of insomnia are associated with mental disorders. In depression, in many cases, "insomnia should be considered as a concomitant disease, and not as a secondary", usually it precedes psychiatric symptoms. "In fact, it is entirely possible that insomnia poses a significant risk for the development of subsequent mental illness." Insomnia occurs in 60% and 80% of people with depression. This may be partially related to the treatment of depression.
It manifests itself in the form of an increase in time in order to fall asleep. Usually the stage of immersion in sleep lasts 4-10 minutes. In this category of patients, this stage can drag on for up to two hours. Most likely this is due to early laying, lack of fatigue and readiness to relax, daylight (for example, in the north, where there are white nights), and coffee. Also, a change in the process of falling asleep occurs due to a person’s fear of nightfall. If we already had experience of sleepless nights, nightmares, then we ourselves unconsciously delay the moment of falling into sleep, remembering what we have experienced.
Another reason for the increase in falling asleep is an overexcited state (strong emotions received in the evening, late guests, a movie watched, shock and much more), inability to find a comfortable position in bed.
If the problem of falling asleep is not repeated the first time, then a vicious circle arises! A person will even more strongly avoid bedtime due to the appearance of fear!
Sleep Hygiene and Lifestyle Changesare usually the first step in treating insomnia. Sleep hygiene includes stabilization of sleep time, exposure to sunlight, a quiet and dark room, and regular exercise. Cognitive-behavioral therapy can be used with this type of treatment.
It is important to identify or rule out medical and psychological causes before deciding on the treatment of insomnia. Most doctors do not recommend relying on sleeping pills because they do not see long-term benefits in them.
Drug-free insomnia treatment strategies provide long-term insomnia improvement and are recommended as a first-line treatment and long-term sleep management strategy.
Music can improve the condition of adult patients with insomnia. Carrying out EEG-BOS training It has been shown to be effective in treating insomnia with improved duration as well as quality of sleep. Self Help Therapy (defined as psychological therapy that can be developed on its own) can improve the quality of sleep in adult patients with insomnia to a small or medium degree.
Paradoxical Technique - This is a cognitive technique of reframing (which can change perception), in which a person suffering from insomnia makes every effort to stay awake instead of trying to fall asleep at night (that is, in essence, struggling with attempts to fall asleep).One of the theories that explains the effectiveness of this method is as follows: a person voluntarily confronts the desire to fall asleep, thereby removing the anxiety about performance that arises from the need or requirement of the body to fall asleep - a passive action. This method has been shown to increase craving for sleep and reduce anxiety, as well as to lower the subjective assessment of latency of the onset of CH.
Many people with insomnia use sleeping pills and other sedatives. Such drugs are prescribed in more than 95% of cases.
Manifest in the process of sleep itself. The latter is very superficial, intermittent. You can wake up from any slightest sound, rustling, whispering, and falling asleep again is very difficult. Experts believe that such patients have a low threshold for awakening. Another variant of this group of disorders can be awakenings from nightmare dreams, after which you no longer want to fall asleep again. If you imagine an ideal situation in which there will be no irritants, then a person suffering from this type of insomnia can calmly oversleep until the morning. Unfortunately, such situations do not happen, because we all toss and turn at night, get up in the toilet, move our limbs.
Occur in the morning, after waking up, and are characterized by:
- It is difficult to open your eyes, get out of bed due to severe fatigue, weakness.
- Daytime drowsiness, apathy (like a paradox, when you try to fall asleep during the day, nothing happens).
In case of insomnia, patients may complain of daytime sleepiness.
- Mood swings, irritability, sometimes anger and anger, decreased working capacity, increased appetite (sometimes a sharp loss), decreased attention span, distraction, and the inability to concentrate on some business.
- Headaches, dizziness, increased blood pressure or its decrease (up to fainting).
- Disruption of the heart (palpitations, arrhythmias, neuralgic pains in the left chest), sweating, trembling.
Separately, it is worth briefly mentioning such a common symptom among somnologists as pseudo-insomnia. This is a condition in which the patient claims that he practically does not sleep at night, although in fact it is not.
A person is fully confident that he suffers from a sleep disorder, although a comprehensive examination reveals that he sleeps at night (possibly intermittently) up to 7 hours!
