Insomnia

When Sleep Problems Become Serious

Insomnia

It’s often difficult to get a comprehensive and insightful definition of insomnia.

We all have bouts of irregular sleep, and we all know one person who complains that they are an ‘insomniac’.

However, it is important to define and describe insomnia so that we can become clear about its effects on our health.

Did you know that insomnia is the second most common mental disorder, and, it’s also known to be a primary risk factor for depression? [1].

We are all aware, depression can lead to serious illness later in life.

Insomnia is a condition that is often under-recognised and under-treated, leading to a significant lowering of quality of life for those suffering from its debilitating effects [2].

Defining Insomnia

insomnia: a maniacal madness

Insomnia, the word comes from the Latin “in” (no) and “somnus” (sleep), and was first described by Johann Heinroth in 1818 [3]. 

According to the Diagnostic and Statistical Manual of Mental Disorders, insomnia is a:

 

dissatisfaction with sleep quantity or quality that results in clinically significant distress or impairment in social, occupational, or other important areas of functioning [4]. 

 

Moreover, the International Classification of Sleep Disorders 2 classifies three types of insomnia, being:

  • Mild insomnia
  • Moderate insomnia
  • Severe insomnia

Each of the above forms of insomnia are classified based on how much of an impact a lack of sleep has on social and occupational activities [3]. 

If you suffer from moderate or severe insomnia then it is important to seek treatment as this form of insomnia can lead to serious impairments at work and at home.

Three Types of Insomnia

three types of Insomnia
  • Transient insomnia (mild)

This is characterised by only brief periods of poor sleep, perhaps a night here and there.

  • Acute insomnia (moderate)

Acute insomnia is when a person has persistent sleeping problems that lasts for more than three weeks.

  • Chronic insomnia (severe)

Chronic insomnia lasts for extended periods of time.

People with more severe insomnia (acute or chronic) usually have difficulty falling asleep (sleep onset), staying asleep (sleep maintenance) and/or seem to wake up too early in the morning [5].

As a consequence, insomniacs are at a far greater risk of workplace injury or accidents.

Causes of Insomnia

causes of insomnia

But where does this sleep insufficiency come from? 

It’s not hard to answer.

In our modern, fast-paced society we lose sleep from such things as:

  • Work demands
  • social/family responsibilities
  • Medical conditions
  • Sleep disorders

This can lead us to a kind of ‘sleep debt’, which lowers our overall physical performance, increases our risk of accidents and affects us psychologically.

Global Insomnia Epidemic

According to the vast array of scientific literature:

 

a whoping 15% of the global population suffer from chronic insomnia [5].

 

The other worrying fact is that insomnia is largely under-recognized and under-treated [6].

This leads to a significant loss in overall quality of life for many people.

Ordinary people might not be fully aware that their lack of quality sleep is having a profound impact on the their daily life.

Just for some general statistics, one scientific review article suggested:

 

diagnosed insomnia in both the UK and North America is somewhere between 5-15%.

 

More startling is that possibly up to 40% of the population show symptoms of daytime tiredness or sleepiness [5].

Nonetheless, insomnia can impede upon our daily activities and tasks by rendering us less productive and with less energy.

Insomnia in the UK

uk sleep

A recent UK survey asked 500 people a simple question:

How often do you have trouble falling asleep?

Of those that responded:

  • 22% said that they do indeed have trouble falling asleep.
  • 27.5% of women have trouble falling asleep.
  • 18.5% of men have trouble falling asleep [7].

This is a clear indication that inadequate sleep is becoming a problem in the UK.

Without proper sleep, we can expect to have a harder time forming new memories and focusing on day to day tasks.

If we magnify the problem of inadequate sleep, we can find it has an anatomy and complexity of its own.

Often a link can be made to problems surrounding non-REM and REM sleep.

Lack of Sleep: Global Problem

costs of sleep

Just recently, the Centre for Disease Control and Prevention (CDC) in the US said:

 

“Insufficient sleep is a public health problem.”

