Insomnia is a very common problem. Research has shown that 30% of people may suffer from difficulties in sleep. This problem affects more women than men and more older people than younger ones.

What is insomnia?

Insomnia itself is not a disease, but it could be considered as a symptom of other medical conditions, just as headache is a symptom of some other medical condition.

Insomnia is defined as the failure to obtain a restful sleep, which in turn affects the patient activity during the daytime. Insomnia can be divided into three types:

• Sleep-onset insomnia: The patient has a difficulty falling asleep at the beginning of the night, but when they fall sleep they continue sleeping naturally.
• Waking up during the night: The patients sleep easily, but complain of lack of sleep and instability while sleep continues.
• Early waking up: The patient complains that he wakes up early and has a difficulty returning to sleep.

There is another division of insomnia, based on its duration:

• Transient insomnia: Lasts for two or three nights. The patient complains of laziness during daytime, lack of concentration, reduced productivity, and sleepiness. People with insomnia are more likely to become depressed.
• Acute insomnia: Lasts for four nights to three weeks.
• Chronic insomnia: More than three weeks.

Does everyone with sleep lasting only for a few hours, have insomnia?

There are misconceptions about the sleep that must be explained. In order to be active the next day, a normal person requires between 4-9 hours of sleep. However, the hours of sleep needed differs individually. Some people believe that they need eight hours of sleep per day and increasing the same will make them healthier, which is a misconception. For example, if you sleep for five hours and feel active the next day, and you have no sleep disorders, then your ideal sleep duration is five hours.

Some people may see their weakness and sleepiness during the daytime as an outcome of insufficient sleep, which leads to excessive focus on sleep, preventing them from having a peaceful sleep at night. Also, physical weakness due to lack of sleep, differs from weakness due to other disorders like work stress, tension, etc.

What causes insomnia?

Insomnia has several causes, but it could be grouped in three types:

(1) Psychiatric causes

(2) Organic causes

(3) Behavioral and environmental causes

1. Psychiatric causes:

Studies have showed that 40% of people with insomnia have psychiatric disorders. This is due to several issues such as, depression, anxiety, family and work pressures, etc.

Psychiatric disorders do not mean that the patient is insane or mentally ill, it means that the psychiatric stress caused due to the lifestyle has affected the sleep.

In most cases, patients with insomnia do not realize that the cause is related to psychiatric disorders. A lot of people are afraid to be diagnosed as mentally ill. The potential connection between psychiatric factors and insomnia must be examined.

Patient complaining of depression usually wake up abruptly early in the morning, whereas patient with anxiety have difficulty in falling asleep.

1. Organic causes:

There are several causes for this and a physician may need to thoroughly examine the patient’s sleep to diagnose these causes. They include:

- Respiratory disorders: Snoring, sleep apnea, central apnea particularly for patients with heart depression, and respiratory allergies of the upper or lower air tract.

- Acid reflux into the esophagus: Acid reflux from the stomach to the esophagus and sometimes into pharynx is one of causes of sleep and anxiety.

- Restless Legs Syndrome: This is an irresistible urge to shift the body in order to stop uneasy sensations. It most commonly affects the legs, but can also affect the arms, and the torso. Movement of the affected parts helps ease the sensations temporarily.

- Discomforting sleep - ‘imbrications of wakening waves into deep sleep waves’ (alpha - delta sleep): Patients with this disorder may sleep for long hours but do not feel fresh when they wake up. They usually describe their sleep as a very light sleep and have trouble going into deep sleep. The Electroencephalograph recorded during sleep shows that the waking waves alpha, intermingle with the deep sleep waves, delta i.e. third and fourth stage of sleep.

- Pain: It leads to insomnia whatever the cause is.

- Other medical causes such as Parkinson's disease, kidney diseases, thyroid disorders, diabetes and other diseases.

