INSOMNIA and its effect on students’ life Master’s Thesis

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

Faculty of Medicine

Department of Psychiatry

My-binh Lam

INSOMNIA

and its effect on students’ life

Master’s Thesis

Supervisor assoc. prof.

TABLE OF CONTENT

1. SUMMERY 3

2. ETHICS COMMITTEE APPROVAL 4

2.1 Permission issued by the Ethics Committee 5

3. INTRODUCTION 6

4. OBJECTIVES OF THE THESIS 7

5. LITERATURE REVIEW 8

5. 1 Characterization of insomnia 8 5. 2 Diagnostic criteria of insomnia 8 5. 3 Risk factors for insomnia 11

5. 4 Sleep cycle 12

5. 5 Insomnia prevention 12

5. 6 Management of insomnia 13

6. RESEARCH METHODOLOGY AND METHODS 15

7. RESULTS 16

6. 1 Demographics 16

6. 2 Sleeping quality 17

6. 3 Sleeping habits 19

6. 3 Insomnia and students’ life 21 6. 4 Students’ symptoms of insomnia 23

8. DISSCUSSION 26

9. CONCLUSION 29

10. PRACTICAL RECOMMENDATIONS 30

11. REFERENCES 31

1. SUMMERY

Author and title of the thesis: My-binh Lam, Insomnia - and its effects on stu-dent’s life.

The aim

To determine the relations of symptoms of insomnia and the daily life of medi-cal students at LSMU and how the amount of sleep of the asked students re-flects on their happiness and their satisfaction of their study results.

Method

A questionnaire was given to 100 medical students of first to last study year at LSMU.

Result

After evaluating the handed out questionnaire it is obvious that students who are sleeping less than 6 hours per night tend to feel unsatisfied with their study success and their physical and mental health. Some of the students who sleeps little experienced insomnia related symptoms at least once in their life, such as headache, lack of concentration and irritability.

Conclusion

Having a regular sleeping cycle and a good sleeping routine is essential to func-tion efficiently during the day. Students tend to stay up late at night either study-ing or workstudy-ing with electronic devices, which is a major factor causstudy-ing insomnia in young adults. The outcomes of chronic lack of sleep ranges from a predisposi-tion to get a common cold due to a weakened immune system to amenorrhea, nau-sea and other gastro-intestinal symptoms. Most of the young adults don’t pay at-tention to a healthy sleeping cycle and are unaware of the side effects on the long run. It might be recommended for the educational system, such as schools and university, to give lectures and classes regarding insomnia and how to develop a good sleep hygiene. 


2.1 Permission issued by the Ethics Committee

Title

Sleep disorders - insomnia

Number

BECMF85

Date of issue

3. INTRODUCTION

Insomnia, better known as sleeplessness, is a sleep disorder in which people have trouble sleeping, difficulties falling asleep or staying asleep during an adequate amount of time. _{The lack of sleep or poor sleep affects a person’s}

mood essentially - people suffering from insomnia often feel tired, worried, stressed and it can result in increased risks of vehicle accidents as well as diffi-culties in focusing and learning [1].

So it’s no surprise that how well we sleep has a direct impact on our physical and mental health. Sleep problems such as insomnia are a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, bipolar disorder, and attention deficit hyperactivity disorder (ADHD). Insomnia can be lasting between days, weeks or even months and can be therefore classified as transient, acute and chronic insomnia [1, 2].

Transient insomnia usually lasts less than a week is mostly caused by environ-mental factors, such as changing the sleeping environment or the timezone, as well as experiencing more stress than usual or suffering from mental illness like depression [3]. Acute insomnia is the inability to consistently sleep well for a period of less than a month and it characterized by difficulties initiating or maintaining sleep or when the sleep that is obtained is non-refreshing or of poor quality [4]. Chronic insomnia lasts for longer than a month. It can be cau-sed by another disorder, or it can be a primary disorder [3, 4].

How a good night sleep benefits the physical and mental health is being explo-red by scientists over the past decades and it is said that the sleeping hours are essential for the brain to learn - the brain is not only working hard to process the events and impressions of the day intensively, but also sorting out informa-tion which are not considered to be important enough to be memorized [5]. Be-sides these beneficial effects to the mental state, having a healthy sleeping cy-cle also strengthens the immune system, reduces stress and improves the organ function and metabolic functions of the body [5] - all these mentioned factors are especially important for students, whose success in studies rely on their physical and mental health.