Suspect the presence of insomnia inherent in patients with mental disorders. It even happens that such people have many of the signs of lack of sleep listed above. Nevertheless, they do not need treatment precisely for insomnia, but it is simply necessary to show them to the therapist, as the existing symptoms can be a sign of mental pathology.
Consequences of insomnia
The consequences of insomnia occur with varying intensity
Regular lack of sleep manifests itself not only in the functioning of the brain, but also in appearance. After several sleepless nights, blue circles and edema appear under the eyes due to impaired blood and lymph circulation, the skin of the face loses its elasticity, healthy color, wrinkles form faster.
It has long been proven that during sleep, the cellular composition of the immune system is updated: new immunoglobulins, cytokines, T-lymphocytes are formed. Prolonged sleep disturbance leads to an increased risk of infectious diseases. In addition, our immunity actively fights with the formation of atypical (cancerous) cells. In chronic insomnia, this struggle is significantly weakened, which increases the possibility of the development of tumors, especially colorectal adenomas (precancer).
With insomnia, strokes and heart attacks are more often observed, which is associated with a dysregulation of the vascular system, increased arterial tone, and arterial hypertension. There is evidence that the risk of sudden cardiac arrest in a dream increases several times. It is possible that this is due to obstructive apnea syndrome.
Insomnia leads to an increased risk of CVD
In sleep disorders, symptoms can occur in the form of increased production of stress hormones (adrenaline, cortisol), which constrict blood vessels and lead to hypertension, angina attacks, and kidney infarction.
Endocrine Disorders and Metabolic Syndrome
Insomnia can manifest itself in the form of increased appetite, and, as a result, weight gain and obesity. Also, over time, tissue sensitivity to insulin decreases, type 2 diabetes develops. As you know, in a dream we grow (concerns children). There is a scientific rationale for this catch phrase: at night, growth hormone (somatotropin) is produced, so insomnia dramatically reduces its production and the child’s growth is suspended.
According to a study conducted in Denmark in 2013, spermogram and libido are worsening in men suffering from various sleep disorders and sleeping less than 5 hours a day. The number of sperm per milliliter of sperm is reduced, their motility, many abnormal cells appear. As for women, their menstrual cycle is disrupted, ovulation stops, the endometrium becomes thinner due to hormonal changes. The reproductive health of insomnia sufferers is significantly reduced.
Insomnia in women can cause menstrual irregularities
Each of us is individual, in the same way each of us is unique. Of course, it is not at all necessary that with chronic insomnia all of the listed disorders will occur, but the risk of their occurrence increases significantly. Someone should get enough sleep for a week, and he will feel overwhelmed, absolutely not working, devoid of strength and attention. Others, on the contrary, do not sleep for months and are able to turn mountains.
One need only remember one thing: the reserves and possibilities of the human body are not unlimited! Do not check it and test it, because such a check can end sadly. The effects of prolonged insomnia are difficult to treat. Take care of yourself and sleep for your pleasure!
Insomnia is a common symptom of depression, so the use of antidepressants is an effective treatment for insomnia, regardless of whether the disease is associated with depression. While all antidepressants help regulate sleep, some of them (such as amitriptyline, doxepin, mirtazapine, trazodone) are prescribed specifically for the treatment of insomnia, as they can have an immediate calming effect. Amitriptyline and doxepin have antihistamines, anticholinergics and antiadrenergic properties that contribute to both their therapeutic effects and protection against side effects. Mirtazapine reduces sleep latency (the time it takes to fall asleep), improves sleep efficiency and increases the total amount of time allotted for sleep in people with depression and insomnia.
Agomelatine, a melatonergic antidepressant that improves sleep and does not cause daytime sleepiness, is licensed in the European Union and TGA Australia. After testing in the United States, its development for use was discontinued in October 2011 by Novartis, which acquired the rights to sell it from the European pharmaceutical company Servier.
Creating a stable sleep pattern can help prevent insomnia or alleviate the patient’s condition. To do this, go to bed and wake up stably at the same time. It is recommended to avoid vigorous exercise and drinking any caffeinated drinks several hours before bedtime, while exercise at the beginning of the day will be very beneficial. The bedroom should be cool and dark, and the bed should be used only for sleep and sex life.
