How are you feeling this morning?
If you’ve had difficulty sleeping the answer is likely to be ‘absolutely exhausted’ and you’re probably wondering how on earth you’re going to make it through the day.
Almost all of us have the occasional night when we don’t have enough sleep – be that because we don’t give ourselves long enough in bed or because we just lie there tossing and turning.
However, if this goes on night after night, life can become a misery.
Developing a basic understanding of sleep science and making a conscious effort to stick to at least some of the basic sleep hygiene advice can work wonders for some people.
However, if you’ve already tried all this and nothing is working you are probably starting to feel quite desperate and may be wondering whether you need professional help. You may even be considering by-passing this and just ordering yourself some sleeping tablets online (please don’t, by the way – see below!).
You may be wondering whether you officially have a diagnosis of insomnia.
Insomnia is defined as insufficient sleep, difficulty falling asleep or staying asleep despite the opportunity to sleep. Interestingly there is no minimum quantity of sleep needed to meet the criteria for insomnia.
Insomnia can be further categorised according to its duration. Problems with sleep occurring on three or more nights a week for three months or more is called chronic insomnia.
If the sleeping difficulty is not caused by another medical problem it is known as primary insomnia.
However, there are a number of other medical conditions which often interfere with sleep (secondary insomnia) and before you reach for the nytol it might be worth thinking about whether any of these could be contributing to your sleeping difficulties and seeking appropriate medical help. In this article I’ll explain more about the causes of both primary and secondary insomnia and the treatments available.
Difficulty with sleeping which is not associated with another medical problem is usually either idiopathic (meaning it arises spontaneously and the cause is unknown) or psycho-social.
Idiopathic insomnia is thought to be due to an inborn in–balance in the factors that govern sleep and wakefulness. Most people with this type of insomnia have had sleep problems all their lives. This type of insomnia can be difficult to treat – although good sleep hygiene, psychological treatments and, occasionally, medication may improve things.
Far more commonly, insomnia is caused by psycho-social factors. Typically it comes on after someone has had a period of stress or other lifestyle reasons for sleep disturbance. The sufferer spends time in bed awake and struggling to sleep and develops a psychological association between the bedroom and wakefulness / anxiety. Furthermore, sleep itself becomes a source of worry and the difficulty in sleeping persists even after the original stress or lifestyle change has resolved.
Although sleeping tablets are sometimes prescribed on a very short term basis, they have significant drawbacks including the potential for addiction and the risk of a ‘hangover’ effect meaning that you can feel very groggy the morning after. They are also associated with higher risks of accidents and even with an increased risk of developing dementia if used long-term.
The best treatment for primary insomnia is usually psychological treatment such as cognitive behavioural therapy or sleep restriction programmes.
The aim of treatment is to re-establish positive psychological associations between the bedroom and sleep and to challenge unhelpful beliefs that people may have developed about their inability to function after a poor night’s sleep (people typically underestimate the amount of sleep they have had and overestimate the impact of lack of sleep on their ability to function).
Good sources of self-help include the book ‘Over-coming insomnia and sleep problems’ by Colin A. Espie and the programme Sleepio.
Causes of Secondary Insomnia
Obstructive Sleep Apnoea
In obstructive sleep apnoea (OSA) the muscles of the throat relax and narrow during sleep leading to a blockage of the airway which causes the sufferer to stop breathing temporarily. This causes a drop in oxygen levels which triggers a brief awakening so that normal breathing resumes.
Often people with OSA are unware of the brief awakenings at night or indeed of the pauses in breathing. It may be a partner who alerts them to the pauses in breathing and often these people are snorers. They may suffer from night sweats or find that they wake frequently to pass urine at night.
Usually people with OSA feel very tired during the day despite thinking that they have spent a decent length of time asleep each night.
OSA is more common in people who are obese, in men, in people over 40 and in smokers. It can also occur in people with a large neck size, or people with nasal obstruction. Alcohol often makes the problem worse, as does taking sedative medication.
If untreated, OSA can be associated with an increased risk of type 2 diabetes, high blood pressure, heart problems and strokes.
OSA is usually diagnosed by sleep studies which involve sleeping attached to monitors to detect pauses in breathing. It is usually treated by wearing a special mask at night which applies pressure to the airways to keep them open. Losing weight and giving up smoking where necessary also help considerably.
Restless Legs Syndrome
This is a condition characterised by the urge to move the legs associated with unpleasant sensations in the legs. It is typically worse during periods of inactivity and is generally worse in the evenings and at night. Usually sufferers find that moving the legs eases the symptoms. Other conditions such as arthritis need to be ruled out before a diagnosis of restless leg syndrome can be made.
Often there is no identifiable cause for restless leg syndrome although approximately half of affected people have a history of the condition in their family.
Sometimes restless leg syndrome can be triggered by iron deficiency or kidney problems and if you think you have the condition it is worth seeing your GP so that these can be ruled out.
Some medications, including antihistamines, some antidepressants, anti-nausea drugs and some medications used to treat epilepsy can make the condition worse, so again it is a good idea to chat to your GP if you are taking any of these types of medication and your legs are keeping you awake at night.
Mild cases of restless leg syndrome can often be improved by avoiding smoking, reducing caffeine / alcohol and increasing daytime exercise as well as stretching and relaxation exercise before bed. Your GP will also probably check your iron levels and suggest iron supplements if these are low.