4. OBJECTIVES OF THE THESIS

The objectives of this thesis is to determine:

1. How many out of 100 students from LSMU are experiencing insomnia on a regular basis

2. The sleep routine of the 100 LSMU students

3. The main environmental factors affecting the duration of sleep in young adults

5. LITERATURE REVIEW

5. 1 Characterization of insomnia

Sleep problems are of growing concern to global public health because poor sleep is associated with impairments in motivation, emotion, and cognitive functioning as well as increased risk for serious medical conditions (e.g., dia-betes, cardiovascular disease, cancer) and all-cause mortality, even when the symptoms are below the threshold for clinical sleep disorders [6]. Insomnia is characterized mainly by the presence of an individual's report of difficulty with sleep. For example, in survey studies, insomnia is defined by a positive respon-se to either question, “Do you experience difficulty sleeping?” or “Do you have difficulty falling or staying asleep?” [6, 7] In case of the presence of a long sleep latency, frequent nocturnal awakenings, or prolonged periods of wakeful-ness during the sleep period or even frequent transient arousals, the diagnosis of insomnia can be established.

5. 2 Diagnostic criteria of insomnia

The common diagnostic criteria for insomnia are: (1) difficulty falling asleep, staying asleep or non-restorative sleep; (2) this difficulty is present despite adequate opportunity and circumstance to sleep; (3) this impairment in sleep is associated with daytime impairment or distress; and (4) this sleep difficulty occurs at least 3 times per week and has been a problem for at least 1 month [7]. Research has shown that among the daytime consequences of insomnia, the increased occurrence of accidents poses the greatest health risk [8]. The ability to work efficiently and productively is also compromised among people suffering from insomnia due to work-related problems, since they are more prone of having a decreased concentration span and more health issues, such as headache, the common cold and the feeling of extreme tiredness [9]. Further-more, insomnia is more frequently associated with psychiatric disorders than

any other medical illness and depression and anxiety are the most common comorbid psychiatric disorders in insomniacs [10]. Insomnia has been declared a major risk for the development of a subsequent psychiatric disorder [11]. Hyperarousal experienced throughout the entire day is said to be strongly rela-ted to insomnia at night. Many patients are unable to “turn off ” their thoughts when trying to sleep, ruminating about sometimes even mundane daytime events and experiencing negatively toned thoughts or fears about the detrimen-tal effects of not being able to sleep [12]. Insomnia can be clarified into prima-ry and secondaprima-ry insomnia. Secondaprima-ry insomnia is the symptom or side effect of another problem. This type of insomnia often is a symptom of an emotional, neurological, or other medical or sleep disorder [13], whereas it is stated that primary insomnia isn't a symptom or side effect of another medical condition. It is its own distinct disorder, and its cause isn’t well understood. Primary in-somnia usually lasts for at least 1 month [12, 13].

Insomnia is measured using the Athens insomnia scale (AIS), which determi-ned by assessing eight factors (Table 1) amongst which first five factors are related to nocturnal sleep and last three factors are related to daytime dysfunc-tion. These are rated on a 0–3 scale and the sleep is finally evaluated from the cumulative score of all factors and reported as an individual's sleep outcome [14]. A cut-off score of ≥6 on the AIS is used to establish the diagnosis of in-somnia.

The evaluation of insomnia requires assessment of nocturnal and daytime sleep-related symptoms, their duration, and their temporal association with psychological or physiological stressors [see table 2].

To eliminate other conditions that could be the cause of insomnia, past medical history and a physical examination need to be done and comprehensive sleep history should be taken, which include sleep habits, medications, alcohol con-sumption, nicotine and caffeine intake, co-morbid illnesses, and sleep envi-ronment [15]. A sleep diary can be used to keep track of the individual's sleep

Table 2. Criteria for diagnosis of insomnia

(From the Diagnostic and Statistical Manual of Mental Disorders, fifth edition)

Dissatisfaction with sleep quantity or quality, with one or more of the following symptoms:
 Dissatisfaction with sleep quantity or quality, with one or more of the following symptoms:
 Difficulty initiating sleep


Difficulty maintaining sleep, characterized by frequent awakenings or trouble returning to sleep after awakenings Early-morning awakening with inability to return to sleep

The sleep disturbance causes clinically significant distress or impairment in daytime func-tioning, as evidenced by at least one of the following:

Fatigue or low energy
 Daytime sleepiness


Impaired attention, concentration, or memory Mood disturbance
 Behavioral difficulties


Impaired occupational or academic function Impaired interpersonal or social function Ne-gative effect on caregiver or family functioning

The sleep difficulty occurs at least 3 nights per week, is present for at least 3 months, and occurs despite adequate op- portunity for sleep

patterns, which is a record of an individual's sleeping and waking times with related information, usually over a period of several weeks [15, 16]. The diary includes time to bed, total sleep time, time to sleep onset, number of awake-nings, use of medications, time of awakening, and subjective feelings in the morning.

