Insomnia

Insomnia is the most common sleep disorder, which affects one in four people.

1. Transient Insomnia

This version of insomnia can last anything from a few days to a week, can be triggered by various factors (such as, excess environmental noise, medications, and extreme temperatures – either hot or cold). One type of transient insomnia experienced by avid travellers is jet lag, in which traveling through time zones causes a temporary disruption of the body's circadian rhythm.

2. Acute Insomnia

Acute insomnia has a sudden onset, and may last for several weeks. Common triggers of acute insomnia include emotional stress or conflict, environmental changes such as moving house or job, or anxiety associated with going to bed. Acute insomnia can also be triggered by the same things that trigger transient insomnia (as stated above).

3. Chronic Insomnia

This type of insomnia can have detrimental effects on a person’s health, quality of life, productivity, and safety, and can last anything from months to years at a time. Insomnia listing for more than 3 months should be evaluated by a sleep doctors to exclude common sleep disorders such a Obstructive Sleep Apnea OSA and Upper Airways Resistance syndrome ( see our separate webpages on these syndromes

In many cases, insomnia may be a consequence of another underlying medical/ structural problem, as discussed below:

1. Craniofacial abnormalities leading to Sleep disorders such as UARS or Sleep Apnea

Evolutionary biologists have explained that the upper airway is the " Achilles Heel” of the modern day human race. Unfortunately, being able to talk and communicate has come at a price.

Our voice box takes up vital airway space and our flattened faces (compared to primates) further compromise the upper airway. Our modern day diet with processed food eaten with a knife and fork has allowed our jaws to become smaller resulting in crowding of our teeth. However our tongues have remained the same size. When one lies flat on one's back during sleep, the airways is narrowed to a 1-2mm slit because of the collapse of an over large tongue in a narrowed down airway. This results in repetitive arousals during sleep leading to chronic insomnia

2. Mental Health Issues

Insomnia is a symptom of many mental health problems, which includes anxiety, depression and bipolar disorder. Unstable mental health disorders can trigger insomnia, but the same is true in reverse that insomnia due to sleep disorders such as UARS can be a major risk factor for mental health issues. See UARS webpage. Research findings suggest that patients with insomnia complaints have a major predictor for onset of depressive disorder within 1-35 years. Insomnia is also linked to certain psychological personality traits, such as social introversion and repression of feelings.

Psychophysiological Insomnia (PPI). PPI is a type of chronic insomnia, which is associated with excessive worrying, specifically focused on not being able to sleep. It appears that this condition is linked to hyper-arousal when going to bed. The hypothesis behind it is that afflicted individuals have a hard time relaxing and settling down when they go to sleep, resulting in "racing thoughts" and the inability to “switch off”. These patients then focus on their difficulty falling asleep, which leads to anxiety that further disturbs sleep. Over time, poor sleep and worrying about sleeping can create a negative connotation with going to bed, which results in a pattern of chronically poor sleep that affects daytime activities. It is believed by some scientists that in addition to heightened arousal, individuals with PPI may have some dysfunctional neurological inhibitory mechanisms that would normally help the mind "dis-engage" from daytime thought patterns, which then prevents them from falling asleep.

3. Physical Health Issues

There are various physical health conditions that are associated with insomnia. These including: musculoskeletal problems, cardiovascular disease, gastrointestinal and urinary problems, neurological problems, respiratory problems, immunological problems, and cancer.

4. Hormonal Imbalances

Levels of sex hormones in men & woman (i.e., oestrogen, progesterone, and testosterone) may have a significant impact on the person’s ability to sleep peacefully. This is especially true for women; the incidence of sleep disturbances in women rises to 40% three years after menopause because of decreased progesterone levels. This results in less stability of the upper airways leading to sleep disorders such as OSA and UARS. Studies have found that hormone replacement therapy to balance the declined hormone levels post in menopausal women can significantly improve sleep patterns by stabilizing the upper airway.

The relationship between sleep and hormone levels is not limited to woman, it occurs in men as well. Lower levels of testosterone correlate with increased severity of OSA - obstructive sleep apnea (a particularly serious sleep disorder). People who have trouble sleeping should an overnight sleep study to rule out and treat this cause of sleep disorder. Recent studies show it is low testosterone that is associated with sleep disturbances in aging men.

