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Insomnia: Types, Causes, Symptoms, Mechanism


What is Insomnia?

Insomnia is among the most common sleep disorder that makes it difficult for a person to fall asleep. People with this condition might also find it hard to stay asleep or find themselves waking up early and unable to get back to sleep. They might also feel tired after waking up as insomnia can such the energy and have adverse effects on working performance, health, and quality of life.

According to the APA (American psychiatric association), insomnia is the most common of all the sleep disorders, as nearly one-third of the adults report experiencing insomnia symptoms. Around 6 to 10% of all adults experience symptoms severe enough to get an insomnia disorder diagnosis.

The CDC (centers for disease control and prevention) states that adults require at least 7 to 9 hours of sleep every 24 hours.

Though symptoms of insomnia are widespread, doctors only make a clinical diagnosis for this condition if they fulfill the following criteria:

  • Sleeping problems are occurring for at least three nights a week for the last three months.
  • The problem in sleeping is causing significant distress or difficulties in the daily functioning of life.

Types of Insomnia

You can experience two types of insomnia; which are:

  • Primary insomnia – This means that the sleeping problems you are facing are not a byproduct of any other mental or physical health issue.
  • Secondary insomnia – This condition refers to the sleeping problems that manifest as a result of other health conditions like depression, pain, arthritis, heartburn, asthma, cancer, etc.

Causes of Insomnia

Insomnia can be the main problem, or it might be a result of another condition. Chronic insomnia usually develops because of stress, life events, or behavior that disrupts sleep. Doctors generally treat the underlying causes to get rid of insomnia, but sometimes it can take significantly longer for this condition to disappear.

Common insomnia causes can include:

Stress

Worrying about the school, work, finances, health, or family can keep the mind active at night, making it hard to fall asleep. Trauma or stressful events in life like illness or death of a loved one, loss of a job, divorce, etc., can also lead to the development of insomnia symptoms.

Poor sleep habits

These habits consist of an irregular bedtime schedule, taking naps, indulging in stimulating activities before bed, sleeping in an uncomfortable environment, using it for work or eating, watching TV, or using a computer or cellphone before bed. All these things can interfere with the sleep cycle and worsen insomnia.

Travel and work schedule

Every person has a natural body clock that guides the sleep-wake cycle, metabolism, and body temperature. It is called circadian rhythms. If you disrupt your body’s circadian rhythm, it can lead to various health problems, including insomnia. Activities like traveling across time zones, frequently changing shifts, working early, or late shifts can disrupt the body’s circadian rhythm.

Excessive eating late in the evening

Taking a light snack before going to bed can be okay, but overeating can make you feel physically uncomfortable. You might also experience heartburn, a backflow of food and acid from the stomach after eating. It can cause a burning sensation that can keep you awake at night.

Mental health disorders

Conditions like anxiety disorders, depression, PTSD, etc., can disrupt a person’s sleeping pattern. Depression can cause a person to wake up early in the morning. Other mental health disorders might also cause a person to experience insomnia symptoms.

Medications

Prescription medications can also interfere with sleep. Drugs like antidepressants and asthma or blood pressure medicines can cause insomnia. Over-the-counter drugs like pain medications, cold and allergy medicines, and weight loss pills often have caffeine and other stimulants that can disrupt a person’s sleeping patterns.

Medical conditions

Some medical issues, including chronic pain, diabetes, gastroesophageal reflux disease (GERD), cancer, asthma, heart disease, Parkinson’s disease, thyroid, and Alzheimer’s, can contribute to insomnia symptoms.

Sleep-related disorders

Disorders like sleep apnea cause a person to stop breathing periodically throughout the night that interrupts their sleep. Other diseases like restless legs syndrome can cause unpleasant sensations in the leg, which results in an irresistible desire to move the legs. People with such conditions might find it challenging to relax and get proper sleep at night.

Caffeine, alcohol, and nicotine

Tea, coffee, cola, and similar drinks can act as stimulants. Drinking these beverages late in the day can keep a person from falling asleep at night. Tobacco products containing nicotine can also interfere with sleep. Alcoholic drinks might make you fall asleep, but they restrict the body from entering deeper sleep stages that result in a person awakening in the middle of the night.