5. 3 Risk factors for insomnia

The main reasons for college students for having a poor sleep include increased part-time working hours, pulling all-nighters to finish a paper or cram for an exam, and watching television at bedtime [16]. Clete A. Kushida, MD, PhD, associate professor in the department of psychiatry and behavioral sciences at Stanford University Medical Center, an attending physician at the Stanford Sleep Disorders Clinic, director of the Stanford University Center for Human Sleep Research and a member of the AASM board of directors, notes that the degree of daytime alertness is arguably the most sensitive measure as to how much sleep is necessary for the specific individual. “If the individual is routi-nely tired or sleepy during the daytime, odds are that he or she is not getting enough sleep,” says Dr. Kushida. “To take it one step further, there are two primary factors that affect the degree of daytime alertness: sleep quantity and sleep quality. For the student-age population, sleep quantity and quality issues are both important. However, key factors affecting sleep quality, such as the major sleep disorders (e.g., obstructive sleep apnea and restless legs

syndrome), are less prevalent in this age group compared to middle-aged or older individuals.”

The sleep environment also plays an important role in developing insomnia. Disruptive factors such as noise, light or extreme temperatures can interfere with sleep [16].

5. 4 Sleep cycle

Understanding the sleep cycle, which consists of  two recurring phases: REM (rapid eye movement) and NREM (non-REM or non-rapid eye movement), is essential to understand the importance of sleep. NREM sleep typically occup-ies 75–80% of total sleep each night. Many of the health benefits of sleep take place during NREM sleep – tissue growth and repair occurs, energy is restored and hormones that are essential for growth and development are released. REM sleep typically occupies 20–25% of total sleep each night. REM sleep, when dreaming occurs, is essential to our minds for processing and consolidating emotions, memories and stress. It is also thought to be vital for learning, stimu-lating the brain regions used in learning and developing new skills and disrupt-ing the sleepdisrupt-ing cycle means to miss out the vital body processes which may result in health issues on the long-term [17, 18].

5. 5 Insomnia prevention

To prevent insomnia from developing or becoming chronic, one of the first steps of management is having a good sleep hygiene. Sleep hygiene is defined as a set of behavioral and environmental recommendations intended to promote healthy sleep, and was originally developed for use in the treatment of mild to moderate insomnia. During sleep hygiene education, patients learn about healthy sleep habits and are encouraged to follow a set of recommendations to improve their sleep (e.g., avoid caffeine, exercise regularly, eliminate noise from the sleeping environment, maintain a regular sleep schedule) [19]. Sleep hygiene recommendations may be delivered via a variety of media (e.g., print- or internet-based), resulting in increased access and therefore it’s quite conve-nient for individuals not likely to seek medical treatment for their sleep pro-blems- in fact, individuals with undiagnosed or untreated sleep disorders may engage in poor sleep hygiene behaviors in an attempt to cope with their poor sleep (e.g., caffeine or alcohol use), and continued efforts should be made to identify these individuals and refer them for more appropriate treatments [20].

The most common sleep hygiene recommendations including caffeine con-sumption, smoking, alcohol use, exercise, stress, noise, sleep timing, and day-time napping - all these factors have a huge impact on developing insomnia [19, 20]. The complex interplay between behavioral and environmental pat-terns must also be considered in the context of sleep hygiene. Modification of one sleep hygiene behavior may lead to unintended (and sometimes undesira-ble) changes in other behaviors. For example, caffeine withdrawal has been associated with increased stress and decreased exercise [21], which could result in a counterproductive adverse impact on sleep. Also, a reduction in napping may lead to increased caffeine use to combat daytime sleepiness. On the other hand, some combinations of sleep hygiene components may result in more collective sleep improvement. For example, daily exercise has been shown to decrease sleep disturbance during smoking cessation [22]. In conclusion, sleep hygiene education has the potential to address the growing public health con-cern of sleep complaints in the general population, especially due to the reason of its cost-effectiveness, ease of dissemination, and accessibility. In general, sleep hygiene should be combined with other psychological techniques, such as restriction of bedtime and stimulus control therapy [19]. As part of the stimulus control therapy, all possible interfering objects, such as a clock, a TV set, and a small light, should be moved out of the bedroom and light sources outside the window should be dimmed well by curtains [19, 20, 21].

