The most common sleep disorder, with an estimated global prevalence of 10-30%, insomnia symptoms include difficulty falling asleep, poor sleep quality and/or quantity and subsequent potential impairment in the day, when sleep opportunity is not actually compromised or absent (Schutte-Rodin et al., 2008). Experiencing symptoms for three times a week for three months is generally accepted as constitutive of chronic insomnia (Bhaskar et al., 2016). Factors contributing to the etiology of insomnia include genetic, environmental, and neurobiological (Levenson et al., 2015) as well as psychological and stress-response related (Basta et al., 2007)
There are no large epidemiology or insomnia prevalence data collected in Egypt. However, there are some studies that looked at prevalence in specific populations or smaller groups. Some reported insomnia and/or poor sleep data are 34% in a sample of healthcare workers (Elhefny et al., 2016), 57% (Elweshahi et al., 2021) and 67% (E. M. Dongol et al., 2021) in similar populations at the height of the recent pandemic, 71% in a university hospital patients sample (Yousif & El-Helbawy, 2013), 55% (Okasha et al., 2021) and 31% (E. Dongol et al., 2021) among samples of university students, and 30% among medical students (Atlam & Elsabagh, 2020), meaning that perhaps about a third of the Egyptian population has experienced one symptom or another related to poor sleep, with increased incidences in higher stress situations such as medical settings or global pandemics. A study on lifestyle habits in the middle east region in the spring of 2020 reports a disturbed sleep prevalence of 63% (Cheikh Ismail et al., 2021).
Common risk factors associated with insomnia are older age, female gender, drug use, as well as anxiety and depression disorders (Bhaskar et al., 2016). On female gender, two studies on women from upper Egypt reports insomnia in 12% females in strong correlation to dysmenorrhea (Arafa et al., 2020; Arafa et al., 2018). Diabetes is also a significant risk factor (Bhaskar et al., 2016).
From the extensive research on insomnia at the outbreak of Covid-19, some of which has been cited in the previous paragraph, it is evident that stress in general (Basta et al., 2007) and anxiety are not risk factors to be underestimated. Not to be underestimated also are behavioral risk factors of insomnia that were exacerbated during/ since the pandemic. Internet addiction has been correlated to decreased sleep quantity and quality (Mahmoud et al., 2022; Shehata & Abdeldaim, 2021; Tahir et al., 2021).
There were some studies done on sleep post-Covid infection and recovery, suggesting that this correlation continues post lockdown measures and early uncertainty of the pandemic, and may even have something to do with the infectious disease itself or its course of treatment.
Comparing ex Covid-patients with their first-degree age and gender matched relatives with no covid history in a small Egyptian town, Abdelghani et al. found that more than three quarters of recoverees experienced sleep disturbances compared to less than half of control and are almost twice as likely to report anxiety and depression (2022). While recognizing that “psychological stressors such as social restrictions, the psychological impact of a new virus with potentially severe morbidity and mortality, apprehensions about infection or infecting others, and illness stigma” could be contributing to the reported sleep disturbances, Abdelghani et al. also hypothesize that, because environment and stress might be similar for all during the pandemic, a) immune response to the virus and b) poorer respiratory control caused by the virus targeting the central nervous system, could be part of the post-covid insomnia etiology (2022). A study looking at chronic fatigue post covid in elderly women found that a quarter of them suffered from insomnia (Aly & Saber, 2021). The most surprising finding in a study of 500 patients recovered from Covid, where about half had been more than two weeks covid free and half less for less than 2 weeks, was not only that a third (160 out of 500) presented with clinical insomnia, but that that third all were from the > two weeks since recovery group, and none in the more recently recovered group reported clinical insomnia, but minor insomnia symptoms only significantly (El Sayed et al., 2021). Only less than 10% of the participants reported no significant sleep problems, and other significant correlations El Sayed et al. report for post Covid insomnia are female gender and age (2021), which as previously mentioned are common risk factors for insomnia in general. Less than 10% also in a smaller study reported no sleep or psychological problems post covid, with the researchers finding that diabetes, female gender and Covid severity were strongly associated with impaired sleep (Ahmed et al., 2021).