5. Medications

Medication-induced insomnia can be caused by a wide variety of drugs. Some of these drugs include decongestants, monoamine oxidase inhibitors (MAOIs), selective-serotonin reuptake inhibitors (SSRIs), corticosteroids, chemotherapeutic agents, calcium channel blockers, beta-agonists, and theophylline.

6. Stimulants

Stimulants (such as caffeine and nicotine) contribute to insomnia by making it harder for the brain to achieve the state of relaxation needed for sleep. The half-life (amount of time it takes the body to break down 50% of a dose) of caffeine is between three and seven hours (depending on each person’s ability to metabolise the substance). Larger amounts and/or repeated doses of caffeine lead to slowed caffeine clearance, causing caffeine's effects to last even longer. As a result, caffeine consumption can impair sleep for many hours. Although, some studies have found that mild caffeine consumption in the morning does not impair sleep, since the body has enough time to process the substance.

Nicotine use and nicotine withdrawal can contribute to insomnia. Even those undergoing nicotine replacement therapy (to quit smoking) experience the adverse effects of nicotine on sleep patterns.

While most people think of alcohol as a sedative, its consumption increases dopamine-released levels within the brain, which has a stimulating effect. Chronic alcohol use is associated with insomnia, as is alcohol withdrawal.

7. Lifestyle

Shift work will also contribute sleep disorder. Shift work sleep disorder is a type of insomnia which affects individuals that work non-standard work schedules (such as rotating shifts, on-call work, or permanent night shifts) trigger a disconnect between the body's circadian rhythm and actual time.

Patients with UARS have usually consulted numerous doctors who are not able to diagnose the condition as they are unaware of this newly documented condition. These doctors usually prescribe anti depressants and sleeping tablets for the anxiety, depression and insomnia . Sleeping tablets make the condition worse as it collapses the already compromised airway even further. All the above prescription medications do not improve the UARS and this condition with all its deleterious effects festers on. (See UARS webpage)

Instead, any patient with insomnia and any of the symptoms mentioned above should be sent for an overnight Sleep Study. Once diagnosed, UARS is better treated with a MAD mandibular advancement device or a CPAP device which opens the airway and up improves all of the symptoms these patients suffer from. (See UARS webpage)

Individuals with abnormal airway anatomy including those with the following:

• UARS patients are typically very thin with
• decreased space behind the tongue/ high riding tongue
• narrow nasal passages/ flimsy nostrils
• small neck circumference
• patients with an overbite / recessed lower mandible/ retrognathia
• Suffer from Bruxism and tension headaches or migraine
• Have adrenal burnout , chronic fatigue and IBS
• Snoring is not a requisite symptom with 10% to 15% or more of patients having never or only intermittently snored (See UARS webpage)

Insomnia has a dramatic toll on individuals and populations, but still conventional treatment options remain far from ideal. Shocking statistics from a 2012 a well-controlled study revealed an association between popular hypnotic sleep aids, such as the Z drugs, zolpidem (Stillnox), eszopiclone (Imovane) and temazepam (Normison), and a more than three-fold increased risk of death!

These alarming findings highlight the need for safe and effective strategies to improve sleep quality, especially since up to 10% of adults in the U.S. use hypnotic sleep aids for a proper night’s rest. It is important to note, however, that individuals who use hypnotic sleep aid drugs often have poor overall sleep quality, which could be the factor causing the sharply increased risk of death. Hypnotic sleep aids are by no means a cure for chronic insomnia, and purely a way to treat a symptom.

Patients with chronic insomnia need to be properly diagnose. They should undergo an overnight sleep study to find out what is happening to the airway during the different sleep stages . UARS is relatively new description of a sleep breathing disorder that’s related to Obstructive Sleep Apnea- OSA which has enormous ramifications on one's health. UARS was first described by researchers at Stanford University in 1993. The lack of education about UARS in the medical community has allowed these patients to go undiagnosed and untreated. At Skin/ Body Health Renewal we see this sleep breathing disorder over and over again and we are excited to share this vital information with you.