5. 6 Management of insomnia

In terms of chronic insomnia management, cognitive-behavioral therapy for insomnia (CBT-I) is the treatment of first choice, encompassing education about sleep and sleep hygiene, sleep restriction, stimulus control, relaxation techniques, and cognitive strategies to combat nocturnal rumination [23]. Many insomniacs suffer from ruminating when they are lying in bed and cannot sleep. In this case, typical strategies of a cognitive-behavioral therapy can be applied in this case [22, 23].

The main elements of cognitive psychological therapy of insomnia are psycho-education, stimulus control, sleep restriction, relaxation therapies, and

cogniti-ve techniques [24]. Psychotherapeutic relaxation techniques are well-tried me-thods in the treatment of insomnia, especially autogenic training, progressive muscle relaxation, and mindfulness exercises have a positive influence on emo-tional and cognitive and physiological arousals, which disturb the process of falling asleep [25]. Most evidence exists for the effectiveness of progressive muscle relaxation in the treatment of insomnia and a huge advantage of that method is that patients can learn it quite quickly, and afterwards, they have an effective method they can use before falling asleep and during longer wake time at night [26].

All these techniques and strategies as a combination are best administered in a group therapy. Trials in the past years have proven persistent efficacy for com-bination therapy [27]. Due to cost-benefit calculations, practitioners and scien-tists keep searching for new and less-expansive forms of insomnia therapy. One recent suggestion was the Intense Sleep Retraining treatment, [28] consis-ting of sleep deprivation for one night, followed by a series of 50 brief nap op-portunities to experience and relearn sleep initiation. The effectiveness howe-ver has yet to be proven with future studies. Self-help therapy in the form of non-pharmacological, standardized psychological treatment manuals, which can be worked through by the patients themselves, appear to be an inexpensive and accessible alternative for mild to moderate severity insomnia disorders [29].

Additionally to the cognitive behavioral therapy, a pharmacological approach can also be initiated in case of severe insomnia. The sedating drugs can be dif-ferentiated into older benzodiazepines (BZs) and more recently developed so-called Z-drugs (zolpidem, zopiclone, zaleplon, and eszopiclone), sedative anti-depressants, low-dose atypical neuroleptics, antihistamines, melatonin, and herbal (= phytotherapeutic) drugs [30].

There is compelling evidence that psychological and pharmacological treat-ment of insomnia is effective. Hypnotic medications are well evaluated for a short-term usage and, therefore, should only be used for a short period of time in clinical practice, until more long-term studies will be published in the future [31].

6. RESEARCH METHODOLOGY AND METHODS

The study was approved by the Ethics Committee of the hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania (No. BECMF85)) and it was planned and created by the author of this thesis.

The main design of the study is loosely based on the INSOMNIA SCREE-NING QUESTIONNARE available at https://www.jpshealthnet.org and the Athen insomnia scale (Annex 3) modified according to the aim of this study. The objects of study are 100 of the first to the last study year medical students of LSMU, Kaunas, Lithuania. The international and Lithuanian participants of this study are chosen randomly as a cross sample which thought to be represen-ting the majority of the LSMU students.

This study was taken place in the way of handing out a printed questionnaire to the LSMU students who were studying in the library of the LSMU university during the time period of October and November 2018. The students were as-ked to answer 13 questions regarding their sleep behavior and their satisfaction of their physical and mental health, as well their experienced symptoms due to poor sleep. Additionally they were asked whether they think starting class later in the morning would improve their study success.

7. RESULTS

6. 1 Demographics

100 students participated in this study. The mean age of the participants was 25 years. The youngest patient was 20 years and the oldest 30 years old. The ma-jority of the participants, were in their mid- and late twenties (35 %, 42 % and 7% respectively). 48% of the study participants were male and there was no difference in gender distribution across the different age groups.

Table 1. Distribution of participants by age group

Table 2. Distribution of participants by study year

The majority of students are from 6th year of medical studies (44%), the minority are from the 4th year (8%).