Because insomnia is very subjective, it is primarily assessed through detailed sleep and medical history and subjective questionnaires such as Insomnia Severity Index or Pittsburgh Sleep Quality Index, covering important aspects related to the multiple symptoms of the disorder in detail (Schutte-Rodin et al., 2008). Objective measures to measure sleep quality include and actigraphy and polysomnography (Schutte-Rodin et al., 2008), but some scientists find that “Objective sleep measures derived from polysomnography or actigraphy show considerably more overlap between individuals with insomnia and good sleepers, making these methods less sensitive and specific than self-reports for identifying insomnia”(Buysse, 2013).
In functional medicine, a model that sees the body as a whole, an assessment tool that is used is the Nutritional Assessment Questionnaire, a subjective questionnaire with more than 300 questions (Weatherby, 2004). Reviewed here are some of the questions related to sleep and insomnia, what the developer of the questionnaire explains as reasons to ask these question, and further assessments he recommends to help understand the client’s answer and determine a course of treatment.
- Question 46; the use of relaxants/sleeping pills: an obvious indicator of the need for improved sleep. (Weatherby, 2004, p.101)
- Question 173; Awaken a few hours after falling asleep, hard to get back to sleep: one of the symptoms associated with insomnia, Weatherby ties this to blood sugar dysregulation causing hypoglycemia late in the evening and disrupting sleep. Tests suggested are fasting blood sugar, 6h glucose insulin tolerance test, and checking adrenal insufficiency 1) by way of an ACG, where positive finding would be static in both systole and diastole and an elevated S2 sound and 2) by testing postural hypotension (Weatherby, 2004, p.276)
- 214; difficulty falling asleep: one of the main and most common manifestations of insomnia, Weatherby links this to adrenal dysfunction and imbalanced cortisol rhythm. Assessment tools suggested are cortisol/DHEA rhythm with salivary adrenal stress, checking adrenal insufficiency by testing for chloride in urine and by ACG and BP as mentioned for question 173 (Weatherby, 2004, p.320)
Primary interventions for insomnia in western medicine are cognitive behavioral therapy, followed by pharmaceuticals (Sateia et al., 2017), such as antihistamines and benzodiazepines (Attele et al., 2000). CBT could involve a variety of techniques, including sleep restriction to combat conditioned arousal and paradoxical intention of staying awake to combat anxiety about sleep, which is sadly why many insomniacs have difficulty initiating sleep (Krystal et al., 2019) An RCT recently found internet based CBT to be beneficial for a sample of Egyptian menopausal women experiencing insomnia (Abdelaziz et al., 2021).
Common nutraceuticals utilized by integrative medicine for insomnia include tryptophan, valerian, melatonin, ginseng, chamomile, and lavender (Attele et al., 2000; Sarris & Byrne, 2011; Zhou et al., 2017). For supporting sleep by supporting blood sugar and adrenal function, Weatherby recommends eliminating caffeine and stimulants, a nutritious snack shortly before bedtime to avoid reawakening due to hypoglycemia, B vitamins and thiamine, beet juice, taurine, vit C, pancreolipase, licorice to balance cortisol rhythm, (Weatherby, 2004, p.46, p.276, p.277, p.460). To support sleep and decrease stress, Pizzorno and Katzinger recommend folate, B6, B12, vit C, ashwagandha, rhodiola, GABA combined with 5-HTP, melatonin, and avoiding caffeine and alcohol (2012, p.6.13-6.15).
Looking at dietary trends in a larger context, one study found that “Difficulty maintaining sleep was associated with fewer foods in the diet … Being on a low fat/cholesterol diet was associated with less non-restorative sleep” (Grandner et al., 2014). Common dietary deficiencies associated with short sleep, especially for females are” calcium, magnesium, and vitamins A, C, D, E” (Ikonte et al., 2019). Closer adherence to a Mediterranean diet was strongly associated with better sleep quality in a sample of middle eastern women (Zaidalkilani et al., 2022). An intervention to increase fruit and vegetable intake over 3 months resulted in significantly decreased insomnia for women (Jansen et al., 2021).
