Panelists from Division of Psychological Medicine answering questions at the Insomnia public forum. (L-R: Dr Tay Woo Kheng, Dr Yap Hwa Ling, Dr Andrew Peh Lai Huat, Mr Christopher Choo).

The Division of Psychological Medicine organised a public forum on the topic of “Insomnia: When Sleep Becomes A Burden” on Saturday, 9 October 2004. This public forum was organised in conjunction with Mental Health Week.

Understanding Insomnia
Dr Andrew Peh Lai Huat
Senior Consultant Psychiatrist

According to Dr Andrew Peh Lai Huat, Senior Consultant Psychiatrist, insomnia occurs when a person complains of prolonged periods of sleepless nights, start worrying about being awake at night, worry about the quality of sleep and thus the concern over impaired performance at work after a poor night’s sleep.

The rate of insomnia increases with age. About 5% of people suffering from insomnia are over 30 and 35% are over the age of 65. In addition, more women are likely to report that they have insomnia than men and shift workers are especially affected.

There are three types of insomnia, transient insomnia, short-term insomnia and chronic insomnia.

Transient insomnia occurs temporarily in a person who normally sleeps well and for which there are clear reasons for the sleeplessness. The likely causes for the temporary insomnia are changes in sleep conditions, work shift, physical

Psychological Treatment of Insomnia
Mr Christopher Choo
Senior Clinical Psychologist

According to Senior Clinical Psychologist Mr Christopher Choo, psychological treatment of insomnia requires an understanding of normal sleep, stress response, how the brain works and some research findings into insomnia.

He added that the learning and practice of Sleep Hygiene and relaxation techniques would also be required in the treatment process.

Sleep is not a passive state, i.e. the brain cells continue to be active. In fact, the sleep cycle consists of five distinct stages, like a roller-coaster ride with many valleys and peaks with awakenings. Awakenings are normal. However, insomniacs tend to over-react to them, thus lengthening each awakening period.

On average, babies require about 16 hours of sleep, teenagers need 9 hours, adults need 8 hours and the elderly need only about 7 hours. However, this is subjective and there can be enormous variations between people. As a general guideline, a good sleep would be if you feel refreshed when you wake up.

Generally nearly all deep sleep is obtained during the first four hours, so you may still feel refreshed after about four to five hours of sleep.

Why can’t people sleep when they are stressed?
This is called the Stress response. When one is stressed, hot triggers are activated. These can be in form of ‘hot thoughts’ e.g. worries or in the form of stimulants, e.g. coffee or nicotine. This results in the release of stress hormones and the activation of the nervous system. This leads to the brain becoming more alert, an increased heart rate, breathing and muscle tension.

To counter the stress response, a relaxation response is needed. Relaxing triggers need to be activated. These can the form of ‘cool thoughts’, relaxation techniques or a warm bath or a glass of milk. This results in a breakdown of stress hormones, leading to the ‘deactivation’ of the nervous system. This eventually leads to the brain calming down and decreased heart rate and muscle tension.

Medication for Treating Insomnia
Dr Yap Hwa Ling
Senior Consultant Psychiatrist

The types of medication used in treating insomnia include hypnotics (sleeping pills), antidepressants, antihistamines and other forms of medication such as melatonin or even herbal therapy.

Sleeping pills e.g. Bezodiazepines, Valium are prescribed for treating insomnia. However, there are dangers when taking sleeping pills. Sleeping pills can cause daytime sleepiness, accidents (e.g. falling asleep while operating machinery or while driving). Sleeping pills can also become addictive and some may become dependent of them. Mixing alcohol and sleeping pills can also be fatal.

Another form of medication is antidepressants. Antidepressants are prescribed for the treatment of depression and anxiety. However, antidepressants have side effects such as sedation.

Stronger, more sedating antidepressants are used if the insomnia is associated with psychiatric disorders or there is a history of substance abuse.

Antihistamines are drugs that are commonly used to treat allergies. However, a side effect of antihistamines is also sedation.

Melatonin is a hormone produced by the pineal gland, a pea-size structure at the center of the brain. Production of melatonin is stimulated by the reduction in light levels, i.e. it is more active at night. While melatonin is used for jet-lag, the safety of use in the long-term is still unknown.

Herbal preparations using kava kava, valerian and passion flower are also sometimes used to induce sleep. However, caution is recommended when using these compounds, as side effects have been reported, e.g. liver damage from kava kava and dizziness from valerian.