The definition of 'Chronic' Insomnia is 3 nights poor sleep per week persisting for 3 months. It means problems in initiating sleep, or staying asleep, or returning to sleep after waking early in the morning.
This effects 10-15% of men and women over 50, affects most women at menopause and continues after that if they are not on HRT. It affects some individuals chronically for many years, with severe health consequences.
This matters because …
Lack of sleep is bad for you. The well-known risks are reduced daytime performance [poor decision-making capacity, memory, and attentiveness] and increased risk of traffic accidents [due to microsleeps]. Equally important is that insomnia is also a risk factor for depression and anxiety, metabolic syndrome, hypertension, coronary heart disease [[1]] and increased mortality in men[[2]]. Why the data doesn't show mortality for women I don't know, but may just be that women haven't been studied. So don't ignore insomnia! Get some help.
Who is at risk?
Insomnia is common if you are older, female, have had previous sleep problems, are disabled, work late/ do night shifts, or have a family history - there is sometimes a genetic basis for insomnia [[3]]. As many as 50% of patients with insomnia have anxiety, depressive symptoms or other psychiatric condition] and depression often presents as insomnia.
What does good sleep look like?
Duration - you consistently get as many sleep cycles [90 minutes is a cycle – see more below about managing cycles] per night as you personally need.
Rising: your rising time is the same every day so that your biorhythms are in-sync.
Sleep quality: you get to sleep without much latency [delay] and sleep undisturbed all night [or get up once to pee].
What goes wrong? Why do problems occur?
It is the rule of 3's. First, 3 basic sleep hygiene issues:A room: that is too warm, too light, too noisy.
A partner: who is too restless, who snores, gets up many times to go to the bathroom,
A lifestyle: that is sleep destroying; so caffeine too late in the day, too much alcohol, eating late in the evening or box set bingeing.
Second, 3 three complex physiological issues:
Hyperarousal, an overactive mental state translating into a stream of troubled or anxious thoughts that keep you awake.
Variable rising time, that messes up the circadian rhythm so the body cannot stabilise itself hormonally or metabolically.
Poor sleep preparation, so two critical sleep requirements are missing: light management and arousal lowering. You need to reduce light levels in the evening [low level lighting or dimmed ceiling lights] and wind down for 30-60 minutes before bed [stop screens, take a bath or shower, listen to calming music or read an actual book ie not a screen variety of text.]
Current thinking about how sleep is controlled
The flip-flop switch: the brain has a Yin and Yang approach to sleep. You are either fully awake or fully asleep, depending on which of two parts of the brain is predominantly active.
The Ascending Reticular Activating System [ARAS] causes wakefulness. The Ventro-Lateral Preoptic Region [VLPR] promotes sleep. Activating one switches off the other – hence the flip-flop switch idea.
To be fully awake, the ARAS stimulates orexin activity to switch off the VLPR. When we need to sleep, the VLPR stimulates GABA and galanin to switch off the ARAS.
What causes insomnia?
Sleep failure is caused by cognitive, emotional, or physiological disturbance. There are therefore multiple possible predisposing factors. The common feature is that these three disturbances all cause hyperarousal. The aroused experience of insomniacs [[4], [5]] means:
- Excessive worrying and racing thoughts that won't go away.
- A feeling of anxiety "will I ever get to sleep? ''
- Increased metabolic rate, blood pressure, and cortisol levels. The EEG displays a high-frequency pattern in response to the cognitive and emotional activity.
Non-Drug Treatment of insomnia
There are 3 things to focus on.
Fix the environmental bedroom issues and the sleep timing problems that are discussed above.
2. Managing Menopause, Depression, Sleep apnoea
Look for these three medical causes of sleep disturbance and treat them specifically. So HRT, antidepressants or CBT and for sleep apnoea, specialist supervised diagnosis and treatment including weight reduction, positive airway pressure or nasal decongestion.
3. Behavioural change
A successful non-drug treatment approach was defined in a Randomized Controlled Trial (RCT) by Jacobs et al in Boston[6].
The two principles are :
- Reduce arousal generally, potentially a permanent cure.
- Choose beneficial behaviours that favour sleep and are effective when you wake up
Use coaching approaches to reduce arousal. CBT, or the Clarity/ insight Principles approach both work to achieve less overall anxiety as a baseline. [We cover the Clarity/ insight Principles approach in the Bios Basecamp. [https://vitalitashealth.kartra.com/page/BiosBasecamp]
Use Daily Meditative Practice. This may be meditation per se, Mindfulness or the technique of Morning Pages/ Night Notes.
Choose beneficial behaviours that favour sleep and are effective when you wake up.
- Bed is for sex or sleep, never for TV, social media or snacking.