Conclusion
Insomnia it is clear is a multifaceted disorder which can be approached from different angles, but there seems to be a central target by both western and functional medicine: stress. Western medicine approaches it first through CBT, and functional medicine through adrenal restoration and nutrient repletion. My approach to insomnia would be to address the behaviors and stressors that could be contributing to it, as well as replenishing nutrients that are inadequate in the diet and perhaps found depleted through medical testing.
Before laying out insomnia interventions that seem beneficial for the Egyptian population especially, it is important to investigate sleep habits in Egypt that may set this population apart from the rest of the world. From the scarce available data, we find that a biphasic sleep pattern is common (Ahmed et al., 2018; Atlam & Elsabagh, 2020; Worthman & Brown, 2007). What is also interesting in a study conducted in 2000, before the height of the digital revolution, is that not only was night sleep onset close to midnight but mean total sleep hours were above 8 (Worthman & Brown, 2007). The reason this is important to discuss for insomnia is because insomnia in general is characterized by difficulty to sleep soundly at appropriate hours, but appropriate hours could mean different things for different people in different worlds. Where the days are long and hot, it makes sense to escape the heat in the afternoon and resume activity after sundown. In a perhaps even warmer part of the middle east where only a quarter of a sample Omani population practiced monophasic sleep, the overall sleep quality and quantity was good, and polyphasic sleepers demonstrated longer total sleep hours and better sleep quality by PSQI (Al-Abri et al., 2020). Even if on the Epworth Sleepiness Scale polyphase sleepers tested higher, in that context and with those findings it might be a sign that this group is more in tune with its unique circadian rhythm; they are sleepy, so they sleep, and sleep the better for it. Night sleep onset is around midnight for the Omani study (Al-Abri et al., 2020).
Another noticeable finding is “a curious link of cosleeping with shorter sleep that yet is also earlier, more regular, and less disturbed.” (Worthman & Brown, 2013). Where anthropologists Worthman and Brown see cosleeping as a sign of finding comfort and protection in a social context and strengthening relationships (2007), we can see this as a sign of lowered stress levels, and therefore less disrupted sleep, in the presence of family.
While it seems that Egyptians could have biological reasons to sleep later than the average westerner and take naps, the evidence reviewed at the beginning of the paper still shows that Egyptians are experiencing poor sleep quality and increased stress. Addressing behaviors such as excessive internet use, especially at night, is still warranted. To address stress, there is evidence that mindful based practices could help improve sleep, alone or in conjunction with CBT (Huberty et al., 2021; Vanhuffel et al., 2018). Listening to music is also an easy way to reduce stress and improve sleep (Jespersen et al., 2015).
As evidenced by the literature, the more nutritious the diet, the better the sleep. As a general rule I would address diet variety first not only because of its associations to better sleep, but also to insure consuming a variety of nutrients in adequate amounts. B vitamins were highlighted by Weatherby (2004) and Pizzorno and Katzinger (2012), so dietary and supplementary sources would be considered. As one of the commonly depleted nutrients in general and with insomnia specifically, vitamin D supplementation has been found to decrease insomnia symptoms (Bahrami et al., 2021; Majid et al., 2018), so I would include it in a protocol for the deficient client.
