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The rapid pace in which our world is evolving and the busy life we are conducting, are complicating the answer to a not so simple question – how to sleep. The following article explains what is insomnia, common causes to insomnia, offers non-medicine strategies to treat insomnia, valuable sleep aids and 12 sleep hygiene tips that will help you to set up a good night sleep.

What is insomnia?

Insomnia is a chronic difficulty which involves problems getting to sleep, maintaining sleep, or waking in the morning not feeling restored [1], and is one of the most prevalent psychological health problems, affecting 1 in 9 people [2]. While occasional sleeplessness or difficulties falling or staying asleep is normal, sufficient sleep is essential to physical and psychological well-being. Sleep deprivation at its worst is literally torturous: it changes brain chemistry and physiology, leading to deterioration of cognition, memory, and mood [3]. It can lead to functional impairment, work absenteeism, impaired concentration and memory, and increased use of medical services [1]. People with insomnia have higher rates of medical illnesses than those that don’t have sleep problems [4]. The rate of people who suffer from sleeping problems is enormous: 44% of the general population reports sleep difficulties every night or almost every night [5]. Up to 75% of insomnia sufferers are experiencing secondary insomnia - arising due to another disease or condition, and only 25-30% of the cases are primary insomnia, which develops independently of other conditions [6]. In spite of reduced quality of life resulting from insomnia, many insomnia sufferers don’t consult a physician or take action to alleviate their insomnia symptoms [6].

Insomnia causes

In order to answer the question – how to sleep, we first need to understand the main causes for insomnia. These may serve a key for understanding the solutions.

1. Internal arousal or conditioned insomnia. Worries and intrusive thoughts are experienced by the majority of people with insomnia during the pre-sleep period. However, in an attempt to control or turn off the unpleasant pre-sleep thinking, paradoxically, the control strategy ends up fuelling the unwanted activity and lengthening the time it takes to fall asleep (sleep onset latency) [2].
2. 2.Disturbed sleep associated with anxiety. Anxiety-related insomnia is often characterized by increased sleep latency and frequent awakenings during the night. Nervousness, tension and apprehensiveness, are also known to correlate with sleep disorders, interfering with a good night sleep [7].
3. 3.Disturbed sleep associated with depression. Many patients sleep less, take longer to fall asleep, awaken more frequently for longer periods during the night, and have more light-sleep stages than deep-sleep stages [7].
4. Disturbed sleep associated with active psychosis [7].
5. Environmental factors. Some people require a calm environment to fall asleep. Disturbances caused by spouse, child, pet, or light, may cause sleep problems. Other factors include Jet lag, a change in the sleep-wake schedule caused in some instances by temperature and hormonal cycles [7].
6. Medical and psychological factors. Examples include side effects of pharmacotherapy, such primary sleep disturbances as sleep apnea and restless-legs syndrome, and secondary sleep disturbances caused by many medical problems, such as hyperthyroidism [7]. On the other hand, Individuals with insomnia have higher rates of medical illnesses than those without sleep problems [4]. 
7. Feelings. Maintaining feelings of anger and hostility relates to poorer sleep quality. Maintaining hostility toward an offender may enhance anxiety by focusing attention on an uncontrollable event. In these instances, practicing forgiveness may help improve the sleep quality [5].
8. Victims of interpersonal transgressions such as sexual assault, partner violence, bullying at school, and childhood abuse and neglect are at heightened risk for experiencing sleep difficulties compared to the general population [5].

In order to treat sleeping problems, there are pharmacologic, psychological interventions, self-help sleep aids, and sleep hygiene practices. The superiority of cognitive-behavioral interventions as opposed to medication was proven in several studies, these interventions produce significant and long lasting sleep improvements in insomniacs [8].

Non-pharmacologic insomnia treatment strategies [9].

Non-pharmacologic management strategies are short-term cognitive-behavioral therapies. They include:

1. Stimulus control therapy. This technique is based on the premise that insomnia is a conditioned response to bedtime and environmental cues that are usually associated with sleep. For example, going to bed only when feeling sleepy, using the bed and bedroom only for sleep and sex and nothing else like watching TV, and getting out of bed and whenever unable to fall asleep.
2. Sleep restriction. Restricting the amount of time spent in bed match the amount of time spent sleeping. For example, if a person is sleeping only 5 hours out of 8 hours spent in bed, the person will be given a sleep window of 5 hours, which will be gradually increased.
3. Relaxation therapies. These are used to deactivate the heightened arousal system.
4. Cognitive therapy. Cognitive therapy aims to alter faulty beliefs and attitudes about sleep, such as unrealistic sleep expectations, misconceptions about the causes of insomnia, and anxiety resulting from excessive attempts to control the sleep process.
5. Paradoxical intention. Persuading a patient to engage with the most feared behavior- staying awake. The person will then reduce the anxiety related to the inability to fall asleep, which in turn will help to fall asleep.

Continue to Part 2: sleep aids and 12 tips to set up a good night sleep. (the bibliography is presented in part 2).

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