Another sleepless night

Most adults have at one time or more in their lives experienced insomnia. Dr Bhojo A. Khealani, a Sleep Specialist and Assistant Professor of Neurology at the Aga Khan University Hospital, defines insomnia as, “either the inability to fall asleep, or to maintain sleep, or experience unrefreshing sleep. It is not only the quantity of sleep, but also the quality of sleep that is important.” Insomnia may be transient with symptoms lasting less than a week, short-term with symptoms lasting for three weeks, or chronic, with symptoms that cross the three week mark. This, in turn, affects the one’s quality of life. The day is much less productive when you feel fatigued and groggy and cannot perform at an optimal level.

Dr Bhojo confirms what research indicates, that it is the urban population, especially women and the elderly that are most prone to insomnia. Amongst women, those who are pregnant or menopausal are in the high-risk groups. The elderly also commonly suffer from insomnia. Dr Arifa Jamal, Geriatric specialist, explains the reason. “By nature, the sleep requirement decreases as we become old, and the nap time increases. Therefore you have elderly patients who sleep late and wake up at 4 am, but you see them dozing off in their chairs in the morning or afternoon. The sleep of the elderly may often be interrupted by medical conditions like incontinence. They cannot go back to sleep once their sleep has been disturbed.”

The latest figures show that insomnia amongst adolescents is on the rise. Renowned psychiatrist Dr Uzma Ambareen explores some of the potential reasons, “Causes can be various pressures, academic stress or relationship woes. Drugs, partying and not having a proper routine and discipline also contribute.” This is why it sometimes becomes difficult to decipher classic insomnia from what is simply a dysfunctional sleep routine. If we go to sleep at 5 am and wake up at 1 pm, we are still getting eight hours of  sleep, but the body clock will definitely chime in and if we try to go back to sleep at midnight, it might be an impossible task. The concept of sleeping late and staying in bed in mornings during weekends leads to a conditioned response and disturbance in the sleep-wake cycle.

Sleep problems that begin during adolescence can become cyclical and continue throughout life if not nipped in the bud. Rushna Shamsi, 30, is a school teacher and a mother of two who confesses to being a chronic insomniac. For Shamsi, intermittent teenage insomnia later became a full-blown case. Today, nothing helps her but medication. She survives on four to five hours of sleep a night, and she is robbed of that too if she takes a nap during the day. And what does she do when she can’t fall asleep? “I keep wondering, logging on to Facebook, flipping through TV channels, and if I feel very depressed then I resort to praying,” she says, convinced that her depression is a side effect of constant sleep deprivation.

Another possibility is that the insomnia is merely a symptom of depression. Stressful situations like exams, financial or career anxiety, divorce, separation or loss of a loved one can trigger insomnia. Dr Bhojo feels that many a times insomnia is transient, “But when it lasts for longer than three months, one must consult the physician.”

Insomnia could be caused by something as trivial as jetlag, a partner or spouse who snores, or a night-shift at work. Withdrawal from drugs, alcohol and sedatives can give one sleepless nights. Stimulant medications can also cause it. Anti-asthma medicines, and medicines given to control high blood pressure may also result in insomnia. Most of the causes of long-term insomnia are connected to an underlying psychiatric or medical condition.

To confirm that your insomnia problem is a serious one that needs medical intervention, you may need to go to a sleep-lab. Pakistan has very few such labs; one is at the Aga Khan University Hospital. A patient may need to be under observation overnight, especially if the doctor suspects a sleep disorder like ‘Obstructive sleep apnea’ which manifests with snoring, poor quality sleep, daytime sleepiness and breath pauses while asleep. In the long-term, apnea can increase risk of strokes, hypertension, heart attack and diabetes mellitus. This is an easily treatable disease.

Sleeplessness can seriously affect the quality of one’s life with consequences including depression, trouble concentrating and daytime sleepiness, affecting every aspect of life from an inability to complete a workday to negatively affecting physical intimacy. There are also the physical conditions, indigestion, headaches, increased blood-pressure, lowered immunity and a decreased energy level.

Fortunately, insomnia is not an irreversible condition. Its treatment, after diagnosis and understanding the cause, might be hidden in sustained lifestyle changes. Sleep hygiene issues need to be looked into. These would include avoiding mental stimulants and exercises at least three to four hours before bedtime. “Go to bed only when feeling sleepy. Use your bedroom for sleep alone. Avoid putting a television in it. If you can’t sleep after half an hour of lying in bed, stop trying to sleep, get out of bed and do something not-too-stimulating till you feel sleepy.  Do something to relax and unwind every night before you go to bed. Try to go to sleep at the same time every night and wake up at the same time every day,” advises Dr Ambareen.

Our food choices also affect our sleep cycle. Ahlaam Ali, nutritionist and founder of PowwerLiving, advises readers to avoid the following kinds of food close to sleep-time: “Foods high in sugar and refined carbohydrates raise blood-sugar levels and can cause a burst of energy that disturbs sleep. Also steer clear of foods that are likely to cause gas, heartburn, or indigestion, such as fatty or spicy foods, garlic-flavoured foods, beans, cucumbers, and peanuts. Foods such as meat that are high in protein can inhibit sleep by blocking the synthesis of serotonin, making us feel more alert,” says Ali. She also advises cutting down on Monosodium Glutamate, nicotine, tobacco and caffeine in all forms near bedtime, if we want a good night’s sleep. Sleep boosters, in Ali’s opinion, include a glass of warm milk with honey. Milk contains tryptophan which, when converted to serotonin in the body, induces sleep. “Lettuce should be an integral part of your evening diet if you are suffering from sleep disorders. The meal should also include legumes, nutritional yeast, fish or poultry. These foods contain vitamin B3 (niacin) which is involved in seratonin synthesis and promotes healthy sleep. Mixed with a little lemon juice for flavour, lettuce juice is an effective sleep-inducing drink highly preferable to the synthetic chemical agents in sleeping pills,” advises Ali.

A majority of patients, considering the frustrating nature of the disorder, head straight for over the counter medicines with no prescription. Not only do they have you hooked, but some of them can have dangerous side-effects. Unfortunately, most GPs will also take the easy way out and prescribe these pills without a proper evaluation or follow-up, and people might continue to take these meds for years. Sherazade Khan recalls how she took a sleeping pill when she suffered from a temporary bout of insomnia. “I begged my parents and forced them to get me a common sleeping pill. I had a really weird reaction and started hallucinating. After that I just took an anti-histamine for a few nights to knock me out,” says Khan. Medication for sleep should be taken as a last resort, and only under a doctor’s supervision.

Published in The Express Tribune, July 4^th, 2010.