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Problems with sleep are a common and widespread occurrence among individuals all over the world. Most adults have experienced at least one night of unsatisfactory sleep. While some people experience poor sleep occasionally and are not bothered, some find it very troubling and seek help. Every health care professional has had to deal with a patient with sleep complaints at one time or the other.

Before we take a closer look at the issue, we need to understand what sleep is and what constitutes poor sleep.


Why do we sleep?
Sleep is a universal behaviour which occurs in all animals. Nevertheless, the exact functions of sleep are not known for certain (Sadock & Sadock, 2007). Sleep is important for physical, emotional and mental well-being (Afkham-Ebrahimi, Rasoulian, Taherifar, & Zare, 2010) as well as for brain regeneration (Giglio et al., 2009). It plays a role in keeping the brain “sharp” as well as overall functioning (Afkham-Ebrahimi et al., 2010; Giglio et al., 2009). It is also agreed that sleep helps restore the brain and conserve energy.


Sleep is a waste of time!
It is estimated that individuals spend up to a third of time alive sleeping. While some may argue that this is time that could be better used on other activities, experience tells us otherwise.
When a person does not sleep satisfactorily, there are problems with attention and concentration. The person also has problems with memory and carrying out skilled actions well. 
When an individual does not sleep for prolonged periods, he/she develops serious physical and mental problems and eventually dies (Sadock & Sadock, 2007).  The world record for staying awake is held by Randy Gardner, who stayed awake continuously for 11 days 24 minutes!


I can sleep more than you!
We differ with regards to the amount of sleep needed to function normally during the day. The average time for sleep needed by individuals varies between 6 and 9 hours. This is not to say that people can do with less or more than this. “Short sleepers” require fewer than 6 hours of sleep each night while “long sleepers” require more than 9 hours to function adequately. People also require more sleep when they engage in physical activity and exercise, when they are ill or pregnant and when there is mental stress and increased mental activity (e.g. during examinations) (Sadock & Sadock, 2007).


So what is Insomnia?
Insomnia is both a technical and lay term used for expressing poor sleep. It is best understood as “a subjective dissatisfaction with the quality and quantity of sleep”. This means that it is the individual who complains of sleeping poorly, even when others report he/she sleeps soundly. Also, the person may complain that sleep is too short, that he/she feels unrefreshed in the morning or he/she feels unhappy with some other aspect of the night’s sleep.
Insomnia may also be differentiated into difficulty falling asleep, difficulty remaining asleep or early morning awakening (waking up earlier than one desires). For it to qualify technically as insomnia, the problem should have been present for at least one month” (APA, 2000).

How common is Insomnia?
It is known that problems with sleep are common among people generally. They are more common among patients who have medical problems. For example, a problem with sleep is often the first and only complaint reported by individuals who have hypertension. Insomnia affects up to one-third of the general population (Ramsawh, Stein, Belik, Jacobi, & Sareen, 2009) but a diagnosis is not often made. About 15% suffer from prolonged episodes. Insomnia tends to be a problem the older an individual gets. It is also commoner among females, those who are married, and those of lower socioeconomic standing. It also more frequent among those who have or have had a mental illness, those who abuse psychoactive substances (alcohol, Indian hemp etc) and those going through stressful experiences (Atalay, 2011).
 
What causes insomnia?
Many things can lead to insomnia. Insomnia of short duration is often due to anxiety (Sadock & Sadock, 2007) and is a normal part of everyday life (WHO, 1992). For example, young adults may find it difficult to sleep the night before an examination or a job interview. Insomnia of long duration often manifests as difficulty falling asleep and is due to a wider range of causes. Poor sleep is common when an individual is ill and sleep problems are very common in general clinics (Makanjuola, 2007). Insomnia is also frequent when an individual suffers from illnesses that cause pain for long periods. In particular, sleep problems are common among patients with psychological disorders, especially anxiety and depression. Insomnia is also a common symptom of most other sleep disorders

Other Sleep disorders?
Insomnia is the commonest problem experienced with sleep all over the world but is by no means the only sleep problem. There is a long list of disorders in which satisfactory sleep is also disrupted.


In Primary hypersomnia the individual sleeps for a long period during the night but still feels sleepy during the day.  


Sleepwalking is usually a problem experienced by some children but may also occur in a few adults. The person wakes up during sleep with a blank staring face, does not communicate and walks around performing familiar activities. The person may get injured in the process and does not remember anything when he/she wakes up the next morning.


In sleep terrors and nightmares, the individual repeated experiences frightening dreams. During sleep terrors, the individual awakens suddenly from sleep with a scream and my rush to the door as if trying to escape. The person does not remember the dream when he/she wakes up. During nightmares the individual is able to remember the dream and does not wake up.


Breathing related sleep disorder, commonly known as snoring occurs when the normal flow of air during breathing is obstructed during sleep. This causes noisy breathing and disturbance of sleep. In addition there is sleepiness during the day, tiredness, a bad temper and difficulty remembering things (Sharafkhaneh, Giray, Richardson, Young, & Hirshkowitz, 2005). It is commoner in people who are obese or have hypertension. It may also cause other heart problems.


Circadian rhythm sleep disorders occur when an individual cannot sleep when they desire to do so and may fall asleep when they wish to remain awake. It consists of different types including: Delayed Sleep Phase Syndrome (DSPS) which is common in teenagers who typically prefer staying up awake till late; Advanced Sleep Phase Syndrome occurs in individuals who find it difficult to remain awake in the evening and wake up early in the morning; Jet Lag occurs in people who spend long periods on long flights; In Irregular Sleep Wake Schedule waking up and sleeping is irregular and disorganised; Shift Work Disorder occurs in people who perform shift work (nurses etc.) and are required to stay awake at night when they should be asleep. Many are however able to adjust in the long term.