1. Behavioral and environmental causes:

- Irregular sleeping and waking up schedules

- Gained insomnia (psychophysiology insomnia): The patient with insomnia might be suffering due to social or psychiatric stress. The condition stays with the patients even after treatment, because patients have improper sleep habits. As a result, their mind becomes busy and anxious about their potential inability to sleep which leads to more complications and insomnia. However, these patients are able to sleep comfortably outside home.

- Laziness and sluggishness: Studies have suggested that people that lead an inactive life have a poor sleep quality as compared to the ones that live an active life. Sportspersons generally have good quality sleep compared to those with a sedentary lifestyle.

- Excessive use of stimulants and alcohol: Stimulants includes drinks like coffee, tea, cola, and chocolate. Cigarette smoking is a major stimulant as well. It has been scientifically proved that Alcohol leads to insomnia and sleep disorder and an increase in sleep apnea.

How can insomnia be treated?

As mentioned earlier, insomnia is a symptom rather than a disease, so the root cause must be diagnosed first, and then treated.

If any member of the family notices that the patient is suffering from snoring, breathing difficulty or moves a lot during sleep, there is a possibility that the patient has a potential organic cause. He or she should be examined by a sleep disorder specialist.

In addition, if any of his friends notice that the patient is experiencing depression or anxiousness, the cause may be psychiatric and the patient should see a psychiatrist.

For other cases with undefined causes, the treatment shall be behavior-based. The treatment could be supported by sleeping pills in the first stages. (See Tips For Healthy Sleep)

How can sleeping pills treat insomnia?

When we speak about the sleeping pills, we should divide insomnia into acute insomnia and chronic insomnia.

• Acute insomnia: It ends usually after treating the cause such as transient stress or long travel, which results in jet lag, etc. If the patient has severe symptoms, accordingly some sleeping pills could be prescribed for a period not exceed 14 days.
• Chronic insomnia: The patient with chronic insomnia should be evaluated by a specialist in the beginning to diagnose the organic and psychiatric causes. The treatment shall consist of methods that are behavior based and could be supported with sleeping pills. The sleeping pills should be prescribed for a limited time and under direct medical supervision.

One must understand that sleeping pills are not an answer to chronic insomnia, and the long termuse of the pills can lead to addiction. The dose prescribed for the patient may lose its efficiency over time and consequently the patient will need a larger dose.

I remember one of my patients who visited my clinic for his first time with insomnia; he was taking 50 mg of valium and 15 of zanax without any effect. When asked about his condition, he said that, he has started taking sleeping pills 30 years ago and over time he needed to increase the dose gradually till it reached large quantities.

Also, abrupt cessation of sleeping pills causes a severe return of insomnia. If the doctor suspects the possibility of sleep apnea, the patient must avoid taking sleeping pills as they increase the severity and complications of apnea.

In this context, I would like to inform you that, the allergy pills are not considered as sleeping pills and cannot be used for insomnia.

What are the tips for patient suffering from insomnia?

Patients with insomnia should organize their sleep timing and follow good sleeping habits in all cases. It is preferable to visit the physician if there is a potential organic or psychiatric cause.

Tips For Healthy Sleep:

- Relax before sleep. Usually, people who continue working until bedtime have a difficulty in sleeping because they do not get the required relaxation that should precede sleep.

- Avoid sleeping when you do not feel sleepy. Instead, try to focus on something that comforts your mind such as reading, or reciting some verses from the Holy Qura'an for relaxation.

- Do not stay in the bed when you are awake, but go to bed when you need to sleep.

- Do not look at the alarm if it distracts you; only use it for waking up at the morning.

- Maintaining regular timing for waking up and sleeping.

- Try to play sports regularly, because it helps achieve peaceful sleep.

- Avoid stimulants as far as possible.

- Avoid smoking.

- A snack before sleep may be helpful.

- Over and above everything mentioned, do not forget to recite prayers (Du`aa) before sleeping.

Ahmed BaHammam, FACP, FCCP
Professor of Medicine
Director, University Sleep Disorders Center
College ofMedicine, King Saud University