References
Abdelaziz, E. M., Elsharkawy, N. B., & Mohamed, S. M. (2021). Efficacy of Internet-based cognitive behavioral therapy on sleeping difficulties in menopausal women: A randomized controlled trial. Perspectives in Psychiatric Care, n/a(n/a). https://doi.org/https://doi.org/10.1111/ppc.13005
Ahmed, G. K., Khedr, E. M., Hamad, D. A., Meshref, T. S., Hashem, M. M., & Aly, M. M. (2021, 2021/11/01/). Long term impact of Covid-19 infection on sleep and mental health: A cross-sectional study. Psychiatry Research, 305, 114243. https://doi.org/https://doi.org/10.1016/j.psychres.2021.114243
Ahmed, M., Zaki, N., Morsy, N., Awadalla, N., Hammad, M., Saleh, N., & Elhefnawi, S. (2018). Survey of sleep practice and sleep-related problems among a sample of Egyptian youths (Vol. 67). https://doi.org/10.4103/ejcdt.ejcdt_2_18
Al-Abri, M. A., Al Lawati, I., Zadjali, F., & Ganguly, S. (2020). Sleep Patterns and Quality in Omani Adults. Nature and science of sleep, 12, 231-237. https://doi.org/10.2147/NSS.S233912
Aly, M. A. E. G., & Saber, H. G. (2021). Long COVID and chronic fatigue syndrome: A survey of elderly female survivors in Egypt. International journal of clinical practice, 75(12), e14886-e14886. https://doi.org/10.1111/ijcp.14886
Arafa, A., Mahmoud, O., Abu Salem, E., & Mohamed, A. (2020, 2020/01/02). Association of sleep duration and insomnia with menstrual symptoms among young women in Upper Egypt. Middle East Current Psychiatry, 27(1), 2. https://doi.org/10.1186/s43045-019-0011-x
Arafa, A. E., Khamis, Y., Hassan, H. E., Saber, N. M., & Abbas, A. M. (2018, 2018/03/01/). Epidemiology of dysmenorrhea among workers in Upper Egypt; A cross sectional study. Middle East Fertility Society Journal, 23(1), 44-47. https://doi.org/https://doi.org/10.1016/j.mefs.2017.07.002
Atlam, S., & Elsabagh, H. (2020, 12/29). Sleep habits and their association with daytime sleepiness among medical students of Tanta University, Egypt. Epidemiologic Methods, 9. https://doi.org/10.1515/em-2019-0034
Attele, A. S., Xie, J., & Yuan, C. (2000). Treatment of insomnia: an alternative approach. Alternative Medicine Review, 5(3), 249-259. http://libproxy.bridgeport.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=107127894&site=eds-live&scope=site
Bahrami, A., Rezaeitalab, F., Farahmand, S. K., Mazloum Khorasani, Z., Arabi, S. M., Bahrami-Taghanaki, H., Ferns, G. A., & Ghayour-Mobarhan, M. (2021, May-Jun). High-dose Vitamin D Supplementation and Improvement in Cognitive Abilities, Insomnia, and Daytime Sleepiness in Adolescent Girls. Basic and clinical neuroscience, 12(3), 339-348. https://doi.org/10.32598/bcn.2021.1910.1
Basta, M., Chrousos, G. P., Vela-Bueno, A., & Vgontzas, A. N. (2007). CHRONIC INSOMNIA AND STRESS SYSTEM. Sleep medicine clinics, 2(2), 279-291. https://doi.org/10.1016/j.jsmc.2007.04.002
Bhaskar, S., Hemavathy, D., & Prasad, S. (2016, Oct-Dec). Prevalence of chronic insomnia in adult patients and its correlation with medical comorbidities. Journal of family medicine and primary care, 5(4), 780-784. https://doi.org/10.4103/2249-4863.201153
Buysse, D. J. (2013). Insomnia. JAMA, 309(7), 706-716. https://doi.org/10.1001/jama.2013.193
Cheikh Ismail, L., Osaili, T. M., Mohamad, M. N., Al Marzouqi, A., Jarrar, A. H., Zampelas, A., Habib-Mourad, C., Omar Abu Jamous, D., Ali, H. I., Al Sabbah, H., Hasan, H., AlMarzooqi, L. M. R., Stojanovska, L., Hashim, M., Shaker Obaid, R. R., ElFeky, S., Saleh, S. T., Shawar, Z. A. M., & Al Dhaheri, A. S. (2021). Assessment of eating habits and lifestyle during the coronavirus 2019 pandemic in the Middle East and North Africa region: a cross-sectional study. The British journal of nutrition, 126(5), 757-766. https://doi.org/10.1017/S0007114520004547
