Insomnia: When Counting Sheep Doesn't Work

How often have you found yourself tossing and turning in bed, incapable of getting a wink of sleep? Time keeps ticking away but you remain wide-awake. With each passing minute, the realization that you will soon have to get up for school or work grows. 

This is what insomnia looks like. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), insomnia is a sleep disorder characterized by "difficulty initiating sleep, difficulty maintaining sleep, and early-morning awakening with inability to return to sleep1." In other words, people with insomnia do not get enough sleep or have poor-quality sleep. The consensus is that children need 9 to 13 hours of sleep per night, whilst adults need 7 to 9 hours for optimal health. 

In addition to the aforementioned symptoms, the disorder causes fatigue, irritability, problems with concentration or memory, sleepiness during the day, and impaired work performance. Insomnia manifests itself in diverse ways and can be categorized into two groups: acute (short-term) and chronic (long-term). Acute insomnia typically stems from poor sleep hygiene, life stressors and environmental factors that disrupt sleep, such as noise and an uncomfortable bed or pillow, and lasts for a few days or weeks, whereas chronic insomnia occurs due to medical conditions and medications. To be diagnosed with chronic insomnia, symptoms must be present for at least 3 nights a week for 3 months or more. As one of the most common health issues of modernity, insomnia greatly influences the lives of millions of people worldwide, ranging from 10% to 30% of the world population, and about 50% of which suffer from chronic insomnia. Its prevalence is higher in females, older adults, and individuals with medical conditions. 

Before truly grasping the dangers of insomnia, we must first understand the importance of sleep. Sleep is a physiological process that allows the mind and body to rejuvenate. Although it appears to be a passive state, sleep involves a remarkably active interplay of brain circuits and plays a significant role in cognitive performance, productivity, and overall health and well-being. During sleep, nerve cells (neurons) reorganize to process information obtained during the day. Neurons also have toxic waste byproducts removed via the brain's waste clearance system, called the glymphatic system. This helps maintain healthy brain functioning. Thus, when sleep is deprived, the brain's glymphatic system is unable to perform its function efficiently, resulting in an accumulation of toxins in the cerebrospinal fluid, a liquid that surrounds the brain and spinal cord. These toxins then act on various areas of the brain, affecting memory, attention, behavior, decision-making, and physical coordination. When lost sleep adds up over time, the effects become progressively worse and may even cause severe brain injury. It can also increase the risk of certain brain diseases. 

For instance, Alzheimer's disease and dementia are believed to be caused by the beta-amyloid protein, which is one of the metabolic waste products found in the brain. As the protein builds up, it clumps together to form plaques between neurons, and consequently blocks cell-to-cell communication at synapses. This is why insomnia is closely linked to neurodegenerative diseases---the toxic waste that ought to be cleared up ends up lingering in the brain, thereby reducing cognitive function. 

Apart from Alzheimer's, insomnia is associated with several psychiatric illnesses. It often exists secondary to depression, anxiety, bipolar disorder, and attention deficit hyperactivity disorder (ADHD). Depression is the most common comorbidity, and insomnia serves as a diagnostic symptom for depressive disorders. Insomnia exacerbates depression by reducing the levels of serotonin, a happiness-boosting hormone, through changes in the sensitivity of its neurotransmitters in the brain. Mental disorders and insomnia tend to go hand-in-hand; living with a mental disorder aggravates the quality of your sleep, and poor sleep negatively impacts your mental health. It is a vicious cycle that is challenging to break, with many people failing to make improvements to their mental state despite undergoing standard treatments. 

The first-line of treatment for acute insomnia is a type of behavioral intervention that involves cultivating good sleep hygiene. In short, sleep hygiene is a practice carried out to develop and maintain healthy sleeping habits aimed to boost sleep quality and overall health. It encompasses both habits and the environment. There are some routines that we can adopt to get the best sleep possible. 

1. Unplug from electronics: Electronic devices emit blue light that restrains the production of melatonin, the hormone that controls your sleep-wake cycle, making it difficult to fall asleep.
2. Have a fixed sleep schedule: Waking up and going to sleep at the same time every day makes your brain familiar with the times it should release hormones that make you sleepy and awake. This maintains the timing of your biological clock.
3.  Make yourself comfortable: Cool sheets, a comfortable mattress, and cozy pillows are critical to pain-free sleep and can deter you from tossing and turning all night.

4. Limit food intake before bedtime: Eating close to bedtime can cause indigestion and acid reflux. Both problems impede a good night's rest and leave you exhausted in the morning.