One of these sleep disorder breathing conditions called UARS is classified as a Sleep Breathing Disorder SBD that is associated with fragmentation of sleep due to the upper airway collapsing whilst breathing during sleep which results in decreased Restorative sleep. This lack of restorative sleep results in numerous Functional Somatic Syndromes FSS syndromes and anxiety disorders.There is a long list of FSS, but among the most prevalent are chronic fatigue syndrome, fibromyalgia syndrome, and irritable bowel syndrome IBS

Patients with UARS have usually consulted numerous doctors who are not able to diagnose the condition as they are unaware of this newly documented condition. These doctors usually prescribe anti depressants and sleeping tablets for the anxiety, depression and insomnia . Sleeping tablets make the condition worse as it collapses the already compromised airway even further. All the above prescription medications do not improve the UARS and this condition with all its deleterious effects festers on.

Instead, any patient with insomnia and any of the symptoms mentioned above should be sent for an overnight Sleep Study. Once diagnosed, UARS is better treated with a MAD mandibular advancement device or CPAP which opens the airway and up improves all of the symptoms these patients suffer from.

There are four sleep stages identified by the American Academy of Sleep Medicine:

Stage 1: features alpha waves and is the period of light sleep, wakefulness when a person is first falling asleep.

Stage 2: features theta waves and transitions between wakefulness and deeper sleep.

Stage 3: deepest and most restorative sleep is associated with muscle relaxation and is the period when glucose levels are stabilised and when testosterone and human growth hormone are stimulated and the physical bodily is restored.

Stage REM: body becomes immobile and relaxed as muscles are turned off. This is when a person dreams and is associated with cellular regeneration, cognitive restoration, memory allocation, and memory retention.

For adult humans, restorative sleep should account for 50% of the total night's sleep, evenly divided between Stage 3 and Stage REM sleep (20-25% each). In someone suffering from UARS, this causes cessation of these two stages as these patients usually wake up just before stage 3 or Stage REM because of the muscle relaxation during this period. Their tongue, which is too big for their mouths, falls back and obstructs the airways. This occurs numerous times throughout the night resulting in these UARS patients never entering restorative sleep.

These patients usually don't know they are deprived of restorative sleep; rather, they're tired, fatigued, moody, or just don't feel healthy, rested, or well. This can have a major impact on our overall quality of life. We all need at least 7 to 8 hours a night of uninterrupted sleep to leave our bodies and minds rejuvenated for the next day. If sleep is cut short, the body doesn’t’t have time to complete all of the phases needed for muscle repair, memory consolidation and release of hormones regulating growth and appetite. We then wake up less prepared to concentrate, make decisions, or engage fully in our work and social activities.

Sleep helps us thrive by contributing to a healthy immune system, and can also balance our appetites by helping to regulate levels of the hormones ghrelin and leptin, which play a role in our feelings of hunger and fullness. So when we’re sleep deprived, we may feel the need to eat more, which can lead to weight gain

The one-third of our lives that we spend sleeping, far from being “unproductive,” plays a direct role in how full, energetic and successful the other two-thirds of our lives can be. Insomnia increases disease risk and exacerbates existing medical conditions in individuals.

Insomnia due telephone disorder conditions such as Sleep Apnea and UARSv can lead to elevated levels of cortisol, epinephrine and other "stress" hormones. These elevated levels of cortisol can cause symptoms such as weight gain, weakened immune system, and an increased risk of developing diabetes and osteoporosis.

Insomnia triggers the release of chemicals (such as interleukin-6 [IL-6] and tumour necrosis factor-alpha [TNF–α]) that promote inflammation in the body. This is associated with arthritis, inflammatory bowel disease, heart disease, and other medical conditions.

Insomnia can exacerbate chronic pain conditions by causing heightened sensitivity to pain and interfering with the body's ability to modulate central pain signals. As a result, poor sleep can increase the amount of pain perceived by people with chronic pain disorders (such as osteoarthritis and fibromyalgia). Therefore, treating insomnia may help reduce pain these individuals suffer on a daily bases.

A study reported that among healthy individuals, average sleep duration of six hours or less per night was associated with a four-fold increased risk of stroke compared to sleep duration of 7 – 8 hours. Therefor always aim for a good night’s rest by elm at first sleep disordered breathing such as Sleep Apnea and UARS.