Risk factors

Once in while everyone experiences a sleepless night, but the risk of insomnia is higher if:

  • You are over the age of 60 – due to changes in sleep patterns and health conditions, insomnia also increases with age.
  • You are a woman – shifting hormones during menopause, and menstrual cycle can cause night sweats and hot flashes that disrupt sleep. Insomnia is also common among pregnant women.
  • You don’t have a proper sleeping schedule – irregular work shifts and traveling can disrupt the sleep-wake cycle and increase the risk of insomnia.
  • You have a mental or physical health disorder – the same factors responsible for causing psychological and physical health problems can also disrupt sleep.
  • You are under a lot of stress – stressful events and times can lead to temporary insomnia. If it lasts for more extended periods, it can cause chronic insomnia.

Signs and Symptoms 

In addition to the disrupted sleep, people with insomnia can also experience the following symptoms:

  • Fatigue and daytime sleepiness
  • Low motivation
  • Lack of energy
  • Lack of coordination
  • Headaches
  • Irritability
  • Anxiety
  • Depression
  • Difficulty concentrating and focusing
  • Gastrointestinal problems
  • Worry about sleeping
  • Needing medication to fall asleep
  • Being clumsy
  • Difficulty working, studying, or socializing
  • Making careless mistakes

All these signs can indicate various levels of insomnia. If you experience these symptoms, consult with a healthcare professional immediately to stop the problem from getting worse. It is easy to control insomnia if treated early.


Mechanism

There are two models of the mechanism of insomnia – cognitive and physiological. The cognitive model shows the hyperarousal and rumination, resulting in preventing a person from falling asleep and causing an episode of insomnia.

The other model – physicological model consists of three significant findings in people who have insomnia:

  • The increased level of urinary cortisol and catecholamines are present in these people that indicate increased arousal and HPA axis activity.
  • These people show increased utilization of global cerebral glucose during wakefulness and in NREM sleep.
  • People with insomnia also exhibit increased full body metabolism and heart rate.

Together, all these findings point to a dysregulation of the arousal system, HPA axis, and cognitive system, all contributing to insomnia. However, it is unknown whether the hyperarousal is a result or the cause of insomnia.

Changed levels of the inhibitory neurotransmitter GABA are also present in the people with insomnia, but the consequences of altered levels of these ubiquitous neurotransmitters are still unknown. Studies conducted to determine whether insomnia is a product of circadian control over sleep or a wake dependent process show inconsistent results.

However, some literature indicates a dysregulation of the circadian rhythm based on core temperature. People with insomnia also have an increased beta activity and decreased delta wave activity in their brain as measured on electroencephalograms, but the implications of this finding are still unknown.

Almost half the women post-menopause experience some sleep disturbance. Typically, the sleeping problem is twice as common in women as men. It can be because of the changes in women’s hormone levels, which can be significant, especially during and post-menopause. Changes in sex hormones in men and women with age can partially explain the increased tendency to develop sleep disorders in older people.


Diagnosis

Doctors use eight different parameters related to sleep to make a diagnosis of insomnia. These parameters represent an overall scale that assesses a person’s sleep pattern. If you experience sleeping problems, consult a sleep specialist for diagnosis. They might also examine the past medical records to eliminate other conditions that might be the cause of insomnia.

After ruling out other possible causes, the expert will take a comprehensive look at your sleep history, including sleep habits, medication, alcohol usage, nicotine and caffeine consumption, comorbid illness, and your sleeping environment.

Some people may need to go through an overnight sleep study to make sure if they have insomnia. This type of research usually involves assessment tools, including a polysomnogram and various sleep latency tests. The sleep specialist carefully determines what sort of problem an individual is having, as people with other disorders, including delayed sleep phase disorder, often get misdiagnosed with primary insomnia.
In most cases, insomnia is a result of another disease or a side effect of some medication or a psychological problem. Almost half of the diagnosed insomnia cases are related to psychiatric disorders. However, determining the cause is not necessary for a diagnosis.


Prevention

You will need to make particular lifestyle changes to prevent the onset of insomnia. The least a person can do to minimize the chances of getting insomnia is to sleep and wake up at the same time each day. Following a sleep routine can create a pattern that might help to prevent insomnia. Avoiding exercise and caffeinated beverages close to bedtime can also prove beneficial in preventing insomnia.

Following are some activities that can improve sleep hygiene:

  • Avoid taking naps
  • Avoid eating heavy meals, drinking alcohol, or taking nicotine before going to sleep
  • Treat pain at bedtime
  • Find ways to relax while sleeping, such as using white noise
  • Make the bedroom dark and cold so it can be more comforting to sleep
  • Remove all the devices like clocks, television, cell phones, etc. from the bedroom to avoid distractions at night
  • Keep a positive attitude while going to sleep
  • Do regular exercise, but not immediately before going to sleep
  • Make sure to not use the bed for anything other than sex and sleep
  • Do not keep on checking the time once you are in bed

Management

The experts first rule out the medical and psychological causes before deciding the treatment for insomnia. Usually, cognitive behavioral therapy is their fist line treatment, as it is useful in providing relief to people with chronic insomnia. This therapy’s effects last well beyond the treatment period, in contrast to the effects of medication that disappear as soon as you stop taking the drugs.