Dongol, E., Shaker, K., Abbas, A., Assar, A., Abdelraoof, M., Saady, E., Hassan, A., Youssef, O., Essam, M., Mahmoud, M., & Leschziner, G. (2021). Sleep quality, stress level and COVID-19 in university students; the forgotten dimension [article]. Sleep Science, 15(Special2), 347-354. https://doi.org/10.5935/1984-0063.20210011
Dongol, E. M., Saleh, A. A., Hussein, A. A. M., Mahmoud, M. M. H., & Galal, I. (2021). Sleep quality and psychological status of health professionals in Egypt during COVID-19 era. SVU-International Journal of Medical Sciences, 4(2), 327-340. https://doi.org/10.21608/svuijm.2021.92429.1215
El Sayed, S., Gomaa, S., Shokry, D., Kabil, A., & Eissa, A. (2021). Sleep in post-COVID-19 recovery period and its impact on different domains of quality of life [Article]. Egyptian Journal of Neurology, Psychiatry & Neurosurgery, 57(1), 1-10. https://doi.org/10.1186/s41983-021-00429-7
Elhefny, R. A., Mously, S. E., Sobhi, S., & Wahed, W. Y. A. (2016, 2016/07/01/). Evaluation of sleep related breathing problems and sleep disturbances among health related employees at Fayoum University Hospitals. Egyptian Journal of Chest Diseases and Tuberculosis, 65(3), 667-672. https://doi.org/https://doi.org/10.1016/j.ejcdt.2016.02.009
Elweshahi, H., Mekky, J., Elwafa, H., & Ashry, M. (2021, January 1, 2021). Sleep and emotional disturbances among the health workers during the COVID-19 pandemic in Egypt [Original Article]. Egyptian Journal of Psychiatry, 42(1), 29-35. https://doi.org/10.4103/ejpsy.ejpsy_42_20
Grandner, M. A., Jackson, N., Gerstner, J. R., & Knutson, K. L. (2014). Sleep symptoms associated with intake of specific dietary nutrients. Journal of sleep research, 23(1), 22-34. https://doi.org/10.1111/jsr.12084
Huberty, J. L., Green, J., Puzia, M. E., Larkey, L., Laird, B., Vranceanu, A. M., Vlisides-Henry, R., & Irwin, M. R. (2021). Testing a mindfulness meditation mobile app for the treatment of sleep-related symptoms in adults with sleep disturbance: A randomized controlled trial. PLoS One, 16(1), e0244717. https://doi.org/10.1371/journal.pone.0244717
Ikonte, C. J., Mun, J. G., Reider, C. A., Grant, R. W., & Mitmesser, S. H. (2019). Micronutrient Inadequacy in Short Sleep: Analysis of the NHANES 2005-2016. Nutrients, 11(10), 2335. https://doi.org/10.3390/nu11102335
Jansen, E. C., She, R., Rukstalis, M., & Alexander, G. L. (2021, 2021/06/01/). Changes in fruit and vegetable consumption in relation to changes in sleep characteristics over a 3-month period among young adults. Sleep Health, 7(3), 345-352. https://doi.org/https://doi.org/10.1016/j.sleh.2021.02.005
Jespersen, K. V., Koenig, J., Jennum, P., & Vuust, P. (2015, Aug 13). Music for insomnia in adults. Cochrane Database Syst Rev(8), Cd010459. https://doi.org/10.1002/14651858.CD010459.pub2
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337-352. https://doi.org/10.1002/wps.20674
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179-1192. https://doi.org/10.1378/chest.14-1617
Mahmoud, O. A. A., Hadad, S., & Sayed, T. A. (2022, 2022/03/22). The association between Internet addiction and sleep quality among Sohag University medical students. Middle East Current Psychiatry, 29(1), 23. https://doi.org/10.1186/s43045-022-00191-3
Majid, M. S., Ahmad, H. S., Bizhan, H., Hosein, H. Z. M., & Mohammad, A. (2018, Sep). The effect of vitamin D supplement on the score and quality of sleep in 20-50 year-old people with sleep disorders compared with control group. Nutr Neurosci, 21(7), 511-519. https://doi.org/10.1080/1028415x.2017.1317395
Okasha, T., Saad, A., Ibrahim, I., Elhabiby, M., Khalil, S., & Morsy, M. (2021). Prevalence of smartphone addiction and its correlates in a sample of Egyptian university students. International Journal of Social Psychiatry, 00207640211042917. https://doi.org/10.1177/00207640211042917
Pizzorno, J. E., & Katzinger, J. (2012). Clinical pathophysiology: A functional perspective: A systems approach to understanding and reversing disease processes. Mind Publishing Inc.
