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Mental Health Information Centre - Southern Africa

Insomnia

What is insomnia?

Insomnia is a common health problem that affects roughly one third of the population. It is the inability for an individual to fall asleep and/or to maintain sleep, resulting in sleep that does not allow the body to recover from daily wear. About 10% of adults suffer from insomnia.

All people need 6 to 10 hours of sleep a night. Less than 4 hours or more than 9 hours is associated with an increased risk of death. Sleep latency is the time needed to fall asleep and is on average 15-20 minutes. Insomnia is associated with an involuntary increase in sleep latency.

Features of insomnia

Difficulty falling and/or staying asleep.
Inability to remain awake during the day, especially in a warm room, on a full stomach, and in the presence of white noise.
Insomniacs usually feel lethargic and tired during the day.
They may also have microsleeps (naps) during the day of which they may not be aware. Insomnia and sleep deprivation is associated with an increased incidence of accidents especially by those persons operating dangerous machinery, as well as an increased incidence of road traffic accidents.

What causes insomnia?

Alcohol: More than 2 drinks close to bedtime changes sleep structure and results in poor quality sleep.

Psychiatric disorders: Depression and anxiety disorders are associated with insomnia.

Medication: Numerous medications are associated with insomnia. Stimulants such as coffee, tea, chocolate, nicotine, and amphetamines cause insomnia. Certain psychiatric medications are associated with insomnia.

Medical conditions: Any disease that is associated with chronic pain may result in insomnia. Heart-lung conditions that cause orthopnoea (difficulty breathing) cause insomnia. Urinary frequency and diuretic medication can also lead to insomnia.

Sleep apnoea: This condition is associated with ear-nose-and-throat obstruction.

Circadian rhythm: Humans have an internal biologic clock that determines their sleep-wake cycle. Any disturbance of this cycle will result in insomnia. Crossing time zones results in jetlag that is often associated with insomnia during the night and somnolence (sleepiness or unnatural drowsiness) during the day.

Environmental changes: Changes in sleep environment such as going on vacation or sleeping in different places when on call can result in insomnia.

Nocturnal myoclonus or restless legs syndrome consists of constantly jerky leg movements throughout the night.

What to do and where to go for help

Many insomniacs attempt to treat themselves through various methods ranging from alcohol use to over-the-counter medications and prescriptions. However, effective behavioural and medication treatments are available and often a combination of the two help in the treatment of insomnia.

The most common medications that are used in the treatment of insomnia are hypnotics. These are drugs that bring on sleep and are primarily used for the short-term management of insomnia. Antidepressants can be used to not only address the sleep symptoms of depression, but have also been found to have sleep-improving properties.

Behavioural treatments produce reliable and lasting benefits for many insomnia patients and avoid the undesirable consequences of many medications. Various techniques include: stimulus control, sleep restriction, progressive muscle relaxation, biofeedback, imagery training, paradoxical intervention, and natural substances.

Sleep hygiene education is a technique used to help patients identify lifestyle and environmental factors that may make it difficult to achieve or maintain sleep.

Useful tips

Avoid stimulants such as caffeine and nicotine before bedtime
Do not use alcohol as a sleep aid and avoid alcohol before bedtime
Exercise regularly but not within 3 hours to bedtime
Minimise light, noise, and extreme temperatures during sleep
Eat only a light snack before bedtime, if hungry
Do not watch the clock after going to bed
Do something relaxing before bedtime, e.g. having a hot bath
Use the bed only for sleeping or sex
Do not nap during the day (except in the elderly)
Get up at the same time each day, even when tired
If not asleep within 20 minutes of going to bed, do a low energy activity (e.g. reading) in another room until tired and then return to bed.
Cognitive therapy is a useful technique for sufferers who often display unrealistic sleep expectations, which leads to performance anxiety due to excessive effort at trying to control the amount and quality of sleep.

Summary

Insomnia disturbs the normal restorative functions of sleep and therefore decreases daytime alertness. This is associated with an increased risk of involvement in accidents. Psychiatric, medical and substance use disorders are associated with insomnia. Non-medication treatment options on their own or with a short (two weeks) prescription of a hypnotic, resolve most cases of insomnia.

Further references/ resources

Sleep Laboratories

Greenacres Hospital: +27 41 363 3504
Groote Schuur Hospital: +27 21 404 4371
Lorne Street EEG & Sleep Lab: +27 31 309 5059
Pretoria Academic Hospital: +27 12 354 2282
Tygerberg Hospital: +27 21 938 5500
Universitas Hospital: +27 51 405 3610
Wits University:+27 11 717 2506



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University of Stellenbosch
South African Medical Research Council
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