Insomnia is a pathological condition in which the process of onset and maintenance of sleep is disrupted. Depending on one or another clinical form of insomnia, difficulties in falling asleep (presomnical form), disturbances in the sleep period (intrasomnical) and after waking up (postsomnical form) are observed; there is also a decrease in sleep efficiency, night awakenings. The diagnosis is established on the basis of physical examination, anamnesis collection, polysomnography. Treatment of insomnia includes compliance with sleep hygiene, the appointment of drug therapy, physiotherapy, psychotherapy.
G47.0 Sleep and sleep maintenance disorders [insomnia]
Insomnia is a violation of the sleep-wake cycle. Pathology is determined by the lack of quality and quantity of sleep, which are necessary for normal human life. The disease occurs in 30-45% of the world’s population. For some of them (10-15%) insomnia is a serious problem that requires taking medications. It should be noted that with age, problems with falling asleep and maintaining physiologically sound sleep are becoming more frequent, so older people face insomnia more often than young people.
Insomnia is a more popular name for pathology used by patients and even doctors, is not correct, since the disease is not accompanied by complete loss of sleep.
Insomnia may be based on a physiological predisposition, psychogenic disorders, diseases of the nervous system and internal organs. Insomnia often occurs in people suffering from neurosis and neurosis-like conditions: psychosis, depression, panic disorders, etc. Patients with somatic diseases that cause night pain, shortness of breath, heart pain, respiratory disorders (arterial hypertension, atherosclerosis, pleurisy, pneumonia, chronic pain, etc.) usually complain about the difficulties of falling asleep and the quality of sleep. Sleep disorders can accompany organic lesions of the central nervous system (stroke, schizophrenia, brain tumors, parkinsonism, epilepsy, hyperkinetic syndromes); pathology of the peripheral nervous system.
Predisposing factors also have an impact on the development of sleep disorders, namely: life in a megalopolis; frequent change of time zones; long-term use of psychotropic drugs; alcohol intake; constant intake of caffeinated beverages; shift work and other occupational hazards (noise, vibration, toxic compounds); violation of sleep hygiene.
The pathogenesis of insomnia is not considered to be fully understood, however, scientific research and experiments in the field of neurology have shown that patients have the same increased brain activity during sleep as when awake (this is indicated by a high level of beta waves); increased levels of hormones at night (cortisol, adrenocorticotropic hormone) and high the level of metabolism.
According to the duration of insomnia, it is divided into:
- Transient, with a duration of no more than a few nights
- Short-term (from several days to weeks)
- Chronic (from three weeks or more)
There are also physiological insomnia (situational) and permanent insomnia (having a permanent character). By origin, there are primary insomnia arising as a result of personal or idiopathic (unexplained) causes, and secondary insomnia arising against or as a result of psychological, somatic and other pathologies.
According to the severity of clinical symptoms , insomnia happens:
- Mild (mild) – rare episodes of sleep disturbance
- Moderate severity – clinical manifestations are moderately pronounced
- Severe – sleep disorders are observed every night and have a significant effect in everyday life.
Clinical signs of insomnia, depending on the time of their manifestation, are divided into groups: presomnic, intrasomnic and postsomnic disorders. Disorders before, after and during sleep can manifest individually and in combination. All 3 types of disorders are observed only in 20% of middle-aged patients and in 36% of elderly patients with insomnia.
Insomnia leads to a decrease in daytime activity, impaired memory and mindfulness. In patients with mental pathology and somatic diseases, the course of the underlying disease is aggravated. Insomnia can cause a delayed reaction, which is especially dangerous for drivers and workers servicing industrial machines.
Patients complain of problems with the onset of sleep. Usually the stage of falling asleep lasts 3-10 minutes. A person suffering from insomnia can spend from 30 to 120 minutes or more on falling asleep.
An increase in the period of sleep onset may be a consequence of insufficient fatigue of the body during late rising or early going to bed; a painful reaction and itching of a somatic nature; taking medications that excite the nervous system; anxiety and fear that arose during the day.
As soon as a person is in bed, the desire to fall asleep instantly disappears, heavy thoughts arise, painful memories pop up in memory. At the same time, there is some motor activity: a person cannot find a comfortable position. Sometimes there is an unreasonable itching, unpleasant sensations on the skin. Sometimes falling asleep happens so imperceptibly that a person perceives it as being awake.
Problems with falling asleep can form strange rituals before going to bed, unusual for healthy people. There may be a fear of sleep deprivation and fear of bed.
The patient complains about the lack of deep sleep, even a minimal stimulus causes awakening followed by prolonged falling asleep. The slightest sound, the light turned on and other external factors are perceived especially acutely.
The cause of spontaneous awakening can be terrible dreams and nightmares, a feeling of filling the bladder (repeated urge to urinate), vegetative respiratory failure, palpitations. A healthy person who does not suffer from insomnia can also wake up, but the threshold of awakening is noticeably higher, subsequent falling asleep is not problematic, the quality of sleep does not suffer.