 

In fact, one scientific article claimed:

 

50-70 million US adults suffer from chronic sleep disorders, with higher cases in women than men [4]. 

 

According to the National Sleep Foundation, insomnia is classified as a condition wherein an individual has great difficulty falling asleep, or staying asleep.

This is even in cases where a person is surrounded by all the right circumstances to fall asleep [5].

Costs of Losing Sleep

Cost of Sleep

Insomnia is expensive!

In Australia, for example, between 2016-2017, insufficient sleep due to mental health problems such as insomnia cost the Australian health system a whopping $1.24 billion [6]. 

In the USA, insomnia accounts for a loss of 11.3 days per individual, per year.

That is almost half a month of productivity loss [7].

Nation-wide, the cumulative costs of insomnia is a staggering 252 days and a cost of just over $63 billion.

The UK, in a 2016 article, calculated insomnia to account for a loss of 200,000 working days a year; costing the system 40 billion pounds [8].

Models of Insomnia

models of insomnia

Insomnia is indeed a highly interesting illness that deserves some more attention in the scientific world.

Several theories on insomnia have previously been developed which have all aimed to answer:

 

“What causes insomnia?”

“Why does it occur in people?”

 

Over the decades, several models of insomnia have been proposed.

Here are a few of those models [9], and each provides a little information on how insomnia is formed.

Model 1: Stay Off Your Phone

stimulus control

Model 1: Stimulus Control Perspective (1972)

In this model of insomnia, one stimulus (something that causes a reaction) can cause a variety of responses.

With individuals suffering from insomnia, it is known that large amounts of time are spent – or wasted – in the bedroom where the individual engages in non-sleep related behaviours (for example, we often spend a lot of time on our phones, laptops, just passing time).

However, to the person suffering from insomnia this behaviour is somewhat justified: staying in (or on) the bed is a form of ‘recuperation’, and is thus restful. 

Here’s the problem…

Because most people (those suffering from insomnia, and people in general) will spend much of their time in the bedroom – the amount of non-sleep hours builds up.

This leads to a distortion of the stimulus control; meaning, it is now much less likely that sleep will occur when you’re in the bedroom. 

What was supposed to be a place for sleep, is now a place for non-sleep activities, which can cause a type of conditioning leading to insomnia.

Model 2: The Behavioural Model

microsleep

Model 2: The Three Factor Model (1987)

This model is also known as the ‘Spielman model’, ‘Behavioural model’ or the ‘Three P model’. The three P’s stand for:

  • Predisposing factors: genetic and physiological
  • Precipitating factors: environmental or psychological stressors
  • Perpetuating factors: behavioural, psychological, environmental factors that inhibit someone from getting back into normal sleep patterns.

Essentially, this model described how acute insomnia can become chronic.

More specifically, the three P model suggests that insomnia occurs in relation to pre-existing (trait) factors, and life stress (also called perpetuating factors) we may be encountering.

Moreover, chronic insomnia, based on this model, happens as a consequence of inadequate coping behaviours (perpetuating factors).

We all have our own ways of coping with certain problems in life, however when it comes to insomnia much of our predisposing factors have a great role to play.

For example, these traits can include overthinking or over-worrying, along with social pressures that force us to sleep at certain sleep schedules. 

When we say ‘perpetuating factors’ what this really means is the various behaviours adopted by an individual which are put in place to compensate for loss, or lack of sleep.

One method of this ‘sleep compensation’ is the idea of “sleep extension.

In this scenario, those suffering from insomnia will ‘make up sleep” by napping and/or heading to bed early, and/or getting out of bed later.

These aspects of an insomniac are carried out to essentially ‘recover lost time sleeping’. 

But there’s a catch to these varying approaches to ‘sleep extension’.

They can fool the insomniac by making them think that extending sleep is a good, and acceptable strategy to eliminate insomnia.

Secondly, it places some emphasis on the idea that having this additional sleep will diminish the symptoms associated with insomnia.

Once again these symptoms can be anything from focusing and concentration difficulties to memory problems.

