Clinical symptoms

People suffering from insomnia complain of difficulty falling asleep, staying asleep, waking up too early or having poor quality sleep that does not give rest. For these symptoms to be considered abnormal, sleep disturbances must lead to discomfort or interfere with daytime functioning. Additionally, they should appear for at least one month, three times a week or more. The above diagnostic criteria for insomnia mean that the duration of symptoms, their frequency, and the extent to which they affect the patient’s daily life are objective determinants of the severity of insomnia. In order to diagnose insomnia, it is not necessary to measure the length and quality of sleep with the help of specialized tests. The patient’s subjective feeling that his sleep is disturbed is enough.

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In research, for example, on sleeping pills, difficulty falling asleep is most often defined as an increase in the period of falling asleep, or sleep latency, exceeding 45 minutes. Difficulty in sustaining sleep is defined as the total time of all awakenings from sleep during the night, i.e. the intervened awake time, greater than 30 minutes. The total sleep time of less than 6-6.5 hours is considered too short. However, this value does not apply to people with low sleep needs (less than 6 hours).

Classification and causes of insomnia

In the International Statistical Classification of Diseases and Health Problems (ICD-10), sleep disorders are divided into inorganic and organic, that is, unrelated to or associated with diseases of the nervous system or somatic. The American Classification of Diseases and Mental Disorders (DSM-IV) divides sleep disorders into primary and secondary sleep disorders, i.e. those occurring spontaneously or accompanying other diseases. From a practical point of view, however, the most useful is the breakdown of insomnia according to the duration of symptoms.

Casual insomnia(lasting up to a few days) andshort-term insomnia(lasting up to 4 weeks) are most often caused by a reaction to stress (e.g. work, school, family problems) or a change in lifestyle (e.g. moving, traveling with a change of zones) time). Short-term insomnia can also be caused by somatic diseases, for example infections, painful diseases.

Chronic insomnia, i.e. insomnia lasting more than a month, is most often associated with mental disorders (especiallydepression and anxiety disorders), chronic somatic diseases (e.g. hormonal disorders, chronic inflammation, e.g. rheumatoid, chronic pain syndromes, neurological and musculoskeletal diseases that prevent physical activity during the day) and addiction to, for example, alcohol. Primary sleep disorders, even in the centers of sleep medicine to which patients are referred, after the exclusion of mental disorders and somatic diseases, are less likely to cause sleep problems than the diseases listed in Figure 1.

Dig. 1.The most common causes of insomnia. Based on Coleman et al. Sleep-wake disorders based on a polysomnographic diagnosis. A national cooperative study. JAMA, 1982; 247 (7): 997–1003.

The frequency of occurrence

Symptoms of insomnia in epidemiological interviews are found in 30–50% of the examined adults. In 16–21% of respondents, symptoms occur at least three times a week or continuously, and 10–28% of respondents describe the severity of symptoms as moderate or severe. About 9-15% of adults in the general population report that the symptoms of insomnia significantly affect their functioning and well-being during the day. The diagnostic criteria for primary insomnia are met in at least 6% of the examined adults.

Diagnostics

The search for the cause of insomnia should begin with an assessment of your overall health. This evaluation, usually performed by a family doctor, includes a medical history, a physical examination, blood pressure measurements and, where appropriate, an ECG and periodic tests. If the somatic state does not indicate a possible cause of insomnia, the next step is to rule out mental disorders. For this purpose, it is worth consulting a psychiatrist. If the result of the mental state examination also does not answer the question about the cause of insomnia, attention should be paid to the patient’s lifestyle and compliance with the rules of sleep hygiene. At this stage in the diagnosis of the cause of insomnia, your doctor will usually recommend a sleep diary. Once you have gathered all of this information, it is possible to make an informed decision about the treatment you should choose. If it is not possible to determine the cause of insomnia, consultation with a sleep disorders treatment clinic is recommended, where specialists assess rare causes of insomnia, such as: circadian rhythm disorders, restless legs syndrome, idiopathic insomnia.

Treatment

Cognitive behavioral therapy

Cognitive-behavioral therapy(CBT) is the primary form of treatment for primary insomnia. Conducting behavioral interventions, i.e. changing behavior, is also advisable in patients with secondary forms of chronic insomnia, i.e. insomnia coexisting with other diseases.

Research results show that most patients with chronic insomnia, regardless of its cause, change their lifestyle and start thinking about sleep in such a way that the insomnia becomes permanent. The most important factors perpetuating insomnia include:

• extending the time spent in bed,
• trying to compensate for the lack of sleep by going to bed earlier or staying longer in bed after a sleepless night,
• naps during the day,
• resignation from physical activity,
• trying to fall asleep by force and waiting for sleep in bed, even when sleep does not come,
• waiting in the evening with tension and fear of what the next night will turn out to be,
• over-concerned with the quality of your own sleep
• taking sleeping pills too often and for too long or drinking alcohol before going to bed.