Age group Percentage (%) n

20-22 yr. 15 15

23-25 yr. 35 35

26-28 yr. 43 43

29-30 years 7 7

Study year Percentage (%) n

1st 10 10 2nd 14 14 3rd 13 13 4th 8 8 5th 11 11 6th 44 44

6. 2 Sleeping quality

The vast majority with 79% of the participants are sleeping 6-8 hours per night, which is recommended and ideal for getting efficient sleep to recharge and feeling refreshed for the next day. 15% of the asked students are sleeping less than 6 hours on a regular basis, which might be too less to provide an adequate amount of time for the body and mind to recover from the daily stress and therefore might be leading to symptoms of insomnia. 6% of the participants stated to sleep more than 8 hours per night. Even though some people are used to this amount of resting hours, too much sleep, hypersomnia, might as be as unhealthy as too little of sleep. Sleeping more than 9 hours might increase the risk of developing diabetes, mental conditions such as symptoms of anxiety, and memory problems - symptoms actually mimicking those of insomnia. Table 3. Distribution of participants by sleeping hours

Being asked whether or when the students having troubles falling asleep, 55% stated that they usually only have problems in falling asleep when they feel stressed over the day. The stress factors include studies (38%), family, friends or social issues (34%), worries about the future (34%) and other personal, not specified reasons (32%). There are no significant differences between the ages, study years or gender regarding the mentioned stress factors. 15% of the participants noted to have troubles falling asleep on a regular basis, without experiencing an extraordinary or unusual amount of stress during the day. None of the asked students are taking sleep medications regularly though, 13% of the students stated to use any kind of medication for sleeping once in a while. Out of these 13 students 5 are sleeping less than 6 hours per night on a regular basis. 5% of the questioned students had experience with sleep medication at least once in their life. The vast majority (82%) never has taken any sort sleeping medication.

Hours of sleep Percentage (%) n

< 6 hours 15 15

6-8 hours 79 79

Table 4. Distribution of participants by having trouble to fall asleep

Table 5. Distribution of participants by reason of insomnia.

Regarding the causes of insomnia, the students were allowed to cross more than one reason.

Table 6. Distribution of participants by taken sleep medication

Troubles falling asleep Percentage (%)

n

yes 15 15

only when stressed 55 55

no 30 30

Reason of insomnia Percentage (%)

n

studies 38 38

family, friends, social issues

34 34

worries about future 34 34

others 32 32

Taken medication Percentage (%) n regularly 0 0 sometimes 13 13 once 5 5 no 82 82

When asked about the duration of time to fall asleep, 50% of the participants stated to need between 15-45 minutes, which is within the normal healthy range of the amount of time a person should fall asleep when lying in bed. A little less than half of the questioned students (41%) stated to need only about 15 minutes to fall asleep every night, whereas 9% are struggling in falling asleep by needing more than 45 minutes after lying in bed and turning out any electronic devices which could interfere with sleeping.

Table 7. Distribution of participants by duration of falling asleep

6. 3 Sleeping habits

The majority of the asked students (63%) are going to bed after 11pm, which could be considered rather late, since class in the morning often are starting around 8:30am. 32% are going to sleep around 11pm and only 5% are in bed around 10pm. None of the questioned students go to bed around 9pm, regardless when class starts next day.

As expected, since 63% of the students are going to bed after 11pm, 62% stated to feel tired and exhausted the next morning when class begins before 9am. 23% of the participants are always feeling exhausted in the morning, regardless how much they were sleeping the night before and more then half to the 13% of students who sometimes feel tired during class are mainly tired when they had a troublesome day beforehand and therefore suffered from sleeplessness in the night as a result. Only 2 out of 100 students answered that they never feel tired in the morning since they always make sure to get enough sleep in the night by going to bed at a for them individually felt appropriate time.

Duration of falling asleep Percentage (%) n

< 15 min 41 41

15-45 min 50 50

Table 8. Distribution of participants by time going to sleep and whether they

feel exhaustion when going to class

When being asked about the activities 1 hour before going to sleep - the students could choose more than 1 answer - almost all students (78%) stated to work or to play with their mobile phones or computers and 23% are usually watching tv. Especially electronics can have a huge impact on the sleep quality and the amount of time for falling asleep, since the bright light and the excitement are keeping the mind awake and on alert. For a better sleep hygiene, quiet activities such as reading a non-study related book might be helpful to calm down and prepare for going to sleep. 14% of the questioned students do so on a regular basis. More of the students rather use the time before bed for studying (27%). 8% of the participants prefer to do sports before going to sleep to get tired and to put the mind at ease. 4% of the students are doing other actives such as praying, meditating or listing to an audio book.