- Set an everyday rising time; even after short sleep to synchronize circadian rhythms.
- Go to bed only when drowsy.
- If awake after 30 minutes, get up, change room, do a relaxing non-screen activity until drowsy.
- When you wakeup in the night and cannot return to sleep, proceed as above.
- Use Heart Math or yoga style breathing to assist sleep initiation [relaxes/ lowers arousal].
Drug Treatment
If the non-drug approach fails then some newer drug alternatives may help [but they are expensive]
Dual Orexin Receptor Agonists [DORA's]. They are 'dual' because both of the two orexin receptors, need to be blocked to shut down the ARAS. The DORA drug Daridorexant [Quviviq], is licensed in both UK and USA and is effective at a dose of 50mg at nighttime [lower doses proved insufficient in trials]. It is a controlled drug. Metabolism is rapid so there is no 'hangover effect' the following day [but the mechanism of action is not sedating of course]. The pharmacokinetics [absorption and metabolism] are the same for all ages, sexes, races and the obese. It is not recommended alongside alcohol or sedatives. A similar drug, Lemborexant is marketed in the United States, Canada, Australia, and Japan.
DORA Guidelines
In the UK the NICE guidelines state
"Daridorexant is recommended for treating insomnia in adults with symptoms lasting for 3 nights or more per week for at least 3 months, and whose daytime functioning is considerably affected, but only if cognitive behavioural therapy for insomnia (CBTi) has been tried and not worked, or CBTi is not available or is unsuitable[7]"
In the UK, CBT requires waiting months unless you pay: consequently, your family doctor may be amenable to a trial of treatment. The FDA make no special requirements.
What is the role of melatonin as a treatment?
Melatonin is not a treatment for insomnia [it performed badly in RCTs]. Its uses are that it regulates day/night [circadian] rhythm, helps jet lag and has some interesting anti-ageing properties.
Early rising and getting exposure to natural light in the morning [or using a SAD light in winter], helps set up the natural melatonin biorhythm. Taking melatonin 30-60 minutes before bed reinforces this.
Practical tips - Managing Sleep cycles
When you sleep full cycles you feel much better even if it is a short night.
- Set your rising time. It must be a broadly workable time that puts you under no pressure leaving the house or starting Working From Home (WFH). Stick to it 7 days a week.
- Work out how many sleep cycles you need. This is how many 'sets of 90 minutes' per night to be ideal. This will therefore be 6, 7.5, or 9 hours [but not 8!] You don't want to wake up mid cycle – you miss REM sleep elements vital for recovery and bodily repair and you will feel groggy.
- Calculate total cycles per week. [eg 4 cycles per night = 28/week]
- Calculate bedtime. Count back from your rising time: this is your bedtime. For example if your rising time is 0630 and you want 5 cycles = 7.5 hours then lights out is at 2300
Special timing issues
Early start. You have a different rising time but STILL count back in cycles to decide lights out time.
Either do fewer cycles or go to bed appropriately early.
Late night up. If you are out late, DO NOT sleep in. Get up as usual. Take a 35 min power nap in the early afternoon if needed, and plan when you can catch up.
Catch up means an early night [or two] to bring your total sleep cycles per week back to the ideal.
ACTION
At the very least adopt the use of sleep cycles and a constant rising time, outlined here.
References
[1] Laugsand LE Vatten LJ Et al. Insomnia and the risk of acute myocardial infarction: a population study. Circulation. 2011; 124: 2073-2081
[2] Vgontzas AN et al. Insomnia with short sleep duration and mortality: the Penn State cohort. Sleep. 2010; 33: 1159-1164
[3] Stein MB, McCarthy MJ, Chen CY, et al. Genome-wide analysis of insomnia disorder. Mol Psychiatry. 2018;23(11):2238-2250. doi:10.1038/s41380-018-0033-5
[4] Dopheide JA. Insomnia overview: epidemiology, pathophysiology, diagnosis and monitoring, and nonpharmacologic therapy. Am J Manag Care. 2020;26:S76-S84. doi:10.37765/ajmc.2020.42769
[5] Bonnet MH, Arand DL. Hyperarousal and insomnia: State of the science. Sleep Medicine Reviews. 2010;14(1):9-15. doi:10.1016/j.smrv.2009.05.002
[6] Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison. Arch Intern Med. 2004;164(17):1888–1896. doi:10.1001/archinte.164.17.1888
[7]https://www.nice.org.uk/guidance/ta922/documents/674#:~:text=So%2C%20daridorexant%20is%20recommended%20for%20routine%20use%20in%20the%20NHS.&text=2.1%20Daridorexant%20(QUVIVIQ%2C%20Idorsia),considerable%20impact%20on%20daytime%20functioning'.
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