In order for insomnia to go away, it is necessary to remove these fixatives. The most important cognitive-behavioral interventions in the treatment of insomnia are shortening of sleep time, stimulus control and sleep hygiene.

Other cognitive-behavioral techniques recommended in the treatment of insomnia are: relaxation training, education about sleep and its role, techniques of cognitive restructuring, techniques of stopping thoughts, activating the imagination, paradoxical thinking.

Pharmacological treatment

In the pharmacological treatment of insomnia, it is possible to use the following groups of drugs: hypnotics, benzodiazepine sedatives, antidepressants, antipsychotics and antihistamines, and over-the-counter preparations, e.g. melatonin , lemon balm, valerian and combination preparations containing plant substances mixed in various proportions.

Hypnotics and benzodiazepine derivativesare the only drugs approved for pharmacological treatment of insomnia in Poland. Hypnotics, which include zopiclone , zolpidem, and zaleplon, can be used as the treatment of choice for casual and short-term insomnia caused by stress, changes in life situation, and other short-term, temporary problems, provided that the planned duration of their intake is short, i.e., not exceeding 2–4 weeks. If taking hypnotics is still necessary, they should be used intermittently, if possible, no more than 3–4 times a week. Short-term and intermittent use of sleeping pills prevents the development of tolerance, which means that the drugs do not lose their beneficial effect on sleep, and the risk of becoming addicted to sleeping pills is significantly reduced. Benzodiazepine derivatives, in addition to their hypnotic effect, also have an anxiolytic, anticonvulsant effect, reduce muscle tension, worsen memory and cognitive functions, inhibit the respiratory center and disturb coordination of movements and balance. For these reasons, their use is not recommended in the treatment of insomnia, unless sleep problems are caused by a state of severe agitation or severe anxiety. They are contraindicated in patients over the age of 65 because of an increased risk of falls and worsening memory. Due to their inhibitory effect on the respiratory center, benzodiazepine derivatives should also not be administered to people with breathing disorders during sleep (obstructive and obstructive snoring). They are contraindicated in patients over the age of 65 because of an increased risk of falls and worsening memory. Due to their inhibitory effect on the respiratory center, benzodiazepine derivatives should also not be administered to people with breathing disorders during sleep (obstructive and obstructive snoring). They are contraindicated in patients over the age of 65 because of an increased risk of falls and worsening memory. Due to their inhibitory effect on the respiratory center, benzodiazepine derivatives should also not be administered to people with breathing disorders during sleep (obstructive and obstructive snoring).sleep apnea). Hypnotics and benzodiazepine derivatives should also not be prescribed to patients with alcohol dependence or a history of alcohol dependence.

If you need to take sleep-promoting medications on a permanent basis, or if the use of hypnotics is contraindicated, your doctor may consider treatmentwith antidepressants, antipsychotics, and antihistamines. Medicines in these three groups are not addictive and can be taken for months or even years. Antidepressants such as doxepin , mianserin , mirtazapine , trazodone are very often used in the treatment of chronic insomnia in sleep disorder treatment clinics. Unlike in the treatment of depression, these drugs should be prescribed in small doses in the case of insomnia, and it is also important that they are taken several hours before going to bed, and not just before going to bed, like sleeping pills.

Antipsychotic drugssuch as, for example , chlorprotein , quetiapine , levomepromazine , olanzapine , promazine, and promethazine , at low doses, are also used to treat insomnia, for example, in patients with a history of addiction or in those with organic mental disorders. Due to possible side effects (e.g. weight gain, lowering blood pressure, possible stiffness and tremors), these drugs should be considered in the treatment of sleep disorders further.

Over-the -counter preparationsare commonly used by people with sleep disorders, most often without consulting a doctor. In the case of chronic sleep disorders, most often caused by depression, anxiety disorders or somatic diseases, this usually delays the time of proper diagnosis and the initiation of effective causal treatment. For this reason, over-the-counter herbal preparations should only be considered as an alternative to sleeping pills when insomnia is clearly stress-induced and of a short-term nature. It’s also worth noting thatonly some of the over-the-counter herbal preparations have been studied in research studies. If such studies have been performed, detailed data are usually available on the website of the manufacturer of a given preparation, with the exact information in which patients and under what conditions it should be used.

Melatoninis not a sleep-promoting substance in the strict sense of the word, but rather a chronobiotic, i.e. a substance that determines the right time to sleep. The main and only physiological task of melatonin is to show the body the hours of the night. Melatonin is most effective in people with sleep disorders caused by shift work, crossing time zones, blind people and in patients with delayed sleep phase syndrome. For other forms of insomnia, melatonin is no longer as effective.