In Narcolepsy the individual has sudden irresistible urges to sleep and is unable to move during these episodes. It is problematic when it occurs at inappropriate times e.g. while talking eating, driving, or during sexual activity). Narcolepsy is often not recognised and is considered laziness on the part of the individual.


Sleep paralysis involves difficulty moving or talking for a short period while going to sleep or waking up. It occurs in as much as half of the population and is often interpreted as a “spiritual attack” especially in the third world.


Periodic limb movement disorder involves brief “kicking” motions of the legs during sleep. It is a common occurrence and is associated with disruption of sleep.

How common are they?
Sleep disorders are common in the general population (Afkham-Ebrahimi et al., 2010; Giglio et al., 2009) but the exact number of people affected is not known (Aloba, Adewuya, Ola, & Mapayi, 2007; Makanjuola, 2007). This is because many people experiencing them never see a doctor or health worker.

Why are they important?
Insomnia is a concern to the general public (Xiang et al., 2009) because they affect physical, social and occupational functioning as well as an individual’s quality of life (Atalay, 2011).
Importantly, some sleep disorders may be mistaken for a psychiatric disorder in patients of all age groups. They may also occur in individuals who already have a psychiatric disorder making it difficult for the clinician to delineate the disorders. This often makes the management of the sleep problem more difficult.
Insomnia and sleep disorders cause personal suffering and reduce an individual’s productivity. They cause those affected to be drowsy during the day and can lead to premature death through accidents at home, the workplace and on the road.

What do I do?
The first step in dealing with sleep problems is to determine the exact nature of the problem. Questions about the persons sleep patterns and changes in these patterns need to be asked. If problems are evident, further question are sufficient to determine if the person has a sleep disorder. Tests are often not necessary but may be needed in difficult cases. 

Most of the time, night-time sleep can be improved by using some general methods known as sleep hygiene. They are found to be helpful irrespective of the cause of the sleep problem. Such measures include;

    Sleep and wake up at about the same time each day
    Avoid drugs that keep one alert at night e.g. coffee
    Avoid naps during the day
    Avoid excitement in the evening e.g. watching movies till late
    Avoid alcohol
    Exercise, especially early in the morning
    Maintain a comfortable sleeping position
    Try a warm bath before going to bed
    Eat at regular times every day and avoid heavy meals before going to bed
    Practice relaxation or meditation in the evening

These measures should be tried before other actions are taken. 

I have sleep problems but I “managed it” on my own
A hidden danger lays in the use of drugs not prescribed by a doctor to deal with sleep problems. Although an initial improvement is observed, because the cause of the problem is not addressed, the individual has to continue taking the drugs in order to sleep. After a while they become less effective when the person has become used to the drugs (“tolerance”). The person then increases the amount of drugs taken and addiction set in Sleep problems should not be taken for granted and assistance should be sought if it persists.
    

References
Afkham-Ebrahimi, A., Rasoulian, M., Taherifar, Z., & Zare, M. (2010). The impact of anxiety on sleep quality. Medical Journal of the Islamic Republic of Iran, 23(4), 184-188.
Aloba, O. O., Adewuya, A. O., Ola, B. A., & Mapayi, B. M. (2007). Validity of the Pittsburgh Sleep Quality Index (PSQI) among Nigerian university students. Sleep Med, 8(3), 266-270. doi: 10.1016/j.sleep.2006.08.003
APA. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th edn., text rev.) (4th ed.). Washington DC, USA: American Psychiatric Association.
Atalay, H. (2011). Comorbidity of insomnia detected by the Pittsburgh sleep quality index with anxiety, depression and personality disorders. Isr J Psychiatry Relat Sci, 48(1), 54-59.
Giglio, L. M., Andreazza, A. C., Andersen, M., Cereser, K. M., Walz, J. C., Sterz, L., & Kapczinski, F. (2009). Sleep in bipolar patients. Sleep Breath, 13(2), 169-173. doi: 10.1007/s11325-008-0215-5
Makanjuola, V. A. (2007). Prevalence of sleep disorders in a primary care setting-the general outpatient clinic of the University College Hospital Ibadan. FWACP(Psych.) Dissertation, University College Hospital, Ibadan.  
Ramsawh, H. J., Stein, M. B., Belik, S. L., Jacobi, F., & Sareen, J. (2009). Relationship of anxiety disorders, sleep quality, and functional impairment in a community sample. [Research Support, Non-U.S. Gov't]. J Psychiatr Res, 43(10), 926-933. doi: 10.1016/j.jpsychires.2009.01.009
Sadock, B. J., & Sadock, V. A. (Eds.). (2007). Kaplan and Sadock's synopsis of psychiatry (10 ed. Vol. 10). Philadelphia, USA: Lippincot Williams & Wilkins.
Sharafkhaneh, A., Giray, N., Richardson, P., Young, T., & Hirshkowitz, M. (2005). Association of psychiatric disorders and sleep apnea in a large cohort. Sleep, 28(11), 1405-1411.
WHO. (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation.
Xiang, Y. T., Weng, Y. Z., Leung, C. M., Tang, W. K., Lai, K. Y., & Ungvari, G. S. (2009). Prevalence and correlates of insomnia and its impact on quality of life in Chinese schizophrenia patients. [Comparative Study]. Sleep, 32(1), 105-109.