In general, the options are:

• Nasal breathing optimization by treating allergies properly with medications or avoidance measures or even allergy shots.
• Dental appliances such as the MAD, a dental device that pulls the lower jaw forward and pulls the tongue forward resulting in a vast improvement in the caliber of the airway.
• CPAP to continually blow air into the airways, stenting the airway to keep it from closing
• A last resort would be surgery which will treat a deviated septum, enlarged tonsils etc
• Avoiding regular use of muscle relaxants/ sleeping pills/ sedatives and other substances that may suppress respiration.
• minimize sleep altering substances such as caffeine, nicotine and alcohol. (See UARS webpage)

1. Improving sleep hygiene

One of the most widely used behavioural therapies is improving "sleep hygiene." There is a correlation between good sleep hygiene and reduced daytime sleepiness. Sleep hygiene includes a number of specific behaviours and environmental factors that contribute to good quality of sleep.

Consider implementing the following sleep hygiene measures for improved sleep quality

• Minimize the amount of light, noise and changes in temperature in the bedroom.
• Avoid eating large meals before bed, as indigestion can make falling asleep difficult.
• Limit the amount of stimulants (such as consuming caffeine, nicotine, and alcohol) consumed during the day, especially close to bedtime. Try to completely avoid these for minimum 4-6hours before bedtime.
• Avoid vigorous exercise during the two hours prior to sleep.
• Avoid bedtime activities that are not related to sleep (such as watching Television, reading, or listening to the radio).
• If worrying about falling asleep and the time, cover the alarm clock to avoid anxiety.

2. Sleep restriction to reset circadian rhythms

Sleep restriction therapy forces the individual to limit the amount of time spent in bed (including naps) to increase the biological need for sleep at night. A study comparing sleep hygiene therapy plus sleep restriction, to sleep hygiene therapy alone found that sleep restriction improved "sleep efficiency", a measure of the proportion of time spent in bed that resulted in sleep.

This process usually begins by restricting the time spent in bed to the amount of time estimated one should spend sleeping. For example, a person who stays in bed for nine hours but only sleeps six will initially restrict time in bed to six hours. These sleep restriction rules can cause mild sleep deprivation in the beginning, however, the sleepiness it creates trains the body to fall asleep more quickly. As the body adjusts, people can extend the amount of time spent in bed by 15 to 20 minutes until they are able to get a full night sleep without spending extra time in bed.

3. Cognitive-behavioural therapy

Cognitive-behavioral therapy (CBT) is used for treatment of chronic insomnia and helps people develop behaviours that are more conducive to sleep. It has been shown to be an effective treatment for both “primary insomnia” (insomnia not due to other diseases) and insomnia caused by other medical problems. Notably, CBT for treatment of chronic primary insomnia may be more effective than the medication zopiclone in older adults.

If the above symptoms apply to you, you need to get an overnight sleep study done at one of the designated branches at Skin/ Body Renewal. Based on an extensive series of questionnaires, the Health Renewal Doctor will determine whether or not you need an overnight home sleep study to measure the AHI (Apnea Hypopneas Index) AND the RERAS (Respiratory Effort Related Arousals). This will give the RDI (Respiratory Distress Index). Measuring the RERAS and RDI is the gold standard for diagnosing UARS and chronic insomnia.

Overnight home Sleep Studies are available at certain Health Renewal branches. If your report is positive for UARS we will refer you back to your referring Health Renewal doctor for a complete evaluation. Certain blood tests will be done to assess your levels of inflammation and cortisol levels. When the doctors look in the mouth, the back of the throat is very narrow and there is a tongue that sits very high up, covering up the uvula, the little thing that hangs down in the middle of your throat. Usually the side of the tongue is serrated and a line can be felt on the cheek mucosa, all indicating that the tongue is too big for the mouth.

When the UARS patient lies down during sleep , the tongue falls back even more, leaving a 1-2mm slit. When you are awake, you can breathe through this slit. But as you fall asleep, the muscles relax as you get deeper into sleep or REM sleep (when you’re dreaming) and that’s when you start to obstruct. Then, once you obstruct, you stop breathing and you get aroused, going to light sleep and the cycle happens over and over again, bypassing restorative sleep with all its consequences.

Book a consultation with our Health Renewal doctors for Insomnia.