Time going to sleep

n Felling exhausted in morning when going to class

aways when class starts < 9am rarely never around 9pm 0 0 0 0 0 a r o u n d 10pm 5 2 6 3 2 a r o u n d 11pm 32 7 23 8 0 later than 11pm 63 14 33 2 0 Total (n) 100 23 62 13 2

Table 8. Distribution of participants by activities 1 hour before going to bed

6. 3 Insomnia and students’ life

To the question whether they are satisfied with their own study success, the majority of 68% answered with “yes“ and 32% with “no“. Out of the 32%, 12 students are either sleeping less than 6 hours per night, and 4 students, who are not satisfied with their study grade are having the recommended 6-8 hours of sleep. Only 1 student out of those, who sleeps more than 8 hours regularly is complaining about his study success.

Activities before going to bed Percentage (%) n

watching TV 23 23

reading a non-study related book

14 14

studying 27 27

using PC / mobile phone 78 78

sports 8 8

Table 9. Distribution of participants by their satisfaction with their study

re-sults in relation to their sleeping hours

Out of curiosity the students were additionally asked whether they believe their grade will improve when classes at university start later than 9am. In own experience it is to say that usually lectures start around 8:30am and most of the students are not paying much attention since they are still too tired to focus. The vast majority of students (73%) believes the effectiveness of studies and therefore an improvement of their grades will be improved when class start later in the morning.

Table 10. Distribution of participants by their opinion whether class starting

later affects their study success

Satisfaction with study success Sleeping hours < 6 hours (%) 6-8 hours (%) > 8 hours (%) yes 68 3 75 5 no 32 12 4 1 Total (n) 100 15 79 6

Improvement of grades when class starts later than 9am

Percentage (%) n

Yes 73 73

Being asked about whether they are satisfied with their physical condition, the majority (64%) answered with “yes“ and 26% with “no“. Most of the participants are satisfied with their mental health 77%, whereas 23% admitted that they are not. Among the students who sleep less than 6 hours every night, 5 them are satisfied with their physical and mental health, whereas 10 out of the 15 persons is not content with either their physical or their mental health. Out of the group of students who sleep 6-8 hours per night, the vast majority (73%) is satisfied with their overall health, only 6% is having either physical or mental struggles.

Table 11. Distribution of participants by their satisfaction with their overall

health in relation to their sleeping hours

6. 4 Students’ symptoms of insomnia

The symptoms of lack of sleep experienced by the participants are the characteristic symptoms of insomnia.

70% of the students had experienced headache because they haven’t had enough sleep the night before. More than half of the student (65%) are feeling easily irritated when sleeping poorly and 70 students are stating that their memory are less efficient the less they sleep. Furthermore, students noted that it is much harder to concentrate when they are tired and 66 students even feeling dizzy or nauseous (4%) during the day when they had not slept enough. Especially among girls symptoms such as weight gain, pimples, acne and other

Satisfaction with Sleeping hours Physical condition Mental

health < 6 hours (%) 6-8 hours (%) > 8 hours (%) yes 64 77 5 73 5 no 26 23 10 6 1 Total (n) 100 100 15 79 6

skin manifestations are more prone. 8 girls even stated to experiences amenorrhea because she was sleeping very little due to a hard time before upcoming exams.

The phenomena of having a blurred vision or even hallucinations were named by 3 and 1 student respectively.

Students who are sleeping poorly are predisposed to catch community acquired infections such as the flu, the common cold or a viral tonsillitis.

Insomnia is shown to be more symptomatic in regards to the mood of the students. 83% of the participants noted that they feel overly melancholic, sad and anxious when they slept too less or very poorly.

Table 12. Distribution of participants by their symptoms associated with

in-somnia. More than 1 symptom could be named

Symptoms Percentage (%) n Headache 70 70 Irritability 65 65 Poor memory 70 70 Lack of concentration 73 73 Dizziness 66 66 Gaining weight 4 4

Pimples, acne, skin irritations 16 16

Amenorrhea 8 8

Nausea 4 4

Blurred vision 3 3

Hallucinations 1 1

Flu, common cold, tonsillitis 16 16

8. DISSCUSSION

The aim of this study is to find the meaning of insomnia in relation to LSMU students’s everyday life in regards of their physical and mental health, as well as their university study success.

100 randomly chosen students of the medical program from LSMU were enrolled in this study, which took place in Kaunas during the time period of October and November 2018.