For more severe cases of restless leg syndrome there are a number of medications which can help. These can have side effects and need to be prescribed and monitored by a doctor so again if you have symptoms which are causing significant sleep disturbance and are not responding to the simple lifestyle measures mentioned above, your GP would be a good port of call.
Depression and sleep problems often go hand in hand and one can lead to the other. Depression can affect sleep in a number of different ways – some people find that they can hardly sleep at all, whilst others find that they sleep a lot more than normal but still feel tired all the time. The classic sleep difficulty for people with depression is that they wake up in the early hours of the morning and just can’t fall asleep again. They also tend to feel at their lowest in mood at this time of day.
Low mood is one of the defining symptoms of depression and goes beyond just feeling a bit fed up or having a bad day. People with depression often find that they feel low no matter what they do and nothing cheers them up. They often stop finding pleasure in things they used to enjoy. Sometimes people with depression can feel that they only way out of their misery is to take their own life. If you have thoughts along these lines, I implore you to seek help – depression is treatable and you need medical help at this point.
People with depression very often blame themselves for things unnecessarily so you may have read that last paragraph and thought to yourself ‘but surely I should just be able to snap out of this – I must be really weak and pathetic’
Please be aware that this is just the depression talking! Depression is an illness – if you had an illness such as asthma or diabetes and you were struggling, you wouldn’t consider yourself weak for seeking help – this is no different!
There is a huge overlap between anxiety and insomnia. As discussed previously, chronic insomnia often follows a period of anxiety. Equally a primary anxiety problem can wreak havoc with your ability to sleep. When we feel anxious, we release more of the stress hormones – adrenaline and cortisol – both of which function by keeping us alert and primed to run from or fight off any threats. It’s pretty difficult to fall asleep with high levels of these hormones whizzing around in your blood stream.
With both anxiety and insomnia – people tend to worry. However with insomnia the worry tends to revolve around sleep, whereas with a more generalised anxiety problem people tend to worry about anything and everything. People with anxiety problems often also experience the physical symptoms of being nervous such as palpitations, sweating, butterflies in the stomach and restlessness. They may even experience panic attacks.
If the underlying problem is anxiety, usually treating the anxiety leads to improvement in sleep. Mild anxiety symptoms may improve with lifestyle measures such as avoiding excessive caffeine (this also triggers the body’s stress response), regular exercise and relaxation techniques such as mindfulness or progressive muscle relaxation.
More significant symptoms may require medical input and can usually be effectively treated with psychological treatments such as cognitive behavioural therapy and / or medication.
These are typical around the time of the menopause and are caused by a fall in levels of the hormone oestrogen at this life stage. Hot flushes can happen at any time but can be particularly disruptive at night. Keeping the bedroom cool, wearing natural fibre night clothes and limiting caffeine / alcohol intake can help. There are also a number of hormonal and non-hormonal treatments available on prescription if the flushes are particularly bothersome.
This can be a problem for both men and women. If you find that you spend more of the night in the bathroom than in bed it could be that you are suffering from overactive bladder (OAB).
OAB is a common problem affecting around 16% of all adults over the age of 40. It is a condition in which people experience often experience a sudden urgent need to pass urine and usually find that they need to pass urine frequently. They may often have to pass urine several times a night and may also experience occasional incontinence.
If you have these symptoms it is worth visiting your GP as OAB can only been diagnosed once more serious problems have been ruled out.
Often sensible lifestyle measures such as restricting fluid intake before bedtime and cutting down caffeine and alcohol can lead to significant improvements.
In women, OAB is often associated with the menopause in which case the use of oestrogen creams or pessaries inserted into the vagina can be helpful.
There are also a number of medications available on prescription for people with bothersome symptoms who find lifestyle changes ineffective.
Gastro-oesophageal reflux disease (GORD) is caused by acid from the stomach splashing up into the oesophagus (gullet). This irritates the lining of the gullet causing ‘heartburn’. When we are upright, the effect of gravity helps to keep acid down in the stomach. When we lie flat acid is more likely to enter the gullet.
This can mean that heartburn keeps us awake at night. If you have heartburn associated with unexplained weight loss, vomiting or swallowing difficulties it is imperative to seek medical advice as these symptoms can sometimes indicate a more serious underlying problem.
If you have more mild or occasional problems then steps such as avoiding eating for at least two hours before bedtime; sleeping propped up on an extra pillow; reducing caffeine and alcohol; avoiding spicy and fatty foods; stopping smoking and losing weight can all help enormously.
If these measures don’t improve things then your GP may suggest a course of treatment with medication to suppress stomach acid.
Asthma / heart failure
Both of these conditions can cause breathlessness that is worse at night. If breathing problems are keeping you awake then this always needs medical attention. If you already know that you have asthma and are waking up at night with symptoms, this suggests that your asthma is not as well controlled as it should be and it is well worth booking an appointment with your asthma nurse or GP to review your asthma management plan.
If you do not know why you are breathless at night then it is very important to have an assessment to find out the underlying cause.
So how are you really feeling this morning?
If you have been struggling with sleep and you’ve tried the usual measures without success it may be time to seek professional help – particularly if you recognise that you may have one of the conditions described in this article.
Sleep is important. You are important. You owe it to yourself and to those you love to take the next step.