Sleep disorders are among the most widespread health problems, with a prevalence of 6 to 10% of the population. While isolated sleepless nights occur in almost all people, the causes should be clarified in the case of longer-lasting sleep problems.
The amount of sleep required varies from person to person and generally decreases with age. While a schoolchild needs about nine hours of sleep, adults only need an average of seven hours and older people only six hours. However, these are average values that can vary greatly from person to person.
In technical language, insomnia is called "insomnia" and sleep deprivation is called "hyposomnia". Other sleep disorders, such as nightmares, sleepwalking or nocturnal breathing disorders(sleep apnea) do not fall under this term. There are additional diseases that are associated with pathologically increased sleep (e.g. narcolepsy), which are also referred to as sleep disorders.
Primary sleep disorders do not have specific causes, but are triggered by psychological stress factors, such as stress or worries, for example, at work or due to family problems. Furthermore, sleep quality and duration can be hindered by unfavorable sleep conditions (e.g., a noisy, bright or uncomfortable sleeping environment). Often a simple trigger leads to a further intensification of the sleep disorder, in which further brooding, thinking about the negative consequences of insomnia and tension further prevents falling asleep.
Secondary sleep disorders are triggered by physical or psychiatric causes. The ingestion of certain substances can also have an influence: In addition to caffeine, alcohol and drugs, medications can also disrupt sleep quality.
Possible physical causes of a secondary sleep disorder are:
The focus is on insufficient duration or quality of nighttime sleep. These difficulties can take different forms. While some people take a long time to fall asleep (sleep onset disorder), others may wake up too early and be unable to continue sleeping (sleep maintenance disorder). The consequences are daytime fatigue, concentration problems and reduced performance or resilience the following day. The performance restriction on the following day and the general level of suffering are the main parameters for assessing the severity of a sleep disorder.
The basis for the diagnosis is a survey of the symptoms. From a duration of one month and a frequency of at least three nights per week, the symptoms are considered to be an expression of a sleep disorder. It can be helpful to keep a sleep diary before visiting the doctor. The following information should be noted in it:
In the doctor's office, the severity of the sleep disorder and possible causes can then be assessed with the help of a conversation (anamnesis). In addition, a physical examination can be performed. This is usually sufficient for the diagnosis of a sleep disorder.
In individual cases or if an underlying cause of the sleep disorder is suspected, additional examinations may be helpful.
Blood sampling and laboratory diagnostics can detect physical causes of a sleep disorder, such as hyperthyroidism.
A simple method of determining physical activity during the day and sleep quality at night are actigraphs or actometers. These technical devices can use sensors to record body movements over a longer period of time. An example of this is modern smartwatches or sports watches that usually include integrated programs for measuring sleep quality.
In some cases, monitoring (polysomnography) in a sleep laboratory can provide further important information about sleep behavior. The following examinations are used:
Efficient sleep hygiene is the first step in the treatment of a sleep disorder and in many cases can achieve an improvement in the symptoms. The sleeping environment should be quiet, dark and comfortable. In addition, time in bed should be limited to bedtime, and such activities as watching television, reading, or other activities in bed should be avoided. In the morning, the bed should be left soon after awakening and staying in bed for a long time should be avoided. In the evening, you should only go to bed when you are already tired. Physical activity and exercise during the day can improve sleep, but physically strenuous or mentally demanding activities should be avoided in the evening. Making the evening more relaxing, such as reading, taking a warm bath, or drinking a hot herbal tea, can promote sleep and provide relaxation. Consumption of alcohol, caffeine, and foods that are difficult to digest should be avoided in general, but especially in the evening. Counterproductive is napping during the day.
If improved sleep hygiene is not sufficient, further therapy options may follow.
Cognitive behavioral therapy can be another valuable tool. Therapy is offered in individual, group, or online sessions. It involves learning how to break negative thinking patterns with the help of a psychotherapist, in addition to relaxation techniques. The relaxation methods used include visualization, progressive muscle relaxation and breathing exercises.
Some treatments are not scientifically proven, but are used by many patients in addition to the above-mentioned therapeutic approaches. These include acupuncture, aromatherapy, homeopathy, light therapy, music therapy, and yoga.
Sleep-promoting agents can also be used in the short term. The prerequisite for this is a complete diagnosis, including exclusion of treatable underlying diseases and an unsuccessful attempt at therapy with non-drug treatment options such as sleep hygiene and psychotherapy. A number of substance groups are available for therapy.
Attention should be paid to the following problems when using over-the-counter and prescription sleep aids, and a specialist should be consulted if in doubt:
Herbal extracts of passionflower, lemon balm, hops or valerian are used by some patients to promote sleep and in many cases are already sufficient for a sufficient therapy. The evidence base for efficacy is weak, so no general recommendation can be made.
Melatonin-based sleeping pills are available over the counter and act on the brain like the body's own sleep hormone melatonin, producing a mild sleep-inducing effect. This is especially helpful for short-term sleep disturbances caused by jet lag or shift work. Melatonin is jointly responsible for the natural sleep-wake cycle and is released in the brain at night. The external supply of the hormone is harmless, but its long-term effectiveness has not been proven. Since it is often sold as a dietary supplement rather than as a drug, it is not subject to the strict legally established quality standards for drugs. Nevertheless, it is a substance with possible adverse effects, so medical consultation is recommended before and during use.
Sedative antihistamines are also available over the counter, but should not be used permanently or by the elderly. Their use is limited to isolated restless nights.
The group of so-called benzodiazepines includes a number of substances that are suitable for short-term treatment of a sleep disorder. They differ in dosage and duration of action. Even though they have a strong sleep-inducing effect, they often lead to fatigue the next day (hangover) due to a long duration of action. An important negative characteristic of benzodiazepines is the rapid development of dependence and tolerance. This means that falling asleep without taking the drug is no longer possible and a steadily higher dose must be taken to fall asleep. Experts therefore advise against long-term treatment with benzodiazepines.
Other prescription sleeping pills are the "Z-substances" (e.g. zolpidem, zopiclone), which are similar to benzodiazepines. These are also suitable for short-term therapy and also have a risk of dependence.
Psychologically induced sleep disorders are often chronic. The best results can be achieved with cognitive behavioral therapy. If a physical cause such as pain or a chronic illness is the trigger, treatment of the underlying condition can at least bring about improvement in most cases.
Untreated insomnia exposes the body to great stress and can lead to complaints such as depressive moodsand high blood pressure. The latter also increases the risk of heart attacks and strokes.
There are no special ways to specifically prevent falling asleep and staying asleep. Adherence to sleep hygiene can often help. However, early detection of the symptoms can intervene quickly and thus minimize the discomfort and risks of insomnia.
Olivia Malvani, BSc
Dr. med. univ. Bernhard Peuker, MSc
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