A research, done by Angelika Anita Schlarb from the Faculty of Psychology and Sports, Bielefeld University in the city of Bielefeld, Germany, about sleep problems in colleague students, in which it is stated that up to 60% of all college students suffer from a poor sleep quality, and 7.7% meet all criteria of an insomnia disorder [32]. This statement correlates with this study.

Around 55% of LSMU students stated to have troubles falling asleep when they are stressed and 15% of students are having sleeping problems even when they don’t experience an extra amount of stress during the day. Gaultney revealed that 27% of all university students are at a risk of at least one sleep disorder. Furthermore, previous findings reported that a minimum 7.7% of students suffer from insomnia [33]. Sleep problems have a great impact on the students’ daily life, for example, the grade point average. Due to irregular daytime routines, chronotype changes, side jobs and exam periods, they need specialized treatments for improving sleep.

As seen in this study, students who sleeps very little - in this questionnaire it means less than 6 hours per night, are tending to struggle with their studies more than students who have a regular healthy sleeping routine. Sleep problems and sleep disorders severely impair university students’ academic success. In a study conducted by Buboltz et al, 31% of all students suffered from morning tiredness [34]. This study shows that around 23% of students are feeling tired in the morning and 62% are suffering from morning tiredness when class starts earlier than 9am. In another study, poor sleepers reported

reduced daytime functioning. Shorter sleep duration and an irregular sleep– wake schedule significantly correlated with a lower GPA [33]. Regarding sleep

A clinical review provided evidence that sleep problems correlated with impeded learning, especially poorer declarative and procedural learning, neurocognitive performance and academic success [35].

Beyond academic considerations, sleep problems in university students are often connected with mental health issues. It is common for students with insomnia to suffer from mental health problems such as chronic fatigue, depression, stress, lower optimism, anxiety and a lower quality of life [36]. Taylor et al controlled the correlation between insomnia and mental health problems for medical problems (ie, migraines, gastrointestinal diseases, sexually transmitted diseases). Even then, significant correlations were found for obsessive–compulsive symptoms, somatization, depression, anxiety and overall symptoms [37]. In this studies, it is obvious that insomnia is strongly related to the mental well-being of the students. Students who sleep little are having a higher tendency to develop melancholy, sadness and anxiety. 83% of the students stated to feel mentally exhausted and developing named symptoms when they were having a prolonged time of poor sleep.

In addition, students suffering from insomnia often thought about their sleep problems or ruminated about daily events. Furthermore, students with worse sleep reported more rumination about a stressful life event (ie, exam) [38]. In this studies, one of the main reasons for the LSMU students to develop insomnia is stress (55%). Among the stress factors, studies (38%) is the main cause keeping them awake, followed by worries about family and social issues and worrying about an uncertain future (34% respectively).

Correspondingly, other studies showed that rumination predicted longer sleep-onset latency and was associated with lower sleep efficiency, wakefulness after sleep onset and reduced sleep quality. A poor sleep quality is often associated with stimulant use in university students [38]. Sleep medication is the second

most common substance group consumed by German university students. Compared to the German study, this study done with mainly international students from all over the world and students from Lithuania, usage of sleep medications is not significant.

Only 13% of the asked students stated to use medications once in a while. None of the asked LSMU students are taking substances on a regular basis. In fact, 82% of the participants are stating not having ever taken sleep medications at all.

The research from rom the Faculty of Psychology and Sports, Bielefeld University, stated that one-quarter of all university students are evening chronotypes. Eveningness is often associated with a poor sleep quality, lower self-control, more procrastination, more stress sensitivity and lower sleep efficiency [49]. This statement also correlates with the results obtained from the 100 LSMU students. The majority of the participants are going to bed after 11pm (63%), regardless the time of class on the next day. None of the asked students are going to sleep before 9pm in the evening. Almost all of the 63 students, who are staying up late at night on a regular manner, experience symptoms of insomnia one way or another, including the feeling of increased irritation and anxiety during the day.

Despite the high prevalence rates and the severe consequences, only a few studies examined the treatment of sleep disorders in university students. A recent systematic review found that there is a lack of specialized treatment of insomnia for college students. Cognitive-behavioral therapy was the most effective approach to improve sleep in university students with relaxation techniques, mindfulness and hypnotherapy additionally benefiting mental health outcomes [40].

9.

CONCLUSION

In synopsis of the study in form of the questionnaire and the literature review it can be concluded that:

1. Around 15 of the 100 students are sleeping less than 6 hours on a regular basis and only 9 of the 100 are having troubles to fall asleep, which means the majority are having a considered healthy sleep. 55 of the students however are having recurrent periods of insomnia due to an increased stress level during the day.