It is also important to comply with the points sleep hygiene - this term denotes the general principles of behavior that normalize sleep. These principles are the basis for proper sleep, which must be observed. These include minimizing the use of caffeine, nicotine and alcohol, striving for regularity and effectiveness of sleep episodes, minimizing the use of drugs, minimizing daytime sleep, regular exercise and promoting a positive sleep environment.
Creating a positive sleep environment helps reduce symptoms of insomnia. In order to create a favorable sleep environment, it is necessary to remove objects that can cause anxiety or disturbing thoughts.
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A 54-year-old patient came to the “Your Doctor” medical center in Chelyabinsk with complaints of prolonged insomnia over the past few years, weakness, irritability, and tobacco abuse.
Insomnia is a short sleep with interruptions that does not bring a sense of relaxation in the morning. During the day, weakness, irritability, fatigue arise, and therefore it is impossible to work fully. Along with these complaints, the patient indicates a decrease in libido and psychological problems in relations with his wife.
The patient has already turned to psychiatrists and neurologists who prescribed Phenazepam and Melatonin. After taking a sufficiently large dose of Phenazepam in tablet form (1.5-2 mg), sleep occurred at night, lasting about 4-5 hours, but in the morning I was worried about dry mouth and decreased attention.
For the first time, sleep disturbances appeared at the age of 29, when the subject worked on his dissertation. He tried to "treat" insomnia with alcohol, but his sleep was still intermittent and shallow. Over the past five years, the patient has noted an increase in tobacco consumption - up to 1.5-2 packs of cigarettes per day. In this regard, sleep disturbances have become more pronounced (intermittent, shallow sleep for about 4 hours per night, which does not bring a sense of relaxation, often with nightmare dreams).
Наследственность психопатологичеки не отягощена. Рождён от нормальной беременности, роды в срок. Раннее психофизическое развитие соответственно возрасту. Посещал детский сад, окончил 10 классов общеобразовательной школы. В детстве описывает себя как робкого и нерешительного ребёнка с комплексом неполноценности, всегда больше увлекался чтением художественной и научной литературы, интересовался математикой, физикой, геометрией. После окончания школы поступил в политехнический институт. В армии не служил по состоянию здоровья (слабое зрение). После окончания вуза был приглашён на одну из кафедр института, занимался наукой и преподавательской деятельностью. Женился в 35 лет. Супруга на 15 лет младше. Всегда считал, что он не достаточно хорош для своей жены, и пытался завоевывать её расположение дорогими подарками и поездками на курорты. Есть двое детей. In recent years, due to economic difficulties, he began to spend more time at work, increased consumption of tobacco and alcohol (in the evenings), and therefore began to experience difficulty falling asleep.
The physique is normal. The skin is pale. The tongue is covered with white coating, the tip of the tongue is red, on the sides of the tongue are reddish traces indicating "liver condition". Pulse diagnostics - “excess” in the “tree” phase, indicating an overload of the liver and gallbladder, “deficiency” of the “water” phase, indicating a possible renal dysfunction.
The respiration in the lungs is vesicular, without wheezing, the abdomen is soft, painless. Departures are normal. Neurological status is normal. From the side of mental status attention is drawn to a decrease in attention, emotional lability, and does not reveal any productive psychosymptomatics. Criticism to the state is maintained. The patient seeks help and is ready to cooperate with doctors to obtain a result.
On the part of blood tests (general analysis, biochemical parameters): normal. Urinalysis is normal. Fluorography is normal. EEG: norm. Echo EEG: normal. Ultrasound of the abdominal organs: moderate signs of fatty liver hepatosis.
F51.0 Insomnia of inorganic etiology
The patient was prescribed complex therapy by a psychotherapist (psychotherapy, reducing tobacco consumption, vitamin therapy - "Neuromultivit" intramuscularly 2 ml for 10 days, "Deprim" 180 mg per day, "Neurostable" 1 tablet 3 times a day , 10 sessions of electric sleep, 10 sessions of shiatsu massage, physiotherapy exercises, yoga with an instructor, walks), as well as by a gastroenterologist ("Heptral" according to the intravenous drip scheme - 10 days, medical diet).
During the course of psychotherapy (sessions of psychoanalysis, cognitive-behavioral therapy), the patient developed a strong sense of self-confidence as a person capable of taking responsibility for his health and relationships with his partner (wife). From the first days of complex treatment, the patient recovered sleep, appetite, improved mood, plans for