The true result of this “sleep extension” is far more damaging.

It leads to something known as a “dysregulation of sleep homeostasis“.

This homeostasis refers to a kind of “internal clock” or timer that drives a pressure for sleep based on the amount of time that has elapsed since your last sleep episode.

No doubt, sleep extension approaches to ‘recover’ from lost sleep greatly impacts our internal sleep homeostasis self-timer.

Model 3: Higher Brain Activity

cant's sleep

Model 3: The Neurocognitive Model (1987)

The neurobiological model of insomnia suggests that people suffering from insomnia show more high-frequency electrical activity in the brain when they go off to sleep. This difference in electrical activity of the brains of insomniacs is vastly different from normal sleepers [10].

Moreover, this electrical activity in the brain has been previously linked to memory formation, in which the neurocognitive model suggests that those suffering from insomnia are victims of something called the normal “mesograde amnesia” of sleep [11].

Do you recall those moments just before dozing off?

Well, it’s normal to forget those, and this is what “mesograde amnesia” refers to.

However, in insomniacs this network of ‘forgetting’ moments before sleep is not functioning as it should be.

This could be due to the increased central nervous system (CNS) activity, along with sensory and cognitive processing  which all lead to a difficulty in sleep [12].

Model 4: It's All In Your Head

ruminating

Cognitive models are based on the idea that worry, or worrying, plays a central role in causing insomnia.

We all worry, some of us worry more than others.

In fact, significant life stress, and anxiety can tip us over the edge into the horrible world of insomnia.

As a consequence, if we are experiencing any unwanted or intrusive thoughts or patterns – such as our job, or any negative lifestyle choices – that interrupt our sleep then we are also prohibiting a good night’s sleep.

So, the cognitive explanation of insomnia also has evidence.

One study from Binghamton University, UK, found that:

 

higher levels of repetitive negative thinking (RNT) were associated with people who were essentially operating as ‘night owls’ [13].

 

Data from this study was derived from 100 students who were questioned about their sleeping habits and behaviours.

How to Monitor Insomnia

monitor sleep

In order to properly monitor insomnia in people, it has been suggested that large-scale studies on individuals suffering from insomnia should be carried out to track certain factors.

These factors contributing to insomnia can include, predisposed, precipitating and perpetual.

Predisposed Factors

Refers to any normal part of what makes you; this could be age, gender, any family hereditary conditions , psychological factors and lifestyle choices.

We all have predisposed factors that will serve an informative part of any diagnosis for insomnia, or medical condition.

Think of these factors like a basic ‘check-up’ by the doctor.

Precipitating Factors

Delving a little deeper…

These can involve anything from stressful life events, like a recent divorce, as well as mental pain and/or a depressive episode.

The use of drugs, sleep apnea, and any debilitating medical condition such as emphysema fall into this category [14].

Perpetuating Factors

Are exactly that.

They ‘perpetuate’ or ‘maintain’ the problem of insomnia.

Some components that make up perpetuating factors can be behaviours or coping strategies that unfortunately help sustain insomnia.

 

If you’re someone who naps during the day, or spends a lot of time on or in your bed, then these could all be perpetuating factors that might inevitably lead to your development of insomnia.

 

The table below lists some of these factors across biological, psychological and social domains.

Predisposed factors  Precipitating factors  Perpetual factors 
Biological domain: psychiatric burden, medical burden, sleep need Biological domain: onset of medical illness, acute injury Biological domain: chronic medical illness 
Psychological domain: personality factors, stress, coping mechanisms to stress. Psychological domain: life stress events Psychological domain: sleep extension
Social domain: Safety of sleep environment Social domain: change in safety of sleeping environment. Social domain: change in safety of sleep conditions.

Treating Insomnia

treating insomnia

Although the diagnosis of insomnia can include physical examinations, review of personal sleep habits or involvement in a sleep study, there are alternate treatments [15].

