Sleep Disorders

Insomnia is persistent difficulty falling asleep, staying asleep or waking too early despite having the opportunity and the setting to sleep, with a consequence the following day. Once it has run most nights for three months it is a condition in its own right and rarely resolves without something being changed.

What keeps it going is usually different from what started it. A stressful month, a new baby, an illness or a stretch of night shifts begins it; then effort and worry about sleep take over. Going to bed earlier to catch up, lying awake watching the clock, and spending nine hours in bed for five hours of sleep all weaken the link between bed and sleeping, and the bedroom itself starts triggering alertness.

Several things feed it and are worth knowing about: caffeine late in the day, alcohol, which shortens the time to fall asleep and then fragments the second half of the night, screens and work in bed, shift work, pain, an enlarged prostate, the menopause, breathing disturbance during sleep, restless legs, and anxiety or depression. Sleep also changes normally with age, and lighter, more broken sleep in later life is not by itself a disorder.

Diagnosis is made from a careful sleep history, and your doctor will usually ask you to keep a simple diary for two weeks first: times into and out of bed, estimated sleep, naps, caffeine, alcohol and how the following day went. What people remember about their sleep and what a diary shows are frequently different, and the diary is what the plan is built on.

Your doctor is looking for the pattern. Difficulty falling asleep, repeated waking, and early morning waking point in different directions, and early waking with low mood points towards depression.

An account from whoever sleeps beside you carries a lot of weight, particularly about loud snoring, pauses in breathing, gasping, or kicking, since those suggest a physical sleep disorder that needs a study in a sleep laboratory instead of behavioural treatment. Your doctor will go through all medicines, alcohol, nicotine, caffeine and any substance use, check thyroid function and haemoglobin where indicated, and ask about mood, pain and night-time urination.

Behavioural treatment is the first-line approach for long-standing insomnia and runs over four to eight weekly sessions. It works by restricting time in bed to the hours you actually sleep and then extending it as sleep consolidates. The first one to two weeks are genuinely harder, with more daytime sleepiness before the improvement arrives, and that is expected instead of being a sign that it is failing. Driving needs care during those weeks.

Most people see real change by week four and hold it afterwards, because the changes are habits and stay with you.

Sleeping tablets work quickly and are prescribed for short courses, usually two to four weeks, while the behavioural changes take effect. Tolerance and dependence build with longer use and stopping after months of nightly use brings a spell of worse sleep, so any long-standing prescription is reduced gradually with your doctor. Where an underlying cause such as a breathing disorder, pain or depression is found, treating it is what fixes the sleep.