Intrasomnic disorders also include increased motor activity, manifested by the syndrome of “restless legs”, when a person makes shaking movements with his legs in a dream. The cause of the syndrome of “sleep apnea”, which is often observed with insomnia, is the inclusion of an arbitrary mechanism of regulation of breathing. Occurs most often with obesity and is accompanied by snoring.
Insomnia also manifests itself in the waking state after waking up. It is difficult for a person to wake up early, he feels broken all over his body. Drowsiness and decreased performance can accompany the patient all day. Often there is non-recurrent daytime drowsiness: even with all the conditions for a good sleep, a person cannot fall asleep.
There are sharp mood swings, which adversely affects communication with other people, often exacerbating psychological discomfort. Some time after waking up, a person complains of headaches, a possible rise in pressure (hypertension). At the same time, a more pronounced increase in diastolic pressure is characteristic.
Insomnia is diagnosed based on the patient’s complaints and his physical condition. At the same time, the actual duration of sleep is not decisive; the 5-hour limit is a kind of minimum: a less prolonged sleep for 3 days is equivalent to one night without sleep.
There are 2 clear diagnostic criteria for insomnia: this is a delay in falling asleep for more than 30 minutes and a decrease in sleep efficiency to 85% or lower (the ratio of the actual sleep time to the time the patient spent in bed).
A violation of the circadian rhythm (early falling asleep and early rising — a person is a “lark” or late falling asleep and late rising – a person is an “owl”) is diagnosed as a pathology if a person experiences postsomnia disorders and does not have the opportunity to sleep longer or fall asleep early.
Sometimes a person suffering from chronic insomnia is offered to keep a diary for a month, in which the periods of wakefulness and sleep are recorded. In cases when insomnia is accompanied by respiratory disorders (obstructive apnea) and motor activity, as well as with the ineffectiveness of drug therapy, a somnologist’s consultation and polysomnography are prescribed. Computer research gives a complete picture of sleep, determines the duration of its phases and evaluates the work of the entire body during sleep.
Diagnosis of insomnia does not cause difficulties, more often it is more difficult to determine the true cause or the combination of factors that caused insomnia. Consultations of narrow specialists are often required in order to identify somatic pathology.
Transient insomnia usually goes away on its own or after eliminating the causes of its occurrence. Subacute and even more chronic insomnia require a more careful approach, although the treatment of the root cause is a fundamental factor.
Successful getting rid of insomnia involves observing sleep hygiene. Daily falling asleep at the same time, the exclusion of daytime sleep, active daytime wakefulness can completely relieve insomnia of the elderly without the use of medications.
Psychotherapy allows you to eliminate psychological discomfort and restore sleep. Acupuncture and phototherapy (treatment with high intensity white light) have shown good results in the treatment of insomnia.
The use of sleeping pills promotes rapid falling asleep and prevents frequent awakenings, however, hypnotics have a number of adverse effects, ranging from addiction to addiction and the effect of recoil. That is why the medical treatment of insomnia begins with herbal preparations (motherwort, mint, oregano, peony, etc. medicinal herbs that have a sedative effect) and products containing melatonin. Drugs with sedative effect (neuroleptics, antidepressants, antihistamines) are prescribed to increase the duration of sleep and reduce motor activity.
Imidazopyridines (zolpidem) and cyclopyrrolones (zopiclone) have a short duration of exposure, do not cause postsomnia disorders – these are some of the safest chemical sleeping pills. A group of tranquilizers – benzodiazepines (diazepam, lorazepam) inhibits brain processes to a greater extent, thereby reducing anxiety and increasing sleep latency. These drugs are addictive, seriously affect the speed of reaction, at the same time enhance the effect of barbiturates and analgesics.
The rules for taking medications for insomnia include: compliance with the duration of treatment with sleeping pills — on average 10-14 days (no more than 1 month); drugs can be prescribed in combination, taking into account their compatibility; one or another drug is selected depending on the concomitant somatic pathology and a minimum set of side effects. For preventive purposes, sleeping pills are prescribed 1-2 times a week. It is important to understand that the use of sleeping pills is an exclusively symptomatic treatment. This fact and a lot of undesirable consequences force you to limit their intake as much as possible.
Prognosis and prevention
To completely get rid of insomnia, the following rules should be followed: do not delay a visit to a neurologist with obvious signs of insomnia; do not take medications without a doctor’s appointment. It is necessary to observe the daily routine (commensurate loads, walks and sufficient time for sleep) and the formation of one’s own stress resistance; emphasis should be placed on psychological techniques and minimal use of medications.
The prognosis for acute and subacute insomnia is favorable, its treatment in most cases does not require the use of hypnotics and tranquilizers. Treatment of advanced chronic insomnia is a long process; only close interaction of the patient with the doctor will allow you to choose an effective treatment regimen and achieve a positive result.