2. The vast majority of the questioned students are going to sleep rather late, meaning after 11pm regardless when class starts the next day, which points out the trend of eveningness among young adults.

3. The main environmental factors affecting the duration of sleep in young adults are the usage of electronic devices, especially in form of mobile pho-nes and computers.

4. The relation of insomnia and physical and mental health are connected. The less a person sleeps the more it is likely for him or her to develop pathologi-cal symptoms physipathologi-cally or mentally.

10. PRACTICAL RECOMMENDATIONS

Within this thesis it is seen that most young adults don’t have a sleeping hygie-ne behygie-nefiting their stressful everyday life. Looking at the questionnaire, the majority of the students are staying up late at night by watching tv or playing with other electronic devices such as mobile phone or computer. The dangers of lack of sleep is mostly unaware by the population, even though almost ever-yone suffers once a while from its symptoms. It might be helpful for especially students to get a proper education about a healthy sleeping cycle and how to avoid overly exhaustion during daytime by having a qualitative good sleep at night. For preventing to develop insomnia, schools and other similar instituti-ons should be working together with doctors, such as psychiatrist and other ex-perts at the sleep-studying field, to provide adequate education to children and students, since awareness is the first step of treatment.

Furthermore it should be considered to start class a little bit later in the morning, since this research shows clearly that the vast majority of students are feeling exhausted in the early morning and the lack of concentration is preven-ting to get the maximum of knowledge and information of lectures starpreven-ting be-fore 9 am.

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12. ANNEXES

Annex 1: List of abbreviations:

AASM American Academy of Sleep Medicine

ADHD Attention deficit hyperactivity disorder

AIS Athens insomnia scale

BZ Benzodiazepines

CBT-I cognitive-behavioral therapy for insomnia

LSMU Lietuvos sveikatos mokslų universitetas

NREM non-rapid eye movement

Annex 2: Athens insmnia scale

Table 1: Athens insomnia scale

(Soldatos CR, Dikeos DG, Paparrigopoulos TJ (June 2000)

Sleep factors

Athens insomnia scale

Sleep induction 0: No problem 1: Slight-ly delay-ed 2: Markedly delayed 3: Very delayed or did not sleep at all Awakenings

du-ring the night

0: No problem 1: Minor problem 2: Con-siderable problem 3: Serious problem or did not sleep at all

Final awakening 0: Not earlier 1: A little earlier 2: Markedly earlier 3: Much earlier or did not sleep at all Total sleep

dura-tion 0: Suf-ficient 1: Slight-ly insuf-ficient 2: Markedly insufficient 3: Very insufficient or did not sleep at all

Sleep quality 0: Satis-factory 1: Slight-ly unsa-tisfactory 2: Markedly unsatisfacto-ry 3: Very unsatisfac-tory or did not sleep at all

Well-being du-ring the day

0: Nor-mal 1: Slight-ly de-creased 2: Markedly

decreased 3: Very decreased

Functioning ca-pacity during the day 0: Nor-mal 1: Slight-ly de-creased 2: Markedly

decreased 3: Very decreased

Sleepiness

du-ring the day 0: None 1: Mild

2:

Annex 3: Questionnaire

Gender: F M Age:

Study year:

1. How many hours do you usually sleep at night?

< 6 hours 6-8 hours > 8 hours

2. Do you have troubles falling asleep?

yes only when I’m stressed no

3. How long does it usually take for you to fall asleep?

< 15 min 15 - 45 min > 45 min

4. What do you usually do 1 hour before going to bed?

watching tv reading a non-study related book

studying using PC / mobile phone Sports others:

5.When do you usually go to bed?

around 9:00 pm around 22 pm around 23 pm later than 23 pm

6. How often do you feel exhausted in the morning when going to class? always only when class starts before 9:00 rarely never, I always make sure to get plenty of sleep

7.If you ever have troubles falling asleep, it’s mostly because of:

studies family / friends / social issues worries about future other stress factors

8. Are you satisfied with your grades? yes no

9. Are you satisfied with your physical condition? yes no

10. Are you satisfied with your mental condition? yes no

11. Have you ever taken medications to help you falling asleep?

regularly yes, sometimes once no

12. Do you think your study results / body or mental condition would improve when class starts later? ( after 9:00 am)

13. Have you ever experienced any diseases / symptoms because of lack of sleep?

no

yes : _ _ _