Sarris, J., & Byrne, G. J. (2011, 2011/04/01/). A systematic review of insomnia and complementary medicine. Sleep Medicine Reviews, 15(2), 99-106. https://doi.org/https://doi.org/10.1016/j.smrv.2010.04.001
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 13(2), 307-349. https://doi.org/10.5664/jcsm.6470
Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 4(5), 487-504. https://pubmed.ncbi.nlm.nih.gov/18853708
Shehata, W. M., & Abdeldaim, D. E. (2021). Internet addiction among medical and non-medical students during COVID-19 pandemic, Tanta University, Egypt. Environmental science and pollution research international, 28(42), 59945-59952. https://doi.org/10.1007/s11356-021-14961-9
Tahir, M. J., Malik, N. I., Ullah, I., Khan, H. R., Perveen, S., Ramalho, R., Siddiqi, A. R., Waheed, S., Shalaby, M. M. M., De Berardis, D., Jain, S., Vetrivendan, G. L., Chatterjee, H., Gopar Franco, W. X., Shafiq, M. A., Fatima, N. T., Abeysekera, M., Sayyeda, Q., Shamat, S. F., Aiman, W., Akhtar, Q., Devi, A., Aftab, A., Shoib, S., Lin, C.-Y., & Pakpour, A. H. (2021). Internet addiction and sleep quality among medical students during the COVID-19 pandemic: A multinational cross-sectional survey. PLoS One, 16(11), e0259594-e0259594. https://doi.org/10.1371/journal.pone.0259594
Vanhuffel, H., Rey, M., Lambert, I., Da Fonseca, D., & Bat-Pitault, F. (2018, Apr). [Contribution of mindfulness meditation in cognitive behavioral therapy for insomnia]. Encephale, 44(2), 134-140. https://doi.org/10.1016/j.encep.2016.12.001 (Apport de la pleine conscience dans les thérapies cognitives et comportementales de l’insomnie.)
Weatherby, D. (2004). Signs and symptoms analysis from a functional perspective: A question by question guide (2nd ed.). Bear Mountain Publishing.
Worthman, C. M., & Brown, R. A. (2007, 03 / 01 /). Companionable sleep: Social regulation of sleep and cosleeping in Egyptian families [Article]. Journal of Family Psychology, 21(1), 124-135. https://doi.org/10.1037/0893-3200.21.1.124
Worthman, C. M., & Brown, R. A. (2013, 2013/02/01/). Sleep budgets in a globalizing world: Biocultural interactions influence sleep sufficiency among Egyptian families. Social Science & Medicine, 79, 31-39. https://doi.org/https://doi.org/10.1016/j.socscimed.2012.03.048
Yousif, M., & El-Helbawy, R. (2013, 2013/10/01/). A six-year sleep lab experience in an Egyptian University Hospital. Egyptian Journal of Chest Diseases and Tuberculosis, 62(4), 717-722. https://doi.org/https://doi.org/10.1016/j.ejcdt.2013.09.006
Zaidalkilani, A. T., Alhaj, O. A., Serag El-Dine, M. F., Fekih-Romdhane, F., AlRasheed, M. M., Jahrami, H. A., & Bragazzi, N. L. (2022). Arab Women Adherence to the Mediterranean Diet and Insomnia. Medicina, 58(1), 17. https://www.mdpi.com/1648-9144/58/1/17
Zhou, E. S., Gardiner, P., & Bertisch, S. M. (2017, 2017/09/01/). Integrative Medicine for Insomnia. Medical Clinics of North America, 101(5), 865-879. https://doi.org/https://doi.org/10.1016/j.mcna.2017.04.005