Doctors recommend medicines for reducing the symptoms in the short run. Most doctors do not prescribe using sleeping aids for the long-term, as they believe it is more important to identify and treat the medical conditions that may be contributing to insomnia.

Non-medication based treatment

These strategies provide long-lasting improvements to insomnia. Non-medication methods include sleep hygiene, stimulus control, behavioral interventions, sleep-restriction therapy, patient education, and relaxation therapy.

Sleep hygiene

It is a term that encompasses all the behaviors that encourage sound sleep. It includes the habits that lay the foundation of good sleeping practices and help prevent insomnia. Though effective, it alone is not adequate to treat chronic insomnia. Doctors usually recommend it with behavioral therapy for maximum effectiveness.

Cognitive-behavioral therapy

In this therapy, the therapist teaches patients improved sleep habits and makes them aware of counter-productive assumptions about sleep. Some of the misconceptions and expectations that experts try to modify includes:

  • Unrealistic sleep expectations – Do I need to get 8 hours of sleep each night?
  • Misconceptions about insomnia causes – Do a chemical imbalance in my system causing insomnia?
  • Amplifying the consequences of insomnia – Inability to do anything after a bad night’s sleep
  • Trying to manage performance anxiety after trying to have a good night’s sleep by controlling the sleep process

Experts all over the world accept CBT as an effective treatment option for insomnia as it does not have any known adverse effects. The only downside of this therapy is that it might take a lot of time and motivation to show its results.

Dietary habits

Making changes to what and how much you eat can also significantly affect your sleeping pattern. Going to bed hungry, consuming an excessive amount of food before bed, drinking alcohol or caffeinated beverages in the evening, etc., are all the things that can deteriorate the quality of sleep. Controlling your dietary habits can help you manage insomnia symptoms.


Medications

Doctors often recommend medications for treating insomnia symptoms. These medicines can be prescription drugs or over the counter medications. Antihistamine, such as Benadryl is an example of over the counter drug helpful in treating insomnia.

These medications can cause long term side effects, so it is crucial to consult with a healthcare professional before using these OTC drugs for insomnia.

Some of the popular prescription medications for insomnia include:

  • Ambien (zolpidem)
  • Lunesta (eszopiclone)

The percentage of people using prescription insomnia medicine increases with age. Adult women are more likely to use these medications than men. However, there is no significant difference in medicine use between people of African, non-Hispanic, and Mexican-American descend.

Following are the types of drugs that doctors recommend for treating insomnia symptoms

  • Antihistamines
  • Melatonin
  • Antidepressants
  • Benzodiazepines
  • Other sedatives
  • Antipsychotics
  • Alternative medicine

Many people tend to use alternative medicines to ease symptoms of insomnia. They consume herbs such as lavender, chamomile, valerian, or cannabis. While these treatment methods are gaining popularity, there is no conclusive clinical evidence which suggests that these treatments are effective.


Prognosis

A survey of around 1.1 million people living in the United States found that those who reported having a sleep of about 7 hours per night had the lowest mortality rate. Those who get more than 8 hours or fewer than 6 hours of sleep had comparatively higher mortality rates.

Getting excess of eight and a half hours of sleep each night was associated with about 15% higher mortality rate. Severe insomnia corresponding to sleeping fewer than 4.5 hours for men and 3.5 hours for women can increase the mortality rate by upto 15%.

With the method used in the survey, it is hard to differentiate between lack of sleep as a result of a disorder that is also a cause of premature death, versus a condition that causes a decreased sleep, and that lack of sleep resulting in early death. After accounting for the associated disorder, the researchers discounted most of the increase in mortality from severe insomnia. They also accounted for the duration of insomnia and the use of sleeping pills to find the accurate mortality rate.

People who get a sleep of between 6.5 to 7.5 hours a night showed the lowest mortality rate. Those who slept only 4.5 hours a night showed very little increase in mortality.

The survey concluded that mild to moderate insomnia, for most people, is associated with increased longevity. Severe insomnia can have a very insignificant effect on mortality rate. However, it is unclear why those who sleep for more than 7.5 hours each night have a high mortality rate.

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