Treatments that target insomnia fall into three categories:

  • Cognitive behavioural therapy
  • Prescription medications 
  • Over the counter sleeping aids 

Treating chronic insomnia has two main objectives:

  • Improving sleep quality and quantity, and 
  • Reducing daytime impairments

First-line Treatments

When treating insomnia with drugs, such as z-drugs like zopiclone, it is important that many considerations are taken into account.

In addition, pharmacologic treatments, such as zopiclone, zolpidem and zaleplon are considered as first-line pharmacotherapy drugs for insomnia [3]. 

Zopiclone, usually taken at prescribed doses of between 3.75 – 7.5mg is a non-benzodiazepine hypnotic, and delays the onset of rapid eye movement (REM) sleep [3].

Furthermore, zopiclone has been known to be effective short-term treatment for insomnia as it reduces sleep latency and nocturnal awakenings, by increasing total sleep time [3].  

Second-line Pharmacotherapy 

We don’t often hear about the other, lesser known treatments for insomnia.

However, these are coined second-line therapies.

Some of these include antidepressants (usually prescribed at very low doses), Trazodone which is a potent sedating antidepressant, and antihistamines which are considered as ‘over the counter sleeping aids’ [3]. 

We Need Our Sleep!

puppies sleeping

When we take into account the various health problems associated with insomnia, and the rising costs that insomnia has on our economies we can see a problem.

However, digging deeper into ourselves, we should understand that our lifestyle choices, such as what and how much we eat, and how we behave in the bedroom, and the irregular hours of our job, contribute to a complex patterning which can steadily evolve into insomnia. 

But there’s one thing that is contributing to this rise in global insomnia rates.

Work.

Our work largely determines the sleep we have.

So, in order to better sleep we need to adjust the way we work [16].

It may sound easy, however if you’re a shift worker, chances are that you’ve already developed a pattern of working irregular hours.

The other problem we face in our ever-so busy world is our bedtime activities.

Yes, we all find ourselves checking our phone well after midnight, and this is certainly a contributor to filling up sleep time with ‘phone time’.

In addition, one article suggests that a rise in those self-employed has left many with a never-ending pile of work. 

What needs to be addressed, by researchers and also insomniacs is a study into our sleeping (or lack of sleep) habits.

By carefully monitoring what we do in our bedroom (the things we engage in) we may well and truly understand why we are missing well-needed sleep. 

As mentioned previously in this article, insomnia messes our sleep homeostasis.

It changes our sleep rhythm. This puts our body out of sync with our health.

 

When your body isn’t in balance, your body will have a way of informing you that something just isn’t right.

References

[1] ttps://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30464-4/fulltext

[2] http://www.sleepreviewmag.com/2014/12/financial-costs-insomnia/

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924526/  

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634348/ 

[5] https://www.sleepfoundation.org/insomnia/what-insomnia  

[6] https://www1.racgp.org.au/ajgp/2019/april/insomnia-theory-and-assessment 

[7] https://aasm.org/insomnia-costing-u-s-workforce-63-2-billion-a-year-in-lost-productivity-study-shows/ 

[8] https://www.bbc.com/news/business-38151180  

[9] https://www.sleepmedres.org/journal/view.php?number=24 

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3212043/  

[11] https://neupsykey.com/models-of-insomnia/ 

[12] https://search.proquest.com/docview/1940749862?pq-origsite=gscholar 

[13] https://www.medicaldaily.com/late-bedtimes-linked-negative-thoughts-throughout-day-sleep-yourself-happier-313420  

[14] http://www.sleepreviewmag.com/2003/07/factors-that-affect-insomnia/  

[15] https://www.mayoclinic.org/diseases-conditions/insomnia/diagnosis-treatment/drc-20355173 

[16] https://theconversation.com/sleep-deprivation-costs-the-economy-billions-and-sends-workers-to-an-early-grave-69753  

  • UPDATED

    10th April 2020 – date of the last edit to this article.

  • AUTHOR
  • SCIENCE

    This article uses only evidence based information.

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Insomnia, the word comes from the Latin “in” (no) and “somnus” (sleep)

Johann Heinroth (1880)

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