Sleepless Nights? Insomnia Causes and Symptoms (Part 1)

Information provided by Dr Keith Hariman, Specialist in Psychiatry

Insomnia is one of the most common reasons adults seek medical advice from doctors. Most of us will likely have personally experienced insomnia or know someone who has. Not getting enough sleep is associated with various health problems, such as an increased risk of cardiovascular diseases, diabetes, suppressed immune system and obesity. Sleep deprivation is also related to multiple workplace issues, such as impaired concentration, high risk of errors and accidents and decreased productivity.

Many articles and information online introduce methods to combat sleep problems but lack a scientific basis. This article is the first part of a 2-part series that addresses the evidence-based solutions for insomnia.

Insomnia Definition

The term insomnia implies the inability to sleep despite adequate opportunities for sleep, resulting in a shortened total sleep duration.¹ While the problems of a sleepless night would resolve after the ‘sleep debt’ has been repaid, those with insomnia experience persistent problems in sleeping. They doze off during the day, have difficulty with daytime functioning and are afflicted by constant fatigue.

It’s common to suffer from bouts of short-term insomnia at times of stress, grief, jet lag, or other physical, psychological, or interpersonal problems. However, short-term insomnia should only last for less than three months. Those with chronic insomnia typically experience symptoms at least three times a week for more than three months, but many individuals have lived with insomnia for years.

What Causes Insomnia?

There are several reasons why people might experience chronic insomnia. Known risk factors include older age, female gender (especially peri- and postmenopausal), personal and family history of insomnia, and a tendency to be easily woken up during sleep.

Medical Conditions that have been linked to Insomnia

• Mental illnesses (Depression, anxiety, substance abuse disorders and posttraumatic stress disorder)
• Diabetes
• Hypertension
• Cancer
• Chronic pain
• Obstructive sleep apnea

Furthermore, some medications and substances, for example, coffee, tea, beta-blockers and certain antidepressants, increase the risk of insomnia. Therefore, treatment of insomnia involves managing the co-existing medical conditions, such as depression or anxiety. Yet, in many cases, a definite cause may not be found. 

How Much Sleep Do You Need?

It is noteworthy that the definition of insomnia doesn’t mention the duration of sleep. While the National Sleep Foundation² recommends between seven and nine hours of sleep for adults, the actual duration of sleep that individuals require for optimal performance varies widely. Some report as little as five hours of sleep. The best way to determine how much sleep you need is by gauging how you feel the next day and how well you can function and perform.

Quality vs Quantity of Sleep

Individuals with insomnia might experience sleep quantity problems, with difficulties falling asleep, staying asleep, or waking up earlier than desired. Alternatively, they might also have trouble with the quality of sleep, not feeling refreshed after waking up.

With impaired daytime functioning, the longer insomnia persists, the higher likelihood of individuals descending into a negative spiral that would worsen their condition. For example, those who struggle to fall asleep quickly at night might worry about excessive fatigue the next day, thereby heightening anxiety levels and making it more difficult to fall asleep. Over time, when functioning levels are affected significantly during the day, stress and anxiety continue to increase, further affecting the ability to fall asleep.

Understanding Insomnia

Evaluating your insomnia is the first step to understanding the nature and severity of the condition, including looking at any co-existing psychiatric and medical problems that may be amenable to treatment.

Keep a Sleep Diary

Given that insomnia is primarily diagnosed through history and self-reporting, it’s helpful to maintain a sleep diary to note down your sleep patterns, problems, times and sleep quality. Given our tendency for recall bias and deviations in estimations, it’s important that your sleep diary is filled in every day for a week or two to gauge any possible patterns. Noting down your sleeping environment is also helpful.

Some smart devices such as certain watches have in-built technology to measure apparent sleep quality, however, their accuracy varies so may be more useful in comparing before and after treatment.

Visiting a Doctor

A trip to the doctor for insomnia involves noting down your history, discussing sleep practices and performing other relevant physical examinations to rule out any co-existing psychiatric and medical problems. In most cases, complicated investigations are typically not required.

Conclusion

Insomnia is a widespread condition that has commonly led to damaging effects on an individual’s health and productivity. The proper management of insomnia involves identifying the precipitating and perpetuating factors of insomnia. Understanding your sleep patterns and keeping a sleep diary is the first step in evaluating the reason for insomnia, which doctors will then use to guide the treatment protocol.

References

1. Darien, I. (2014). International classification of sleep disorders, American Academy of Sleep Medicine.
2. Sleep Foundation. (2021). ‘How Much Sleep Do We Really Need?’ A OneCare Media Company. 10 March. Available at: <https://www.sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need#:~:text=National%20Sleep%20Foundation%20guidelines1,to%208%20hours%20per%20night> [Accessed 3 June 2021].